Evaluation of the Infertile Couple — MCQs
A 35-year-old woman presents with 4 months of amenorrhea, increased FSH, LH, and decreased estrogen. What is the most likely diagnosis?
In a couple, which of the following investigations are included in the initial work-up for infertility?
A couple comes for evaluation of infertility. The HSG was normal but semen analysis revealed azoospermia. What is the diagnostic test to differentiate between testicular failure and vas deferens obstruction?
Primary amenorrhea is defined as:
Which among the following hormones can be used as an indicator for ovarian reserve in a patient who presents with infertility?
Most reliable sign of sexual intercourse in a married woman examined after 48 hours?
Minimum sperm count for normal semen analysis according to WHO:
A 35-year-old female presented with complaints of infertility. She has previous history of PID. Preliminary investigations like USG showed normal organs and hormone levels were also normal. What is the next best investigation?
A patient with infertility has an ultrasound (USG) suggestive of a uterine anomaly. Which of the following is the best method to confirm the diagnosis?
A lady on treatment for infertility developed ascites, abdominal pain, and dyspnea. An ultrasound (USG) of the patient was done. What will be the diagnosis?
Evaluation of the Infertile Couple Indian Medical PG Practice Questions and MCQs
Question 1: A 35-year-old woman presents with 4 months of amenorrhea, increased FSH, LH, and decreased estrogen. What is the most likely diagnosis?
- A. Premature ovarian insufficiency (Correct Answer)
- B. Menopause
- C. Late menopause
- D. Perimenopause
Explanation: ***Premature ovarian insufficiency (POI)*** - The patient's age (35 years) combined with 4 months of **amenorrhea**, increased **FSH** and **LH**, and decreased **estrogen** is characteristic of premature ovarian insufficiency (also called premature ovarian failure). - The hormonal profile (**hypergonadotropic hypogonadism**) indicates ovarian failure occurring before the age of **40 years**, which defines POI. - POI affects approximately **1% of women under 40** and can present with amenorrhea, infertility, and symptoms of estrogen deficiency. *Menopause* - Menopause is diagnosed after **12 consecutive months of amenorrhea** in a woman, typically occurring around age **51 years** (natural menopause). - While the hormonal profile of elevated FSH/LH and low estrogen is consistent with menopause, the patient's **age of 35 years** and **only 4 months of amenorrhea** do not meet the criteria for natural menopause. *Late menopause* - Late menopause refers to menopause occurring at a later age than average, typically after age **55 years**. - This diagnosis is completely inconsistent with the patient's age of 35 years. *Perimenopause* - Perimenopause is the transitional phase leading up to menopause, characterized by **irregular menstrual cycles** and **fluctuating hormone levels**. - While FSH levels may be elevated at times, perimenopause typically shows **variable hormone levels** rather than the sustained pattern of high FSH/LH with low estrogen seen in this case. - The **sustained amenorrhea** and pronounced hormonal shifts indicate ovarian failure (POI) rather than perimenopausal transition.
Question 2: In a couple, which of the following investigations are included in the initial work-up for infertility?
- A. Testicular biopsy, USG, Sperm penetration test
- B. Ovulation, tubal patency, Mantoux test
- C. Semen analysis, CXR, Mantoux
- D. Semen analysis, Tubal patency test, Ovulation test (Correct Answer)
Explanation: ***Semen analysis, Tubal patency test, Ovulation test*** - This option correctly identifies the **key initial investigations** for both male and female factors in infertility: **semen analysis** for male fertility, **tubal patency test** for assessing fallopian tube function, and **ovulation test** to confirm female ovulatory cycles. - These tests are fundamental in a comprehensive initial infertility work-up as they address the most common causes of infertility. *Testicular biopsy, USG, Sperm penetration test* - While **testicular biopsy** and **sperm penetration test** are relevant, they are typically **second-line investigations** performed if initial tests (like semen analysis) are abnormal. - **Ultrasound (USG)** is a general imaging modality and not a primary, specific infertility test for both partners as listed. *Ovulation, tubal patency, Mantoux test* - **Ovulation** and **tubal patency** are essential, but the **Mantoux test** (for tuberculosis) is generally not part of the *initial routine* infertility work-up unless there is clinical suspicion or prevalence in the region. - The Mantoux test is specific for a particular infection, and not a broad screening test for infertility. *Semen analysis, CXR, Mantoux* - **Semen analysis** is appropriate, but a **Chest X-ray (CXR)** and **Mantoux test** are not routine initial investigations for infertility. - These tests would only be indicated if there were specific clinical signs or a history suggestive of underlying pulmonary or infectious disease.
Question 3: A couple comes for evaluation of infertility. The HSG was normal but semen analysis revealed azoospermia. What is the diagnostic test to differentiate between testicular failure and vas deferens obstruction?
