Fertility and Infertility Practice Questions

Q: A 30-year-old woman presents with primary infertility. Which of the following tests is typically performed to evaluate male factor infertility?

Semen analysis. ***Semen analysis*** - **Semen analysis** is the cornerstone test for evaluating male factor infertility, assessing sperm count, motility, and morphology. - It is a non-invasive and highly informative initial step to identify potential male reproductive issues. *Hysterosalpingography* - This procedure evaluates the **patency of fallopian tubes** and the shape of the uterine cavity in women. - It is a diagnostic tool for female infertility, not male factor infertility. *Laparoscopy* - **Laparoscopy** is a surgical procedure used to visualize pelvic organs, often to diagnose conditions like **endometriosis** or **pelvic adhesions** in women. - It is an invasive procedure and is not used to directly evaluate male fertility. *Endometrial biopsy* - An **endometrial biopsy** involves taking a tissue sample from the uterine lining to assess for conditions like **endometrial hyperplasia** or **receptivity issues** in women. - This test is specific to female reproductive health and not for male factor infertility evaluation.

Q: A 35-year-old woman presents with a history of recurrent miscarriages and is found to have a septate uterus. What is the most appropriate management?

Hysteroscopic resection of the septum. ***Hysteroscopic resection of the septum*** - A **septate uterus** is a congenital uterine anomaly strongly associated with **recurrent miscarriages** due to inadequate vascularization and implantation failure. - **Hysteroscopic resection (metroplasty)** is the gold standard treatment, as it is minimally invasive and effectively restores a normal uterine cavity, significantly improving pregnancy outcomes. *Cerclage placement* - **Cerclage** is used to treat **cervical insufficiency**, where the cervix prematurely dilates during pregnancy, leading to miscarriage or preterm birth. - This patient's miscarriages are attributed to a uterine anomaly, not cervical incompetence; therefore, cerclage would not address the underlying problem. *Progesterone therapy* - **Progesterone therapy** is sometimes used for threatened miscarriage or in cases of luteal phase defect, which is a hormonal imbalance. - While it might support early pregnancy, it does not correct structural abnormalities like a **septate uterus**, which is the primary cause of recurrent miscarriages in this scenario. *In vitro fertilization* - **In vitro fertilization (IVF)** is primarily used for **infertility** in cases like blocked fallopian tubes, male factor infertility, or unexplained infertility. - While it helps achieve pregnancy, it does not correct the **septate uterus** and thus would not prevent miscarriages caused by the uterine anomaly itself.

Q: What is the primary risk associated with the use of clomiphene citrate for ovulation induction in women with polycystic ovary syndrome (PCOS)?

Multiple gestations. ***Multiple gestations*** - **Clomiphene citrate** stimulates the release of multiple eggs, increasing the chance of **more than one embryo** implanting, leading to twin or higher-order pregnancies. - This increased risk is due to its mechanism of action, which involves blocking estrogen receptors in the hypothalamus and pituitary, leading to increased **gonadotropin release**. *Ovarian hyperstimulation syndrome (OHSS)* - While a risk with ovarian stimulation, **OHSS** is more commonly associated with injectable gonadotropins, not typically the primary risk with oral **clomiphene citrate** at standard doses. - OHSS presents with enlarged ovaries, ascites, and electrolyte imbalances, which are less frequent or severe with clomiphene compared to more potent fertility drugs. *Uterine fibroids* - **Clomiphene citrate** has no direct causal link to the development or exacerbation of **uterine fibroids**, which are benign smooth muscle tumors of the uterus. - Fibroids are influenced by estrogen, and clomiphene's anti-estrogenic effects are localized and generally do not promote fibroid growth. *Endometrial cancer* - Short-term use of **clomiphene citrate** for ovulation induction is not associated with an increased risk of **endometrial cancer**. - While prolonged unopposed estrogen can increase this risk, clomiphene's anti-estrogenic effects on the endometrium mitigate this concern during treatment cycles.

Q: In evaluating a woman for infertility, which test is essential for assessing ovulatory function?

Serum progesterone. ***Serum progesterone*** - A **mid-luteal phase serum progesterone level** (typically measured 7 days before the expected next menses, around day 21 of a 28-day cycle) is the primary biochemical indicator of **ovulation and corpus luteum function**. - A level of **greater than 3 ng/mL (or 10 nmol/L)** indicates that ovulation has occurred, as the corpus luteum produces progesterone after ovulation. *Pelvic ultrasound* - A **pelvic ultrasound** can monitor follicular development and detect the presence of a corpus luteum, which provides indirect evidence of ovulation, but it does not directly confirm the hormonal event of ovulation. - It is crucial for assessing **uterine and ovarian morphology** and can identify conditions like polycystic ovaries or fibroids, but it's not the definitive test for ovulatory function itself. *Hysterosalpingogram* - A **hysterosalpingogram (HSG)** is an imaging test used to evaluate the patency of the **fallopian tubes** and the shape of the **uterine cavity**. - It is essential for assessing tubal factor infertility and uterine anomalies, but it provides no information about ovulatory function. *Laparoscopy* - **Laparoscopy** is a minimally invasive surgical procedure used to directly visualize the pelvic organs and identify conditions such as **endometriosis, adhesions, or pelvic inflammatory disease**. - While it can diagnose structural causes of infertility, it is an invasive procedure and does not directly assess ovulatory function; rather, it identifies anatomical issues that might prevent conception even with normal ovulation.

