Contraception and Family Planning — MCQs

Contraception and Family Planning Indian Medical PG Practice Questions and MCQs

Question 141: Which of the following is NOT a barrier contraceptive method?

A. Diaphragm
B. Condom
C. Today
D. Centchroman (Correct Answer)

Explanation: **Explanation:** The correct answer is **Centchroman** because it is a hormonal contraceptive, not a barrier method. **1. Why Centchroman is the correct answer:** Centchroman (commercially known as **Saheli**) is a **Selective Estrogen Receptor Modulator (SERM)**. It works by preventing the implantation of the blastocyst by altering the endometrium and speeding up ovum transport. It is a non-steroidal, once-a-week pill developed by CDRI, Lucknow. Since it acts biochemically on receptors rather than physically blocking sperm, it is not a barrier method. **2. Why the other options are incorrect:** * **Diaphragm:** A traditional mechanical barrier for females. It is a dome-shaped silicone cup inserted into the vagina to cover the cervix, preventing sperm from entering the uterus. * **Condom:** The most common mechanical barrier method (available for both males and females). It prevents pregnancy and provides protection against STIs by physically isolating the semen. * **Today:** This is the brand name for a **Vaginal Contraceptive Sponge**. It acts as a combined barrier: it physically blocks the cervix, absorbs sperm, and contains a chemical spermicide (Nonoxynol-9) to kill sperm. **Clinical Pearls for NEET-PG:** * **Centchroman (Saheli):** Included in the National Family Planning Program of India under the name **'Chhaya'**. * **Dosage of Saheli:** 30 mg twice a week for the first 3 months, followed by once a week. * **Drug of Choice:** Centchroman is the contraceptive of choice for lactating mothers and women where estrogen is contraindicated. * **Barrier Methods:** These are the only contraceptives that provide protection against **STIs and HIV**.

Question 142: What is the failure rate of contraception?

A. 0-5 per 100 woman-years
B. 5-10 per 100 woman-years
C. 0-1 per 100 woman-years
D. 9-20 per 100 woman-years (Correct Answer)

Explanation: The failure rate of contraception is measured using the **Pearl Index**, defined as the number of unintended pregnancies per 100 woman-years of exposure. ### **Explanation of the Correct Answer** **Option D (9-20 per 100 woman-years)** is correct because it represents the typical failure rates of the most commonly used "user-dependent" reversible contraceptives. While "perfect use" rates are low, "typical use" rates for methods like **Combined Oral Contraceptive Pills (COCPs)** are approximately **9%**, and for **Barrier methods (Condoms)**, they range from **13% to 18%**. When averaged across the general population using these common methods, the failure rate falls within the 9-20 range. ### **Analysis of Incorrect Options** * **Option A & B (0-10 per 100 woman-years):** These ranges are too narrow. While they cover highly effective methods (like IUCDs), they fail to account for the high typical-use failure rates of condoms and behavioral methods (withdrawal/rhythm). * **Option C (0-1 per 100 woman-years):** This represents **LARC (Long-Acting Reversible Contraception)** like the Levonorgestrel-IUS (0.2) or Implants (0.05), and permanent sterilization. It does not reflect the general failure rate of contraception as a whole. ### **High-Yield NEET-PG Pearls** * **Most Effective Reversible Method:** Subdermal Progestogen Implant (Failure rate ~0.05). * **Pearl Index Formula:** (Total accidental pregnancies × 1200) / (Total months of exposure). * **Ideal Contraceptive for Lactating Mothers:** Progestogen-only pills (POPs) or Centchroman (Saheli). * **Lactational Amenorrhea Method (LAM):** Only reliable for the first 6 months postpartum if the mother is exclusively breastfeeding and remains amenorrheic. Typical failure rate is ~2%.

Question 143: What instrument is used to remove an IUD embedded in the myometrium?

