Tests For Ovulation

TESTS FOR OVULATION

Q. 1

Luteal phase defect is best diagnosed by :

 A

Serum progesterone levels

 B

Endometrial biopsy

 C

Basal body temperature

 D

Ultrasonography

Q. 1

Luteal phase defect is best diagnosed by :

 A

Serum progesterone levels

 B

Endometrial biopsy

 C

Basal body temperature

 D

Ultrasonography

Ans. B

Explanation:

Endometrial biopsy


Q. 2

Perforation of the uterus while doing endometrial biopsy in a case of suspeccted genital tuberculosis needs :

 A

Laparascopy

 B

Observation

 C

Immediate laparotomy

 D

a and b both

Q. 2

Perforation of the uterus while doing endometrial biopsy in a case of suspeccted genital tuberculosis needs :

 A

Laparascopy

 B

Observation

 C

Immediate laparotomy

 D

a and b both

Ans. D

Explanation:

Ans. is a and b i.e. Laparoscopy and Observation                                                             

  • Perforation of the uterus occurs in 0.63% of D and C’s done.
  • Perforation should be suspected when the sound / curette meets no resistance at the point expected. Management
  • Curettage can be continued if the area of suspicion can be avoided.
  • In case suction curettage is being done and is associated with perforation : Laparoscopy must be used to continue the procedure to avoid aspiration of bowel into the uterine cavity.
  • Unless there is evidence of haemorrhage injury to bowel or evulsion of omentum -conservative treatment of uterine perforation is the best                                                                                                                
  • In hemodynamically stable patients, laparoscopy is the method of choice for evaluating perforation size and site.
  • The patient should be observed for atleast 24 hours in the hospital for possible infection or hemorrhage.
  • Most of the patients require only expectant treatment. Only in those who bleed internally laparotomy may be required.

Q. 3

What is the cause for luteal phase defect ?

 A

Progesterone is inadequately secreted

 B

Excess estrogen is secreted

 C

Excess progesterone is secreted

 D

All

Q. 3

What is the cause for luteal phase defect ?

 A

Progesterone is inadequately secreted

 B

Excess estrogen is secreted

 C

Excess progesterone is secreted

 D

All

Ans. A

Explanation:

Ans. is a i.e. Progesterone is inadequately secreted                

Luteal phase Defect is a condition when there is delay in the development of the endometrium of more than 2 days beyond the actual cycle day.

This adversely affects the endometrial receptivity to blastocyst implantation.

Etiology :

Luteal phase defect is due to inadequte progesterone production by corpus luteum. Inadequate progesterone secretion could be due to :

  1. Inadequate follicular development
  2. Inadequate FSH or LH secretion
  3. Hyperprolactinemia

Diagnosis : The diagnosis of luteal phase defect can be done by :

  • BBT Chart :
  1. slow rise of temperature taking 4 – 5 days following fall in the mid cycle.
  2. rise of temperature sustains less than 10 days.
  • Endometrial biopsy: Biopsy done in post ovulatory period reveals endometrium at least 2 days out of phase.
  • Serum progesterone° estimated on 5th day following ovulation is less than 10 ng/ml.

Management :

  • Adminstration of vaginal or intramuscular progesterone (50 – 100 mg/d) begining 3 days after documentation of an LH surge and continued till :

–  Either first day of next menstrual cycle. Or

–  If pregnancy occurs till 8-10 wks of gestation.

  • In unresponsive cases, clomiphene citrate may be tried.

Q. 4

Smita is a case of infertility. What is the right time in her menstrual cycle to do endometrial biopsy.

 A

12 – l4 days

 B

17 – 19 days

 C

20 – 22 days

 D

3-5days

Q. 4

Smita is a case of infertility. What is the right time in her menstrual cycle to do endometrial biopsy.

 A

12 – l4 days

 B

17 – 19 days

 C

20 – 22 days

 D

3-5days

Ans. C

Explanation:

Ans. is c i.e. 20 – 22 days     

ENDOMETRIAL BIOPSY

  • OPD procedure for hormonal evaluation in case of infertility / DUB/TB.
  • Usually performed in pre – menstrual phase from lateral wall of vagina.
  • Interpretation :

Presence of secretory endometrium Progesterone phase (cycles has been ovulatory)

Presence of proliferative endometrium  Anovulatory cycle

Luteal phase defect can also be diagnosed by endometrial biopsy (which shows a lag of 2 – 3 days between calendar and histological dating of specimen).

