Fertility and Infertility Practice Questions

Q: Clomiphene citrate is primarily used for treating which condition in women?

Anovulation in women. ***Anovulation in women*** - **Clomiphene citrate** is a selective estrogen receptor modulator (SERM) that blocks estrogen receptors in the hypothalamus, leading to increased **GnRH** pulsatility and subsequently increased **FSH** and **LH** release. - This surge in **gonadotropins** stimulates follicular development and ovulation, making it a primary treatment for **anovulatory infertility**. *Menorrhagia during puberty* - **Menorrhagia** (heavy menstrual bleeding) during puberty is often related to an **immature hypothalamic-pituitary-ovarian axis**, leading to anovulatory cycles. - While clomiphene induces ovulation, it is not the primary treatment for managing **menorrhagia** in adolescents; hormonal therapies like oral contraceptives or progestins are typically used. *Hormonal therapy for menopause* - **Menopause** is characterized by ovarian failure and a significant decline in estrogen production. - **Clomiphene** is used to stimulate ovulation, not to replace hormones or manage menopausal symptoms, which are typically treated with **hormone replacement therapy (HRT)**. *Infertility due to endometriosis* - **Endometriosis** causes infertility through various mechanisms including anatomical distortion, inflammation, and altered peritoneal fluid, which clomiphene does not directly address. - Treatment for **endometriosis-related infertility** often involves surgical removal of endometrial implants, assisted reproductive technologies, or hormonal suppression therapy.

Q: Which of the following is NOT an indication for hysterosalpingography?

Detect endometriosis. ***Detect endometriosis*** - Hysterosalpingography (HSG) primarily visualizes the **uterine cavity** and **fallopian tubes**; it cannot directly detect endometrial implants outside the uterus. - **Laparoscopy** is the gold standard for diagnosing endometriosis, allowing direct visualization and biopsy of lesions. *Study uterine anomalies* - HSG is effective in outlining the shape and structure of the **uterine cavity**, making it useful for identifying congenital abnormalities like **septate** or **bicornuate uteri**. - It helps distinguish between different types of anomalies that can impact fertility or pregnancy outcomes. *Detect uterine synechiae* - **Intrauterine adhesions**, or synechiae (Asherman's syndrome), appear as filling defects or irregular contours within the endometrial cavity on an HSG. - The contrast medium outlines these adhesions, indicating areas where the uterine walls are abnormally fused. *Evaluate fallopian tube patency in infertility* - HSG is a standard diagnostic tool to assess whether the **fallopian tubes are open** (patent) or blocked, which is a common cause of infertility. - The spill of contrast medium into the peritoneal cavity indicates tubal patency, while absence of spill suggests **tubal obstruction**.

Q: Which of the following is not a risk factor for ectopic pregnancy?

Barrier methods of contraception (e.g., condoms). ***Barrier methods of contraception (e.g., condoms)*** - **Barrier methods** like condoms prevent fertilization entirely by blocking sperm-egg interaction - They do not alter tubal anatomy, tubal motility, or hormonal environment - Therefore, they are **NOT a risk factor** for ectopic pregnancy and represent the correct answer to this negation question *OCP (in cases of contraceptive failure)* - Oral contraceptive pills (OCPs) **dramatically reduce the overall risk of all pregnancies**, including ectopic pregnancies - If contraceptive failure occurs, OCPs do not increase ectopic risk—they do not cause tubal damage or dysfunction - The parenthetical qualifier "(in cases of contraceptive failure)" in the option is medically imprecise; **OCPs themselves are NOT a risk factor for ectopic pregnancy** - Note: Some epidemiological studies show a higher **proportion** of ectopic among the rare pregnancies that occur on OCPs, but this is a statistical artifact, not a causal relationship *PID* - **Pelvic inflammatory disease (PID)** is a **major established risk factor** for ectopic pregnancy - It causes inflammation, scarring, and adhesions of the **fallopian tubes** - This tubal damage impedes normal transport of the fertilized ovum to the uterus, leading to ectopic implantation - PID increases ectopic risk by 6-10 fold *Previous ectopic pregnancy* - A history of **previous ectopic pregnancy** is one of the **strongest risk factors** for recurrence - It indicates underlying tubal pathology (damage, dysfunction, or anatomical abnormality) - Recurrence risk is approximately **10-25%** in subsequent pregnancies - This reflects persistent tubal factors that predispose to abnormal implantation

Q: In which phase of the menstrual cycle should a tubal patency test be performed?

