Fertility and Infertility Practice Questions

Q: Consider the following statements regarding infertility: 1. Endometrial biopsy provides information regarding ovulatory factor 2. Both tubal and peritoneal factors can be assessed at laparoscopy 3. Unexplained infertility may be due to luteal phase defect Which of the statements given above is/are correct?

1, 2 and 3. ***Correct: 1, 2 and 3*** - **Statement 1** - **Endometrial biopsy** was historically used to assess the histological changes in the endometrium that correlate with the hormonal environment (progesterone effect), indirectly confirming **ovulation** and luteal phase adequacy. *Note: Current guidelines (ASRM) no longer recommend routine endometrial biopsy for infertility evaluation, as serum progesterone and ultrasound monitoring are preferred.* - **Statement 2** - **Laparoscopy with chromopertubation** is the gold standard for direct visualization of the fallopian tubes (assessing patency, hydrosalpinx, adhesions) and peritoneal factors such as **endometriosis**, pelvic adhesions, or sequelae of pelvic inflammatory disease. This statement is definitively correct. - **Statement 3** - **Unexplained infertility** may be attributed to subtle factors including **luteal phase defect** (LPD). *Note: The concept of LPD is controversial in modern reproductive medicine, with current evidence not strongly supporting it as a distinct diagnosis. Unexplained infertility is more commonly attributed to subtle sperm dysfunction, oocyte quality issues, or immunological factors.* *Incorrect: 1 and 3 only* - This option incorrectly excludes statement 2, which is clearly correct. **Laparoscopy** is a fundamental diagnostic tool for evaluating both tubal patency and peritoneal factors in the infertility workup. *Incorrect: 2 and 3 only* - This option incorrectly excludes statement 1. While endometrial biopsy is not routinely recommended in current practice, it was a recognized method for assessing ovulatory function and luteal phase adequacy at the time of this examination (2019). *Incorrect: 1 and 2 only* - This option incorrectly excludes statement 3. In the context of this 2019 examination, luteal phase defect was considered a potential cause of unexplained infertility, even though this concept is now controversial in modern reproductive medicine.

Q: Hysterosalpingography (HSG) is least helpful in detecting which of the following?

Pelvic adhesions. ***Pelvic adhesions*** - HSG primarily visualizes the uterine cavity and fallopian tubes, making it **poorly suited to detect adhesions outside these structures**. - **Pelvic adhesions** are better evaluated with **laparoscopy**, which allows direct visualization of the abdominal and pelvic organs. *Asherman syndrome* - This condition involves **intrauterine adhesions** which manifest as filling defects or synechiae within the uterine cavity on HSG. - HSG is highly effective in detecting these adhesions and their extent. *Congenital uterine anomaly* - HSG can visualize the shape of the uterine cavity and detect various **congenital anomalies** such as a septate, bicornuate, or arcuate uterus. - The contrast dye fills the uterus, outlining its internal morphology. *Tubal patency* - One of the primary uses of HSG is to assess the **patency of the fallopian tubes** by observing the free spill of contrast into the peritoneal cavity. - Blockages or hydrosalpinges can be clearly identified.

Q: Implantation of a fertilised ovum occurs on which day following fertilisation?

Day 6. ***Day 6*** * Fertilization occurs in the **ampulla** of the fallopian tube, and the zygote undergoes cleavage as it travels towards the uterus. * By day 5-6, the embryo develops into a **blastocyst** with an outer trophoblast layer and inner cell mass. * **Implantation begins on day 6-7** post-fertilization when the blastocyst attaches to the endometrium, making day 6 the correct answer for when implantation occurs. * The process continues and is complete by day 10-12, but the initial attachment (implantation) starts on day 6. *Incorrect: Day 14* * Day 14 marks the time of **ovulation** in a typical 28-day menstrual cycle, not implantation. * By day 14 post-fertilization, the embryo would have been implanted for approximately one week. *Incorrect: Day 20* * Implantation occurs much earlier, around day 6-12 post-fertilization. * By day 20 post-fertilization, the implanted embryo would be well into **gastrulation and organogenesis**. *Incorrect: Day 10* * While the implantation process may continue until day 10-12, it **begins on day 6**, not day 10. * Day 10 represents a later stage when implantation is nearly complete, but the question asks when implantation occurs (i.e., begins).

