Fertility and Infertility Practice Questions

Q: Which of the following is the MOST important risk factor for tubal ectopic pregnancy?

Tubal damage due to pelvic infections (e.g., PID). ***Tubal damage due to pelvic infections (e.g., PID)*** - **Pelvic inflammatory disease (PID)** is a leading cause of tubal damage, leading to scarring and adhesions that impair ovum transport and increase the risk of **ectopic pregnancy**. - **Chlamydia trachomatis** and **Neisseria gonorrhoeae** are common bacterial causes of PID, causing subclinical inflammation that can significantly alter tubal architecture. *Scarring and adhesions from previous tubal surgery* - While previous **tubal surgery** (e.g., tubal ligation reversal, salpingectomy) can create scarring and adhesions, this is a less common risk factor than PID, which affects a much larger population. - The type of surgery and individual healing process influence the degree of risk, making it more variable than the widespread impact of untreated **pelvic infections**. *Contraceptive failure with an intrauterine device (IUD)* - The use of an **IUD** does not directly cause ectopic pregnancy but is associated with a higher proportion of pregnancies being ectopic if a woman conceives while using an IUD. - IUDs are very effective at preventing **intrauterine pregnancies**, so any pregnancy that does occur is more likely to be ectopic due to the relative reduction of intrauterine conceptions. *Structural abnormalities of the fallopian tubes (e.g., DES exposure)* - **Structural abnormalities**, such as those caused by **diethylstilbestrol (DES) exposure** *in utero*, can increase the risk of ectopic pregnancy by altering tubal morphology and function. - However, DES exposure is a historical cause and less prevalent in current populations, while **pelvic infections** remain a widespread and significant factor contributing to tubal damage.

Q: Which of the following is the most reliable test for ovulation?

Serum Progesterone level. ***Serum Progesterone level*** - A **serum progesterone level** measured approximately 7 days after the presumed ovulation (mid-luteal phase) is the most reliable biochemical indicator of ovulation. A level of **≥3 ng/mL** confirms ovulation. - The rise in progesterone is due to its production by the **corpus luteum** formed after the rupture of the mature follicle during ovulation. *Basal body temperature* - **Basal body temperature (BBT)** charting shows a slight increase (0.5-1.0°C) after ovulation due to the thermogenic effect of progesterone. However, this rise is **retrospective** and only indicates that ovulation has already occurred. - BBT can be influenced by various factors, such as illness, stress, and sleep patterns, making it **less precise** than direct hormonal measurement. *Vaginal cytology* - **Vaginal cytology** can show changes in epithelial cell morphology (e.g., increased cornified cells) during the periovulatory period due to estrogen influence. - These changes are **indicative of estrogen activity** and cervical mucus quality, but they do not directly confirm the rupture of the follicle or the release of an egg. *Endometrial biopsy* - An **endometrial biopsy** can reveal secretory changes in the endometrium characteristic of the luteal phase, which are a result of progesterone production after ovulation. - However, this is an **invasive procedure** and not a practical or primary test used solely for confirming ovulation.

Q: Twin pregnancy is least associated with:

Young female. ***Young female*** - **Young maternal age** is generally associated with a *lower* incidence of twin pregnancies, particularly dizygotic twins. - The likelihood of dizygotic twinning *increases with maternal age* up to about 35-39 years. *Multigravida* - **Multiparity** (being a multigravida) is associated with an *increased* likelihood of twin pregnancies. - The chance of having twins increases with each successive pregnancy. *Genetic* - There is a **genetic predisposition** to dizygotic twinning, often running in families. - A family history of twinning, especially on the maternal side, increases the chances of having twins. *Patient receiving fertilization treatment* - **Assisted reproductive technologies (ART)**, such as *in vitro fertilization (IVF)*, significantly *increase* the risk of multiple pregnancies, including twins. - This is due to the transfer of multiple embryos or ovarian stimulation leading to multiple ovulations.

Q: What does a decreasing level of anti-müllerian hormone (AMH) indicate?

Decreased ovarian reserve. ***Decreased ovarian reserve*** - **Anti-Müllerian hormone (AMH)** is produced by **granulosa cells** of early-stage ovarian follicles and reflects the size of the **primordial follicle pool**. - A **decreasing AMH level** indicates a reduction in the number of remaining ovarian follicles, signifying **diminished ovarian reserve** and a lower reproductive potential. *No significant change in ovarian reserve* - This is incorrect because AMH levels are directly correlated with the size of the **ovarian follicular pool**. - A decrease in AMH specifically suggests a **decline in the number of viable follicles**. *Ovarian hyperstimulation syndrome* - **Ovarian hyperstimulation syndrome (OHSS)** is a complication of **fertility treatments** that cause an exaggerated response of the ovaries, leading to enlargement and fluid retention. - While AMH levels can be high in individuals prone to OHSS, a **decreasing AMH level** does not indicate OHSS; rather, it suggests reduced ovarian function. *Polycystic ovary syndrome (PCOS)* - Women with **PCOS** typically have **elevated AMH levels** due to an increased number of small antral follicles and arrested follicular development. - Therefore, a **decreasing AMH level** would generally argue against PCOS or indicate successful management that has reduced the follicle count.