Preovulatory. ***Preovulatory*** - Performing a **tubal patency test** during the **preovulatory phase** (also known as the late follicular phase) minimizes the risk of interfering with a potential early pregnancy, as ovulation has not yet occurred. - The endometrium is thinner during this time, potentially allowing for better visualization and reducing the chance of discomfort. *Menstrual* - Performing the test during the **menstrual phase** is typically avoided due to the presence of blood and tissue, which can obscure visualization and increase the risk of infection. *Premenstrual* - The **premenstrual phase** occurs after ovulation and before menstruation, making it possible that a pregnancy could be inadvertently disrupted if conception has occurred. - The **endometrium is thick** during this phase, which could also interfere with visualization and test interpretation. *Luteal* - The **luteal phase** begins after ovulation, meaning there is a higher risk of disrupting an early, undetected **pregnancy** if the test is performed during this time. - Similar to the premenstrual phase, the **endometrium is secretory and thick**, which can complicate the procedure and interpretation.

Q: A 23-year-old woman accompanied by her mother-in-law comes to the infertility clinic. She has been having regular intercourse for 6 months but is not able to conceive. What is the next best step?

Reassure and review the couple after 6 months. ***Reassure and review the couple after 6 months*** - Infertility is defined as the inability to conceive after **12 months** of regular, unprotected intercourse in women under 35 years old. For women aged 35 or older, this period is 6 months. - Since the patient is 23 years old and has been trying for only 6 months, she does not yet meet the diagnostic criteria for infertility. The appropriate action is to advise them to continue trying and to return for evaluation if conception does not occur after a full year. *Semen analysis for husband* - While a semen analysis is a crucial initial step in an infertility workup, it is premature at this stage given the duration of attempted conception. - It would be appropriate to order this test after the couple has met the criteria for infertility (12 months for women under 35). *Hysterolaparoscopy* - This is an invasive procedure typically reserved for more advanced stages of an infertility workup, especially when suspected pathologies like endometriosis or tubal factor infertility are present. - It is not indicated as an initial step for a couple who has only been trying to conceive for 6 months and does not yet meet the definition of infertility. *Diagnostic hysteroscopy* - A diagnostic hysteroscopy is used to visualize the inside of the uterus to identify intrauterine pathologies that could contribute to infertility. - Like hysterolaparoscopy, it is an invasive diagnostic tool and should only be considered after initial, less invasive investigations have been performed and the couple meets the criteria for infertility.

Q: What will be the Hysterosalpingogram (HSG) finding?

Hydrosalpinx. ***Hydrosalpinx*** - The image, likely a hysterosalpingogram (HSG), shows a **dilated and fluid-filled fallopian tube** with no spillage of contrast into the peritoneal cavity, which is characteristic of hydrosalpinx. - The **contrast media fills the tubal lumen** but is unable to egress, indicating distal tubal obstruction and fluid accumulation. *Cornual block* - A cornual block would present as **obstruction at the uterine ostium** of the fallopian tube, preventing contrast from entering the tubal lumen. - In this image, contrast has clearly entered and dilated the fallopian tube, ruling out a cornual block. *Normal findings* - Normal HSG findings would show **patent fallopian tubes** with free spill of contrast into the peritoneal cavity. - The visible **dilation** and **lack of spill** in the image are distinctly abnormal. *Bicornuate uterus* - A bicornuate uterus is a **congenital uterine anomaly** characterized by two separate uterine horns. - While the uterus appears somewhat irregular, the dominant feature is the dilated fallopian tube, which is not a hallmark of a bicornuate uterus.

Q: A 20 year old woman is evaluated for primary infertility. Hysterosalpingography was done and reveals an anomaly. What is the anomaly seen in the image?

Septate uterus. ***Septate uterus*** - The image exhibits a **single uterine cavity** with a **septum** or indentation extending downwards, splitting the cavity into two distinct portions superiorly. - This configuration, particularly with an external contour that is typically **convex or flat**, is characteristic of a septate uterus, which is often associated with recurrent pregnancy loss and infertility. *Uterine didelphys* - This anomaly involves **two completely separate uteri**, each with its own cervix and often a separate vagina. - The image clearly shows a single main uterine body that then divides superiorly, not two entirely distinct uteri. *Bicornuate uterus* - A bicornuate uterus typically has two uterine horns that are **divergent externally**, creating a **deep indentation** on the external contour of the fundus. - While it also involves a divided uterine cavity, the external contour in the image appears more convex or flat, which is less consistent with a bicornuate uterus where the outer fundal contour is notably indented. *Unicornuate uterus* - This anomaly results from the **failure of one Müllerian duct to develop**, leading to a uterus that has only one horn and one fallopian tube. - The image presents a uterus with two distinct horns, ruling out a unicornuate uterus.

