Fertility and Infertility — MCQs

A G2 P1 female with 6 weeks amenorrhea presents with bleeding PV, hypotension, and altered sensorium. She has pain in the abdomen and on per vaginal examination cervical movement tenderness is present. On USG, there is free fluid present in the right paracolic gutter. What is the most probable diagnosis?

Q258

What is the primary goal of management in a woman with recurrent miscarriages?

Q259

A 34-year-old woman presents with a history of recurrent spontaneous abortions. Which of the following is the most appropriate initial investigation?

Q260

A 38-year-old woman with a history of polycystic ovary syndrome (PCOS) is unable to conceive after 18 months of trying. She has regular cycles and no other significant medical history. What is the most appropriate next step in her infertility workup?

Fertility and Infertility Indian Medical PG Practice Questions and MCQs

Question 251: Twin pregnancy, but due to two different men is called:

A. Superfetation
B. Superfecundation (Correct Answer)
C. Both of the options
D. None of the options

Explanation: ***Superfecundation*** - This phenomenon occurs when **two separate ova** are fertilized by **sperm from two different males** during the same menstrual cycle. - This results in fraternal (dizygotic) twins with different biological fathers, which is genetically rare but biologically possible. *Superfetation* - This occurs when a **second, new pregnancy** is established in an already pregnant individual, meaning two pregnancies at different stages of development coexist. - This is extremely rare in humans and typically implies fertilization of an ovum released during an ongoing pregnancy. *Both of the options* - These terms describe distinct biological phenomena with different underlying mechanisms. - Superfecundation involves concurrent fertilization by different fathers, while superfetation involves sequential fertilization resulting in pregnancies of different gestational ages. *None of the options* - Superfecundation accurately describes the scenario of twins conceived by two different fathers. - Therefore, there is a correct option among the choices provided.

Question 252: A 27-year-old female presented to OPD of infertility clinic. She was prescribed bromocriptine. What could be the possible reason?

A. Hypogonadotropic hypogonadism
B. Hyperprolactinemia (Correct Answer)
C. Pelvic inflammatory disease
D. Polycystic ovary syndrome

Explanation: ***Hyperprolactinemia*** - **Bromocriptine** is a **dopamine agonist** that effectively reduces elevated prolactin levels, which can cause anovulation and infertility. - High prolactin can inhibit GnRH release leading to impaired follicular development and **infertility**. *Hypogonadotropic hypogonadism* - This condition involves low levels of **gonadotropins (LH and FSH)**, leading to reduced ovarian function. - Treatment typically involves **gonadotropin therapy** (e.g., FSH and LH agonists), not bromocriptine. *Pelvic inflammatory disease* - PID is an infection of the female reproductive organs, often leading to **fallopian tube blockage** and infertility. - Treatment involves **antibiotics** to clear the infection and often surgical correction, not bromocriptine. *Polycystic ovary syndrome* - PCOS is a hormonal disorder characterized by **anovulation**, hyperandrogenism, and polycystic ovaries. - Management often includes **lifestyle modifications**, metformin, clomiphene citrate, or letrozole, not primarily bromocriptine, unless there is co-existing hyperprolactinemia.

Question 253: Best time to schedule hysterosalpingogram (HSG) in a regular 28-day cycle?

A. Day 2-5
B. Day 7-10 (Correct Answer)
C. Day 14-16
D. Day 20-22

Explanation: **Day 7-10** - Scheduling an **HSG** between day 7 and 10 of a 28-day cycle ensures the procedure is performed after menstrual bleeding has stopped and before **ovulation**. - This timing minimizes the risk of interfering with a potential **pregnancy** and provides clear imaging as the uterine lining is thin. *Day 2-5* - Performing an HSG during **heavy menstrual bleeding** can lead to inaccurate results due to blood obscuring the view or increasing the risk of infection. - The uterine lining is still shedding, which might affect the interpretation of the **uterine cavity**. *Day 14-16* - This period is around the time of **ovulation**, increasing the risk of performing the procedure during a very early, unrecognized pregnancy. - Introducing contrast agents during early pregnancy could potentially harm the **fetus**. *Day 20-22* - At this stage, the **endometrium** is thick, which can make it difficult to visualize the uterine cavity accurately. - If **fertilization and implantation** have occurred, performing an HSG could dislodge the embryo or expose it to radiation.