Q: Which among the following hormones can be used as an indicator for ovarian reserve in a patient who presents with infertility?

FSH. **FSH** - **FSH** (Follicle-Stimulating Hormone) measured on **day 2 or 3** of the menstrual cycle is a **reliable and well-established indicator of ovarian reserve**. Elevated FSH levels (>10-15 IU/L) suggest diminished ovarian reserve, meaning fewer or lower quality eggs remain. - As the number of ovarian follicles decreases, the **inhibin B** produced by these follicles also decreases, leading to a compensatory rise in FSH due to reduced negative feedback on the pituitary gland. - **Among the given options, FSH is the correct answer.** Note: In current practice, **Anti-Müllerian Hormone (AMH)** and **Antral Follicle Count (AFC)** are considered superior markers for ovarian reserve, but these are not among the options listed. *LH/FSH ratio* - The **LH/FSH ratio** is primarily used in the diagnosis of **Polycystic Ovary Syndrome (PCOS)**, where a ratio of >2 or >3:1 is often observed. - While reflecting a hormonal imbalance, it is not a direct or primary indicator of the quantity or quality of a woman's **ovarian reserve**. *LH* - **LH** (Luteinizing Hormone) is essential for triggering ovulation but does not directly assess the **ovarian reserve**. - Its levels fluctuate significantly throughout the menstrual cycle, particularly peaking during the ovulatory phase (LH surge), making it unreliable as a standalone marker for the follicle pool size. *Estrogen* - **Estrogen** levels, specifically **estradiol (E2)**, are produced by developing follicles and vary considerably throughout the menstrual cycle. - While day 3 estradiol can provide some insight into ovarian function (elevated E2 may suppress FSH, masking diminished reserve), it is not a primary marker for overall **ovarian reserve** assessment and can be influenced by multiple factors.

Q: A 26-year-old patient has had three consecutive spontaneous abortions early in the second trimester. As part of an evaluation for this problem, the least useful test would be:

Postcoital test. ***Postcoital test*** - The **postcoital test** evaluates sperm-mucus interaction and is primarily used in cases of **infertility** (difficulty conceiving), not recurrent pregnancy loss after conception. - While it assesses factors like **cervical mucus quality** and sperm viability within the cervical canal, these issues are less likely to be the primary cause of recurrent second-trimester miscarriages. *Hysterosalpingogram* - A **hysterosalpingogram (HSG)** is crucial for evaluating uterine anomalies (e.g., **septate uterus**, **bicornuate uterus**) or **intrauterine adhesions** (Asherman's syndrome) that can lead to recurrent second-trimester losses. - It also assesses **fallopian tube patency**, although tube issues are more commonly associated with infertility than recurrent miscarriage once pregnancy is established. *Chromosomal analysis of the couple* - **Parental chromosomal abnormalities**, such as **balanced translocations**, are a significant cause of recurrent spontaneous abortions, including those in the second trimester, due to genetically unbalanced gametes. - Karyotyping the couple helps identify if one or both partners carry such a structural anomaly, which would increase the risk of an aneuploid fetus. *Endometrial biopsy in the luteal phase* - An **endometrial biopsy** in the luteal phase can assess for **luteal phase defect (LPD)**, a condition where inadequate progesterone production or endometrial response may prevent proper implantation or maintenance of early pregnancy. - While its role in recurrent miscarriage is debated, some consider it relevant, particularly if the abortions occur in the early second trimester or if there is a concern for proper **endometrial receptivity**.

Q: In cases of recurrent abortions, the most common uterine malformation seen is?

Mullerian fusion defects. ***Mullerian fusion defects*** - **Mullerian fusion defects**, particularly **septate uterus**, are the most common uterine malformations associated with recurrent abortions. This is because the septum has poor vascularity, which impairs implantation and early fetal development. - The presence of a **fibrous or muscular septum** within the uterine cavity can compromise the uterine environment, leading to early pregnancy loss. *Unicornuate uterus* - A **unicornuate uterus** results from the complete or partial failure of development of one Mullerian duct. - While it can be associated with adverse pregnancy outcomes, it is **less common** than septate uterus in cases of recurrent abortion. *Asherman syndrome* - **Asherman syndrome** involves the formation of intrauterine adhesions (scar tissue) typically due to trauma to the endometrial lining, such as from D&C procedures or infections. - While it causes recurrent pregnancy loss due to compromised endometrial receptivity and uterine cavity distortion, it is an **acquired condition**, not a congenital uterine malformation. *Non-specific uterine malformation* - This option is too **broad and vague** to be the most accurate answer. - While other uterine malformations can contribute to recurrent abortions, **Mullerian fusion defects** (specifically septate uterus) are the most frequently encountered in these cases.