Q: How do chlamydial infections lead to fallopian tube damage and infertility?

By persistent immune response causing fibrosis and scarring. ***By persistent immune response causing fibrosis and scarring*** - **Chlamydial infections** can persist in the fallopian tubes, leading to a **chronic inflammatory response**. - This sustained inflammation results in **fibrosis** and **scar tissue formation**, which distorts the normal anatomy and function of the fallopian tubes, leading to infertility. *Through direct cellular lysis and tissue destruction* - While *Chlamydia* can infect and replicate within cells, its primary damage mechanism in the fallopian tubes is not through **extensive direct cellular lysis** or immediate widespread tissue destruction. - The damage is more insidious and chronic, driven by the host's immune response rather than acute cellular death. *By production of cytotoxins that damage cilia* - *Chlamydia trachomatis* does not primarily produce potent **cytotoxins** that directly devastate ciliary function in the way some bacterial pathogens might. - Ciliary damage occurs as a *consequence* of inflammation, rather than being the direct result of a specific chlamydial exotoxin. *By stimulating tubal spasm and stenosis* - While inflammation can indirectly affect tubal motility, **chlamydial infections** do not specifically cause primary **tubal spasm** or acute **stenosis** as their main mechanism of damage. - The long-term consequence of inflammation is scarring and stricture, which can lead to stenosis, but this is a secondary effect of chronic inflammation and fibrosis.

Q: A patient with infertility has an ultrasound (USG) suggestive of a uterine anomaly. Which of the following is the best method to confirm the diagnosis?

Hysteroscopy + Laparoscopy. ***Hysteroscopy + Laparoscopy*** - This combination allows for a comprehensive evaluation: **hysteroscopy** visualizes the uterine cavity to confirm the type of anomaly (e.g., septum), while **laparoscopy** assesses the external uterine contour and overall pelvic anatomy. - It is considered the **gold standard** for diagnosing complex uterine anomalies as it provides the most detailed information for both diagnosis and surgical planning. *Hysterosalpingography (HSG)* - HSG can delineate the **uterine cavity morphology** and patency of fallopian tubes. - However, it is an **X-ray based test** and does not provide information about the external contour of the uterus, which is crucial for differentiating anomalies like a bicornuate from a septate uterus. *Transvaginal Sonography (TVS)* - While TVS is an excellent initial screening tool and can suggest a uterine anomaly, it often **lacks the definitive resolution** to precisely classify the anomaly, especially differentiating between septate and bicornuate uteri. - Its accuracy can be **operator-dependent** and limited in visualizing the external uterine contour. *Laparoscopy* - Laparoscopy alone provides an excellent view of the **external uterine contour** and pelvic organs. - However, it **does not visualize the internal uterine cavity**, which is essential for identifying and classifying anomalies such as a uterine septum.

Q: A 24-year-old female patient presents with a few weeks of amenorrhea, a left adnexal mass on ultrasound, and a beta-hCG level of $2500 \mathrm{mIU} / \mathrm{mL}$. No fetal heart rate is detected on the ultrasound. What is the most appropriate management?

Single dose methotrexate. **Single dose methotrexate** - A **beta-hCG level of 2500 mIU/mL** in conjunction with an adnexal mass and no fetal heart rate visible on ultrasound is consistent with an **unruptured ectopic pregnancy** in a hemodynamically stable patient. - **Methotrexate** is a systemic treatment that inhibits trophoblastic cell growth, leading to the resolution of the ectopic pregnancy without surgery. *Expectant management* - This approach is typically reserved for patients with very **low and declining beta-hCG levels** who are completely asymptomatic and have no evidence of rupture. - With a beta-hCG of 2500 mIU/mL and a definite adnexal mass, the risk of rupture is significant, making expectant management inappropriate. *Salpingectomy* - **Salpingectomy** (surgical removal of the fallopian tube) is usually indicated for **ruptured ectopic pregnancies**, hemodynamically unstable patients, or when medical management fails. - While it's an effective treatment, the patient's current presentation (unruptured, stable beta-hCG) allows for a less invasive medical approach first. *Milking of tube* - **"Milking" or "expressing" the tube** is an outdated and potentially harmful maneuver that involves squeezing the fallopian tube to push the ectopic pregnancy out. - This method is associated with **high rates of recurrence** and potential for tubal damage, and is not a recommended treatment for ectopic pregnancy.