Question 254: A 34-year-old with recurrent miscarriages and history of septate uterus presents for counseling. Which intervention is most suitable to prevent future pregnancy losses?

A. Hysteroscopic resection
B. IVF with PGD
C. Cervical cerclage
D. Strassman's metroplasty (Correct Answer)

Explanation: ***Strassman's metroplasty*** - **Strassman's metroplasty** is a surgical procedure specifically designed to correct a **septate uterus** by removing or unifying the uterine septum to create a single functional cavity. This improves uterine shape and capacity, addressing the primary anatomical defect causing recurrent miscarriages. - By correcting the **septate uterus**, this intervention directly targets the underlying structural cause of the patient's **recurrent pregnancy losses**, making it the most suitable treatment among the options provided. - While **hysteroscopic septum resection** is now the preferred modern approach for septate uterus, Strassman's metroplasty (abdominal approach) remains a valid surgical option, particularly in cases where hysteroscopic approach is not feasible. *Hysteroscopic resection* - **Hysteroscopic resection** is indeed used for removing an **intrauterine septum** and is currently the **preferred minimally invasive approach** for septate uterus. - However, in the context of this question, Strassman's metroplasty represents the classical **abdominal surgical approach** for the same condition, and both can be effective, though hysteroscopic resection has largely replaced open surgery due to lower morbidity. *IVF with PGD* - **IVF with preimplantation genetic diagnosis (PGD)** is used to screen embryos for genetic abnormalities before implantation, which is not the cause of miscarriages in cases of **septate uterus**. - This intervention does not address the **structural abnormality** of the uterus, which is the primary problem in this patient. *Cervical cerclage* - **Cervical cerclage** is used to treat **cervical insufficiency**, where the cervix dilates prematurely, leading to late-trimester pregnancy loss. - While recurrent miscarriages can sometimes be linked to cervical issues, the history of a **septate uterus** points to a uterine structural anomaly as the primary cause, making cerclage a secondary or irrelevant intervention in this context.

Question 255: A 30-year-old woman presents with primary infertility for 2 years. Her menstrual cycles are irregular (35-45 days). Investigations reveal FSH 15 IU/L, AMH 0.5 ng/mL. Semen analysis is normal and HSG shows patent tubes. What is the most appropriate first-line treatment?

A. Letrozole (Correct Answer)
B. IVF with donor eggs
C. Clomiphene citrate
D. Gonadotropins

Explanation: ***Letrozole*** - This patient has **diminished ovarian reserve (DOR)** evidenced by **FSH 15 IU/L** (borderline elevated) and **AMH 0.5 ng/mL** (significantly low), along with **irregular cycles suggesting anovulation**. - **Letrozole**, an aromatase inhibitor, is the **preferred first-line ovulation induction agent** in patients with DOR who are anovulatory. It works by reducing estrogen production, leading to increased FSH release and follicular development. - **Advantages over clomiphene:** Letrozole has fewer anti-estrogenic effects on the endometrium and cervical mucus, making it superior in DOR patients where endometrial receptivity is crucial. - Given her young age (30 years) and evidence of some ovarian reserve (AMH 0.5, not undetectable), a trial of **2-3 cycles of ovulation induction** before proceeding to IVF is reasonable and cost-effective. *IVF with donor eggs* - This is **premature as first-line therapy**. While the patient has DOR, she still has detectable AMH (0.5 ng/mL), indicating some ovarian function remains. - The **first step** would be attempting conception with her own eggs through ovulation induction, and if that fails, **IVF with autologous (own) eggs** should be tried before considering donor eggs. - Donor egg IVF is typically reserved for patients with **premature ovarian failure**, very advanced age, or after repeated failed IVF cycles with own eggs. *Clomiphene citrate* - While clomiphene is an effective **ovulation induction agent**, it has significant **anti-estrogenic effects** on the endometrium (causing thinning) and cervical mucus (reducing quality). - In patients with **DOR**, where pregnancy rates are already compromised, these anti-estrogenic effects can further reduce success rates. - **Letrozole has been shown to have better pregnancy outcomes** in various populations, including those with DOR, making it the preferred first-line agent. *Gonadotropins* - Injectable gonadotropins (FSH/LH) directly stimulate follicular development and are more potent than oral agents. - However, they carry **higher risks**: multiple gestations (20-30%), ovarian hyperstimulation syndrome (OHSS), and significantly higher cost. - They are typically reserved as **second-line therapy** after failed response to oral ovulation induction agents, or as part of IVF protocols. - Starting with less aggressive, safer oral agents like letrozole is the **standard stepwise approach** in infertility management.

