Subfertility EMQ Test Part 2
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1) A 28-year-old woman with a BMI of 21 kg/m2 attends the fertility clinic with her partner. She has very infrequent periods. She is treated with clomifene therapy to induce ovulation, but the treatment fails. Which test will indicate if this woman is likely to have a good clinical and endocrine response to laparoscopic ovarian drilling?
Serum LH on day 5 of her cycle
2) A 30-year-old man presents to the fertility clinic with his partner to discuss about starting a family. He admits to being HIV positive and is very compliant with his medications and is under follow-up with the local sexual health service team. His viral load is found to be 30 copies per mL recently. The woman is 26 years old and has regular cycles and has had a child in her previous relationship.
For each of the following questions, choose an appropriate management option from the list A–L. Each response may be chosen once, more than once or not at all.
Semenalysis to find if the parameters are normal. Unprotected intercourse for
conception around the period of fertility with viral load less than 50 copies/mL is
3) During the course of fertility investigations, a 28-year-old woman with a BMI of 35 kg/m2 is found to have polycystic ovaries on ultrasound scanning. Her menstrual cycle has a length of 35–70 days. Her partner’s semen analysis is normal.
Advise women with World Health Organization (WHO) group II anovulatory
infertility who have a BMI of ≥30 kg/m2
to lose weight. Inform them that this
alone may restore ovulation, improve their response to ovulation induction agents
and have a positive impact on pregnancy outcomes.
4) A woman with hydrosalpinges needs IVF treatment.
Explanation: Laparoscopic cystectomy Women with ovarian endometrio-
mas should be offered laparoscopic cystectomy because this improves the chance of
5) A woman with unilateral 3 cm endometrioma.
Explanation Advise them to try to conceive for a total of 2 years before IVF will
6) A 28-year-old has PCOS and a BMI of 33. She has a 2-year history of second-ary subfertility. There are no other factors affecting fertility.
Explanation: Metformin The treatment options in any order are clomi-
phene citrate or metformin or a combination of both. Women with a BMI of 30 or
over should be encouraged to lose weight. Metformin may be more successful in
ovulation induction in women with raised BMI.
7) Which test is probably the best biochemical marker of polycystic ovaries?
It has been suggested recently that the threshold number of follicles to define a
polycystic ovary should be 25, and that the biochemical marker of AMH may be
even more precise than ultrasound, with a threshold serum concentration of
8) A woman with a previous diagnosis of pelvic endometriosis presents to the clinic with cylical rectal bleeding. Vaginal and rectal examinations are inconclusive. What is the most appropriate initial assessment to identify or exclude rectal endometriosis?
In women with symptoms and signs of rectal endometriosis, transvaginal
sonography is useful for identifying or ruling out rectal endometriosis.
Reference ESHRE. Management of women with endometriosis. ESHRE Guideline. September 2013.
9) A 30-year-old woman and her partner present to the subfertility clinic anxious to conceive. They have been trying for a pregnancy for 2 years now. The woman has regular
cycles with normal BMI and no prior medical illness. Semenalysis shows a volume of 2 mL with a count of 4 million/mL and 5% normal forms; 35% have progressive motility.
Repeat semenalysis is advised with a single abnormal test preferably after 3 months.
World Health Organization reference values:
40% or more motile or 32% or more with progressive motility
10) A woman with a regular 35-day cycle attends the fertility clinic. Investigations are instigated. Which test should be arranged to check for ovulation?
Serum progesterone should be measured 7 days before the expected day of menstruation.
11) A man is found to have azoospermia during the course of fertility investigations. He has two children from a previous relationship. He denies any significant medical history. On examination, he is muscular and both testes are small an soft.
The man already has children so has proven fertility. This rules out many of the
causes of azoospermia above. Anabolic steroid abuse is common in gym users and
results in pituitary suppression. This is the most likely cause of his azoospermia
and small testes.