A. Hysteroscope
B. Curette
C. Hook
D. All of the above (Correct Answer)

Explanation: The management of a displaced or embedded Intrauterine Device (IUD) depends on its location and the degree of penetration into the uterine wall. When an IUD is embedded in the myometrium, several instruments can be utilized depending on the clinical scenario and the visibility of the device. **Explanation of the Correct Answer:** The correct answer is **All of the above** because each instrument serves a specific role in the retrieval process: * **Hysteroscope:** This is the gold standard for diagnosing and managing an embedded IUD. It allows for direct visualization of the device and the use of grasping forceps to precisely dislodge it from the myometrium under vision. * **Curette:** A sharp or blunt curette can be used to gently scrape the endometrial lining or free the limbs of an IUD that are partially buried in the superficial layers of the myometrium. * **Hook (IUD Hook):** This is a classic blind procedure instrument. It is designed to "catch" the frame or the thread of the IUD to pull it out when the strings are not visible at the external os. **Clinical Pearls for NEET-PG:** * **Missing Strings:** The first step in management is a per-speculum examination. If strings are not seen, the next step is an **Ultrasound (USG)** to confirm the IUD is intrauterine. * **X-ray Abdomen (KUB):** If USG shows an empty uterus, an X-ray is performed to look for an extrauterine (perforated) IUD. * **Perforated IUD:** If the IUD has completely perforated the uterus and is in the peritoneal cavity, **Laparoscopy** is the treatment of choice. * **Pregnancy with IUD:** If the strings are visible in the first trimester, the IUD should be removed to decrease the risk of septic abortion. If strings are not visible, the IUD is left in situ.

Question 144: Which of the following is a barrier method of contraception?

A. Oral contraceptive pill
B. Intrauterine device
C. Spermicide (Correct Answer)
D. Tubectomy

Explanation: **Explanation:** The correct answer is **C. Spermicide**. Barrier methods of contraception work by physically or chemically preventing sperm from entering the uterine cavity and reaching the oocyte. Spermicides (such as Nonoxynol-9) act as a **chemical barrier** by disrupting the sperm cell membrane, thereby immobilizing or killing them before they can pass through the cervix. Other common barrier methods include condoms (male and female), diaphragms, and cervical caps. **Analysis of Incorrect Options:** * **A. Oral contraceptive pill:** This is a **hormonal method**. It primarily works by inhibiting ovulation through the suppression of FSH and LH, and secondarily by thickening cervical mucus. * **B. Intrauterine device (IUD):** This is an **intrauterine contraceptive device**. While it prevents fertilization, its mechanism is primarily mediated through a sterile inflammatory response in the endometrium (Copper-T) or hormonal changes (LNG-IUD), rather than acting as a mechanical barrier. * **D. Tubectomy:** This is a **permanent/surgical method** of sterilization. It involves the surgical ligation or occlusion of the fallopian tubes to prevent the union of sperm and ovum. **NEET-PG High-Yield Pearls:** * **Nonoxynol-9** is the most common spermicide used globally. * **Dual Protection:** Condoms are the only barrier method that provides significant protection against both pregnancy and **STIs/HIV**. * **Failure Rates:** Barrier methods generally have higher "typical use" failure rates compared to LARC (Long-Acting Reversible Contraception) like IUDs. * **Ideal Use:** Spermicides are most effective when used in combination with mechanical barriers like a diaphragm.

Question 145: Which of the following can be transmitted through the placenta?

