Fertility and Infertility Practice Questions

Q: Which of the following is the least invasive assisted reproductive technique?

Intra-Uterine Insemination. ***Intra-Uterine Insemination (IUI)*** - **IUI** involves directly placing **sperm** into the **uterus**, bypassing the cervix after sperm washing, making it the least invasive method among the options. - It is often used for mild male factor infertility, unexplained infertility, or when a woman has cervical mucus issues. *GIFT (Gamete Intra-Fallopian Transfer)* - **GIFT** is more invasive as it requires a **laparoscopic procedure** to place both **sperm** and **eggs** directly into the fallopian tube. - While fertilization occurs *in vivo* (in the body), the surgical aspect makes it more invasive than IUI. *ZIFT (Zygote Intra-Fallopian Transfer)* - **ZIFT** involves **IVF** to fertilize eggs in the lab, but then requires a **laparoscopic procedure** to place the resulting **zygotes** (early embryos) into the fallopian tube. - The combination of *in vitro* fertilization and surgical placement makes it more invasive than IUI. *IVF (In Vitro Fertilization)* - **IVF** involves **oocyte retrieval** (a transvaginal ultrasound-guided procedure) and **fertilization in vitro** (in the lab), followed by **embryo transfer** into the uterus. - While embryo transfer is less invasive than laparoscopic procedures, the initial oocyte retrieval makes IVF generally more invasive than IUI.

Q: Which of the following is the primary factor considered in the initial assessment of embryo viability in IVF before genetic testing?

Embryo quality. ***Embryo quality*** - **Embryo quality** is a comprehensive assessment based on developmental stage, cell number, fragmentation, and symmetry, all of which are critical indicators of viability prior to more sophisticated testing. - It encompasses multiple morphological and developmental parameters that provide the initial basis for selecting embryos for transfer. *Embryo age* - **Embryo age**, or developmental stage (e.g., day 3 cleavage stage or day 5/6 blastocyst), is a component of embryo quality but not the sole primary factor. - While blastocysts generally have a higher implantation potential, the quality within each age group is still paramount. *Genetic testing results* - **Genetic testing results** (e.g., PGT-A for aneuploidy) are a secondary assessment performed *after* initial embryo quality has been established and an embryo has been biopsied. - This testing provides chromosomal information but does not replace the initial morphological evaluation of embryo health and developmental potential. *Embryo morphology* - **Embryo morphology** is a crucial part of assessing embryo quality, but "embryo quality" is a broader term that also includes aspects like developmental rate and cellular dynamics, not just static appearance. - Morphology refers to the visual characteristics like cell number, degree of fragmentation, and symmetry of blastomeres or blastocyst expansion, which are all *components* of overall embryo quality.

Q: When is Hysterosalpingography (HSG) ideally performed?

Just after menstruation. ***Just after menstruation*** - HSG is ideally performed in the **early proliferative (follicular) phase**, typically **2-5 days after menstruation ends** or on **cycle days 7-10**. - At this time, the **endometrium is thin**, providing optimal visualization of the uterine cavity and tubal anatomy with minimal discomfort. - This timing avoids disrupting a **potential pregnancy**, as ovulation has not yet occurred and the likelihood of conception is minimal. - Performing the procedure after menstrual flow has ceased also reduces the risk of **infection** and ensures better image quality. *Between menstruation and ovulation* - This timeframe is too broad and vague, spanning approximately **14 days** (the entire follicular phase). - While it technically includes the correct timing, it also encompasses periods when HSG should **not** be performed, such as just before ovulation when fertilization may be imminent. - This option lacks the specificity required for proper clinical timing. *Just before ovulation* - Performing HSG just before ovulation (around day 12-14) carries a significant risk of **disrupting a potential pregnancy** if fertilization has occurred or is about to occur. - The **endometrium** is thicker at this stage in preparation for implantation, which can obscure findings and increase patient discomfort. - This timing also increases the risk of **flushing a fertilized egg** out of the fallopian tube. *At any time* - Performing HSG at any time is not advisable due to multiple risks, including the possibility of performing the procedure on a **pregnant woman**, which can cause harm. - The **uterine lining thickness** varies throughout the cycle, significantly affecting imaging quality and procedural comfort. - Timing during or near menses would result in blood obscuring the contrast and poor visualization.

