Fertility and Infertility — MCQs

Fertility and Infertility Indian Medical PG Practice Questions and MCQs

Question 91: What is the gold standard investigation for uterine cavity evaluation?

A. Ultrasonography
B. Saline sonography
C. Hysterosalpingography
D. Hysteroscopy (Correct Answer)

Explanation: **Explanation:** **Hysteroscopy** is considered the **gold standard** for evaluating the uterine cavity because it allows for direct visualization of the endometrium and the internal architecture of the uterus. Unlike indirect imaging, it provides real-time assessment of the size, shape, and vascularity of any intrauterine pathology (such as polyps, submucosal fibroids, or synechiae) and offers the unique advantage of "see-and-treat"—allowing for simultaneous diagnosis and operative intervention (biopsy or resection). **Analysis of Incorrect Options:** * **Ultrasonography (USG):** Usually the first-line screening tool. While excellent for assessing the myometrium and ovaries, its sensitivity for small intrauterine lesions is lower than hysteroscopy. * **Saline Infusion Sonography (SIS):** Better than a routine USG for detecting intracavitary lesions as the saline distends the cavity. However, it remains an indirect method and cannot provide a definitive histological diagnosis or immediate treatment. * **Hysterosalpingography (HSG):** Primarily used to assess **tubal patency**. While it can show filling defects in the uterus, it has a high false-positive rate and cannot distinguish between different types of intrauterine masses. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard for Tubal Patency:** Laparoscopic Chromopertubation. * **Best time for Hysteroscopy:** Early follicular phase (Day 6 to Day 10), when the endometrium is thinnest. * **Distension Media:** CO2 (diagnostic), Normal Saline (bipolar cautery), or Glycine (monopolar cautery). * **HSG Timing:** Performed in the pre-ovulatory phase (Day 7 to Day 10) to avoid interfering with a potential pregnancy and to ensure the endometrium is thin.

Question 92: In Vitro Fertilization (IVF) is indicated for which type of infertility?

A. Azoospermia (Correct Answer)
B. Tubal infertility
C. Infertility due to Pelvic Inflammatory Disease (PID)
D. Uterine agenesis

Explanation: **Explanation:** **Correct Option: A. Azoospermia** In Vitro Fertilization (IVF), specifically when combined with **Intracytoplasmic Sperm Injection (ICSI)**, is the definitive treatment for severe male factor infertility, including azoospermia. In cases of obstructive azoospermia (or even non-obstructive cases where focal spermatogenesis exists), sperm can be retrieved surgically via techniques like **TESA** (Testicular Sperm Aspiration) or **MESA** (Microsurgical Epididymal Sperm Aspiration). Since these sperm are often immature or few in number, they cannot fertilize an egg naturally or via standard IVF; ICSI is required to inject a single viable sperm directly into the oocyte. **Why other options are incorrect:** * **B & C (Tubal infertility/PID):** While IVF was originally developed for tubal factor infertility (often a sequel of PID), these options are technically **sub-types** of infertility. In the context of NEET-PG questions where multiple options seem plausible, "Azoospermia" is often highlighted as the primary indication for advanced ART (Assisted Reproductive Technology) because it bypasses the absolute biological barrier of absent sperm in the ejaculate. *Note: If this were a "Multiple Correct" format, B and C would also be indications.* * **D. Uterine agenesis:** IVF alone cannot treat uterine agenesis (Mayer-Rokitansky-Küster-Hauser syndrome) because the patient lacks a site for implantation. While IVF can be used to create an embryo using the patient's ovaries, **Surrogacy** is mandatory for a successful pregnancy. **High-Yield Clinical Pearls for NEET-PG:** * **First IVF Baby:** Louise Brown (1978); First in India: Kanupriya Agarwal (Durga). * **ICSI Indication:** Best for male factor infertility (oligo-astheno-teratozoospermia) and prior IVF failure. * **OHSS (Ovarian Hyperstimulation Syndrome):** The most serious complication of the controlled ovarian stimulation phase of IVF. * **Luteal Phase Support:** Always required in IVF (usually via Progesterone) because the aspiration of follicles depletes the corpus luteum's functional capacity.

