Fertility and Infertility Practice Questions

Q: A 27-year-old female married for 3 years regularly cohabiting with husband presents to Gynaecology OPD with complaints of inability to conceive for 2 years. During clinical evaluation hysterosalpingography was done which revealed irregular outline of uterine cavity and rigid fallopian tubes with nodulations. Most likely cause for this condition is :

Genital Tuberculosis. ***Genital Tuberculosis*** - The combination of **infertility**, an **irregular uterine cavity outline**, and **rigid fallopian tubes with nodulations** on hysterosalpingography (HSG) is highly suggestive of genital tuberculosis. - **Tuberculosis** can cause significant scarring and obstruction in the female reproductive tract, leading to these characteristic HSG findings and impaired fertility. *Syphilis* - While syphilis is a sexually transmitted infection, it typically causes **chancre formation**, **rash**, and systemic symptoms; it does not typically lead to the described HSG findings of an irregular uterine cavity or rigid, nodulated fallopian tubes. - Infertility can be a consequence of untreated syphilis (e.g., through miscarriage), but the specific morphological changes seen in the uterus and tubes are not characteristic of this infection. *Genital Herpes* - Genital herpes is caused by the herpes simplex virus and is characterized by recurrent outbreaks of **painful blisters and ulcers** in the genital area. - It does not cause structural changes to the uterus or fallopian tubes that would result in an irregular uterine outline or rigid, nodulated tubes as seen on HSG. *Gonorrhoea* - Gonorrhoea can cause **pelvic inflammatory disease (PID)**, which can lead to tubal damage and infertility; however, the typical HSG findings are often **hydrosalpinx** or extensive peritubal adhesions, rather than rigid, nodulated tubes with an irregular uterine outline. - While it can result in tubal obstruction, the specific pattern described in the question (irregular uterine outline, rigid tubes with nodulations) is more characteristic of the chronic inflammatory and fibrotic changes associated with tuberculosis.

Q: Which of the following days of menstrual cycle is best for endometrial sampling to diagnose ovulation?

21st - 23rd day. ***21st - 23rd day*** - This period corresponds to the **mid-secretory phase** (~7 days post-ovulation), when **progesterone-induced secretory changes** are fully established and most reliable for histological confirmation of ovulation. - The endometrium shows **mature secretory features** including prominent subnuclear vacuoles, stromal edema, and spiral artery development, making it the **textbook recommendation** for endometrial dating. *12th - 14th day* - This represents the **late proliferative phase** or **periovulatory period**, when ovulation is occurring but secretory changes have not yet developed. - Endometrial histology would show **proliferative features** with straight tubular glands and mitotic activity, lacking the progesterone effect needed to diagnose ovulation. *16th - 20th day* - This period falls in the **early secretory phase**, showing only **initial secretory changes** that may be incomplete or unreliable for definitive diagnosis. - While some progesterone effect may be present, the changes are **not fully mature** compared to the optimal 21st-23rd day window recommended in standard gynecology texts. *8th - 10th day* - This corresponds to the **early proliferative phase**, well before ovulation occurs, when estrogen dominates and no secretory changes are present. - Endometrial sampling would show **proliferative endometrium** with no evidence of progesterone effect, making it unsuitable for diagnosing ovulation.

Q: Which of the following are factors for poor outcome following tuboplasty? 1. Dense pelvic adhesions 2. Length of reconstructed tube less than 4 cm 3. Bilateral hydrosalpinx 4. Reversal after 5 years of sterilization procedure Select the correct answer using the code given below.

1, 2 and 3. ***1, 2 and 3*** - **Dense pelvic adhesions** impair tubal motility and increase the risk of ectopic pregnancy, leading to poor outcomes after tuboplasty. - A **reconstructed tube length less than 4 cm** significantly reduces the available surface area for fertilization and embryo transport, negatively impacting fertility success rates. - **Bilateral hydrosalpinx** indicates severe tubal damage with impaired ciliary function and potentially toxic fluid accumulation, which drastically reduces the chances of successful pregnancy even after surgical repair. *1, 2 and 4* - This option incorrectly includes "Reversal after 5 years of sterilization procedure" while omitting bilateral hydrosalpinx, which is a more significant poor prognostic factor. - While duration since sterilization can influence outcomes, anatomical factors like hydrosalpinx are more critical predictors of tuboplasty failure. *2, 3 and 4* - This option incorrectly omits "Dense pelvic adhesions," which is one of the most important poor prognostic factors in tuboplasty. - Severe pelvic adhesions directly compromise tubal function and significantly increase ectopic pregnancy risk. *1, 3 and 4* - This option incorrectly omits "Length of reconstructed tube less than 4 cm," which is a critical anatomical factor directly influencing tuboplasty success. - Adequate tubal length is essential for proper gamete transport and fertilization; tubes shorter than 4 cm have significantly reduced success rates.