Endometrial biopsy is contraindicated in suspected malignancy / sepsis. 130

Test

Time

Observation

TESTS FOR DOCUMENTING OVULATION

  1. Basal Body Temp
  2. Cervical mucus
  3. Vaginal cytology
  4. Endometrial Biopsy
  5. Serum Progesterone
  6. Follicular Monitoring
  7. Laparoscopy

Through out cycle Day 12 – 14

Day 21 – 23

Day 12 – 14

Day 21 – 23

Premenstrual phase
D8 and D21

D10 – D14 Secretory phase

Biphasic pattern

Cervical mucus is clear watery, stretchability present, ferning present.

Cervical mucus is thick, viscid, tack present

ferning absent.

Estrogen dominated smears – clear. discrete corn-fined, polygonal, superficial cells (predominant cells) Progesterone dominated smear –containing dirty, predominantly intermediate (Navicular) cells. Secretory Endometrium (Confirming ovulation)

D – 8 < 1 ng/ml

D – 21 > 6.5 ng/m1

Follicle is measured by USG.

Recent corpus luteum is directly seen

PAT TESTS FOR TUBAL ENCY : (Or for any Tubal Pathology) : viz

Insufflation test

HSG

Sono hystero salpingography Fallopscopy

(Mid follicular phase) Day 6 – Day 11 (not performed later so that if pregnancy has occurred & zygote formed it is not disrupted & not earlier when the patient is menstruating as retrograde menstruation can cause endometriosis)

TEST FOR CERVICAL FACTOR : viz

  • Post coital test 
  • Immunological tests              Done just before ovulation (as cervical mucus is most
  • Miller kurzrok test                    receptive for sperm at that time).

Also know :

  • Any radiological investigation in a young / reproductive age woman should be done between Day 1 to Day 10 of cycle.
  • Endometrial Biopsy for diagnosis of T:B should be done in late premenstrual phase° as tubercles are present in superficial layer and shed during menstruation. The tissue obtained is subjected to polymerase chain reaction test instead of culture. 

Q. 5

Fern test is due to :

 A

Presence of NaCI under progesterone effect

 B

Presence of NaCI under estrogenic effect

 C

LH/FSH

 D

Mucus secretion by Glands

Q. 5

Fern test is due to :

 A

Presence of NaCI under progesterone effect

 B

Presence of NaCI under estrogenic effect

 C

LH/FSH

 D

Mucus secretion by Glands

Ans. B

Explanation:

Ans. is b i.e. Presence of NaCI under estrogenic effect        

Fern test is for documenting ovulation.

Procedure : A specimen of cervical mucus is obtained and is spread on a clean Glass slide and allowed to dry. It is then viewed under the low power microscope.

Result and interpretation : Under the influence of estrogen on Day12-Day 14 cervical mucus shows characteristic pattern of fern formation. The ferning is due to the presence of sodium chloride in the mucus secreted under estrogen effect.

After ovulation on Day 21-23, ferning disappears because protein content increases and Sodium chloride decreases under the effect of progesterone.

Disappearance of ferning after ovulation and if previously present its disappearance is presumptive evidence of corpus luteum activity.

Also know : • Cervical mucus will show palm leaf pattern due to Estrogen.

  • Spin barkeit of cervical mucus in a woman is maximum at ovulatory phase.
  • Spin barkeit is demonstrated in Proliferative phase.

Q. 6

The hormone responsible for a positive “Fern test” is :

 A

Estrogen

 B

Progesterone

 C

FSH

 D

LH

Q. 6

The hormone responsible for a positive “Fern test” is :

 A

Estrogen

 B

Progesterone

 C

FSH

 D

LH

Ans. A

Explanation:

Estrogen


Q. 7

In an infertile woman. endometrial biopsy reveals proliferative changes. Which Hormone should be preferred ?

 A

MDPA

 B

Desogestrol

 C

Norethisterone

 D

None of the above

Q. 7

In an infertile woman. endometrial biopsy reveals proliferative changes. Which Hormone should be preferred ?