Question 93: Which of the following is NOT an indication for artificial insemination with husband's semen?

A. Impotence
B. Unexplained infertility
C. Azoospermia (Correct Answer)
D. Blockage of the ejaculatory duct

Explanation: **Explanation:** Artificial Insemination with Husband’s Semen (AIH) is a technique where the husband's processed sperm is placed directly into the female reproductive tract. The fundamental requirement for AIH is the **presence of viable spermatozoa** in the husband's ejaculate or retrieved via minor surgical procedures. **Why Azoospermia is the Correct Answer:** Azoospermia is defined as the total absence of spermatozoa in the ejaculate. Since AIH relies on using the husband's own sperm, it is impossible to perform if no sperm are available. In cases of absolute azoospermia (specifically non-obstructive), the couple must opt for **Artificial Insemination with Donor semen (AID)** or IVF/ICSI if testicular sperm extraction is not feasible. **Analysis of Incorrect Options:** * **Impotence (A):** This is a common indication for AIH. If the husband cannot achieve or maintain an erection for vaginal intercourse, semen can be collected via masturbation or vibratory stimulation and used for insemination. * **Unexplained Infertility (B):** AIH (specifically Intrauterine Insemination - IUI) is a first-line treatment for unexplained infertility, often combined with mild ovarian stimulation to increase the density of motile sperm near the oocyte. * **Blockage of the Ejaculatory Duct (D):** This is a form of obstructive azoospermia. While sperm is absent in the ejaculate, it is still being produced. In such cases, sperm can be retrieved directly from the epididymis (PESA/MESA) or testes (TESA) and used for AIH/IUI or ICSI. **High-Yield Clinical Pearls for NEET-PG:** * **IUI Timing:** Usually performed 36 hours after hCG "trigger" injection. * **Sperm Requirement:** For successful IUI, the post-wash Total Motile Sperm Count (TMSC) should ideally be >5–10 million. * **Cervical Factor:** AIH is the treatment of choice for infertility caused by hostile cervical mucus or cervical stenosis.

Question 94: In semen banks, at what temperature is semen preserved?

A. Dry ice
B. Deep freeze
C. Liquid nitrogen (Correct Answer)
D. Liquid air

Explanation: **Explanation:** **Correct Answer: C. Liquid nitrogen** The standard method for long-term preservation of semen (cryopreservation) is storage in **liquid nitrogen at -196°C**. At this ultra-low temperature, all metabolic activities of the spermatozoa are suspended, effectively "stopping the clock" on cellular aging and preventing biochemical reactions that would lead to cell death. This process typically involves the use of cryoprotectants (like glycerol) to prevent the formation of intracellular ice crystals, which would otherwise rupture the sperm cell membrane. **Why other options are incorrect:** * **Dry Ice (Solid CO₂):** Maintains a temperature of approximately **-78.5°C**. While cold, this is insufficient for long-term stability; metabolic processes are not completely halted, leading to rapid deterioration of sperm quality. * **Deep Freeze:** Standard medical deep freezers reach **-20°C to -80°C**. These temperatures are used for short-term storage of certain reagents or vaccines but are inadequate for preserving the structural integrity of gametes over months or years. * **Liquid Air:** While it can reach temperatures around -190°C, it is highly unstable and poses a significant **fire/explosion hazard** because the liquid oxygen component can react violently with organic materials. **High-Yield Clinical Pearls for NEET-PG:** * **Quarantine Period:** Semen samples are typically frozen and quarantined for **6 months** before use to re-test the donor for HIV, Hepatitis B, and Hepatitis C (due to the window period of these infections). * **Cryoprotectant:** **Glycerol** is the most commonly used agent to protect sperm from cold shock. * **Post-thaw Motility:** Usually, 50% or more of the initial motility is lost during the freezing and thawing process. * **Vitrification:** A "flash-freezing" technique used more commonly for oocytes and embryos to avoid ice crystal formation.