Q: Repeated curettage leads to infertility due to:

Asherman's syndrome. ***Asherman's syndrome*** - **Asherman's syndrome** is characterized by the formation of **intrauterine adhesions** or **fibrous bands** within the uterine cavity, often resulting from trauma to the endometrium. - **Repeated curettage**, especially following miscarriage or postpartum hemorrhage, is a major cause as it can damage the **basal layer of the endometrium**, preventing its regeneration and leading to scar tissue formation, which can cause infertility. *Uterine fibroids* - **Uterine fibroids** (leiomyomas) are **benign muscular tumors** of the uterus that can cause heavy menstrual bleeding and pelvic pain but do not typically develop due to curettage. - While large or submucosal fibroids can impact fertility, they are not directly caused by repeated curettage or associated with intrauterine adhesions. *Sheehan's syndrome* - **Sheehan's syndrome** is a condition of **hypopituitarism** caused by **ischemic necrosis of the pituitary gland** typically following severe postpartum hemorrhage and hypovolemic shock. - It is unrelated to repeated curettage and presents with hormonal deficiencies (e.g., amenorrhea, lactation failure) rather than uterine scarring. *Endometrial carcinoma* - **Endometrial carcinoma** is a **malignant proliferation of endometrial cells**, most commonly seen in postmenopausal women, and is not a consequence of repeated curettage. - It can cause abnormal uterine bleeding but does not directly lead to infertility through uterine adhesions or scarring from instrumentation.

Q: In which scenario should testing for microdeletion of the Y-chromosome be considered for a patient with a normal karyotype?

Sperm concentration of 2 million/ml. ***Sperm concentration of 2 million/ml*** - A sperm count of **2 million/ml** indicates severe oligozoospermia, which is a strong clinical indicator for considering Y-chromosome microdeletion testing. - Y-chromosome microdeletions, particularly in the **AZF (Azoospermia Factor) regions**, are a common genetic cause of male infertility, leading to very low or absent sperm counts. *Semen volume of 2 ml (normal range)* - A semen volume of 2 ml falls within the **normal reference range**, suggesting no issues related to seminal vesicle or prostate function. - This finding does not point towards a genetic cause of infertility like a Y-chromosome microdeletion. *Normal morphology sperms >4% (normal finding)* - A percentage of normal morphology sperms greater than 4% is considered **within the normal range** according to strict Kruger criteria. - This finding indicates good sperm quality in terms of shape and structure, and does not suggest a need for Y-chromosome microdeletion testing. *Presence of fructose in semen (normal finding)* - The presence of fructose in semen is a **normal finding**, indicating proper seminal vesicle function and patency of the ejaculatory ducts. - Its presence rules out conditions like ejaculatory duct obstruction or agenesis of the seminal vesicles, and therefore does not indicate a need for Y-chromosome microdeletion testing.

Q: Which of the following methods is considered the best for obtaining a specimen for semen analysis?

A specimen obtained by masturbation in a clinical setting. ***A specimen obtained by masturbation in a clinical setting*** - This method ensures **complete ejaculation** and minimizes the risk of **contamination** or **sperm loss**, providing the most accurate representation of semen quality. - Collection in a clinical setting allows for proper storage conditions and timely analysis, which are crucial for maintaining **sperm viability** and motility. *A specimen obtained by coitus interruptus into a wide vessel* - This method carries a high risk of **losing the initial portion** of the ejaculate, which is typically the **most sperm-rich part**, leading to inaccurate results. - There is also a greater chance of **contamination** from vaginal fluids or external sources, affecting the specimen's integrity. *A specimen obtained through sexual intercourse with ejaculation into a wide vessel* - This method is prone to **contamination** from vaginal secretions and bacteria, which can interfere with accurate semen analysis. - The process may also result in **loss of ejaculate**, particularly the initial portion, impacting the overall volume and sperm concentration measurements. *A specimen collected using a condom* - Most condoms contain **spermicides** that are toxic to sperm, which would severely compromise the viability and motility of the sperm, rendering the analysis invalid. - Even if non-spermicidal condoms are used, the lubricants and materials in the condom might still affect sperm quality and motility, making this an unreliable collection method.

