Fertility and Infertility Practice Questions

Q: Best time to schedule hysterosalpingogram (HSG) in a regular 28-day cycle?

Day 7-10. **Day 7-10** - Scheduling an **HSG** between day 7 and 10 of a 28-day cycle ensures the procedure is performed after menstrual bleeding has stopped and before **ovulation**. - This timing minimizes the risk of interfering with a potential **pregnancy** and provides clear imaging as the uterine lining is thin. *Day 2-5* - Performing an HSG during **heavy menstrual bleeding** can lead to inaccurate results due to blood obscuring the view or increasing the risk of infection. - The uterine lining is still shedding, which might affect the interpretation of the **uterine cavity**. *Day 14-16* - This period is around the time of **ovulation**, increasing the risk of performing the procedure during a very early, unrecognized pregnancy. - Introducing contrast agents during early pregnancy could potentially harm the **fetus**. *Day 20-22* - At this stage, the **endometrium** is thick, which can make it difficult to visualize the uterine cavity accurately. - If **fertilization and implantation** have occurred, performing an HSG could dislodge the embryo or expose it to radiation.

Q: What is the primary goal of management in a woman with recurrent miscarriages?

Diagnose underlying causes. ***Diagnose underlying causes*** - The most crucial step in managing recurrent miscarriages is to identify any **reversible or treatable causes** to prevent future losses. - This involves a thorough investigation including **genetic testing**, hormonal assays, uterine imaging, and screening for **thrombophilias**. *Prevent future pregnancies* - This is not a primary goal; the aim is to **achieve a successful pregnancy**, not avoid them. - Preventing future pregnancies would negate the desire of a woman experiencing recurrent miscarriages, which is typically to have a healthy baby. *Immediate surgical intervention* - **Surgical intervention** is only indicated for specific uterine anomalies (e.g., septate uterus) or cervical incompetence, and rarely as an immediate first step in all cases. - Most causes of recurrent miscarriage are **not amenable to immediate surgery**. *Routine use of anticoagulants* - **Anticoagulants** are used specifically when an underlying **thrombophilia** (e.g., Antiphospholipid Syndrome) is diagnosed. - They are not a routine first-line treatment without a definitive diagnosis.

Q: A 34-year-old woman presents with a history of recurrent spontaneous abortions. Which of the following is the most appropriate initial investigation?

Antiphospholipid antibodies. ***Antiphospholipid antibodies*** - **Antiphospholipid syndrome (APS)** is one of the most common **treatable** causes of **recurrent spontaneous abortions**, accounting for 10-15% of cases. - APS causes recurrent pregnancy loss through placental thrombosis and inflammation. - Testing includes **lupus anticoagulant**, **anticardiolipin antibodies**, and **anti-β2 glycoprotein I antibodies**. - Early identification allows for **effective treatment** with low-dose aspirin and/or heparin in subsequent pregnancies, significantly improving outcomes. *Thyroid function tests* - While **thyroid dysfunction** can contribute to miscarriage and is part of the comprehensive workup for recurrent pregnancy loss, it is less commonly the primary cause compared to APS. - Thyroid testing is important but typically yields positive findings in a smaller proportion of cases. *Karyotyping of both partners* - **Parental chromosomal abnormalities** (e.g., balanced translocations) are found in 2-5% of couples with recurrent miscarriages. - While this is part of the comprehensive initial workup for RPL, it is less commonly positive than APS testing. - When present, parental karyotype abnormalities typically cause first-trimester losses due to embryonic aneuploidy. - APS testing is often prioritized as the **most appropriate initial** investigation because it identifies a **highly treatable** condition. *Hysterosalpingography* - **Hysterosalpingography (HSG)** or other imaging (ultrasound, sonohysterography) assesses uterine structural abnormalities (e.g., septum, fibroids, adhesions). - Uterine anomalies account for 10-15% of recurrent losses but are typically evaluated as part of the comprehensive workup rather than as the single most important initial test.

Q: A 38-year-old woman with a history of polycystic ovary syndrome (PCOS) is unable to conceive after 18 months of trying. She has regular cycles and no other significant medical history. What is the most appropriate next step in her infertility workup?