Q: Identify the most common risk factor for ectopic pregnancy.

History of pelvic inflammatory disease. ***History of pelvic inflammatory disease*** - **Pelvic inflammatory disease (PID)** is the *most common risk factor* for ectopic pregnancy as it can cause *inflammation* and *scarring* of the fallopian tubes, impairing ovum transport. - The resulting tubal damage, such as *adhesions* and *strictures*, creates a hostile environment for the fertilized egg, making it more likely to implant outside the uterus. *Previous ectopic pregnancy* - While a *significant risk factor*, a history of **ectopic pregnancy** is not the most common risk factor overall, as its prevalence is lower than that of PID. - Women who have had one ectopic pregnancy have a *10-15% chance* of having another, but this is a *recurrent risk* rather than a primary cause in the general population. *Use of intrauterine devices* - **Intrauterine devices (IUDs)**, particularly *progestin-releasing IUDs*, do not cause ectopic pregnancies but instead prevent intrauterine pregnancies. - If a pregnancy does occur with an IUD in place, there is a *higher chance* that it will be ectopic due to the successful prevention of uterine implantation. *Advanced maternal age* - Although **advanced maternal age** (typically defined as over 35 years) is associated with an *increased risk of infertility* and other pregnancy complications, it is not the leading risk factor for ectopic pregnancy. - The association is often due to the *cumulative exposure to other risk factors* over time, such as PID, rather than age itself directly causing ectopic implantation.

Q: In IVF, during cleavage stage embryo transfer, embryos are typically transferred back to uterine cavity at which cell stage?

4-8. ***4-8*** - **Cleavage stage embryo transfer** typically occurs on **day 3** after fertilization, when the embryo has divided into approximately **6-8 cells** (within the 4-8 cell range). - This stage is the **most common timing** for cleavage stage transfers in conventional IVF, chosen for transfer into the **uterine cavity** as it allows for adequate embryo assessment while mimicking natural progression toward implantation. - Day 3 transfers at this stage are preferred when blastocyst culture is not planned or available. *2* - An embryo with only 2 cells is at the **very early cleavage stage**, typically observed on **day 1** (approximately 24 hours) after fertilization. - Transferring at this early stage is **rarely done** in modern IVF practice as it provides insufficient time for embryo quality assessment and viability evaluation. *2-4* - A 2-4 cell stage embryo is typically seen on **day 2** after fertilization (approximately 48 hours). - While day 2 transfers can be performed, **day 3 transfers** (4-8 cell stage) are generally preferred for cleavage stage embryo transfer as they allow better morphological assessment and selection of viable embryos. *8-16* - An 8-16 cell embryo is typically seen on **day 4** and represents the **morula stage**, characterized by compaction of cells. - This stage is **beyond the typical cleavage stage transfer window** - embryos at this point would usually be cultured further to **blastocyst stage** (day 5-6) rather than transferred at the morula stage.

Q: What is the drug of choice (DOC) for medical management of ectopic pregnancy?

Methotrexate (Intramuscular). ***Methotrexate (Intramuscular)*** - **Methotrexate** is the **drug of choice** for the medical management of **ectopic pregnancy** that meets specific criteria (e.g., hemodynamically stable, small unruptured ectopic mass, and absence of fetal cardiac activity). - It works by inhibiting **dihydrofolate reductase**, thereby interfering with **DNA synthesis** and cell proliferation of the rapidly dividing trophoblastic tissue. *Actinomycin D* - **Actinomycin D** is an **antineoplastic antibiotic** that is used in the treatment of various cancers, such as Wilms' tumor and gestational trophoblastic disease. - While it has anti-proliferative effects, it is not the standard first-line treatment for **ectopic pregnancy** given the effectiveness and established safety profile of methotrexate. *Prostaglandin F2 alpha* - **Prostaglandin F2 alpha** (e.g., dinoprost) is primarily used for **induction of labor**, **abortion**, or management of **postpartum hemorrhage** due to its myometrial contraction stimulation properties. - It does not specifically target the trophoblastic tissue of an ectopic pregnancy and is not indicated for its medical management. *Mifepristone* - **Mifepristone** is an **anti-progestin** used to induce medical abortion, often in combination with misoprostol. - While it terminates intrauterine pregnancies by blocking progesterone receptors, it is not effective as a standalone treatment for **ectopic pregnancy**, as it does not directly target the ectopic trophoblastic tissue.

Q: An infertile woman has bilateral tubal block at cornua diagnosed on hysterosalpingography. Next treatment of choice is?