Question 95: What percentage of infertility cases are attributed to male factors?

A. 5%
B. 20%
C. 30% (Correct Answer)
D. 50%

Explanation: **Explanation:** Infertility is defined as the inability of a couple to conceive after 12 months of regular, unprotected intercourse. Statistically, infertility is a "couple's issue," with contributions from both partners. According to standard textbooks like **Dutta and Jeffcoate**, the distribution of infertility factors is generally categorized as follows: * **Male Factors:** ~30–40% * **Female Factors:** ~40–50% (Tubal/Peritoneal: 25-30%, Ovulatory: 15-20%, Endometriosis: 5-10%) * **Combined (Both):** ~10–20% * **Unexplained:** ~10% **Why 30% is correct:** While some studies suggest male factors contribute to up to 40% of cases, in the context of standard medical examinations like NEET-PG, **30%** is the most widely accepted figure for isolated male factor infertility. **Analysis of Incorrect Options:** * **A (5%):** This is far too low; male factors are a primary cause in nearly one-third of all cases. * **B (20%):** This underestimates the prevalence. While 20% may represent the "combined" factor group, it does not account for the total male contribution. * **D (50%):** This is an overestimation for isolated male factors. However, if you combine isolated male factors with "combined factors," the male contribution can approach 50%, but as a standalone category, 30% is the standard. **High-Yield Clinical Pearls for NEET-PG:** 1. **Initial Investigation:** Semen analysis is the first and most important step in evaluating the male partner. 2. **Most Common Cause:** Idiopathic oligospermia is the most common cause of male infertility, while **Varicocele** is the most common *identifiable* surgical cause. 3. **WHO Criteria (2021):** Remember the lower reference limits: Volume ≥1.4 mL, Concentration ≥16 million/mL, Total Motility ≥42%, and Normal Morphology ≥4%.

Question 96: Which of the following methods for assessment of female infertility 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 (Correct Answer)

Explanation: **Explanation:** The assessment of ovulation is a cornerstone of infertility evaluation. Among the options provided, **Hormonal Study** is the most reliable and precise method for predicting and confirming the timing of ovulation. **1. Why Hormonal Study is Correct:** The "Gold Standard" for predicting ovulation is the detection of the **LH (Luteinizing Hormone) surge**. Monitoring serum or urinary LH levels can predict ovulation approximately **24–36 hours** before it occurs. Additionally, a mid-luteal phase (Day 21) serum progesterone level >3 ng/mL confirms that ovulation has taken place. These hormonal markers provide objective, quantifiable data compared to physical signs. **2. Why Other Options are Incorrect:** * **Basal Body Temperature (BBT):** BBT rises (0.5–1.0°F) due to the thermogenic effect of progesterone. However, this rise occurs **after** ovulation has already happened. It is a retrospective tool and is easily influenced by fever, stress, or irregular sleep, making it poor for precise prediction. * **Fern Test & Spinnbarkeit Phenomenon:** These reflect high estrogen levels (pre-ovulatory phase) which cause the cervical mucus to become thin, stretchy, and exhibit a ferning pattern on microscopy. While they indicate the *approach* of ovulation, they are subjective, can be affected by infections, and do not pinpoint the exact timing as accurately as an LH surge. **Clinical Pearls for NEET-PG:** * **Most accurate method to *predict* ovulation:** LH Surge (Urinary kits). * **Most accurate method to *confirm* ovulation:** Mid-luteal Progesterone or Serial Transvaginal Ultrasound (showing follicle disappearance/collapse). * **Spinnbarkeit:** Refers to the "stretchability" of mucus; maximum stretch (10-12 cm) occurs just before ovulation. * **Mittelschmerz:** Mid-cycle pelvic pain associated with ovulation.

Question 97: In which case homologous artificial insemination is used in females?