Q: A 36-year-old female came for treatment of infertility. To test for her ovarian reserve, what is measured?

FSH. ***FSH*** - **Follicle-stimulating hormone (FSH)** levels, particularly on day 3 of the menstrual cycle, are a common and reliable indicator of **ovarian reserve**. - Elevated basal FSH levels suggest diminished ovarian reserve due to the **decreased negative feedback** from fewer ovarian follicles. *LH* - **Luteinizing hormone (LH)** is primarily involved in **ovulation** and corpus luteum formation, not directly in assessing ovarian reserve. - While LH levels can be measured, they do not provide as direct an assessment of the **number and quality of remaining follicles** as FSH. *LH/FSH ratio* - The **LH/FSH ratio** is often evaluated in the context of **polycystic ovary syndrome (PCOS)**, where it can be elevated. - It is not a primary marker used to assess **ovarian reserve** in infertile women without other symptoms of PCOS. *Estradiol* - **Estradiol** levels are measured as part of fertility assessments, often in conjunction with FSH. - However, isolated estradiol levels are not the most direct or reliable indicator of overall **ovarian reserve** on their own.

Q: Most important criterion in semen analysis is

Sperm motility. ***Sperm motility*** - **Sperm motility** (particularly progressive motility) is considered the most critical criterion in semen analysis as it directly reflects the functional ability of sperm to reach and fertilize an egg. - According to WHO guidelines, at least **32% progressive motility** is required for normal fertility. - A high concentration of non-motile or poorly motile sperm will not result in successful natural conception, regardless of other parameters. - **Progressive motility** is the best single predictor of natural fertility potential. *Sperm concentration* - **Sperm concentration** refers to the number of sperm per milliliter of semen (normal ≥15 million/mL). - While low concentration (oligozoospermia) affects fertility, adequate motility is essential for these sperm to reach the egg. - High concentration with poor motility has limited clinical value. *Semen volume* - **Semen volume** (normal ≥1.5 mL) is important for sperm delivery but does not directly assess sperm quality or function. - Abnormal volume can affect fertility, but motility remains the key functional parameter. *Total sperm count* - **Total sperm count** is calculated as volume × concentration (normal ≥39 million per ejaculate). - While important, total count without assessment of motility does not predict fertilization capacity.

Question 1

Which of the following is the MOST important risk factor for tubal ectopic pregnancy?

Accepted Answer

Tubal damage due to pelvic infections (e.g., PID)

Answer

Scarring and adhesions from previous tubal surgery

Answer

Contraceptive failure with an intrauterine device (IUD)

Answer

Structural abnormalities of the fallopian tubes (e.g., DES exposure)

Question 2

Which of the following is the most reliable test for ovulation?

Accepted Answer

Serum Progesterone level

Answer

Basal body temperature

Answer

Vaginal cytology

Answer

Endometrial biopsy

Question 3

Twin pregnancy is least associated with:

Accepted Answer

Young female

Answer

Genetic

Answer

Patient receiving fertilization treatment

Answer

Multigravida

Question 4

What does a decreasing level of anti-müllerian hormone (AMH) indicate?

Accepted Answer

Decreased ovarian reserve

Answer

Ovarian hyperstimulation syndrome

Answer

Polycystic ovary syndrome (PCOS)

Answer

No significant change in ovarian reserve

Question 5

Which among the following hormones can be used as an indicator for ovarian reserve in a patient who presents with infertility?

Accepted Answer

FSH

Answer

LH/FSH ratio

Answer

LH

Answer

Estrogen

Question 6

A 26-year-old patient has had three consecutive spontaneous abortions early in the second trimester. As part of an evaluation for this problem, the least useful test would be:

Accepted Answer

Postcoital test

Answer

Endometrial biopsy in the luteal phase

Answer

Hysterosalpingogram

Answer

Chromosomal analysis of the couple

Question 7

Which of the following is true regarding superfecundation?

Accepted Answer

The fertilization of two ova from the same cycle by sperm from separate acts of intercourse

Answer

Can only occur through in vitro fertilization techniques

Answer

Occurs only in bipartite uterus

Answer

Results in twins with different fathers having identical genetic makeup

Question 8

In cases of recurrent abortions, the most common uterine malformation seen is?

Accepted Answer

Mullerian fusion defects

Answer

Asherman syndrome

Answer

Unicornuate uterus

Answer

Non-specific uterine malformation

Question 9

A 36-year-old female came for treatment of infertility. To test for her ovarian reserve, what is measured?

Accepted Answer

FSH

Answer

LH

Answer

LH/FSH ratio

Answer

Estradiol

Question 10

Most important criterion in semen analysis is

Accepted Answer

Sperm motility

Answer

Sperm concentration

Answer

Semen volume

Answer

Total sperm count

Fertility and Infertility — MCQs

Fertility and Infertility — MCQs

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