Fertility and Infertility Practice Questions

Q: Cervical mucus examination of a 22 year old infertile woman is done to look for all the following except:

Presence of HPV. ***Presence of HPV*** - Cervical mucus examination is primarily used to assess the **physical properties** of mucus related to fertility, such as **consistency**, **elasticity**, and **crystallization**. - Detecting the **human papillomavirus (HPV)** typically involves specific viral DNA tests (e.g., PCR) or cytology (Pap smear) for cellular changes, not a routine mucus examination. *Spinnbarkeit* - This refers to the **elasticity** or **stretchability** of cervical mucus, which increases around **ovulation** due to rising estrogen levels, facilitating sperm transport. - Assessing spinnbarkeit is a standard part of evaluating cervical mucus quality in infertility workups. *Cellularity of mucus* - The cellularity of cervical mucus, particularly the presence of a high number of **leukocytes** (white blood cells), can indicate **inflammation** or **infection**, which might impair sperm viability and function. - This assessment helps in identifying potential reproductive tract infections affecting fertility. *Ferning* - This phenomenon describes the characteristic **fern-like crystallization pattern** of dried cervical mucus, which is prominent at **mid-cycle** due to high estrogen levels and low progesterone. - The presence or absence of ferning helps in identifying the **ovulatory phase** and assessing hormonal influence on cervical mucus.

Q: A woman undergoing treatment of infertility presents with triplet pregnancy. The most probable drug given to her for treatment of infertility would have been:

Inj HMG. ***Inj HMG*** - **Human menopausal gonadotropin (HMG)**, which contains both **FSH and LH**, stimulates the development of multiple ovarian follicles. - This increased follicular development, when followed by ovulation, significantly raises the risk of **multiple pregnancies**, including triplets, in women undergoing infertility treatment. *Inj GnRH analogue* - **GnRH analogues** are primarily used to suppress natural gonadotropin release and prevent premature ovulation, often as part of controlled ovarian hyperstimulation. - While used in infertility treatments, their direct action is not typically to induce **multiple ovulation** leading to triplets; rather, they regulate the cycle before other stimulating agents are given. *Clomiphene Citrate* - **Clomiphene citrate** is an oral anti-estrogen that works by increasing natural FSH and LH production, leading to the development of one or a few follicles. - Although it can cause **twin pregnancies** in about 5-10% of cases, the incidence of triplets or higher-order multiples is much lower (less than 1%), making it less likely to be the cause of triplets than HMG. *Inj hCG* - **Human chorionic gonadotropin (hCG)** is given to trigger **final oocyte maturation and ovulation** once follicles have reached an appropriate size after stimulation with other agents. - While essential for ovulation, hCG itself does not stimulate follicular development and therefore isn't the primary drug responsible for the **multiple follicle growth** that leads to triplet pregnancy.

Q: Which one of the following is NOT a cause of recurrent spontaneous abortion?

Rubella infection. ***Rubella infection*** - While rubella infection during pregnancy can lead to serious **congenital anomalies** (congenital rubella syndrome) and fetal death, it is **NOT a typical cause of recurrent spontaneous abortions** - Rubella primarily causes **single pregnancy loss** or teratogenic effects in ongoing pregnancies, rather than the pattern of repeated losses seen in recurrent abortion - The infection does not create the persistent maternal factors (immunological, thrombophilic, or anatomical) that characterize causes of recurrent pregnancy loss *Antiphospholipid syndrome* - This autoimmune disorder is a **well-established cause of recurrent pregnancy loss** (accounts for 10-15% of cases) - Antiphospholipid antibodies cause **thrombosis in placental vasculature**, leading to placental insufficiency and infarction - Results in repeated pregnancy losses, typically in the second trimester *Inherited thrombophilia* - Conditions like **Factor V Leiden mutation** and **prothrombin gene mutation** increase thrombotic risk - Cause **placental microthrombi** that compromise fetal blood supply - Recognized as a cause of recurrent spontaneous abortion, though the association is stronger for late pregnancy loss *Chromosomal abnormality* - **Parental balanced translocations** are an important cause of recurrent spontaneous abortion (3-5% of couples) - While random fetal aneuploidy is the most common cause of sporadic abortion, parental chromosomal rearrangements lead to **recurrent unbalanced offspring** and repeated losses - Karyotyping of both partners is recommended after recurrent pregnancy loss

Q: Which one of the following is an abnormal parameter in accordance with WHO Semen Analysis Criteria (Normal reference value)?