A. Chlamydia
B. Herpes simplex
C. Toxoplasma
D. All of the above (Correct Answer)

Explanation: The correct answer is **D. All of the above**. ### **Medical Concept: Vertical Transmission** Vertical transmission refers to the passage of a pathogen from mother to baby. This can occur via three routes: **transplacental** (in utero), **peripartum** (during labor/delivery via birth canal), or **postpartum** (via breastfeeding). While many organisms are traditionally associated with specific routes, research confirms that Chlamydia, HSV, and Toxoplasma can all cross the placental barrier. ### **Analysis of Options** * **Toxoplasma gondii (C):** This is a classic member of the **TORCH** complex. It is a protozoan that crosses the placenta, especially if the mother acquires a primary infection during pregnancy, leading to the classic triad of chorioretinitis, hydrocephalus, and intracranial calcifications. * **Herpes Simplex Virus (B):** While 85-90% of neonatal HSV is acquired during delivery (ascending infection or contact with lesions), **transplacental transmission** occurs in approximately 5% of cases, leading to "Congenital HSV," characterized by skin vesicles, microcephaly, and chorioretinitis. * **Chlamydia trachomatis (A):** Though most commonly associated with neonatal conjunctivitis and pneumonia acquired during birth, Chlamydia has been detected in placental tissue and amniotic fluid, confirming that transplacental transmission is possible and may lead to preterm labor or miscarriage. ### **NEET-PG High-Yield Pearls** * **TORCH Complex:** Includes **T**oxoplasmosis, **O**thers (Syphilis, Varicella, Parvovirus B19, HIV), **R**ubella, **C**ytomegalovirus (CMV), and **H**erpes. All of these cross the placenta. * **Most common** infection transmitted transplacentally: **CMV**. * **Most common** cause of congenital sensorineural deafness: **CMV**. * **Hepatitis B:** Does **not** typically cross the placenta; transmission usually occurs during delivery (peripartum). This is why HBIG and the vaccine are given to the neonate immediately.

Question 146: Mala-N is a:

A. POP pill
B. Mini pill
C. Combined pill (Correct Answer)
D. Once a month pill

Explanation: **Explanation:** **Mala-N** is a **Combined Oral Contraceptive Pill (COCP)** provided free of cost by the Government of India under the National Family Planning Programme. 1. **Why it is a Combined Pill:** It contains two hormones: an estrogen and a progestogen. Specifically, each tablet of Mala-N contains **0.03 mg of Ethinyl Estradiol** and **0.15 mg of Levonorgestrel**. The primary mechanism of action is the inhibition of ovulation by suppressing the release of FSH and LH from the pituitary gland. 2. **Why other options are incorrect:** * **POP (Progestogen-Only Pill) / Mini Pill:** These contain only a low dose of progestogen (e.g., Norethisterone or Desogestrel) and no estrogen. They are primarily used during lactation. * **Once a month pill:** These are long-acting hormonal preparations (like Quinestrol) which are not part of the standard Indian national program and have higher failure rates and side effects. **High-Yield Clinical Pearls for NEET-PG:** * **Composition:** One pack contains 28 tablets: **21 hormonal pills** and **7 brown iron tablets** (containing 60mg elemental iron as Ferrous Fumarate) to maintain the habit of pill-taking and treat anemia. * **Mala-N vs. Mala-D:** Both have the same hormonal composition. The only difference is that **Mala-N** (N for 'Nishulk') is distributed free at government centers, while **Mala-D** (D for 'Dhan') is a socially marketed brand sold at a subsidized price. * **Centchroman (Saheli):** Do not confuse Mala-N with Saheli. Saheli is a non-steroidal, once-a-week pill containing Ormeloxifene. * **Failure Rate:** The typical failure rate of COCPs is approximately 9% (0.3% with perfect use).

Question 147: A woman on combined oral contraceptive pills forgot to take them for two successive doses. What is the next best course of action?

A. Continue the next pill on the following day as scheduled.
B. Take three pills on the next day, then resume one pill daily.
C. Take the missed pills as soon as remembered, continue the remaining pills at the usual time, and use backup contraception for the next seven days. (Correct Answer)
D. Take two pills each day for the remainder of the cycle.