IVF. ***IVF*** - For **bilateral cornual tubal block**, In Vitro Fertilization (IVF) is the most effective and often preferred treatment. It bypasses the blocked tubes entirely by fertilizing the egg outside the body. - This approach offers the highest success rates when tubal patency cannot be restored or in cases of severe tubal damage. *Laparoscopy and hysteroscopy* - While these procedures diagnose and treat various infertility causes, they are less effective for **bilateral cornual block**. - **Hysteroscopy** might be used to confirm the block or perform canalization, but the success rate for achieving pregnancy with this method is low. *Tuboplasty* - **Tuboplasty** refers to surgical repair of the fallopian tubes, which is generally not recommended for **cornual block**. - Success rates for achieving live birth after tuboplasty for cornual occlusion are very low, and it carries risks such as ectopic pregnancy. *Hydrotubation* - This procedure involves flushing the fallopian tubes with fluid and is primarily used for **mild distal tubal block** or as a diagnostic step with contrast medium to confirm patency. - It is unlikely to effectively resolve a **significant bilateral cornual block**, which requires more definitive intervention.

Q: In a case of recurrent spontaneous abortion, which of the following investigations is least indicated?

Testing for TORCH infections. ***Testing for TORCH infections*** - While TORCH infections (Toxoplasmosis, Other [syphilis, parvovirus B19, varicella-zoster], Rubella, Cytomegalovirus, Herpes simplex virus) can cause **spontaneous abortion**, they are **rarely a cause of recurrent spontaneous abortion**. - Recurrent infections are uncommon, making chronic or repeated TORCH infections an unlikely primary driver for multiple losses. *Hysteroscopy* - **Hysteroscopy** is often indicated to evaluate for **intrauterine structural abnormalities** such as septa, polyps, fibroids, or Asherman's syndrome, which can contribute to recurrent pregnancy loss. - These structural issues can interfere with implantation and uterine blood supply, leading to repeated abortions. *Thyroid function tests* - Both **hypothyroidism and hyperthyroidism** are associated with an increased risk of recurrent spontaneous abortion. - **Thyroid hormone imbalances** can disrupt ovulation, implantation, and early fetal development. *Testing for antiphospholipid antibodies* - **Antiphospholipid syndrome (APS)** is a significant and treatable cause of recurrent spontaneous abortion due to **thrombotic events** in the placental circulation. - Testing for lupus anticoagulant, anti-cardiolipin antibodies, and anti-beta-2 glycoprotein I antibodies is a **standard part of the workup** for recurrent pregnancy loss.

Question 1

A 30-year-old woman presents with primary infertility. Which of the following tests is typically performed to evaluate male factor infertility?

Accepted Answer

Semen analysis

Answer

Hysterosalpingography

Answer

Laparoscopy

Answer

Endometrial biopsy

Question 2

A 35-year-old woman presents with a history of recurrent miscarriages and is found to have a septate uterus. What is the most appropriate management?

Accepted Answer

Hysteroscopic resection of the septum

Answer

Cerclage placement

Answer

Progesterone therapy

Answer

In vitro fertilization

Question 3

What is the primary risk associated with the use of clomiphene citrate for ovulation induction in women with polycystic ovary syndrome (PCOS)?

Accepted Answer

Multiple gestations

Answer

Ovarian hyperstimulation syndrome

Answer

Uterine fibroids

Answer

Endometrial cancer

Question 4

In evaluating a woman for infertility, which test is essential for assessing ovulatory function?

Accepted Answer

Serum progesterone

Answer

Pelvic ultrasound

Answer

Hysterosalpingogram

Answer

Laparoscopy

Question 5

Identify the most common risk factor for ectopic pregnancy.

Accepted Answer

History of pelvic inflammatory disease

Answer

Previous ectopic pregnancy

Answer

Use of intrauterine devices

Answer

Advanced maternal age

Question 6

In IVF, during cleavage stage embryo transfer, embryos are typically transferred back to uterine cavity at which cell stage?

Accepted Answer

4-8

Answer

2

Answer

2-4

Answer

8-16

Question 7

What is the best indicator for ovarian reserve?

Accepted Answer

Anti-Müllerian Hormone (AMH) - Reflects antral follicle count

Answer

Follicle Stimulating Hormone (FSH) - Day 2-3 cycle marker

Answer

Estradiol (E2) - Fluctuates during cycle

Answer

LH/FSH ratio - Relevant in PCOS diagnosis

Question 8

What is the drug of choice (DOC) for medical management of ectopic pregnancy?

Accepted Answer

Methotrexate (Intramuscular)

Answer

Actinomycin D

Answer

Prostaglandin F2 alpha

Answer

Mifepristone

Question 9

An infertile woman has bilateral tubal block at cornua diagnosed on hysterosalpingography. Next treatment of choice is?

Accepted Answer

IVF

Answer

Tuboplasty

Answer

Hydrotubation

Answer

Laparoscopy and hysteroscopy

Question 10

In a case of recurrent spontaneous abortion, which of the following investigations is least indicated?

Accepted Answer

Testing for TORCH infections

Answer

Thyroid function tests

Answer

Hysteroscopy

Answer

Testing for antiphospholipid antibodies

Fertility and Infertility — MCQs

Fertility and Infertility — MCQs

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