Volume 14%* - WHO criteria state that **≥ 4% of sperms should have normal morphology** (strict criteria) - A morphology of >14% is **well within the normal range** (more than 3 times the threshold) - This represents a normal finding, not an abnormality *Progressive forward motility of sperms > 50%* - WHO guidelines indicate that **progressive motility (PR) should be ≥ 32%** - Progressive forward motility of >50% is **significantly above the threshold** - This indicates excellent sperm motility and is a normal finding *Sperm concentration < 10 million/ml* - Normal reference value for sperm concentration is **≥ 15 million/ml** - While <10 million/ml would be considered abnormal (**oligozoospermia**), the question asks for "an abnormal parameter" - **Volume < 1.0 ml is the best answer** as it represents a more significant deviation from normal values (1.0 vs 1.5 ml threshold) compared to other parameters

Q: Which one of the following causes the greatest risk of ectopic pregnancy?

Previous ectopic pregnancy. ***Previous ectopic pregnancy*** - A history of prior ectopic pregnancy significantly increases the risk of a **recurrent ectopic pregnancy** due to potential **tubal damage** from the previous event. - This is considered the **highest risk factor** among the choices provided because it indicates a pre-existing vulnerability in the reproductive system. *Intrauterine contraceptive devices use* - While IUDs do not cause ectopic pregnancies, they **prevent intrauterine pregnancies** more effectively than ectopic ones, leading to a higher proportion of pregnancies being ectopic if conception occurs. - The absolute risk of an ectopic pregnancy with an IUD in place is still **lower than in women not using contraception** but the ratio of ectopic to intrauterine pregnancies is higher. *Previous normal delivery* - A history of previous normal delivery is generally **protective against ectopic pregnancy**, as it suggests healthy tubal function and uterine environment. - This factor has **no association** with an increased risk of ectopic pregnancy. *Previous medical termination of pregnancy* - There is generally **no significant increased risk** of ectopic pregnancy associated with a single medical termination of pregnancy, especially when performed early in gestation. - Repeated or complicated terminations, especially surgical, *could* theoretically increase risk due to **tubal damage or inflammation**, but medical termination typically carries little to no added risk.

Q: Rokitansky-Küster-Hauser syndrome is associated with:

All of the options. ***All of the options*** Rokitansky-Küster-Hauser (MRKH) syndrome is associated with **all three features** listed, making this the correct answer. **Primary amenorrhea with Müllerian agenesis:** - This is the **hallmark feature** of MRKH syndrome - Müllerian agenesis leads to **absent or underdeveloped uterus and upper two-thirds of vagina** - Patients present with **primary amenorrhea** despite normal pubertal development - The external genitalia and lower vagina are normal **Normal hormone profile:** - MRKH syndrome patients have **functioning ovaries** with normal oogenesis - **Normal 46,XX karyotype** - **Normal FSH, LH, estrogen, and progesterone levels** - Normal development of **secondary sexual characteristics** (breast development, pubic hair, normal height) - This distinguishes MRKH from androgen insensitivity syndrome **Renal abnormalities:** - Present in **15-30% of MRKH type 1** cases - Present in **up to 50% of MRKH type 2** (MURCS association - Müllerian, Renal, Cervicothoracic Somite abnormalities) - Common anomalies include **renal agenesis** (unilateral or bilateral), **ectopic kidney**, **horseshoe kidney**, and **hydronephrosis** - Renal ultrasound is recommended as part of initial evaluation **Why "All of the options" is correct:** All three features—primary amenorrhea with Müllerian agenesis, normal hormone profile, and renal abnormalities—are characteristic associations of MRKH syndrome, making this the most complete and accurate answer.