A. Hormonal disturbance
B. Tubal block
C. Cervical factor (Correct Answer)
D. All of the above

Explanation: **Explanation:** **Homologous Artificial Insemination (AIH)** involves the clinical deposition of the husband's processed semen into the female reproductive tract (usually intrauterine). The primary goal is to bypass barriers that prevent sperm from reaching the fallopian tubes naturally. **Why Cervical Factor is Correct:** In cases of **cervical factor infertility**, the cervical mucus may be hostile (due to antisperm antibodies) or too thick/scanty to allow sperm penetration. By performing Intrauterine Insemination (IUI), the sperm is placed directly into the uterine cavity, effectively **bypassing the cervical barrier**. This is a classic indication for AIH. **Why Other Options are Incorrect:** * **Tubal Block:** For AIH/IUI to be successful, at least one fallopian tube must be **patent** (open) to allow the sperm to meet the egg for fertilization. If both tubes are blocked, the only viable option is In-Vitro Fertilization (IVF). * **Hormonal Disturbance:** While hormonal issues (like anovulation) cause infertility, they are primarily managed with **ovulation induction** (e.g., Clomiphene or Gonadotropins). AIH may be used as an adjunct, but it does not directly treat the hormonal pathology itself. **High-Yield NEET-PG Pearls:** * **Indications for AIH:** Unexplained infertility, cervical factor, mild male factor (oligozoospermia), and anatomical defects like hypospadias or retrograde ejaculation. * **Prerequisite:** A hysterosalpingogram (HSG) or laparoscopy must confirm **tubal patency** before attempting AIH. * **Semen Processing:** Raw semen is never injected into the uterus; it must be "washed" to remove prostaglandins, which can cause severe uterine contractions and anaphylaxis.

Question 98: Which of the following is used as a surrogate for the endogenous LH surge in IVF?

A. IGF
B. GnRH
C. HCG (Correct Answer)
D. HMG

Explanation: **Explanation:** In the final stages of Controlled Ovarian Hyperstimulation (COH) for IVF, the **endogenous LH surge** must be simulated to induce final oocyte maturation and trigger ovulation. **Why HCG is the Correct Answer:** Human Chorionic Gonadotropin (HCG) is the most commonly used surrogate for LH because it shares a common **alpha-subunit** with LH and has a **beta-subunit** that is structurally similar. Crucially, HCG binds to the same **LH/hCG receptor** on the granulosa cells. Due to its longer half-life (>24 hours compared to 60 minutes for LH), a single bolus of HCG effectively mimics the mid-cycle LH surge, leading to the resumption of meiosis in the oocyte and luteinization of the follicle. **Analysis of Incorrect Options:** * **IGF (Insulin-like Growth Factor):** This is a growth factor that modulates the action of FSH on granulosa cells but does not trigger ovulation. * **GnRH (Gonadotropin-Releasing Hormone):** While GnRH *agonists* can be used to trigger an endogenous LH surge (the "GnRH trigger"), GnRH itself is a hypothalamic hormone, not a surrogate for the surge. * **HMG (Human Menopausal Gonadotropin):** This contains both FSH and LH activity and is used for **follicular recruitment and growth**, not for the final trigger. **High-Yield Clinical Pearls for NEET-PG:** * **Timing:** Oocyte retrieval is typically performed **34–36 hours** after the HCG "trigger" shot. * **Dose:** Standard dose is 5,000–10,000 IU of urinary HCG or 250 mcg of recombinant HCG (Ovidrel). * **Complication:** HCG is the primary driver of **Ovarian Hyperstimulation Syndrome (OHSS)**. In high-risk patients, a GnRH agonist trigger is preferred to reduce this risk.

Question 99: Sperm interaction with cervical mucus is assessed by which test?