 A

MDPA

 B

Desogestrol

 C

Norethisterone

 D

None of the above

Ans. A

Explanation:

Ans. is a i.e MDPA

Synthetic progesterones :

Progesterone derivatives

have weak antiovulatory actions.

except – Chlormadione acetate

eg : MDPA, Mesogestrol, Dydrogesterone, Hydroxy progesterone caproate, Nomegesterel

19 Nortestosterone derivatives

have strong antiovulatory actions

eg- Desogestrel, Norgestimate, Gestodene, Norethindrone, Norethisterone Norgesterel

In the question the infertile woman’s endometrial biopsy shows proliferative changes. As we know endometrial biopsy for infertility is taken on D 21-23 with the aim to rule out anovulation. Normally on these days endometrial biopsy should show secretory changes (as ovulation occurs on D-14 and subsequent there is increase in progesterone levels in body) But in case of anovulation endometrial biopsy does not show secretory changes but show proliferative changes.

The hormone which should be administered here is obviously progesterone. but that derivative of progesterone which has weak antiovulatory effect and not strong one as it would further inhibit anovulation

So, our answer is MDPA


Q. 8

Ovulation is associated most commonly with?

 A LH surge
 B

Increase in progesterone

 C Increase in FSH
 D

Increase in basal body temperature

Q. 8

Ovulation is associated most commonly with?

 A LH surge
 B

Increase in progesterone

 C Increase in FSH
 D

Increase in basal body temperature

Ans. A

Explanation:

LH surge REF: Ganong WF: Review of Medical Physiology, 22nd ed (chapter 23) Figure 6-10, William’s obstetrics 22″d edition Figure 3-1.

“The onset of the gonadotropin surge resulting from increasing secretion of estrogen by preovulatory follicles is a relatively precise predictor of the time of ovulation, occurring some 34 to 36 hours before the release of the ovum from the follicle. The peak of LH secretion occurs 10 to 12 hours before ovulation and stimulates the resumption of the meiosis process in the ovum with the release of the first polar body”


Q. 9

Investigation of choice in post-menopausal bleeding is?

 A Fractional curettage
 B

D & C

 C Endometrial biopsy
 D

Coagulation profile

Q. 9

Investigation of choice in post-menopausal bleeding is?

 A Fractional curettage
 B

D & C

 C Endometrial biopsy
 D

Coagulation profile

Ans. C

Explanation:

Endometrial biopsy REF: Novak’s gynecology 13 th edition p. 453

The importance of the endometrial biopsy cannot be overemphasized for the pre- or postmenopausal woman with abnormal uterine bleeding. It is well accepted that endometrial biopsy performed in the office is just as accurate as dilation and curettage and certainly more economical


Q. 10

Which is not a test for ovulation?

 A Fern test
 B

Basal body temperature

 C Hysteroscopy
 D

LH surge

Q. 10

Which is not a test for ovulation?

 A Fern test
 B

Basal body temperature

 C Hysteroscopy
 D

LH surge

Ans. C

Explanation:

Hysteroscopy REF: 12th edition of Novak’s Gynecology p. 408

METHODS TO DOCUMENT OVULATION:

  • Luteinizing Hormone Monitoring Documentation of the LH surge represents a remarkably reproducible method of predicting ovulation. Ovulation occurs 34 to 36 hours after the onset of the LH surge and about 10 to 12 hours after the LH peak
  • Basal Body Temperature The least expensive method of confirming ovulation is for the
    patient to record her temperature each morning on a basal body temperature (BBT) chart.
  • Midluteal Serum Progesterone
  • Ultrasound Monitoring Ovulation can also be documented by monitoring the development of a dominant follicle by ultrasound until ovulation takes place
  • A ferning pattern is seen when periovulatory cervical mucus is spread and dried on a microscope slide.

Q. 11

One of the risks of the endometrial biopsy that was performed on this patient is perforation of the uterus. The endometrial biopsy device is placed through the cervix and into the endometrial cavity. If complete perforation occurs, what is the sequence of layers that the biopsy device would penetrate prior to entering the peritoneal cavity?