Explanation: ### Explanation **1. Why Option C is Correct:** The management of missed Combined Oral Contraceptive Pills (COCPs) depends on the number of pills missed and the timing within the cycle. According to the WHO Medical Eligibility Criteria (MEC) and standard guidelines, missing **two or more consecutive pills** (≥48 hours since the last pill was taken) significantly increases the risk of "escape ovulation" due to the loss of follicular suppression. * **Action:** The user should take the most recent missed pill immediately (even if it means taking two pills in one day), discard any other missed pills, and continue the pack as scheduled. * **Backup:** Because the contraceptive efficacy is compromised, **barrier methods (condoms)** or abstinence must be used for the **next 7 days** of continuous pill-taking to allow for adequate suppression of the hypothalamic-pituitary-ovarian axis. **2. Why Other Options are Incorrect:** * **Option A:** Simply continuing the next day ignores the missed doses and the increased risk of ovulation; it fails to provide the necessary backup protection. * **Option B:** Taking three pills at once is not recommended as it increases the risk of estrogenic side effects (nausea, vomiting) without providing additional contraceptive benefit. * **Option D:** Doubling the dose for the remainder of the cycle is unnecessary and leads to hormonal fluctuations and side effects. **3. NEET-PG High-Yield Pearls:** * **One Pill Missed (<48 hours):** Take the missed pill immediately. No backup contraception is required. * **Two or More Pills Missed (≥48 hours):** Take the most recent missed pill + 7 days of backup contraception. * **The "7-Day Rule":** If these 7 days extend into the last week of the pack (hormone-free interval), skip the placebo pills/break and start the new pack immediately. * **Emergency Contraception (EC):** If ≥2 pills are missed in the **first week** of the pack and unprotected intercourse occurred in the previous 5 days, EC should be considered.

Question 148: Use of combined oral contraceptive pills is contraindicated in women with any of the following conditions except?

A. Lactation
B. Diabetes
C. Thromboembolism
D. Tuberculosis (Correct Answer)

Explanation: **Explanation:** The correct answer is **Tuberculosis**. Combined Oral Contraceptive Pills (COCPs) contain both estrogen and progestogen. Their contraindications are primarily based on the **WHO Medical Eligibility Criteria (MEC)**, focusing on cardiovascular risks and hormonal sensitivities. 1. **Why Tuberculosis is the correct answer:** Tuberculosis itself is not a contraindication to COCP use. However, it is a "high-yield" distractor because **Rifampicin** (a first-line anti-TB drug) is a potent hepatic enzyme inducer. It increases the metabolism of estrogen, potentially leading to contraceptive failure. While the *medication* requires caution (MEC Category 3), the *disease* itself does not prohibit use. 2. **Why other options are incorrect:** * **Lactation:** Estrogen suppresses prolactin's action on breast tissue, reducing milk quantity and quality. It is contraindicated in the first 6 months of breastfeeding (MEC 4 if <6 weeks; MEC 3 if 6 weeks to 6 months). * **Thromboembolism:** Estrogen increases the synthesis of clotting factors (II, VII, IX, X) and decreases Antithrombin III. A history of VTE or current VTE is an absolute contraindication (MEC 4). * **Diabetes:** COCPs are contraindicated in diabetics with **vascular complications** (nephropathy, retinopathy, neuropathy) or disease duration >20 years (MEC 4) due to the increased risk of arterial thrombosis. **High-Yield Clinical Pearls for NEET-PG:** * **MEC Category 4 (Absolute Contraindication):** Smoker >35 years (≥15 cigarettes/day), Migraine with aura, Undiagnosed abnormal uterine bleeding, Breast cancer, and History of Stroke/IHD. * **Drug Interaction:** For patients on Rifampicin, the preferred method is an IUD or Injectable MPA, as these are not affected by liver enzyme induction. * **Benefit:** COCPs are protective against Ovarian and Endometrial cancers.

Question 149: Oral contraceptive pills (OCPs) are absolutely contraindicated in which of the following conditions?