Q: In low ovarian reserve, anti-Müllerian hormone level will be:

<1 ng/ml. ***<1 ng/ml*** - **Low ovarian reserve** is characterized by a reduced quantity and quality of oocytes, which is reflected by **low anti-Müllerian hormone (AMH)** levels. - An AMH level of ** 7 ng/ml* - AMH levels **>7 ng/ml** are considered **high** and can be indicative of conditions such as **polycystic ovary syndrome (PCOS)**. - While high AMH suggests a large number of growing follicles, it is not associated with low ovarian reserve. *>10 ng/ml* - This level is also considered **very high**, even more suggestive of conditions like **PCOS** or a very robust ovarian reserve. - It is far from indicating a diminished or low ovarian reserve.

Q: The window of implantation occurs at which of the following time periods after fertilization?

6-10 days. ***6-10 days*** - The uterus is most receptive to implantation during the **"window of implantation,"** which occurs roughly **6 to 10 days post-fertilization**, coinciding with the mid-luteal phase. - During this period, the **endometrial lining** undergoes specific changes, guided by hormonal signals from **progesterone**, making it optimal for the blastocyst to attach. *12 days* - While implantation can still occur, the **peak receptivity window** is generally considered to be narrower, between 6 and 10 days. - By day 12, changes in the **endometrial environment** may start to reduce the likelihood of successful implantation. *12 weeks* - **12 weeks** refer to the end of the first trimester of pregnancy and is far too late for the initial implantation event. - Implantation must have occurred much earlier for a viable pregnancy at this stage. *6 weeks* - **6 weeks** refers to an established pregnancy, at which point implantation would have occurred several weeks prior. - The process of implantation is completed within the first two weeks post-fertilization.

Question 1

Clomiphene citrate is primarily used for treating which condition in women?

Accepted Answer

Anovulation in women

Answer

Menorrhagia during puberty

Answer

Hormonal therapy for menopause

Answer

Infertility due to endometriosis

Question 2

Which of the following is NOT an indication for hysterosalpingography?

Accepted Answer

Detect endometriosis

Answer

Evaluate fallopian tube patency in infertility

Answer

Study uterine anomalies

Answer

Detect uterine synechiae

Question 3

Which of the following is not a risk factor for ectopic pregnancy?

Accepted Answer

Barrier methods of contraception (e.g., condoms)

Answer

PID

Answer

Previous ectopic pregnancy

Answer

OCP (in cases of contraceptive failure)

Question 4

In which phase of the menstrual cycle should a tubal patency test be performed?

Accepted Answer

Preovulatory

Answer

Menstrual

Answer

Premenstrual

Answer

Luteal

Question 5

A 23-year-old woman accompanied by her mother-in-law comes to the infertility clinic. She has been having regular intercourse for 6 months but is not able to conceive. What is the next best step?

Accepted Answer

Reassure and review the couple after 6 months

Answer

Hysterolaparoscopy

Answer

Diagnostic hysteroscopy

Answer

Semen analysis for husband

Question 6

What will be the Hysterosalpingogram (HSG) finding?

Accepted Answer

Hydrosalpinx

Answer

Cornual block

Answer

Normal findings

Answer

Bicornuate uterus

Question 7

A 20 year old woman is evaluated for primary infertility. Hysterosalpingography was done and reveals an anomaly. What is the anomaly seen in the image?

Accepted Answer

Septate uterus

Answer

Uterine didelphys

Answer

Bicornuate uterus

Answer

Unicornuate uterus

Question 8

A lady on treatment for infertility developed ascites, abdominal pain, and dyspnea. The ultrasound image is shown below. What is the most likely diagnosis?

Accepted Answer

OHSS

Answer

PCOS

Answer

Theca lutein cyst

Answer

Mucinous cystadenomas

Question 9

In low ovarian reserve, anti-Müllerian hormone level will be:

Accepted Answer

<1 ng/ml

Answer

1-4 ng/ml

Answer

>7 ng/ml

Answer

>10 ng/ml

Question 10

The window of implantation occurs at which of the following time periods after fertilization?

Accepted Answer

6-10 days

Answer

12 days

Answer

12 weeks

Answer

6 weeks

Fertility and Infertility — MCQs

Fertility and Infertility — MCQs

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