 A

Endometrium, myometrium, serosa

 B

Ovary, fallopian tube, broad ligament

 C

Round ligament, cardinal ligament, uterosacral ligament

 D

Serosa, myometrium, endometrium

Q. 11

One of the risks of the endometrial biopsy that was performed on this patient is perforation of the uterus. The endometrial biopsy device is placed through the cervix and into the endometrial cavity. If complete perforation occurs, what is the sequence of layers that the biopsy device would penetrate prior to entering the peritoneal cavity?

 A

Endometrium, myometrium, serosa

 B

Ovary, fallopian tube, broad ligament

 C

Round ligament, cardinal ligament, uterosacral ligament

 D

Serosa, myometrium, endometrium

Ans. A

Explanation:

The uterus is a hollow, muscular organ that lies between the bladder and the rectum in the true pelvis.

The uterus can be divided into three major segments: the uterine fundus, the uterine corpus (or body), and the cervix.

The fallopian tubes enter the uterine fundus laterally in the region called the cornua.

Moving from the inside (or hollow) portion of the uterus to the peritoneal cavity, the layers that would be penetrated are the endometrium, the myometrium, and the serosa.

The endometrium is the portion of the uterus that proliferates during the menstrual cycle and sheds (the menses) if pregnancy does not occur, or supports the pregnancy if conception and implantation take place.
The myometrium is comprised of three layers: an inner layer of longitudinal smooth muscle, a middle layer of circular smooth muscle (the stratum vasculare), and an outer layer of longitudinal and circular smooth muscle (the stratum supervascularae).
The final layer is the uterine serosa.
 
The ovary, fallopian tube, and broad ligament are found posterolateral to the uterus. A biopsy device that perforated the uterus could also injure these structures, but the direct path of perforation is through the endometrium, myometrium, and serosa.
Note:
The round ligament, cardinal ligament, and uterosacral ligament are supporting structures attached to the uterus. Again, while a perforating biopsy instrument could possibly involve these structures, this would not be the direct path of perforation.
The serosa, myometrium, and endometrium are the correct structures that would be perforated, but they are in the wrong order. Starting within the uterus, the first layer is the endometrium, next is the myometrium and finally the serosa.
Ref: Shaw’s Textbook of Gynaecology, 13th Ed  Page 7-10

Q. 12

Which among the following is the best diagnostic method for finding out ovulation?

 A

Ultrasound

 B

Laparoscopy

 C

Endometrial biopsy

 D

Chromotubation

Q. 12

Which among the following is the best diagnostic method for finding out ovulation?

 A

Ultrasound

 B

Laparoscopy

 C

Endometrial biopsy

 D

Chromotubation

Ans. C

Explanation:

The finding of secretory endometrium confirms ovulation.

The use of an endometrial biopsy (EMB) near the end of the luteal phase can provide reassurance of an adequate maturational effect on the endometrial lining.

Within 48 hours of ovulation, the cervical mucus changes under the influence of progesterone to become thick, tacky, and cellular, with loss of the crystalline fernlike pattern on drying.

 
Ref: Ghadir S., Ambartsumyan G., DeCherney A.H. (2013). Chapter 53. Infertility. In A.H. DeCherney, L. Nathan, N. Laufer, A.S. Roman (Eds), CURRENT Diagnosis & Treatment: Obstetrics & Gynecology, 11e.

 


Q. 13

Which of the following methods for assessment of female fertility during a menstrual cycle can best predict the timing of ovulation?

 A

Basal Body Temperature (BBT)

 B

Fern Test

 C

Spinnbarkeit phenomenon

 D

Hormonal study

Q. 13

Which of the following methods for assessment of female fertility during a menstrual cycle can best predict the timing of ovulation?

 A

Basal Body Temperature (BBT)

 B

Fern Test

 C

Spinnbarkeit phenomenon

 D

Hormonal study

Ans. D

Explanation:

The best method of assessment of female fertility that allows accurate prediction of ovulation is the measurement of urinary LH surge (Hormonal Test).

 
Ref: Clinical Gynaecological Endocrinology and Infertility By Speroff, 7th Edition, Page 1036; Textbook of Gynecology By DC Dutta, 4th Edition, Page 106 221; Management of Common Problems in Obstetrics and Gynecology By T. Murphy Goodwin, Martin 4. N. Montoro, Laila Muderspach, Subir Roy, 5th Edition, Page 430

 


Q. 14

Which is NOT a documentation test for ovulation in women of reproductive age?