Q: A woman with a history of primary infertility is found to have two fibroids in the cornual region and bilateral tubal blockage, with normal ovulation and semen analysis. What is the most appropriate treatment?

Assisted Reproductive Technology (ART). ***Assisted Reproductive Technology (ART)*** - ART, specifically **in vitro fertilization (IVF)**, is the most appropriate treatment as it bypasses both the **tubal blockage** and the **cornual fibroids**, which can interfere with sperm transport and implantation, respectively. - While myomectomy could address the fibroids, it doesn't resolve the tubal blockage, making ART the most direct path to conception given the multifactorial infertility. *Laparoscopic Myomectomy* - This procedure would remove the **fibroids**, which may improve uterine receptivity and reduce potential pregnancy complications. - However, it would not address the **bilateral tubal blockage**, meaning natural conception would still be impossible without further intervention, making it less appropriate as a standalone treatment for primary infertility with multiple causes. *Uterine Artery Embolization* - **Uterine artery embolization (UAE)** is primarily used to manage symptoms of fibroids, such as bleeding and pain, and is generally **not recommended** for women desiring future fertility due to potential risks to ovarian function and uterine blood supply. - It also does not resolve the **tubal factor infertility**. *Hysterectomy* - **Hysterectomy** is the surgical removal of the uterus and is a definitive treatment for problematic fibroids. - However, it permanently **sterilizes** the patient and is therefore completely inappropriate for a woman desiring fertility.

Q: What is the minimum percentage for normal sperm morphology according to WHO criteria in seminal fluid analysis?

4 %. ***4 %*** - According to the **World Health Organization (WHO) 2010 criteria** (maintained in WHO 2021, 6th edition), a minimum of **4% normal forms** is considered the lower reference limit for **sperm morphology**. - This seemingly low percentage reflects the **strict criteria (Tygerberg's strict criteria)** used for assessing sperm shape and structure, which evaluates the head, midpiece, and tail dimensions. - Values ≥4% are considered within normal range for **male fertility potential**. *8 %* - An 8% normal morphology would be considered **above the lower reference limit** according to current WHO guidelines. - While quantitatively better and indicating good sperm quality, it is not the *minimum* threshold required for classification as normal. *6 %* - A **6% normal morphology** is above the 4% minimum threshold set by WHO for normal sperm morphology. - This value is not the designated **lower reference limit** for identifying normal morphology as per the standard recommendations. *10 %* - A 10% normal morphology indicates **very good sperm morphology**, well above the lower reference limit. - However, the question asks for the **minimum percentage** for normal classification, and 10% is not that lower threshold.

Q: A 35-year-old female presented with complaints of infertility. She has previous history of PID. Preliminary investigations like USG showed normal organs and hormone levels were also normal. What is the next best investigation?

Hysterosalpingography. ***Hysterosalpingography*** - Given the history of **pelvic inflammatory disease (PID)**, there is a significant risk of **tubal blockage** or damage, which is a common cause of **infertility**. - **Hysterosalpingography (HSG)** is the gold standard investigation to assess the patency and morphology of the **fallopian tubes** and uterine cavity. *Urine culture and sensitivity* - This test is used to detect **urinary tract infections**. While important in general health, it is rarely the primary cause of infertility in the absence of urinary symptoms. - The patient's history of **PID** points towards gynecological causes rather than urinary ones as the likely source of infertility. *Repeat USG* - The initial **ultrasound (USG)** has already shown normal organs, indicating no obvious uterine or ovarian structural abnormalities. - Repeating the same investigation without new symptoms or findings is unlikely to provide additional diagnostic information regarding infertility, especially not **tubal patency**. *Endometrial biopsy* - An **endometrial biopsy** is typically performed to assess the health of the **uterine lining** for conditions like chronic endometritis or abnormal uterine bleeding. - While helpful in specific scenarios, it does not evaluate **fallopian tubal patency**, which is a crucial step in assessing infertility after **PID**.

Q: In a couple, which of the following investigations are included in the initial work-up for infertility?