Q: What is the most common first-line investigation used to assess the patency of fallopian tubes?

Hysterosalpingogram. ***Hysterosalpingogram (HSG)*** - **Hysterosalpingogram (HSG)** is the **most common first-line investigation** for assessing tubal patency in infertility workup. - It involves injecting a radio-opaque contrast dye through the cervix into the uterine cavity and fallopian tubes, followed by X-ray imaging. - HSG effectively visualizes the **uterine cavity anatomy** and **tubal patency**, detecting blockages or abnormalities. - It is **minimally invasive, outpatient-based**, and provides both diagnostic and potentially therapeutic benefit (flushing effect). *Sonohysterogram* - **Sonohysterogram (SIS)** primarily evaluates the **uterine cavity** for intrauterine pathology like polyps, fibroids, or septae using saline infusion and ultrasound. - A modified version (**HyCoSy** - hystero-salpingo-contrast sonography) can assess tubal patency but is **less commonly used** than HSG as a first-line test. - Standard sonohysterogram does not directly visualize tubal patency. *Laparoscopic chromopertubation* - **Laparoscopic chromopertubation** is the **gold standard invasive method** for directly visualizing tubal patency. - A colored dye (methylene blue) is injected through the cervix and observed flowing through the fimbriated ends of the tubes under direct laparoscopic visualization. - It is **reserved for cases** where non-invasive tests are inconclusive or when concurrent treatment of pelvic pathology (adhesions, endometriosis) is planned. - It is **not a first-line test** due to its invasive nature, cost, and need for anesthesia. *CT scan* - **CT scan** is not used for assessing fallopian tube patency. - While it provides excellent anatomical detail of pelvic organs, it cannot effectively demonstrate the patency or flow through the narrow fallopian tube lumen. - CT is useful for evaluating pelvic masses, malignancies, or complications but not for functional tubal assessment.

Q: Which of the following is the marker of ovarian reserve?

Anti-Mullerian hormone. ***Anti-Mullerian hormone*** - **Anti-Mullerian hormone (AMH)** is produced by the granulosa cells of small antral and pre-antral follicles in the ovary. - AMH levels correlate with the size of the **primordial follicle pool**, making it the **most reliable indicator of ovarian reserve**. - Unlike other markers, AMH remains relatively **constant throughout the menstrual cycle** and can be measured on any day. - AMH is the **preferred marker** in fertility assessment and IVF planning. *β-hCG* - **Beta-human chorionic gonadotropin (β-hCG)** is a hormone produced during pregnancy by the developing placenta. - Its presence indicates pregnancy and is not a marker for **ovarian reserve**. *Placental alkaline phosphatase* - **Placental alkaline phosphatase (PLAP)** is an enzyme produced by the placenta. - It serves as a biological marker for certain cancers (e.g., germ cell tumors) and sometimes for placental function, but not **ovarian reserve**. *Serum estradiol* - **Serum estradiol** levels fluctuate significantly throughout the menstrual cycle and are influenced by numerous factors. - While **Day 3 estradiol** combined with FSH was historically used for ovarian reserve assessment, elevated levels can indicate poor reserve (due to early follicular recruitment). - However, it is **not as reliable or cycle-independent as AMH** for assessing the overall **follicle pool**.

Q: A 28-year old woman comes with infertility. Husband's semen analysis is normal. Endometrial biopsy shows secretory changes with no evidence of tuberculosis. On hysterosalpingography both tubes show tubal blockage. What should be the next step in management?

Diagnostic laparoscopy and chromo-pertubation. ***Diagnostic laparoscopy and chromo-pertubation*** - This procedure directly visualizes the fallopian tubes and surrounding pelvic structures, allowing for definitive confirmation of tubal blockage and identification of potential causes like **endometriosis** or **adhesions**. - **Chromo-pertubation** involves injecting a dye through the cervix to assess tubal patency and identify the exact location and nature of the blockage. *IVF* - While IVF is a viable option for tubal factor infertility, it is generally considered after a more thorough diagnostic workup, especially when the cause of blockage is unknown and potentially treatable. - Proceeding directly to IVF without assessing the possibility of surgical correction might be premature and miss an opportunity for natural conception or a less invasive intervention. *Tuboplasty* - **Tuboplasty** is a surgical procedure to repair or reconstruct damaged fallopian tubes. - However, its success depends on the extent of damage and the specific type of blockage, which can only be determined after a diagnostic evaluation like laparoscopy. *ICSI* - **ICSI (Intracytoplasmic Sperm Injection)** is a specialized form of IVF primarily used for severe male factor infertility, not tubal blockage, especially when the husband's semen analysis is normal. - While ICSI can be part of an IVF cycle, it's not the primary next step for diagnosing or treating tubal blockage in a woman with normal male factor.