A. Smoking more than 10 cigarettes a day
B. Active liver disease (Correct Answer)
C. Diabetes mellitus
D. Mild hypertension

Explanation: Combined oral contraceptive pills (OCPs) contain estrogen and progestogen, which undergo extensive hepatic metabolism. In **active liver disease** (e.g., viral hepatitis, decompensated cirrhosis, or hepatocellular carcinoma), the liver’s ability to metabolize these hormones is severely impaired. This leads to the accumulation of steroids, potential hepatotoxicity, and worsening of the underlying condition. Furthermore, estrogen increases the risk of gallbladder disease and hepatic adenomas, making active liver disease a **WHO Medical Eligibility Criteria (MEC) Category 4** (absolute contraindication). **Analysis of Incorrect Options:** * **Smoking:** While smoking is a major risk factor, it is only an absolute contraindication (MEC 4) if the woman is **$\geq$35 years old and smokes $\geq$15 cigarettes/day**. Smoking <15 cigarettes/day or being <35 years old are relative contraindications (MEC 3/2). * **Diabetes Mellitus:** OCPs are generally safe for diabetics unless there are associated vascular complications (nephropathy, retinopathy, neuropathy) or the disease duration is >20 years. * **Mild Hypertension:** Controlled or mild hypertension (140–159/90–99 mmHg) is a relative contraindication (MEC 3). Absolute contraindication (MEC 4) applies only to severe hypertension ($\geq$160/$\geq$100 mmHg) or vascular disease. **High-Yield Clinical Pearls for NEET-PG:** * **MEC Category 4 (Absolute Contraindications):** Undiagnosed vaginal bleeding, breast cancer, pregnancy, history of DVT/PE, migraine with aura, and breastfeeding <6 weeks postpartum. * **Drug Interactions:** Enzyme inducers like **Rifampicin** and **Antiepileptics** (Phenytoin, Carbamazepine) decrease OCP efficacy, necessitating alternative contraception. * **Non-contraceptive benefits:** OCPs reduce the risk of ovarian and endometrial cancers.

Question 150: Which of the following is the most common site of tubal ligation?

A. Ampulla
B. Isthmus (Correct Answer)
C. Interstitial
D. Fimbria

Explanation: **Explanation:** The **isthmus** is the most common and preferred site for tubal ligation (sterilization) in clinical practice. This is primarily due to its anatomical characteristics: the isthmus is the narrowest, straightest, and most muscular part of the Fallopian tube. Its relatively thin diameter and lack of extensive mucosal folding make it the easiest segment to grasp, ligate, and excise (as seen in the Pomeroy technique) or to occlude using mechanical devices like Filshie clips or Falope rings. **Analysis of Options:** * **Isthmus (Correct):** Its accessibility and narrow lumen ensure a high success rate for occlusion and provide the best opportunity for surgical reversal (tubal re-anastomosis) later, as there is minimal diameter discrepancy between the two ends. * **Ampulla:** While this is the widest part of the tube and the most common site for fertilization and ectopic pregnancies, it is not ideal for ligation. Its large diameter and thin walls make it prone to bleeding and less suitable for mechanical clips. * **Interstitial:** This segment lies within the muscular wall of the uterus. It is surgically inaccessible for standard tubal ligation and carries a high risk of hemorrhage if tampered with. * **Fimbria:** Fimbriectomy (Kroener technique) is a method of sterilization, but it is rarely performed today because it is irreversible and has a higher failure rate compared to isthmic ligation. **High-Yield Clinical Pearls for NEET-PG:** * **Pomeroy Technique:** The most commonly used method of tubal ligation; it involves creating a loop in the **isthmus**, ligating it with absorbable suture, and excising the loop. * **Failure Rates:** The overall failure rate of tubal sterilization is approximately 0.5 per 100 women. * **Ectopic Risk:** If a woman becomes pregnant after tubal ligation, there is a high probability (approx. 30%) that the pregnancy is **ectopic**. * **Counseling:** Tubal ligation should always be considered a **permanent** method of contraception.

Practice by Chapter

Natural Family Planning Methods

Practice Questions

Barrier Methods

Practice Questions

Hormonal Contraceptives

Practice Questions

Intrauterine Devices

Practice Questions

Emergency Contraception

Practice Questions

Permanent Contraception Methods

Practice Questions

Contraception in Special Populations

Practice Questions

Contraceptive Counseling

Practice Questions

Side Effects and Complications of Contraceptives

Practice Questions

Future Contraceptive Technologies

Practice Questions

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