- A. Serum FSH (Correct Answer)
- B. Testicular FNAC
- C. Testosterone levels
- D. Karyotyping
Explanation: ***Serum FSH*** - In **testicular failure**, the pituitary gland tries to compensate for poor sperm production by increasing **follicle-stimulating hormone (FSH)**, leading to **elevated FSH levels**. - In **vas deferens obstruction**, the testes are producing sperm normally, so the pituitary does not need to overstimulate them, resulting in **normal FSH levels**. *Testicular FNAC* - **Fine needle aspiration cytology (FNAC)** of the testis can *confirm* the presence or absence of sperm production but is not the primary diagnostic test to *differentiate* between the two conditions without prior hormonal assessment. - It is an **invasive procedure** typically considered after initial hormone testing and physical examination. *Testosterone levels* - **Testosterone levels** primarily reflect the Leydig cell function and can be normal in both **testicular failure** (especially germ cell-specific failure) and **vas deferens obstruction**. - While low testosterone can indicate Leydig cell dysfunction, it doesn't specifically differentiate between the two causes of azoospermia in all cases. *Karyotyping* - **Karyotyping** is used to detect **chromosomal abnormalities** (e.g., Klinefelter syndrome) that can cause testicular failure. - While important for identifying underlying genetic causes, it does not directly differentiate between existing testicular failure and vas deferens obstruction based on direct physiological function.
Question 4: Primary amenorrhea is defined as:
- A. Imperforate hymen exists
- B. None of the above
- C. Menstruation does not occur even after 15 years of age (Correct Answer)
- D. Menstruation does not occur even after 18 years
Explanation: ***Menstruation does not occur even after 15 years of age*** - Primary amenorrhea is defined as the **absence of menstruation by age 15** in individuals with normal secondary sexual characteristics. - This definition is crucial for determining when to initiate investigation for underlying causes. *Imperforate hymen exists* - While an imperforate hymen can cause **cryptomenorrhea** (menstruation occurring but not flowing out), it is a specific cause of primary amenorrhea, not the definition itself. - An imperforate hymen is identified by a **bulging, bluish membrane** at the vaginal introitus. *None of the above* - This option is incorrect because the first option accurately defines primary amenorrhea. - The definition of primary amenorrhea is clinically well-established and widely accepted. *Menstruation does not occur even after 18 years* - This age cut-off is **too late** for the definition of primary amenorrhea, as investigations should ideally begin earlier. - Delaying evaluation until age 18 could potentially delay the diagnosis and treatment of underlying conditions affecting fertility and overall health.
Question 5: Which among the following hormones can be used as an indicator for ovarian reserve in a patient who presents with infertility?
- A. FSH (Correct Answer)
- B. LH/FSH ratio
- C. LH
- D. Estrogen
Explanation: **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.
Question 6: Most reliable sign of sexual intercourse in a married woman examined after 48 hours?
- A. Sperm detection (Correct Answer)
- B. Acid phosphatase
- C. Hymenal tears
- D. Vaginal tears
Explanation: ***Sperm detection*** - **Viable sperm** can be detected in the cervical mucus for up to 5 days, and sometimes longer, making it the most reliable indicator of recent intercourse even after 48 hours. - The presence of **spermatozoa**, even non-motile ones, provides direct evidence of male ejaculate in the female genital tract. - Sperm can persist in the vaginal canal for 3-5 days and in cervical mucus for up to 7 days post-intercourse. *Acid phosphatase* - While a component of seminal fluid, **acid phosphatase** degrades rapidly and its detection is generally reliable only within 24-36 hours post-intercourse. - Post 48 hours, the levels of acid phosphatase would likely be too low to be reliably used as conclusive evidence. - It is more useful for recent intercourse detection within 24 hours. *Hymenal tears* - **Hymenal tears** are not a reliable sign of recent intercourse within a marriage context, as some women may not experience tearing, or tears may have healed. - In a married woman, previous intercourse would have likely already altered the hymen, making new tears less indicative of recent activity. - The hymen shows significant variation and may be absent or already disrupted. *Vaginal tears* - **Vaginal tears** are typically associated with forceful or traumatic intercourse, or in cases of sexual assault, rather than consensual marital intercourse. - The absence of vaginal tears does not rule out consensual sexual activity, nor does its presence definitively confirm it in this specific context after 48 hours. - Not a reliable marker for consensual intercourse.
Question 7: Minimum sperm count for normal semen analysis according to WHO:
- A. 10 million/mL
- B. 2 million/mL
- C. 15 million/mL (Correct Answer)
- D. 5 million/mL
Explanation: ***15 million/mL*** - According to the **World Health Organization (WHO)** guidelines, a **minimum sperm concentration of 15 million/mL** is considered normal for a semen analysis. - This threshold is used to define **normozoospermia**, which indicates a healthy sperm count. *10 million/mL* - This value is **below the WHO reference range** for normal sperm concentration and would be considered **oligozoospermia**. - A sperm count of 10 million/mL suggests a **reduced likelihood of natural conception**. *2 million/mL* - A sperm count of 2 million/mL is significantly low and indicates **severe oligozoospermia**, which is associated with a very **low probability of natural conception**. - This value is far below the normal range defined by WHO. *5 million/mL* - This concentration is also below the normal WHO threshold, indicating **oligozoospermia**. - While higher than 2 million/mL, it still falls within the range suggesting **reduced fertility potential**.