Q: Which investigation would be more appropriate in a 32-year-old nulliparous patient who presents to the gynecology OPD due to inability to conceive, having undergone uterine dilatation and curettage for menorrhagia not controlled medically around 4 years ago, and who is otherwise healthy on general examination?

Hysterosalpingography. ***Hysterosalpingography*** - This procedure uses **X-rays** and **contrast dye** to visualize the inside of the uterus and fallopian tubes, which is crucial for assessing **tubal patency** and uterine cavity abnormalities. - Given the patient's history of **dilatation and curettage (D&C)**, there is a risk of **Asherman's syndrome** (intrauterine adhesions), which hysterosalpingography can effectively diagnose. *Laparoscopy* - While laparoscopy can provide a direct visual assessment of pelvic organs and tubal patency, it is a **more invasive** surgical procedure with associated risks. - It is typically reserved for cases where less invasive tests like hysterosalpingography are inconclusive or suggest abnormalities requiring surgical intervention. *CT scan of abdomen and pelvis* - A CT scan is primarily used for evaluating **soft tissue structures** and detecting tumors or masses, but it is not the most appropriate initial investigation for assessing uterine cavity or fallopian tube patency in fertility workup. - It involves significant radiation exposure and provides **limited detail** compared to hysterosalpingography for the specific concerns in this patient. *X-ray of pelvis* - A standard X-ray of the pelvis offers a general view of **bone structures** and gross abnormalities but provides no information about the patency of the fallopian tubes or the morphology of the uterine cavity. - It is completely unsuitable for evaluating the causes of infertility related to uterine or tubal factors.

Q: Which of the following is a cause of male infertility?

All of the options. ***All of the options*** - **Idiopathic**, **varicocele**, and **Yq11 microdeletion** are all recognized causes of male infertility, making this the most comprehensive and correct answer. - Male infertility can stem from a variety of factors, including genetic, structural, hormonal, and unexplained (idiopathic) causes. *Idiopathic* - Refers to cases where no specific cause for infertility can be identified despite thorough investigation, accounting for a significant proportion of male infertility. - This diagnosis is made by **exclusion** after ruling out other known causes. *Varicocele* - A common and treatable cause of male infertility, characterized by **dilated veins in the pampiniform plexus** of the scrotum. - Varicoceles can impair sperm production and function due to **increased scrotal temperature** and oxidative stress. *Yq11 microdeletion* - Refers to deletions in the **azoospermia factor (AZF) region** on the long arm of the Y chromosome, which are genetic causes of severe spermatogenic failure. - These deletions disrupt genes essential for sperm production, leading to conditions ranging from **oligozoospermia** (low sperm count) to **azoospermia** (absence of sperm).

Q: Cervical hostility is assessed by the following tests, except:

Hysterosalpingography (HSG). ***Hysterosalpingography (HSG)*** - **Hysterosalpingography (HSG)** is an imaging procedure used primarily to evaluate the patency of the fallopian tubes and the shape of the uterine cavity. - It does **not** assess cervical mucus quality, sperm-cervical mucus interaction, or any other component of cervical hostility. - HSG is used for tubal factor infertility assessment, not cervical factor assessment. *Spinbarkeit* - **Spinbarkeit** refers to the stretchability or elasticity of cervical mucus, which is a key physical property evaluated to assess cervical mucus quality. - This test assesses the ability of cervical mucus to stretch (normally 6-10 cm at ovulation), indicating adequate estrogen effect and favorable conditions for sperm penetration. - It is a direct measure of cervical mucus receptivity and is used to evaluate cervical factors in infertility. *Post coital test* - The **post coital test** (PCT), or Sims-Huhner test, directly evaluates the interaction between sperm and cervical mucus after intercourse. - It assesses sperm survival and motility within the cervical canal, making it a direct measure of cervical hostility. - The test examines whether cervical mucus is hospitable or hostile to sperm migration. *Miller-Kurzrok test* - The **Miller-Kurzrok test** is an in vitro test that assesses sperm-cervical mucus interaction by observing sperm penetration into a sample of cervical mucus on a slide. - This test is specifically designed to identify potential cervical factors affecting sperm motility and penetration. - It directly evaluates cervical hostility by testing the compatibility between sperm and cervical mucus.