Question 256: A 30-year-old female with 8 weeks of amenorrhea presents with sudden onset lower abdominal pain and vaginal bleeding. She is hypotensive with a positive pregnancy test. Ultrasound shows no intrauterine pregnancy. What is the most likely diagnosis?

A. Threatened abortion
B. Ectopic pregnancy (Correct Answer)
C. Molar pregnancy
D. Ovarian torsion

Explanation: ***Correct: Ectopic pregnancy*** - The combination of **amenorrhea**, **positive pregnancy test**, **abdominal pain**, **vaginal bleeding**, and **hypotension** with no intrauterine pregnancy on ultrasound is highly indicative of a **ruptured ectopic pregnancy**. - **Hypotension** suggests significant blood loss into the abdominal cavity (hemoperitoneum), a common and dangerous complication of a ruptured ectopic pregnancy. - This is a medical emergency requiring immediate surgical intervention. *Incorrect: Threatened abortion* - This is characterized by vaginal bleeding with a **closed cervix** and an **intrauterine pregnancy** seen on ultrasound, which is not the case here. - While bleeding is present, the **hypotension** and **empty uterus** on ultrasound rule out threatened abortion. *Incorrect: Molar pregnancy* - A molar pregnancy would present with a positive pregnancy test and vaginal bleeding, but typically features an **abnormally large uterus** for gestational age and characteristic **"snowstorm" appearance** on ultrasound, not an empty uterus. - **Hypotension** in this context is not a typical initial presentation of molar pregnancy; rather, it's suggestive of acute blood loss, more consistent with rupture. *Incorrect: Ovarian torsion* - Ovarian torsion causes **sudden, severe unilateral pelvic pain** and may be associated with nausea and vomiting but typically does not involve **vaginal bleeding** or a **positive pregnancy test**. - While pain can be severe, **hypotension** due to acute blood loss is not characteristic of ovarian torsion itself, differentiating it from a ruptured ectopic pregnancy.

Question 257: A G2 P1 female with 6 weeks amenorrhea presents with bleeding PV, hypotension, and altered sensorium. She has pain in the abdomen and on per vaginal examination cervical movement tenderness is present. On USG, there is free fluid present in the right paracolic gutter. What is the most probable diagnosis?

A. Abruptio placenta
B. Placenta previa
C. Missed abortion
D. Ruptured ectopic (Correct Answer)

Explanation: ***Ruptured ectopic*** - The combination of **amenorrhea**, **vaginal bleeding**, **abdominal pain**, and signs of **hypovolemic shock** (hypotension, altered sensorium) is highly suggestive of a ruptured ectopic pregnancy. - The presence of **cervical motion tenderness** and **free fluid in the paracolic gutter** on ultrasound strongly indicates intra-abdominal hemorrhage. *Abruptio placenta* - This condition typically occurs in the **second or third trimester** of pregnancy, not at 6 weeks gestation. - While it causes vaginal bleeding and abdominal pain, the presentation of **profound shock** in early pregnancy with free fluid suggests an ectopic rupture rather than placental abruption. *Placenta previa* - **Painless vaginal bleeding** in the second or third trimester is characteristic of placenta previa. - It would not explain the severe abdominal pain, cervical motion tenderness, or signs of hypovolemic shock in a 6-week pregnancy. *Missed abortion* - A missed abortion involves the **death of the embryo/fetus** with retention of products of conception, often with minimal or no symptoms. - It would not typically present with **hypotension**, **altered sensorium**, **severe abdominal pain**, or **free fluid in the abdomen**.

Question 258: What is the primary goal of management in a woman with recurrent miscarriages?

