Fertility and Infertility Practice Questions

Q: Which among the following hormones can be used as an indicator for ovarian reserve in a patient who presents with infertility?

FSH. **FSH** - **FSH** (Follicle-Stimulating Hormone) measured on **day 2 or 3** of the menstrual cycle is a **reliable and well-established indicator of ovarian reserve**. Elevated FSH levels (>10-15 IU/L) suggest diminished ovarian reserve, meaning fewer or lower quality eggs remain. - As the number of ovarian follicles decreases, the **inhibin B** produced by these follicles also decreases, leading to a compensatory rise in FSH due to reduced negative feedback on the pituitary gland. - **Among the given options, FSH is the correct answer.** Note: In current practice, **Anti-Müllerian Hormone (AMH)** and **Antral Follicle Count (AFC)** are considered superior markers for ovarian reserve, but these are not among the options listed. *LH/FSH ratio* - The **LH/FSH ratio** is primarily used in the diagnosis of **Polycystic Ovary Syndrome (PCOS)**, where a ratio of >2 or >3:1 is often observed. - While reflecting a hormonal imbalance, it is not a direct or primary indicator of the quantity or quality of a woman's **ovarian reserve**. *LH* - **LH** (Luteinizing Hormone) is essential for triggering ovulation but does not directly assess the **ovarian reserve**. - Its levels fluctuate significantly throughout the menstrual cycle, particularly peaking during the ovulatory phase (LH surge), making it unreliable as a standalone marker for the follicle pool size. *Estrogen* - **Estrogen** levels, specifically **estradiol (E2)**, are produced by developing follicles and vary considerably throughout the menstrual cycle. - While day 3 estradiol can provide some insight into ovarian function (elevated E2 may suppress FSH, masking diminished reserve), it is not a primary marker for overall **ovarian reserve** assessment and can be influenced by multiple factors.

Q: What does a decreasing level of anti-müllerian hormone (AMH) indicate?

Decreased ovarian reserve. ***Decreased ovarian reserve*** - **Anti-Müllerian hormone (AMH)** is produced by **granulosa cells** of early-stage ovarian follicles and reflects the size of the **primordial follicle pool**. - A **decreasing AMH level** indicates a reduction in the number of remaining ovarian follicles, signifying **diminished ovarian reserve** and a lower reproductive potential. *No significant change in ovarian reserve* - This is incorrect because AMH levels are directly correlated with the size of the **ovarian follicular pool**. - A decrease in AMH specifically suggests a **decline in the number of viable follicles**. *Ovarian hyperstimulation syndrome* - **Ovarian hyperstimulation syndrome (OHSS)** is a complication of **fertility treatments** that cause an exaggerated response of the ovaries, leading to enlargement and fluid retention. - While AMH levels can be high in individuals prone to OHSS, a **decreasing AMH level** does not indicate OHSS; rather, it suggests reduced ovarian function. *Polycystic ovary syndrome (PCOS)* - Women with **PCOS** typically have **elevated AMH levels** due to an increased number of small antral follicles and arrested follicular development. - Therefore, a **decreasing AMH level** would generally argue against PCOS or indicate successful management that has reduced the follicle count.

Q: A 26-year-old patient has had three consecutive spontaneous abortions early in the second trimester. As part of an evaluation for this problem, the least useful test would be:

Postcoital test. ***Postcoital test*** - The **postcoital test** evaluates sperm-mucus interaction and is primarily used in cases of **infertility** (difficulty conceiving), not recurrent pregnancy loss after conception. - While it assesses factors like **cervical mucus quality** and sperm viability within the cervical canal, these issues are less likely to be the primary cause of recurrent second-trimester miscarriages. *Hysterosalpingogram* - A **hysterosalpingogram (HSG)** is crucial for evaluating uterine anomalies (e.g., **septate uterus**, **bicornuate uterus**) or **intrauterine adhesions** (Asherman's syndrome) that can lead to recurrent second-trimester losses. - It also assesses **fallopian tube patency**, although tube issues are more commonly associated with infertility than recurrent miscarriage once pregnancy is established. *Chromosomal analysis of the couple* - **Parental chromosomal abnormalities**, such as **balanced translocations**, are a significant cause of recurrent spontaneous abortions, including those in the second trimester, due to genetically unbalanced gametes. - Karyotyping the couple helps identify if one or both partners carry such a structural anomaly, which would increase the risk of an aneuploid fetus. *Endometrial biopsy in the luteal phase* - An **endometrial biopsy** in the luteal phase can assess for **luteal phase defect (LPD)**, a condition where inadequate progesterone production or endometrial response may prevent proper implantation or maintenance of early pregnancy. - While its role in recurrent miscarriage is debated, some consider it relevant, particularly if the abortions occur in the early second trimester or if there is a concern for proper **endometrial receptivity**.

Q: In cases of recurrent abortions, the most common uterine malformation seen is?

Mullerian fusion defects. ***Mullerian fusion defects*** - **Mullerian fusion defects**, particularly **septate uterus**, are the most common uterine malformations associated with recurrent abortions. This is because the septum has poor vascularity, which impairs implantation and early fetal development. - The presence of a **fibrous or muscular septum** within the uterine cavity can compromise the uterine environment, leading to early pregnancy loss. *Unicornuate uterus* - A **unicornuate uterus** results from the complete or partial failure of development of one Mullerian duct. - While it can be associated with adverse pregnancy outcomes, it is **less common** than septate uterus in cases of recurrent abortion. *Asherman syndrome* - **Asherman syndrome** involves the formation of intrauterine adhesions (scar tissue) typically due to trauma to the endometrial lining, such as from D&C procedures or infections. - While it causes recurrent pregnancy loss due to compromised endometrial receptivity and uterine cavity distortion, it is an **acquired condition**, not a congenital uterine malformation. *Non-specific uterine malformation* - This option is too **broad and vague** to be the most accurate answer. - While other uterine malformations can contribute to recurrent abortions, **Mullerian fusion defects** (specifically septate uterus) are the most frequently encountered in these cases.

Q: A 36-year-old female came for treatment of infertility. To test for her ovarian reserve, what is measured?

FSH. ***FSH*** - **Follicle-stimulating hormone (FSH)** levels, particularly on day 3 of the menstrual cycle, are a common and reliable indicator of **ovarian reserve**. - Elevated basal FSH levels suggest diminished ovarian reserve due to the **decreased negative feedback** from fewer ovarian follicles. *LH* - **Luteinizing hormone (LH)** is primarily involved in **ovulation** and corpus luteum formation, not directly in assessing ovarian reserve. - While LH levels can be measured, they do not provide as direct an assessment of the **number and quality of remaining follicles** as FSH. *LH/FSH ratio* - The **LH/FSH ratio** is often evaluated in the context of **polycystic ovary syndrome (PCOS)**, where it can be elevated. - It is not a primary marker used to assess **ovarian reserve** in infertile women without other symptoms of PCOS. *Estradiol* - **Estradiol** levels are measured as part of fertility assessments, often in conjunction with FSH. - However, isolated estradiol levels are not the most direct or reliable indicator of overall **ovarian reserve** on their own.

Q: Most important criterion in semen analysis is

Sperm motility. ***Sperm motility*** - **Sperm motility** (particularly progressive motility) is considered the most critical criterion in semen analysis as it directly reflects the functional ability of sperm to reach and fertilize an egg. - According to WHO guidelines, at least **32% progressive motility** is required for normal fertility. - A high concentration of non-motile or poorly motile sperm will not result in successful natural conception, regardless of other parameters. - **Progressive motility** is the best single predictor of natural fertility potential. *Sperm concentration* - **Sperm concentration** refers to the number of sperm per milliliter of semen (normal ≥15 million/mL). - While low concentration (oligozoospermia) affects fertility, adequate motility is essential for these sperm to reach the egg. - High concentration with poor motility has limited clinical value. *Semen volume* - **Semen volume** (normal ≥1.5 mL) is important for sperm delivery but does not directly assess sperm quality or function. - Abnormal volume can affect fertility, but motility remains the key functional parameter. *Total sperm count* - **Total sperm count** is calculated as volume × concentration (normal ≥39 million per ejaculate). - While important, total count without assessment of motility does not predict fertilization capacity.