Q: Which of the following is the most reliable test for ovulation?

Serum Progesterone level. ***Serum Progesterone level*** - A **serum progesterone level** measured approximately 7 days after the presumed ovulation (mid-luteal phase) is the most reliable biochemical indicator of ovulation. A level of **≥3 ng/mL** confirms ovulation. - The rise in progesterone is due to its production by the **corpus luteum** formed after the rupture of the mature follicle during ovulation. *Basal body temperature* - **Basal body temperature (BBT)** charting shows a slight increase (0.5-1.0°C) after ovulation due to the thermogenic effect of progesterone. However, this rise is **retrospective** and only indicates that ovulation has already occurred. - BBT can be influenced by various factors, such as illness, stress, and sleep patterns, making it **less precise** than direct hormonal measurement. *Vaginal cytology* - **Vaginal cytology** can show changes in epithelial cell morphology (e.g., increased cornified cells) during the periovulatory period due to estrogen influence. - These changes are **indicative of estrogen activity** and cervical mucus quality, but they do not directly confirm the rupture of the follicle or the release of an egg. *Endometrial biopsy* - An **endometrial biopsy** can reveal secretory changes in the endometrium characteristic of the luteal phase, which are a result of progesterone production after ovulation. - However, this is an **invasive procedure** and not a practical or primary test used solely for confirming ovulation.

Question 1

Which of the following is the least invasive assisted reproductive technique?

Accepted Answer

Intra-Uterine Insemination

Answer

GIFT

Answer

ZIFT

Answer

IVF

Question 2

Which of the following is the primary factor considered in the initial assessment of embryo viability in IVF before genetic testing?

Accepted Answer

Embryo quality

Answer

Genetic testing results

Answer

Embryo age

Answer

Embryo morphology

Question 3

When is Hysterosalpingography (HSG) ideally performed?

Accepted Answer

Just after menstruation

Answer

Between menstruation and ovulation

Answer

Just before ovulation

Answer

At any time

Question 4

Repeated curettage leads to infertility due to:

Accepted Answer

Asherman's syndrome

Answer

Uterine fibroids

Answer

Sheehan's syndrome

Answer

Endometrial carcinoma

Question 5

In which scenario should testing for microdeletion of the Y-chromosome be considered for a patient with a normal karyotype?

Accepted Answer

Sperm concentration of 2 million/ml

Answer

Semen volume of 2 ml (normal range)

Answer

Normal morphology sperms >4% (normal finding)

Answer

Presence of fructose in semen (normal finding)

Question 6

Which of the following methods is considered the best for obtaining a specimen for semen analysis?

Accepted Answer

A specimen obtained by masturbation in a clinical setting

Answer

A specimen obtained by coitus interruptus into a wide vessel

Answer

A specimen obtained through sexual intercourse with ejaculation into a wide vessel

Answer

A specimen collected using a condom

Question 7

Which investigation would be more appropriate in a 32-year-old nulliparous patient who presents to the gynecology OPD due to inability to conceive, having undergone uterine dilatation and curettage for menorrhagia not controlled medically around 4 years ago, and who is otherwise healthy on general examination?

Accepted Answer

Hysterosalpingography

Answer

Laparoscopy

Answer

CT scan of abdomen and pelvis

Answer

X-ray of pelvis

Question 8

Which of the following is a cause of male infertility?

Accepted Answer

All of the options

Answer

Idiopathic

Answer

Yq11 microdeletion

Answer

Varicocele

Question 9

Cervical hostility is assessed by the following tests, except:

Accepted Answer

Hysterosalpingography (HSG)

Answer

Post coital test

Answer

Spinbarkeit

Answer

Miller-Kurzkrok test

Question 10

Which of the following is the most reliable test for ovulation?

Accepted Answer

Serum Progesterone level

Answer

Basal body temperature

Answer

Vaginal cytology

Answer

Endometrial biopsy

Fertility and Infertility — MCQs

Fertility and Infertility — MCQs

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