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OG28.1-4,OG30.1-2 | Infertility and Endocrine Gynaecology — Practice Quiz
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A 28-year-old woman and her 31-year-old husband present with inability to conceive. They have been having regular unprotected intercourse for 14 months. Her menstrual cycles are regular (28 days). The MOST appropriate first investigation to request is:
Correct. Semen analysis is non-invasive, inexpensive, and provides immediate information about 40–50% of all infertility causes. It must always be the first investigation in any infertile couple, regardless of whether cycles are regular.
In any infertile couple, semen analysis is the first investigation — it is non-invasive, cheap, and tests the male factor that contributes to 40–50% of cases.
Semen analysis is the first step because male factor accounts for roughly 40–50% of cases and the test is non-invasive and low-cost. HSG and laparoscopy are invasive and should follow, not precede, exclusion of a male factor.
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Infertility is defined as failure to achieve a clinical pregnancy after regular unprotected intercourse. Which combination of duration and clinical threshold is CORRECT?
Correct. The standard threshold is 12 months, shortened to 6 months for women aged 35 or older, because declining ovarian reserve accelerates with age and earlier investigation is warranted.
Infertility threshold: 12 months (under 35 years) or 6 months (35 years and older) of regular unprotected intercourse without conception.
The WHO/NICE definition is 12 months for women under 35 and 6 months for women aged 35 and older. The shorter threshold reflects age-related ovarian decline, not a general 6-month rule for all.
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During hysterosalpingography (HSG) for infertility evaluation, the radiologist reports bilateral proximal tubal block with no spill of contrast. Which statement about this finding is MOST accurate?
Correct. Proximal block on HSG is frequently caused by tubal spasm triggered by contrast pressure or patient discomfort. This should be confirmed by sonosalpingography or laparoscopy and dye test before labelling it as true occlusion and recommending IVF.
Proximal tubal block on HSG may be spasm, not true occlusion. Always confirm by laparoscopy and dye test or sonosalpingography before labelling it as organic disease.
Proximal 'block' on HSG is a well-recognised false-positive finding due to tubal spasm, and is not a diagnosis by itself. Confirmation by another modality (e.g., laparoscopy and dye, sonosalpingography) is mandatory before advising surgery or ART.
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A 26-year-old woman with PCOS and anovulatory infertility starts clomiphene citrate. She has been on it for 3 cycles without ovulation. The MOST appropriate next step in her management is:
Correct. Letrozole (an aromatase inhibitor) is the preferred first-line ovulation induction agent in PCOS with clomiphene resistance. The PPCOS II trial (NEJM 2014) demonstrated superior ovulation and live birth rates with letrozole compared with clomiphene in PCOS.
Letrozole (aromatase inhibitor) has level-1 evidence superiority over clomiphene for PCOS-related anovulation (PPCOS II, NEJM 2014) and is the agent of choice in clomiphene-resistant PCOS.
Clomiphene doses above 150 mg/day are not recommended as efficacy does not increase beyond this threshold and side effects worsen. Letrozole is the evidence-based next step for clomiphene-resistant PCOS, not direct IVF. IVF is indicated after simpler methods fail.
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A woman on gonadotrophin stimulation for ovulation induction presents on day 9 with 5 follicles measuring 18–20 mm bilaterally. She feels abdominal bloating and mild nausea. Oestradiol is markedly elevated. The MOST important immediate step is:
Correct. Multiple large follicles with a markedly elevated oestradiol indicate a risk of severe OHSS. The hCG trigger drives corpus luteum formation and VEGF release — the proximate cause of OHSS. Withholding hCG and cancelling or coasting (waiting for oestradiol to fall before triggering) is the standard preventive strategy.
OHSS prevention: withhold hCG trigger when oestradiol is excessively elevated or multiple large follicles are present. Coasting (withholding gonadotrophins and deferring trigger until oestradiol falls) reduces OHSS risk.
Administering hCG trigger when there is hyperresponse precipitates severe OHSS. The key principle is that OHSS severity is driven by the hCG trigger (and subsequent luteal phase support), so withholding the trigger or substituting a GnRH agonist trigger is the primary prevention strategy.
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A couple is found to have severe male factor infertility with a sperm count of 2 million/mL, motility 10%, and morphology 2% normal forms. The most appropriate ART modality for this couple is:
Correct. ICSI is indicated for severe oligoasthenoteratozoospermia (OAT) because conventional IVF insemination requires a minimum sperm concentration and motility that is absent here. ICSI bypasses the requirement for natural sperm-oocyte interaction by direct injection.
ICSI is indicated when conventional IVF insemination cannot be used — principally severe OAT, previous fertilisation failure, or obstructive azoospermia (surgical sperm retrieval).