 A

Fern test

 B

Basal body temperature

 C

Hysteroscopy

 D

LH surge

Q. 14

Which is NOT a documentation test for ovulation in women of reproductive age?

 A

Fern test

 B

Basal body temperature

 C

Hysteroscopy

 D

LH surge

Ans. C

Explanation:

Methods to document ovulation:

  • Luteinizing Hormone Monitoring Documentation of the LH surge represents a remarkable reproducible method of predicting ovulation. Ovulation occurs 34 to 36 hours after the onsof the LH surge and about 10 to 12 hours after the LH peak.
  • Basal Body Temperature
  • Midluteal Serum Progesterone
  • Ultrasound Monitoring Ovulation
  • A ferning pattern is seen when periovulatory cervical mucus is spread and dried on a microscope slide.

Q. 15

A 26 year old female presents with a chief complaint of menstrual bleeding 10 days prior to the usual onset of menses. She states that her last menstrual period was heavier than usual. The physician examines her and performs a pregnancy test (which is negative) then concludes that she is probably experiencing dysfunctional bleeding due to anovulation. If an endometrial biopsy were performed, which of the following would be the most likely histologic appearance of this type of endometrium?

 A

Asynchronous secretory endometrium

 B

Decidualized stroma with inactive glands

 C

Early proliferative endometrium

 D

Proliferative endometrium with stromal breakdown

Q. 15

A 26 year old female presents with a chief complaint of menstrual bleeding 10 days prior to the usual onset of menses. She states that her last menstrual period was heavier than usual. The physician examines her and performs a pregnancy test (which is negative) then concludes that she is probably experiencing dysfunctional bleeding due to anovulation. If an endometrial biopsy were performed, which of the following would be the most likely histologic appearance of this type of endometrium?

 A

Asynchronous secretory endometrium

 B

Decidualized stroma with inactive glands

 C

Early proliferative endometrium

 D

Proliferative endometrium with stromal breakdown

Ans. D

Explanation:

The most common cause of dysfunctional uterine bleeding is anovulation.
This is caused by excessive and prolonged estrogen effect without the postovulatory progesterone effect.
This occurs most often around menarche and menopause, when subtle hormonal imbalances commonly occur.
An estrogenic stimulation causes the endometrial glands to proliferate.
Persistent proliferation without a progesterone phase will eventually break down and bleed even though there is no secretory change present and the stroma is not menstrual.
That is why this is called “anovulation bleed,” because it is a non-ovulatory bleed that may seem like normal menstruation.
 
Asynchronous secretory endometrium refers to secretory endometrium that has a mismatch of 2 or more days between the glands and the stroma. For example, the glands may be at day 17 while the stroma shows more maturity, corresponding to day 22. This is a type of dysfunctional ovulatory bleeding and clinically presents with infertility. It is usually due to an inadequate luteal phase because the corpus luteum is not producing enough progesterone even though ovulation has occurred.
 
Decidualized stroma with inactive glands is the common histologic appearance of patients taking oral contraceptives. These patients have asynchronous glands and stroma. The glands are usually not active and the stroma appears to be ready for implantation. This reverts to normal with discontinuation of oral contraceptives.
 
Early proliferative endometrium and late secretory endometrium (choice D) are physiologic phases of the normal menstrual cycle.
 
Ref: Hoffman B.L., Schorge J.O., Schaffer J.I., Halvorson L.M., Bradshaw K.D., Cunningham F.G., Calver L.E. (2012). Chapter 8. Abnormal Uterine Bleeding. In B.L. Hoffman, J.O. Schorge, J.I. Schaffer, L.M. Halvorson, K.D. Bradshaw, F.G. Cunningham, L.E. Calver (Eds), Williams Gynecology, 2e.

 


Q. 16

A young female is suggested for doing laparoscopy for finding out the tubal factors for her infertility. Hysterosalpingography was done 6 months before which was appeared normal. Regarding laparoscopy in this patient consider the following:

Assertion: Ideal time for doing laparoscopy in this patient is during proliferative phase

Reason: Recent corpus luteum can be visualized and endometrial biopsy can be taken within same sitting.