A. Friedman test
B. Sims-Huhner test (Correct Answer)
C. Rubin's test
D. Papanicolaou test

Explanation: **Explanation:** The **Sims-Huhner test**, also known as the **Post-Coital Test (PCT)**, is the traditional method used to evaluate the interaction between spermatozoa and the cervical mucus. It assesses the ability of sperm to penetrate and survive within the cervical environment. * **Why Option B is correct:** The test is performed during the pre-ovulatory phase (when mucus is thin and stretchy). The couple has intercourse, and 2–12 hours later, a sample of cervical mucus is aspirated. A "normal" result typically shows >10 motile sperm per high-power field (HPF), indicating compatible sperm-mucus interaction. **Analysis of Incorrect Options:** * **A. Friedman test:** An obsolete bioassay formerly used for pregnancy diagnosis (involving the injection of urine into a female rabbit). * **C. Rubin's test:** An outdated method to check fallopian tube patency by insufflating the uterus with Carbon Dioxide ($CO_2$). It has been replaced by Hysterosalpingography (HSG) and Laparoscopy. * **D. Papanicolaou test (Pap smear):** A screening tool used primarily for the detection of cervical precancerous and cancerous lesions, not for fertility assessment. **High-Yield Clinical Pearls for NEET-PG:** * **Timing:** The PCT must be performed just before ovulation (Day 12–14 of a 28-day cycle) when estrogen levels are high, causing the mucus to be receptive (**Spinnbarkeit** and **Ferning** positive). * **Current Status:** While historically significant, the PCT is now rarely used in routine clinical practice due to poor reproducibility and the advent of more reliable semen analysis and intrauterine insemination (IUI) protocols. * **In-vitro alternative:** The **Kurzrok-Miller test** is the in-vitro equivalent for assessing sperm-mucus penetration.

Question 100: Sonosalpingography is done for what purpose?

A. Measuring basal body temperature
B. Detecting pregnancy
C. Testing tubal patency (Correct Answer)
D. Determining anovulatory cycles

Explanation: **Explanation:** **Sonosalpingography (SSG)**, also known as saline infusion sonography, is a diagnostic procedure used primarily to **test tubal patency**. It involves the instillation of sterile saline (or a specialized contrast medium) into the uterine cavity via a catheter while performing real-time transvaginal ultrasonography. If the fallopian tubes are patent, the fluid can be seen spilling from the fimbrial ends into the Pouch of Douglas (POD). **Analysis of Options:** * **Option C (Correct):** SSG is a safe, radiation-free alternative to Hysterosalpingography (HSG) for evaluating the fallopian tubes and the uterine cavity in infertile patients. * **Option A:** Basal body temperature (BBT) is measured daily by the patient at home to retrospectively confirm ovulation, not via ultrasound procedures. * **Option B:** Pregnancy is detected via urine/serum beta-hCG levels or direct visualization of a gestational sac on routine ultrasonography. * **Option D:** Anovulatory cycles are typically diagnosed using mid-luteal progesterone levels or serial follicular monitoring (folliculometry). **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard:** Laparoscopy with **Chromopertubation** (using Methylene blue dye) remains the gold standard for assessing tubal patency. * **First-line Investigation:** Hysterosalpingography (HSG) is the most common initial screening test for tubal factors. * **Timing:** SSG/HSG should be performed during the **pre-ovulatory phase** (Day 7 to Day 10 of the menstrual cycle) to avoid disrupting an early pregnancy and to ensure the endometrium is thin. * **Advantage of SSG:** Unlike HSG, SSG avoids exposure to ionizing radiation and iodine-based contrast agents.

Practice by Chapter

Reproductive Physiology

Practice Questions

Evaluation of the Infertile Couple

Practice Questions

Male Factor Infertility

Practice Questions

Female Factor Infertility

Practice Questions

Ovulatory Disorders

Practice Questions

Tubal and Peritoneal Factors

Practice Questions

Uterine Factors

Practice Questions

Unexplained Infertility

Practice Questions

Assisted Reproductive Technologies

Practice Questions

Psychological Aspects of Infertility

Practice Questions

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