Q: Asherman's syndrome typically results from

Excessive curettage during abortion. ***Excessive curettage during abortion*** - **Asherman's syndrome** is characterized by the formation of **intrauterine adhesions** or **synechiae** - This results from trauma to the **basal layer of the endometrium** during procedures like excessive or repeated curettage following abortion, miscarriage, or childbirth - The curettage causes scarring that leads to partial or complete obliteration of the uterine cavity - **Most common cause** of intrauterine adhesions and presents with amenorrhea, hypomenorrhea, or infertility *Post-partum haemorrhage* - While post-partum hemorrhage can lead to uterine procedures, it is not a direct cause of Asherman's syndrome itself - The syndrome is caused by the **curettage performed** to manage the hemorrhage or retained products, not the hemorrhage directly - PPH is an indication for intervention, but the procedural trauma causes the adhesions *Prolonged usage of oral contraceptives* - Oral contraceptives work by suppressing ovulation and altering the endometrial lining - They cause endometrial thinning but do not cause physical trauma to the endometrium - They do not lead to the formation of intrauterine adhesions characteristic of Asherman's syndrome *Use of intrauterine contraceptive device* - An **intrauterine contraceptive device (IUD)** prevents pregnancy by causing a sterile inflammatory reaction - While IUDs can cause endometritis or perforation in rare cases, they do not typically lead to the severe endometrial trauma and subsequent adhesion formation seen in Asherman's syndrome - Asherman's syndrome requires basal endometrial damage, which IUDs do not typically cause

Q: A 25-year-old woman with a history of three consecutive abortions has been investigated thoroughly to determine the cause of recurrent pregnancy loss. In the absence of a demonstrable cause, what is the chance of a viable birth in subsequent pregnancy?

60%. ***60%*** - In cases of **unexplained recurrent pregnancy loss** (3 consecutive miscarriages with no identifiable cause), approximately **60-70%** of women will achieve a successful live birth in their subsequent pregnancy with supportive care. - This favorable prognosis reflects that many recurrent losses are due to **sporadic chromosomal abnormalities** rather than persistent underlying pathology. - **Unexplained RPL** actually has a better prognosis than explained RPL, as there is no persistent pathological factor. - Supportive care including reassurance, regular monitoring, and psychological support improves outcomes. *40%* - This underestimates the success rate for unexplained recurrent pregnancy loss. - A **40%** success rate would suggest a poorer prognosis more typical of cases with **identified but untreated underlying causes** or more complex pathology. - Current evidence supports a higher success rate (60-70%) for unexplained cases. *20-30%* - This represents a significantly poor prognosis not typical for unexplained recurrent pregnancy loss. - Such low rates might be seen in cases with **severe untreated underlying conditions** such as antiphospholipid syndrome without treatment or structural uterine anomalies. - This does not reflect the natural history of unexplained RPL. *Less than 20%* - This represents an extremely poor prognosis inconsistent with unexplained recurrent pregnancy loss. - Such rates would only be expected in cases with **severe, uncorrectable pathology** or multiple comorbidities. - The question specifically states "absence of a demonstrable cause," making this option incorrect.

Q: Where are antisperm antibodies usually present?

Cervix. ***Cervix*** - Antisperm antibodies are commonly found in the **cervical mucus**, where they can immobilize or agglutinate sperm, preventing their passage into the uterus. - The cervix acts as a key immunological barrier, and its secretions can contain antibodies that interfere with **sperm motility and viability**. *Vagina* - While some antibodies may be present, the **acidic environment** of the vagina is generally hostile to sperm, and it is not the primary site for antisperm antibody action in infertility. - The vagina's role is more about initial sperm reception rather than a concentrated immunological barrier against sperm movement. *Fallopian tube* - The fallopian tubes are primarily involved in **sperm capacitation**, fertilization, and early embryo transport. - Although immune cells exist, it is not the most common location for significant levels of antisperm antibodies to cause issues with sperm transport into the uterus. *Uterus* - The uterus is mainly a site for sperm transport to the fallopian tubes and implantation of the embryo. - While immune responses can occur, the **cervix** is the more critical location for antisperm antibody presence causing clinical infertility by blocking sperm entry.