Semen analysis for her partner. ***Semen analysis for her partner*** - This is a crucial initial step because **male factor infertility** accounts for a significant proportion (approximately 30-50%) of infertility cases. - Given that the woman has **regular cycles** despite her PCOS history, implying ovulation, a complete infertility workup must include evaluation of the male partner. *Laparoscopy to check for endometriosis* - This would be considered if there were symptoms suggestive of **endometriosis**, such as severe dysmenorrhea or chronic pelvic pain, which are not mentioned. - It is an **invasive procedure** and not a first-line diagnostic step in the absence of other indicators for endometriosis. *Clomiphene citrate therapy* - This medication is primarily used to induce **ovulation** in anovulatory women, which is not indicated here as the patient has **regular cycles**. - While PCOS is associated with anovulation, her regular cycles suggest she is likely ovulating, so this would not be the initial intervention. *In vitro fertilization (IVF)* - IVF is an advanced and **expensive reproductive technology** typically reserved for cases where simpler treatments have failed or severe infertility factors are identified (e.g., severe male factor, tubal blockage). - It is **premature** to consider IVF before completing a basic infertility workup that includes evaluating all potential factors.

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: A lady on treatment for infertility developed ascites, abdominal pain, and dyspnea. An ultrasound (USG) of the patient was done. What will be the diagnosis?

Ovarian Hyperstimulation Syndrome (OHSS). ***Ovarian Hyperstimulation Syndrome (OHSS)*** - The clinical presentation of infertility treatment followed by **ascites, abdominal pain, and dyspnea** is highly suggestive of OHSS. The ultrasound image shows **enlarged ovaries with multiple follicular cysts**, which is characteristic of severe OHSS. - OHSS is a potentially serious complication of **ovarian stimulation** during infertility treatment, where excessive ovarian response leads to systemic changes from increased vascular permeability. *Theca lutein cysts* - These cysts typically develop due to **excessive stimulation by hCG**, often seen with gestational trophoblastic disease or multiple pregnancies. - While they can be large and multiple, they are not typically associated with the rapid onset of severe systemic symptoms like **ascites and dyspnea** in the context of infertility treatment directly. *Mucinous cystadenoma* - This is a type of **benign ovarian tumor** that can grow very large and cause abdominal distension, but it is not typically associated with infertility treatment or the acute systemic symptoms of ascites and dyspnea as seen here. - Imaging would typically show a **multilocular cyst with internal septations**, not the numerous small follicular cysts seen in the image. *Polycystic Ovary Syndrome (PCOS)* - PCOS is a common cause of infertility, characterized by **anovulation, hyperandrogenism, and polycystic ovaries** on ultrasound (multiple small follicles in a string-of-pearls pattern). - While the ultrasound shares some similarities with multiple follicles, PCOS does not cause the acute symptoms of **ascites, abdominal pain, and dyspnea** that are directly linked to the rapid onset of severe OHSS.

Question 1

Best time to schedule hysterosalpingogram (HSG) in a regular 28-day cycle?

Accepted Answer

Day 7-10

Answer

Day 2-5

Answer

Day 14-16

Answer

Day 20-22

Question 2

A 34-year-old with recurrent miscarriages and history of septate uterus presents for counseling. Which intervention is most suitable to prevent future pregnancy losses?

Accepted Answer

Strassman's metroplasty

Answer

Hysteroscopic resection

Answer

IVF with PGD

Answer

Cervical cerclage

Question 3

A 30-year-old woman presents with primary infertility for 2 years. Her menstrual cycles are irregular (35-45 days). Investigations reveal FSH 15 IU/L, AMH 0.5 ng/mL. Semen analysis is normal and HSG shows patent tubes. What is the most appropriate first-line treatment?

Accepted Answer

Letrozole

Answer

IVF with donor eggs

Answer

Clomiphene citrate

Answer

Gonadotropins

Question 4

What is the primary goal of management in a woman with recurrent miscarriages?

Accepted Answer

Diagnose underlying causes

Answer

Immediate surgical intervention

Answer

Prevent future pregnancies

Answer

Routine use of anticoagulants

Question 5

A 34-year-old woman presents with a history of recurrent spontaneous abortions. Which of the following is the most appropriate initial investigation?

Accepted Answer

Antiphospholipid antibodies

Answer

Thyroid function tests

Answer

Karyotyping of both partners

Answer

Hysterosalpingography

Question 6

A 38-year-old woman with a history of polycystic ovary syndrome (PCOS) is unable to conceive after 18 months of trying. She has regular cycles and no other significant medical history. What is the most appropriate next step in her infertility workup?

Accepted Answer

Semen analysis for her partner

Answer

Laparoscopy to check for endometriosis

Answer

Clomiphene citrate therapy

Answer

In vitro fertilization (IVF)

Question 7

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 8

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 9

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 10

A lady on treatment for infertility developed ascites, abdominal pain, and dyspnea. An ultrasound (USG) of the patient was done. What will be the diagnosis?

Accepted Answer

Ovarian Hyperstimulation Syndrome (OHSS)

Answer

Theca lutein cysts

Answer

Mucinous cystadenoma

Answer

Polycystic Ovary Syndrome (PCOS)

Fertility and Infertility — MCQs

Fertility and Infertility — MCQs

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