Q: A 32-year-old woman with a history of polycystic ovary syndrome (PCOS) presents with irregular menses and difficulty conceiving for the past year. She has been on metformin and lifestyle modifications with no improvement, and ultrasound shows multiple small follicles in the ovaries. What is the most appropriate next step in her management?

Letrozole. ***Letrozole*** - **Letrozole** is an **aromatase inhibitor** that lowers estrogen levels, leading to increased FSH and improved ovulation rates, particularly in women with **PCOS** unresponsive to clomiphene citrate or as a first-line agent. - It has shown better live birth rates and lower multiple pregnancy rates compared to **clomiphene citrate** in women with **PCOS**. *Clomiphene citrate* - **Clomiphene citrate** is often a first-line treatment for **anovulatory infertility** in women with **PCOS**, but the patient has not responded to initial treatments and **Letrozole** has demonstrated superior outcomes in this population. - Its mechanism involves blocking estrogen receptors in the hypothalamus, leading to increased **FSH** and **LH** release, but it can have anti-estrogenic effects on the endometrium and cervical mucus. *Gonadotropins* - **Gonadotropins** (FSH, LH) are more potent ovulation-inducing agents typically reserved for women who fail to ovulate with oral agents like **clomiphene** or **letrozole**, or in conjunction with assisted reproductive technologies (ART). - Their use carries a higher risk of **ovarian hyperstimulation syndrome (OHSS)** and multiple pregnancies compared to oral agents. *Laparoscopic ovarian drilling* - **Laparoscopic ovarian drilling** is a surgical procedure considered for women with **PCOS** who do not respond to medical ovulation induction, or when other indications for laparoscopy exist. - It involves puncturing the ovarian surface with a laser or electrocautery to destroy androgen-producing tissue, aiming to restore ovulation, but it is more invasive than medical therapies.

Question 1

Which among the following hormones can be used as an indicator for ovarian reserve in a patient who presents with infertility?

Accepted Answer

FSH

Answer

LH/FSH ratio

Answer

LH

Answer

Estrogen

Question 2

What does a decreasing level of anti-müllerian hormone (AMH) indicate?

Accepted Answer

Decreased ovarian reserve

Answer

Ovarian hyperstimulation syndrome

Answer

Polycystic ovary syndrome (PCOS)

Answer

No significant change in ovarian reserve

Question 3

A 26-year-old patient has had three consecutive spontaneous abortions early in the second trimester. As part of an evaluation for this problem, the least useful test would be:

Accepted Answer

Postcoital test

Answer

Endometrial biopsy in the luteal phase

Answer

Hysterosalpingogram

Answer

Chromosomal analysis of the couple

Question 4

In cases of recurrent abortions, the most common uterine malformation seen is?

Accepted Answer

Mullerian fusion defects

Answer

Asherman syndrome

Answer

Unicornuate uterus

Answer

Non-specific uterine malformation

Question 5

A 36-year-old female came for treatment of infertility. To test for her ovarian reserve, what is measured?

Accepted Answer

FSH

Answer

LH

Answer

LH/FSH ratio

Answer

Estradiol

Question 6

Most important criterion in semen analysis is

Accepted Answer

Sperm motility

Answer

Sperm concentration

Answer

Semen volume

Answer

Total sperm count

Question 7

A 32-year-old woman with a history of polycystic ovary syndrome (PCOS) presents with irregular menses and difficulty conceiving for the past year. She has been on metformin and lifestyle modifications with no improvement, and ultrasound shows multiple small follicles in the ovaries. What is the most appropriate next step in her management?

Accepted Answer

Letrozole

Answer

Clomiphene citrate

Answer

Gonadotropins

Answer

Laparoscopic ovarian drilling

Fertility and Infertility — MCQs

Fertility and Infertility — MCQs

On this page

Practice by Chapter

Want unlimited practice?