A. Diagnose underlying causes (Correct Answer)
B. Immediate surgical intervention
C. Prevent future pregnancies
D. Routine use of anticoagulants

Explanation: ***Diagnose underlying causes*** - The most crucial step in managing recurrent miscarriages is to identify any **reversible or treatable causes** to prevent future losses. - This involves a thorough investigation including **genetic testing**, hormonal assays, uterine imaging, and screening for **thrombophilias**. *Prevent future pregnancies* - This is not a primary goal; the aim is to **achieve a successful pregnancy**, not avoid them. - Preventing future pregnancies would negate the desire of a woman experiencing recurrent miscarriages, which is typically to have a healthy baby. *Immediate surgical intervention* - **Surgical intervention** is only indicated for specific uterine anomalies (e.g., septate uterus) or cervical incompetence, and rarely as an immediate first step in all cases. - Most causes of recurrent miscarriage are **not amenable to immediate surgery**. *Routine use of anticoagulants* - **Anticoagulants** are used specifically when an underlying **thrombophilia** (e.g., Antiphospholipid Syndrome) is diagnosed. - They are not a routine first-line treatment without a definitive diagnosis.

Question 259: A 34-year-old woman presents with a history of recurrent spontaneous abortions. Which of the following is the most appropriate initial investigation?

A. Thyroid function tests
B. Karyotyping of both partners
C. Antiphospholipid antibodies (Correct Answer)
D. Hysterosalpingography

Explanation: ***Antiphospholipid antibodies*** - **Antiphospholipid syndrome (APS)** is one of the most common **treatable** causes of **recurrent spontaneous abortions**, accounting for 10-15% of cases. - APS causes recurrent pregnancy loss through placental thrombosis and inflammation. - Testing includes **lupus anticoagulant**, **anticardiolipin antibodies**, and **anti-β2 glycoprotein I antibodies**. - Early identification allows for **effective treatment** with low-dose aspirin and/or heparin in subsequent pregnancies, significantly improving outcomes. *Thyroid function tests* - While **thyroid dysfunction** can contribute to miscarriage and is part of the comprehensive workup for recurrent pregnancy loss, it is less commonly the primary cause compared to APS. - Thyroid testing is important but typically yields positive findings in a smaller proportion of cases. *Karyotyping of both partners* - **Parental chromosomal abnormalities** (e.g., balanced translocations) are found in 2-5% of couples with recurrent miscarriages. - While this is part of the comprehensive initial workup for RPL, it is less commonly positive than APS testing. - When present, parental karyotype abnormalities typically cause first-trimester losses due to embryonic aneuploidy. - APS testing is often prioritized as the **most appropriate initial** investigation because it identifies a **highly treatable** condition. *Hysterosalpingography* - **Hysterosalpingography (HSG)** or other imaging (ultrasound, sonohysterography) assesses uterine structural abnormalities (e.g., septum, fibroids, adhesions). - Uterine anomalies account for 10-15% of recurrent losses but are typically evaluated as part of the comprehensive workup rather than as the single most important initial test.

Question 260: A 38-year-old woman with a history of polycystic ovary syndrome (PCOS) is unable to conceive after 18 months of trying. She has regular cycles and no other significant medical history. What is the most appropriate next step in her infertility workup?

A. Laparoscopy to check for endometriosis
B. Clomiphene citrate therapy
C. In vitro fertilization (IVF)
D. Semen analysis for her partner (Correct Answer)

Explanation: ***Semen analysis for her partner*** - This is a crucial initial step because **male factor infertility** accounts for a significant proportion (approximately 30-50%) of infertility cases. - Given that the woman has **regular cycles** despite her PCOS history, implying ovulation, a complete infertility workup must include evaluation of the male partner. *Laparoscopy to check for endometriosis* - This would be considered if there were symptoms suggestive of **endometriosis**, such as severe dysmenorrhea or chronic pelvic pain, which are not mentioned. - It is an **invasive procedure** and not a first-line diagnostic step in the absence of other indicators for endometriosis. *Clomiphene citrate therapy* - This medication is primarily used to induce **ovulation** in anovulatory women, which is not indicated here as the patient has **regular cycles**. - While PCOS is associated with anovulation, her regular cycles suggest she is likely ovulating, so this would not be the initial intervention. *In vitro fertilization (IVF)* - IVF is an advanced and **expensive reproductive technology** typically reserved for cases where simpler treatments have failed or severe infertility factors are identified (e.g., severe male factor, tubal blockage). - It is **premature** to consider IVF before completing a basic infertility workup that includes evaluating all potential factors.

Practice by Chapter

Reproductive Physiology

Practice Questions

Evaluation of the Infertile Couple

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Male Factor Infertility

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Female Factor Infertility

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Ovulatory Disorders

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Tubal and Peritoneal Factors

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Uterine Factors

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Unexplained Infertility

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Assisted Reproductive Technologies

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Psychological Aspects of Infertility

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