12) A 35-year-old woman presents to the gynaecology clinic with pelvic pain and dysmenorrhoea. A pelvic examination demonstrates tenderness and fullness in the right iliac fossa. Which test should be used to diagnose or exclude an ovarian endometrioma?
Clinicians are recommended to perform transvaginal sonography to diagnose or
to exclude ovarian endometrioma.
13) A 24-year-old woman, virgo intacta, presents to the gynaecology clinic with abdominal and pelvic pain, dysmenorrhoea and dyschezia. What is the most
appropriate initial assessment for the diagnosis of endometriosis?
The guideline development group recommends that clinicians perform a clinical
examination in all women with suspected endometriosis, although vaginal
examination may be inappropriate for adolescents and/or women without
previous sexual intercourse. In such cases, a rectal examination can be helpful for
the diagnosis of endometriosis.
14) A man is found to have azoospermia. His serum FSH and testosterone levels are normal. On examination, he has normal secondary sexual characteristics and both testes are of normal size. His karyotype is normal and a cystic fibrosis screen is negative. A testicular biopsy shows germ cells to be present.
With maturation arrest, germ cells are present in the testes, but the process of
spermatogenesis is arrested, at either the spermatocyte or spermatid stage. This
will result in azoospermia, but a testicular biopsy will confirm germ cells to be
present. Leydig and Sertoli cells are present so there will be normal secondary
sexual characteristics and normal feedback to the pituitary, resulting in a normal
15) A 27-year-old woman presents to the fertility clinic with secondary subfertility. She has a 7-year-old child born of normal conception and had a normal delivery. She has ever
used only male condom for contraception. Her cycles have been regular until a year ago. She gets very slight bleeding and has not had a period for 3 months. She complains
of vague headache and difficulty in looking out of the corner of both her eyes. Urine pregnancy test is negative in the clinic today.
Serum prolactin is likely to be elevated with anovulation and possible bitemporal
hemianopia. Galactorrhoea may be associated.
16) A 32-year-old woman and her husband present to the clinic with 1 year of subfertility. Investigations show them to have unexplained infertility. The woman requests treatment as she has read on the internet that there are drugs that can be used to ‘boost fertility’
Do not offer oral ovarian stimulation agents (such as clomifene citrate,
anastrozole or letrozole) to women with unexplained infertility
17) A 36-year-old HIV-negative patient wishes to conceive with a man who is HIV positive. However, he is not compliant with HAART.
Explanation: Sperm washing If the man is HIV positive but he is not
compliant with HAART or the viral load is greater than 50 copies/ml, sperm wash-
ing should be offered. It reduces, but does not eliminate, the risk of HIV
18) A woman with a BMI of 28 kg/m2 and polycystic ovarian syndrome (PCOS) has attempted ovulation induction with clomifene citrate without success. She now returns to the clinic with pelvic pain that is worse around the time of menstruation
For women with WHO group II ovulation disorders who are known to be
resistant to clomifene citrate, consider one of the following second-line
treatments, depending on clinical circumstances and the woman’s preference:
offered as a first-line treatment
In this case, the woman’s symptoms could be suggestive of endometriosis, so
laparoscopic ovarian drilling would allow inspection of the peritoneal cavity at
the same time.
19) A 32-year-old woman presents to the fertility clinic with primary subfertility. Her periods are regular and her husband’s semenalysis is reported to be normal. She undergoes a hysterosalpingogram, which shows filling of the uterine cavity but no further progression of the dye beyond both cornua.
Laparoscopic assessment of the tubes is required to ascertain the findings and the
level of damage along with a complete pelvic assessment.
20) A man is found to have azoospermia. His serum FSH level is elevated but his testosterone is normal. On examination, the man is tall and has gynaecomastia. Both testes are in the scrotum but are small and soft.
From the clinical description, this is most likely to be Klinefelter’s syndrome
(karyotype 47,XXY), which can be confirmed by karyotyping. Primary testicular
failure is also possible, but the features of a tall man with gynaecomastia make it
much more likely that this is a case of Klinefelter syndrome.
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