Question 8: A 35-year-old female presented with complaints of infertility. She has previous history of PID. Preliminary investigations like USG showed normal organs and hormone levels were also normal. What is the next best investigation?
- A. Urine culture and sensitivity
- B. Repeat USG
- C. Hysterosalpingography (Correct Answer)
- D. Endometrial biopsy
Explanation: ***Hysterosalpingography*** - Given the history of **pelvic inflammatory disease (PID)**, there is a significant risk of **tubal blockage** or damage, which is a common cause of **infertility**. - **Hysterosalpingography (HSG)** is the gold standard investigation to assess the patency and morphology of the **fallopian tubes** and uterine cavity. *Urine culture and sensitivity* - This test is used to detect **urinary tract infections**. While important in general health, it is rarely the primary cause of infertility in the absence of urinary symptoms. - The patient's history of **PID** points towards gynecological causes rather than urinary ones as the likely source of infertility. *Repeat USG* - The initial **ultrasound (USG)** has already shown normal organs, indicating no obvious uterine or ovarian structural abnormalities. - Repeating the same investigation without new symptoms or findings is unlikely to provide additional diagnostic information regarding infertility, especially not **tubal patency**. *Endometrial biopsy* - An **endometrial biopsy** is typically performed to assess the health of the **uterine lining** for conditions like chronic endometritis or abnormal uterine bleeding. - While helpful in specific scenarios, it does not evaluate **fallopian tubal patency**, which is a crucial step in assessing infertility after **PID**.
Question 9: A patient with infertility has an ultrasound (USG) suggestive of a uterine anomaly. Which of the following is the best method to confirm the diagnosis?
- A. Hysterosalpingography (HSG)
- B. Transvaginal Sonography (TVS)
- C. Hysteroscopy + Laparoscopy (Correct Answer)
- D. Laparoscopy
Explanation: ***Hysteroscopy + Laparoscopy*** - This combination allows for a comprehensive evaluation: **hysteroscopy** visualizes the uterine cavity to confirm the type of anomaly (e.g., septum), while **laparoscopy** assesses the external uterine contour and overall pelvic anatomy. - It is considered the **gold standard** for diagnosing complex uterine anomalies as it provides the most detailed information for both diagnosis and surgical planning. *Hysterosalpingography (HSG)* - HSG can delineate the **uterine cavity morphology** and patency of fallopian tubes. - However, it is an **X-ray based test** and does not provide information about the external contour of the uterus, which is crucial for differentiating anomalies like a bicornuate from a septate uterus. *Transvaginal Sonography (TVS)* - While TVS is an excellent initial screening tool and can suggest a uterine anomaly, it often **lacks the definitive resolution** to precisely classify the anomaly, especially differentiating between septate and bicornuate uteri. - Its accuracy can be **operator-dependent** and limited in visualizing the external uterine contour. *Laparoscopy* - Laparoscopy alone provides an excellent view of the **external uterine contour** and pelvic organs. - However, it **does not visualize the internal uterine cavity**, which is essential for identifying and classifying anomalies such as a uterine septum.
Question 10: A lady on treatment for infertility developed ascites, abdominal pain, and dyspnea. An ultrasound (USG) of the patient was done. What will be the diagnosis?
- A. Theca lutein cysts
- B. Mucinous cystadenoma
- C. Polycystic Ovary Syndrome (PCOS)
- D. Ovarian Hyperstimulation Syndrome (OHSS) (Correct Answer)
Explanation: ***Ovarian Hyperstimulation Syndrome (OHSS)*** - The clinical presentation of infertility treatment followed by **ascites, abdominal pain, and dyspnea** is highly suggestive of OHSS. The ultrasound image shows **enlarged ovaries with multiple follicular cysts**, which is characteristic of severe OHSS. - OHSS is a potentially serious complication of **ovarian stimulation** during infertility treatment, where excessive ovarian response leads to systemic changes from increased vascular permeability. *Theca lutein cysts* - These cysts typically develop due to **excessive stimulation by hCG**, often seen with gestational trophoblastic disease or multiple pregnancies. - While they can be large and multiple, they are not typically associated with the rapid onset of severe systemic symptoms like **ascites and dyspnea** in the context of infertility treatment directly. *Mucinous cystadenoma* - This is a type of **benign ovarian tumor** that can grow very large and cause abdominal distension, but it is not typically associated with infertility treatment or the acute systemic symptoms of ascites and dyspnea as seen here. - Imaging would typically show a **multilocular cyst with internal septations**, not the numerous small follicular cysts seen in the image. *Polycystic Ovary Syndrome (PCOS)* - PCOS is a common cause of infertility, characterized by **anovulation, hyperandrogenism, and polycystic ovaries** on ultrasound (multiple small follicles in a string-of-pearls pattern). - While the ultrasound shares some similarities with multiple follicles, PCOS does not cause the acute symptoms of **ascites, abdominal pain, and dyspnea** that are directly linked to the rapid onset of severe OHSS.
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