Semen analysis, Tubal patency test, Ovulation test. ***Semen analysis, Tubal patency test, Ovulation test*** - This option correctly identifies the **key initial investigations** for both male and female factors in infertility: **semen analysis** for male fertility, **tubal patency test** for assessing fallopian tube function, and **ovulation test** to confirm female ovulatory cycles. - These tests are fundamental in a comprehensive initial infertility work-up as they address the most common causes of infertility. *Testicular biopsy, USG, Sperm penetration test* - While **testicular biopsy** and **sperm penetration test** are relevant, they are typically **second-line investigations** performed if initial tests (like semen analysis) are abnormal. - **Ultrasound (USG)** is a general imaging modality and not a primary, specific infertility test for both partners as listed. *Ovulation, tubal patency, Mantoux test* - **Ovulation** and **tubal patency** are essential, but the **Mantoux test** (for tuberculosis) is generally not part of the *initial routine* infertility work-up unless there is clinical suspicion or prevalence in the region. - The Mantoux test is specific for a particular infection, and not a broad screening test for infertility. *Semen analysis, CXR, Mantoux* - **Semen analysis** is appropriate, but a **Chest X-ray (CXR)** and **Mantoux test** are not routine initial investigations for infertility. - These tests would only be indicated if there were specific clinical signs or a history suggestive of underlying pulmonary or infectious disease.

Question 1

Consider the following statements regarding infertility:

1. Endometrial biopsy provides information regarding ovulatory factor
2. Both tubal and peritoneal factors can be assessed at laparoscopy
3. Unexplained infertility may be due to luteal phase defect Which of the statements given above is/are correct?

Accepted Answer

1, 2 and 3

Answer

1 and 3 only

Answer

2 and 3 only

Answer

1 and 2 only

Question 2

Hysterosalpingography (HSG) is least helpful in detecting which of the following?

Accepted Answer

Pelvic adhesions

Answer

Asherman syndrome

Answer

Congenital uterine anomaly

Answer

Tubal patency

Question 3

Implantation of a fertilised ovum occurs on which day following fertilisation?

Accepted Answer

Day 6

Answer

Day 14

Answer

Day 20

Answer

Day 10

Question 4

How do chlamydial infections lead to fallopian tube damage and infertility?

Accepted Answer

By persistent immune response causing fibrosis and scarring

Answer

Through direct cellular lysis and tissue destruction

Answer

By production of cytotoxins that damage cilia

Answer

By stimulating tubal spasm and stenosis

Question 5

A patient with infertility has an ultrasound (USG) suggestive of a uterine anomaly. Which of the following is the best method to confirm the diagnosis?

Accepted Answer

Hysteroscopy + Laparoscopy

Answer

Hysterosalpingography (HSG)

Answer

Transvaginal Sonography (TVS)

Answer

Laparoscopy

Question 6

A 24-year-old female patient presents with a few weeks of amenorrhea, a left adnexal mass on ultrasound, and a beta-hCG level of $2500 \mathrm{mIU} / \mathrm{mL}$. No fetal heart rate is detected on the ultrasound. What is the most appropriate management?

Accepted Answer

Single dose methotrexate

Answer

Expectant management

Answer

Salpingectomy

Answer

Milking of tube

Question 7

A woman with a history of primary infertility is found to have two fibroids in the cornual region and bilateral tubal blockage, with normal ovulation and semen analysis. What is the most appropriate treatment?

Accepted Answer

Assisted Reproductive Technology (ART)

Answer

Laparoscopic Myomectomy

Answer

Uterine Artery Embolization

Answer

Hysterectomy

Question 8

What is the minimum percentage for normal sperm morphology according to WHO criteria in seminal fluid analysis?

Accepted Answer

4 %

Answer

8 %

Answer

6 %

Answer

10 %

Question 9

A 35-year-old female presented with complaints of infertility. She has previous history of PID. Preliminary investigations like USG showed normal organs and hormone levels were also normal. What is the next best investigation?

Accepted Answer

Hysterosalpingography

Answer

Urine culture and sensitivity

Answer

Repeat USG

Answer

Endometrial biopsy

Question 10

In a couple, which of the following investigations are included in the initial work-up for infertility?

Accepted Answer

Semen analysis, Tubal patency test, Ovulation test

Answer

Testicular biopsy, USG, Sperm penetration test

Answer

Ovulation, tubal patency, Mantoux test

Answer

Semen analysis, CXR, Mantoux

Fertility and Infertility — MCQs

Fertility and Infertility — MCQs

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