Q: Antisperm antibodies are usually present in:

Cervix. ***Cervix*** - The **cervical mucus** is the most clinically significant site in the **female reproductive tract** where **antisperm antibodies** interfere with fertility. - These antibodies can **agglutinate sperm**, **immobilize sperm**, or reduce their ability to penetrate through cervical mucus and reach the ovum, contributing to **immunological infertility**. - In the context of local immune responses affecting fertilization, the **cervix** acts as a critical immunological barrier where ASAs are detected and clinically relevant. - Note: Antisperm antibodies can also be detected in **serum** (blood) and are commonly found in **seminal plasma** in males, but among reproductive tract sites in females, the **cervix** is the primary location of clinical significance. *Vagina* - The **acidic environment** (pH 3.8-4.5) of the vagina is generally hostile to sperm, but it is not a primary site for antisperm antibody formation or action. - While some immune cells exist, the vagina's protective function relies more on acidic pH and normal flora rather than specific antisperm antibodies. *Fallopian tube* - The fallopian tubes are primarily involved in **sperm transport**, **fertilization**, and **embryo transport**, but are not a primary site where antisperm antibodies cause clinical infertility problems. - Although sperm encounter the tubal environment, the **cervical mucus** at the cervix acts as a more significant and earlier immunological barrier. *Uterus* - The uterine cavity is generally more accommodating to sperm after they pass through the cervical barrier, and is not the primary site for antisperm antibody-mediated infertility. - The **cervix** serves as the critical immunological checkpoint before sperm reach the uterine environment.

Q: A 25 year old infertile woman is noted to have blocked fallopian tubes on Hysterosalpingography. Which of the following is the best next step for this woman?

Laparoscopy. ***Laparoscopy*** - A **blocked fallopian tube** identified on hysterosalpingography (HSG) requires direct visualization to confirm the diagnosis, assess the extent of the blockage, identify any associated pelvic pathology (adhesions, endometriosis), and potentially perform surgical correction (e.g., salpingostomy, fimbrioplasty, adhesiolysis). - Laparoscopy allows for **definitive diagnosis** of tubal pathology and can be therapeutic. It is particularly indicated when there is suspicion of correctable pathology or when the patient prefers attempting natural conception. - **Note**: In modern practice, IVF is increasingly considered as first-line for bilateral tubal disease, but laparoscopy remains important for diagnostic purposes and when surgical correction is feasible. *Clomiphene citrate therapy* - This therapy is primarily used to induce **ovulation** in anovulatory infertility, which is not the primary issue when blocked fallopian tubes are identified. - It would be ineffective in overcoming a physical **tubal obstruction**, as sperm and egg cannot meet regardless of ovulation status. *Intrauterine insemination* - IUI involves placing sperm directly into the uterus, bypassing cervical factors, but it still requires at least one **patent fallopian tube** for fertilization to occur. - With blocked fallopian tubes, IUI would not address the problem of the egg and sperm being unable to meet, making it an inappropriate choice. *Gonadotropin therapy* - Gonadotropins (FSH and LH) are used to stimulate **follicle development** and ovulation, similar to clomiphene but often for more resistant cases or controlled ovarian hyperstimulation. - This therapy does not resolve **tubal blockages** and would not be effective in achieving pregnancy in the presence of blocked fallopian tubes without patent tubes for fertilization.

Q: A 29 year old woman is noted to have three consecutive first trimester spontaneous abortions. Examination reveals fibroid uterus. Which of the following types of uterine fibroids would most likely lead to recurrent abortions?