IUI requires a minimum total motile sperm count (typically >5 million post-wash) and is not suitable for severe OAT. Conventional IVF insemination also requires adequate motile sperm concentration. ICSI, which injects a single sperm directly into the oocyte, is the technique of choice for severe male factor.
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A 22-year-old woman presents with irregular periods (8–10 cycles/year) and moderate acne. Her BMI is 27. Transvaginal ultrasound shows 14 follicles in one ovary measuring 2–9 mm, arranged peripherally around an echogenic stroma. Serum TSH and prolactin are normal. Which ONE additional criterion is needed to satisfy the Rotterdam 2003 diagnosis of PCOS?
Correct. The Rotterdam 2003 criteria require 2 of 3 features: (1) oligo/anovulation, (2) clinical or biochemical hyperandrogenism, and (3) polycystic ovarian morphology (PCOM). She already satisfies oligo-ovulation (8–10 cycles/year) and PCOM (14 follicles, peripheral arrangement, echogenic stroma). The third Rotterdam feature — hyperandrogenism — would clinch the diagnosis with only 2 criteria needed. Acne is a clinical sign of hyperandrogenism and may itself be sufficient if documented as moderate or severe.
Rotterdam 2003 PCOS diagnosis: 2 of 3 criteria — oligo/anovulation, clinical or biochemical hyperandrogenism, PCOM on ultrasound — after excluding thyroid disease and hyperprolactinaemia.
Rotterdam 2003 requires 2 of 3 features: oligo/anovulation, hyperandrogenism, and PCOM. She already meets 2 criteria (oligo-ovulation + PCOM). To illustrate what ELSE could establish the diagnosis, hyperandrogenism (clinical = acne/hirsutism, or biochemical = elevated free testosterone) is the third criterion. LH:FSH ratio and HOMA-IR are NOT Rotterdam diagnostic criteria.
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A 25-year-old woman with newly diagnosed PCOS has BMI 32, oligomenorrhoea, and mild hirsutism. She is not seeking fertility currently. The MOST appropriate first-line long-term management is:
Correct. In overweight or obese women with PCOS, lifestyle modification (targeting 5–10% weight loss) is the cornerstone of first-line management. Weight reduction improves insulin resistance, reduces androgen levels, restores menstrual cyclicity, and reduces long-term metabolic risk — all without pharmacological side effects.
In overweight/obese women with PCOS, 5–10% weight loss through lifestyle modification is first-line: it reduces insulin resistance, lowers androgens, restores ovulation, and reduces cardiovascular/metabolic risk.
While COCP and metformin are second-line options for menstrual regulation and metabolic risk respectively, lifestyle modification addressing underlying insulin resistance is the evidence-based first step in overweight/obese PCOS. Spironolactone is used for hirsutism but does not address the underlying metabolic disorder and should come after lifestyle measures.
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A 30-year-old woman presents with rapidly progressive hirsutism over 6 months, clitoromegaly, and deepening of the voice. Serum testosterone is 280 ng/dL. The MOST important immediate next step is:
Correct. Testosterone above 200 ng/dL with rapid virilisation (clitoromegaly, voice change) is a red flag for an androgen-secreting tumour — either ovarian (Sertoli-Leydig, hilus cell) or adrenal. Imaging is the immediate priority before any medical treatment, since the cause must be excluded urgently.
Testosterone above 200 ng/dL, especially with rapid virilisation (clitoromegaly, voice change, temporal balding), mandates urgent imaging to exclude an androgen-secreting tumour before any medical treatment is started.
Testosterone above 200 ng/dL with rapid virilisation is a surgical emergency. PCOS very rarely elevates testosterone above 150 ng/dL. Late-onset CAH is associated with milder elevation. Imaging to localise an androgen-secreting tumour takes absolute priority over medical management in this scenario.
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A 28-year-old woman with hirsutism and irregular periods is found to have elevated serum 17-hydroxyprogesterone (17-OHP). This finding is MOST consistent with:
Correct. Elevated 17-OHP is the biochemical hallmark of 21-hydroxylase deficiency, the most common cause of CAH. Non-classical (late-onset) CAH mimics PCOS clinically but is distinguished by elevated basal or ACTH-stimulated 17-OHP. It is found in up to 8% of women presenting with a PCOS-like phenotype — explaining why 17-OHP must be checked in all suspected PCOS cases.
Elevated 17-hydroxyprogesterone (17-OHP) is the marker of 21-hydroxylase deficiency (non-classical CAH), which must be excluded in all women with a PCOS-like presentation before the diagnosis of PCOS is confirmed.
Elevated 17-OHP specifically indicates a block in the 21-hydroxylase enzyme step, accumulating this steroid precursor. PCOS does not characteristically elevate 17-OHP; adrenal Cushing's syndrome elevates cortisol and DHEAS; Sertoli-Leydig tumours elevate testosterone and androstenedione, not 17-OHP.
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