 A

Both Assertion and Reason are true, and Reason is the correct explanation for Assertion

 B

Both Assertion and Reason are true, and Reason is not the correct explanation for Assertion

 C

Assertion is true, but Reason is false

 D

Assertion is false, but Reason is true

Q. 16

A young female is suggested for doing laparoscopy for finding out the tubal factors for her infertility. Hysterosalpingography was done 6 months before which was appeared normal. Regarding laparoscopy in this patient consider the following:

Assertion: Ideal time for doing laparoscopy in this patient is during proliferative phase

Reason: Recent corpus luteum can be visualized and endometrial biopsy can be taken within same sitting.

 A

Both Assertion and Reason are true, and Reason is the correct explanation for Assertion

 B

Both Assertion and Reason are true, and Reason is not the correct explanation for Assertion

 C

Assertion is true, but Reason is false

 D

Assertion is false, but Reason is true

Ans. D

Explanation:

Laparoscopic and dye test are done doing secretory phase of the cycle for finding out the tubal factors of infertility.
 
Ref: Textbook of Gynaecology By D.C.Dutta, 4th Edition, Page 224, 226.

Q. 17

 

In an infertile woman, endometrial biopsy reveals proliferative changes. Which Hormone should be prefered?

 A

MDPA

 B

Desogestrol

 C

Norethisterone

 D

None of the above

Q. 17

 

In an infertile woman, endometrial biopsy reveals proliferative changes. Which Hormone should be prefered?

 A

MDPA

 B

Desogestrol

 C

Norethisterone

 D

None of the above

Ans. A

Explanation:

Synthetic analogues of progesterone like medroxyprogesterone acetate or norethindrone acetate, suppress ovulation and endometrial growth.
 
Ref: Diagnosis Of Endometrial Biopsies And Curettings: A Practical Approach By Michael T. Mazur, Robert J. Kurman, 2005, Page 122

Q. 18

The best time to do an endometrial biopsy in a patient with suspected endometrial cancer is which of the following?

 A

9 – 10 day

 B

20 – 21 day

 C

26th day

 D

2nd day

Q. 18

The best time to do an endometrial biopsy in a patient with suspected endometrial cancer is which of the following?

 A

9 – 10 day

 B

20 – 21 day

 C

26th day

 D

2nd day

Ans. C

Explanation:

The endometrial biopsy is done just prior to the expected menstrual period, when the uterine lining is at its thickest. Indications for doing endometrial biopsy are chronic anovulation, abnormal vaginal bleeding, suspected uterine cancer, and infertility. Transvaginal ultrasonography is generally done before obtaining an endometrial biopsy.


Q. 19

There is a mid-cycle shift in the basal body temperature (BBT) after ovulation in women. This is caused by :

 A

FSH-peak

 B

LH-peak

 C

Oestradiol

 D

Progesterone

Q. 19

There is a mid-cycle shift in the basal body temperature (BBT) after ovulation in women. This is caused by :

 A

FSH-peak

 B

LH-peak

 C

Oestradiol

 D

Progesterone

Ans. D

Explanation:

D i.e. Progesterone

Progesterone is thermogenic & responsible for the rise in basal body temperatureQ at the time of ovulation

  • Increase in basal body temperature at the time ovulation in reliable indicator of time of ovulation The rise starts 1-2 days after ovulation
  • Other indicators of ovulation

Secretory patternQ on biopsy of endometrium

Thick cervical mucus that forms a fern pattern


Q. 20

Time of ovulation is detected by all EXCEPT:

September 2012

 A

Urine LH

 B

Urine FSH

 C

Serum progesterone

 D

Basal body temperature

Q. 20

Time of ovulation is detected by all EXCEPT:

September 2012

 A

Urine LH

 B

Urine FSH

 C

Serum progesterone

 D

Basal body temperature

Ans. B

Explanation:

Ans. B i.e. Urine FSH

Physiology

  • Best predictor of ovulation: Pre-ovulatory rise in LH
  • In normal menstrual cycle, progesterone is secreted by: Corpus luteum
  • Inhibin is secreted by: Graffian follicle
  • LH precedes ovulation by: 24 hours (Ovulation coincides with LH surge)
  • Ovulatory period: Corresponds to 14 days before next menstruation
  • FSH stimulates: Growth of granulosa cells (measure of ovarian reserve)
  • LH stimulates: Follicle rupture and ovulation.


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