Submucosal. ***Submucosal*** - **Submucosal fibroids** are located directly beneath the **endometrium** and can protrude into the uterine cavity, disrupting the normal implantation site and early fetal development. - Their presence significantly increases the risk of **implantation failure** and **recurrent first-trimester spontaneous abortions** due to mechanical distortion and altered uterine blood flow. *Cervical* - **Cervical fibroids** are rare and located in the uterine cervix; while they can cause symptoms like bleeding or difficulty with delivery, they are less likely to directly impact **early implantation** or cause **recurrent first-trimester abortions**. - Their primary impact is often related to labor and delivery complications rather than early pregnancy loss. *Intramural* - **Intramural fibroids** are located within the muscular wall of the uterus and are the most common type. While large or numerous intramural fibroids can sometimes contribute to pregnancy complications, their direct impact on **recurrent first-trimester abortions** is generally less significant compared to submucosal fibroids. - Their effect on fertility often depends on their size, number, and proximity to the **endometrial cavity**. *Subserosal* - **Subserosal fibroids** are located on the outer surface of the uterus, beneath the serosa, and typically grow outwards. - They usually have **minimal to no impact** on implantation or early pregnancy development, thus they are unlikely to be a cause of **recurrent first-trimester abortions**.

Question 1

Cervical mucus examination of a 22 year old infertile woman is done to look for all the following except:

Accepted Answer

Presence of HPV

Answer

Spinnbarkeit

Answer

Cellularity of mucus

Answer

Ferning

Question 2

A woman undergoing treatment of infertility presents with triplet pregnancy. The most probable drug given to her for treatment of infertility would have been:

Accepted Answer

Inj HMG

Answer

Inj GnRH analogue

Answer

Clomiphene Citrate

Answer

Inj hCG

Question 3

Which one of the following is NOT a cause of recurrent spontaneous abortion?

Accepted Answer

Rubella infection

Answer

Antiphospholipid syndrome

Answer

Inherited thrombophilia

Answer

Chromosomal abnormality

Question 4

Which one of the following is an abnormal parameter in accordance with WHO Semen Analysis Criteria (Normal reference value)?

Accepted Answer

Volume < 1.0 ml

Answer

Normal morphology of sperms > 14%

Answer

Progressive forward motility of sperms > 50%

Answer

Sperm concentration < 10 million/ml

Question 5

Which of the following is correct regarding obesity and infertility?

Accepted Answer

It is associated with hypogonadotropic hypogonadism

Answer

It is always associated with endometrial atrophy

Answer

It is associated with hypergonadotropic hypogonadism

Answer

There is no change in HPO axis

Question 6

Which one of the following causes the greatest risk of ectopic pregnancy?

Accepted Answer

Previous ectopic pregnancy

Answer

Intrauterine contraceptive devices use

Answer

Previous normal delivery

Answer

Previous medical termination of pregnancy

Question 7

Rokitansky-Küster-Hauser syndrome is associated with:

Accepted Answer

All of the options

Answer

Normal hormone profile

Answer

Primary amenorrhoea with mullerian agenesis

Answer

Renal abnormalities

Question 8

Antisperm antibodies are usually present in:

Accepted Answer

Cervix

Answer

Vagina

Answer

Fallopian tube

Answer

Uterus

Question 9

A 25 year old infertile woman is noted to have blocked fallopian tubes on Hysterosalpingography. Which of the following is the best next step for this woman?

Accepted Answer

Laparoscopy

Answer

Clomiphene citrate therapy

Answer

Intrauterine insemination

Answer

Gonadotropin therapy

Question 10

A 29 year old woman is noted to have three consecutive first trimester spontaneous abortions. Examination reveals fibroid uterus. Which of the following types of uterine fibroids would most likely lead to recurrent abortions?

Accepted Answer

Submucosal

Answer

Cervical

Answer

Intramural

Answer

Subserosal

Fertility and Infertility — MCQs

Fertility and Infertility — MCQs

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