Fertility and Infertility — MCQs

A 32-year-old woman with a history of polycystic ovary syndrome (PCOS) presents with irregular menses and difficulty conceiving for the past year. She has been on metformin and lifestyle modifications with no improvement, and ultrasound shows multiple small follicles in the ovaries. What is the most appropriate next step in her management?

Fertility and Infertility Indian Medical PG Practice Questions and MCQs

Question 331: Ectopic pregnancy typically lasts longer before rupture in which location?

A. Interstitial (Correct Answer)
B. Isthmic
C. Ampullary
D. Cervical

Explanation: ***Interstitial*** - An **interstitial ectopic pregnancy** occurs in the portion of the fallopian tube that passes through the **uterine muscular wall**, allowing for greater distention. - This anatomical location provides more space for the pregnancy to grow before rupture occurs, often leading to a later presentation and more catastrophic hemorrhage when rupture does happen. *Cervical* - A **cervical ectopic pregnancy** implants in the endocervical canal, an area not designed to support a growing pregnancy. - These pregnancies typically present with heavy bleeding early on and do not usually have a prolonged course before significant complications arise. *Isthmic* - **Isthmic ectopic pregnancies** occur in the narrowest part of the fallopian tube, which has a limited capacity for expansion. - Due to the small lumen and muscular wall, these pregnancies tend to rupture earlier, often within 6-8 weeks, and are associated with a high risk of hemorrhage. *Ampullary* - **Ampullary ectopic pregnancies** are the most common type, occurring in the widest part of the fallopian tube. - While they can grow to a larger size than isthmic pregnancies, the thin wall of the ampulla means they typically rupture earlier than interstitial pregnancies, usually by 8-10 weeks.

Question 332: Which of the following statements about clomiphene citrate is true?

A. It can also be used for male infertility with oligozoospermia
B. Chance of pregnancy is threefold compared to placebo
C. Risk of multiple pregnancy is 6-10%
D. Enclomiphene has antiestrogenic effects (Correct Answer)

Explanation: ***Enclomiphene has antiestrogenic effects*** - **Enclomiphene** is the trans-isomer of clomiphene citrate and acts as a **selective estrogen receptor antagonist** at hypothalamic estrogen receptors. - Clomiphene citrate is a racemic mixture containing approximately **38% zuclomiphene** (cis-isomer with weak estrogenic effects) and **62% enclomiphene** (trans-isomer with antiestrogenic effects). - The **antiestrogenic action of enclomiphene** blocks negative feedback of estrogen on the hypothalamus, leading to increased GnRH release and subsequent FSH/LH secretion, which stimulates ovulation. - This statement is **medically accurate and true**. *Chance of pregnancy is threefold compared to placebo* - While clomiphene citrate does increase pregnancy rates in women with ovulatory dysfunction, the claim of a **"threefold" increase is not consistently supported** by high-quality evidence. - Live birth rates typically show more modest improvements (approximately **1.5-2x**) compared to expectant management. - The ovulation rate improvement is more dramatic, but live birth rate (the more clinically relevant outcome) is less than threefold. *Risk of multiple pregnancy is 6-10%* - This statement is actually **medically accurate** - the multiple pregnancy rate with clomiphene citrate is approximately **5-10%** (predominantly twins at 5-10%, with <1% higher-order multiples). - However, in the context of "which statement is true," option D is more definitively and universally correct. *It can also be used for male infertility with oligozoospermia* - While clomiphene has been explored **off-label** for male infertility, it is **not FDA-approved** for this indication. - Evidence for its efficacy in improving sperm parameters or pregnancy rates in male factor infertility is **limited and inconsistent**. - It is not considered a standard first-line treatment for oligozoospermia.

Question 333: A 32-year-old woman with a history of polycystic ovary syndrome (PCOS) presents with irregular menses and difficulty conceiving for the past year. She has been on metformin and lifestyle modifications with no improvement, and ultrasound shows multiple small follicles in the ovaries. What is the most appropriate next step in her management?

A. Clomiphene citrate
B. Letrozole (Correct Answer)
C. Gonadotropins
D. Laparoscopic ovarian drilling

Explanation: ***Letrozole*** - **Letrozole** is an **aromatase inhibitor** that lowers estrogen levels, leading to increased FSH and improved ovulation rates, particularly in women with **PCOS** unresponsive to clomiphene citrate or as a first-line agent. - It has shown better live birth rates and lower multiple pregnancy rates compared to **clomiphene citrate** in women with **PCOS**. *Clomiphene citrate* - **Clomiphene citrate** is often a first-line treatment for **anovulatory infertility** in women with **PCOS**, but the patient has not responded to initial treatments and **Letrozole** has demonstrated superior outcomes in this population. - Its mechanism involves blocking estrogen receptors in the hypothalamus, leading to increased **FSH** and **LH** release, but it can have anti-estrogenic effects on the endometrium and cervical mucus. *Gonadotropins* - **Gonadotropins** (FSH, LH) are more potent ovulation-inducing agents typically reserved for women who fail to ovulate with oral agents like **clomiphene** or **letrozole**, or in conjunction with assisted reproductive technologies (ART). - Their use carries a higher risk of **ovarian hyperstimulation syndrome (OHSS)** and multiple pregnancies compared to oral agents. *Laparoscopic ovarian drilling* - **Laparoscopic ovarian drilling** is a surgical procedure considered for women with **PCOS** who do not respond to medical ovulation induction, or when other indications for laparoscopy exist. - It involves puncturing the ovarian surface with a laser or electrocautery to destroy androgen-producing tissue, aiming to restore ovulation, but it is more invasive than medical therapies.

Practice by Chapter

Reproductive Physiology

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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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