Q: In a 28 year old infertile woman with anovulation, the following parameters will indicate ovulation EXCEPT:

Insler score. ***Insler score*** - The **Insler score** assesses cervical mucus quality (amount, ferning, spinnbarkeit, cellularity) and is used to evaluate the **potential for sperm penetration**. - While it reflects **estrogen effects** on the cervix, it does not directly confirm *ovulation* itself but rather the *cervical environment* suitable for conception. *Serum estradiol levels* - **Estradiol levels** typically peak *before ovulation* (during the follicular phase) and then decline, followed by a secondary rise during the luteal phase due to the corpus luteum. - While reflecting **follicle development**, a singular estradiol level doesn't definitively confirm the *occurrence* of ovulation, but rather the hormonal changes leading up to it. *Vaginal smear* - A **vaginal smear** can show changes in **cytology** (e.g., increased superficial cells, decreased parabasal cells) under dominant *estrogen influence* in the pre-ovulatory phase. - Post-ovulation, progesterone causes changes like an increase in basal cells and clumping; however, like estradiol, it indicates hormonal milieu rather than direct evidence of *ovulation*. *Urinary LH levels* - A surge in **luteinizing hormone (LH)** is the direct trigger for **ovulation**, typically occurring 24-36 hours *before* the actual release of the egg. - Detecting the **LH surge** in urine is a widely used and reliable method to predict the imminent occurrence of ovulation.

Question 1

A 27-year-old female married for 3 years regularly cohabiting with husband presents to Gynaecology OPD with complaints of inability to conceive for 2 years. During clinical evaluation hysterosalpingography was done which revealed irregular outline of uterine cavity and rigid fallopian tubes with nodulations. Most likely cause for this condition is :

Accepted Answer

Genital Tuberculosis

Answer

Syphilis

Answer

Genital Herpes

Answer

Gonorrhoea

Question 2

Which of the following days of menstrual cycle is best for endometrial sampling to diagnose ovulation?

Accepted Answer

21st - 23rd day

Answer

12th - 14th day

Answer

8th - 10th day

Answer

16th - 20th day

Question 3

Which of the following are factors for poor outcome following tuboplasty?

1. Dense pelvic adhesions
2. Length of reconstructed tube less than 4 cm
3. Bilateral hydrosalpinx
4. Reversal after 5 years of sterilization procedure

Select the correct answer using the code given below.

Accepted Answer

1, 2 and 3

Answer

1, 2 and 4

Answer

2, 3 and 4

Answer

1, 3 and 4

Question 4

What is the most common first-line investigation used to assess the patency of fallopian tubes?

Accepted Answer

Hysterosalpingogram

Answer

Sonohysterogram

Answer

Laparoscopic chromopertubation

Answer

CT scan

Question 5

Which of the following is the marker of ovarian reserve?

Accepted Answer

Anti-Mullerian hormone

Answer

β-hCG

Answer

Placental alkaline phosphatase

Answer

Serum estradiol

Question 6

A 28-year old woman comes with infertility. Husband's semen analysis is normal. Endometrial biopsy shows secretory changes with no evidence of tuberculosis. On hysterosalpingography both tubes show tubal blockage. What should be the next step in management?

Accepted Answer

Diagnostic laparoscopy and chromo-pertubation

Answer

IVF

Answer

Tuboplasty

Answer

ICSI

Question 7

Asherman's syndrome typically results from

Accepted Answer

Excessive curettage during abortion

Answer

Post-partum haemorrhage

Answer

Prolonged usage of oral contraceptives

Answer

Use of intrauterine contraceptive device

Question 8

A 25-year-old woman with a history of three consecutive abortions has been investigated thoroughly to determine the cause of recurrent pregnancy loss. In the absence of a demonstrable cause, what is the chance of a viable birth in subsequent pregnancy?

Accepted Answer

60%

Answer

Less than 20%

Answer

40%

Answer

20-30%

Question 9

Where are antisperm antibodies usually present?

Accepted Answer

Cervix

Answer

Vagina

Answer

Fallopian tube

Answer

Uterus

Question 10

In a 28 year old infertile woman with anovulation, the following parameters will indicate ovulation EXCEPT:

Accepted Answer

Insler score

Answer

Serum estradiol levels

Answer

Vaginal smear

Answer

Urinary LH levels

Fertility and Infertility — MCQs

Fertility and Infertility — MCQs

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