Fertility and Infertility — MCQs

Fertility and Infertility Indian Medical PG Practice Questions and MCQs

Question 111: What is oligospermia?

A. Sperm count less than 20 million/cubic millimeter (Correct Answer)
B. Absence of sperms
C. Absence of semen
D. Decreased spermatogenesis

Explanation: **Explanation:** **Oligospermia** is defined as a deficiency in the number of spermatozoa in the semen. According to the traditional criteria often tested in exams like NEET-PG, a sperm count **less than 20 million/mL** (or cubic millimeter) is considered oligospermia. While the WHO 2010/2021 manuals have lowered the lower reference limit to 15 million/mL, the 20 million threshold remains a classic benchmark in clinical obstetrics and gynecology. **Analysis of Options:** * **Option A (Correct):** Oligospermia specifically refers to the quantitative reduction of sperm density below the normal threshold. * **Option B (Incorrect):** The total absence of spermatozoa in the ejaculate is termed **Azoospermia**. * **Option C (Incorrect):** The total absence of semen (failure to ejaculate) is termed **Aspermia**. * **Option D (Incorrect):** Decreased spermatogenesis is a physiological process/pathology that *leads* to oligospermia, but it is not the definition of the term itself. **High-Yield Clinical Pearls for NEET-PG:** * **Asthenozoospermia:** Reduced sperm motility (<40% total motile or <32% progressively motile). * **Teratozoospermia:** Increased percentage of abnormal sperm morphology (<4% normal forms by Kruger’s strict criteria). * **Necrozoospermia:** All sperms in the ejaculate are dead. * **Normal Semen Volume:** 1.5 to 5 mL. * **Fructose:** Produced by seminal vesicles; its absence in azoospermia suggests obstructive pathology (e.g., congenital bilateral absence of vas deferens).

Question 112: What is meant by homologous sperm in the context of In Vitro Fertilization (IVF)?

A. Sperm from a donor and the female partner
B. Sperm from the male partner and the female partner (Correct Answer)
C. Sperm from the male partner and a surrogate
D. Sperm from a donor and a surrogate

Explanation: **Explanation:** In the context of Assisted Reproductive Technology (ART), the term **"homologous"** refers to the use of gametes (sperm or oocytes) derived from the intended parents themselves (the legal couple). Therefore, **homologous IVF** involves using the sperm of the male partner and the oocytes of the female partner to create an embryo. **Breakdown of Options:** * **Option B (Correct):** This describes a standard IVF procedure where both genetic materials come from the couple seeking treatment. It is "homologous" because the biological parents are the same as the intended social parents. * **Option A (Incorrect):** This refers to **Heterologous IVF** (specifically Donor Insemination/IVF), where the sperm is sourced from a third-party donor rather than the male partner. * **Option C & D (Incorrect):** These involve **Surrogacy**. While Option C uses the partner's sperm, the involvement of a surrogate (a third party providing the uterus) moves it out of the standard definition of a simple homologous procedure. Option D represents a "double-donor" or "donor-surrogate" scenario, which is entirely heterologous. **High-Yield Clinical Pearls for NEET-PG:** * **Terminology:** *Homologous* = Husband/Partner; *Heterologous* = Donor. * **IUI vs. IVF:** Intrauterine Insemination using the husband's sperm is termed **AIH** (Artificial Insemination Husband), whereas using donor sperm is **AID** (Artificial Insemination Donor). * **Indications for Homologous IVF:** Bilateral tubal block (most common), severe endometriosis, or unexplained infertility where the husband’s semen parameters are sufficient for fertilization. * **Legal Aspect:** Under the ART (Regulation) Act in India, informed consent is mandatory for both homologous and heterologous procedures, with strict anonymity protocols for donors.

Question 113: Which uterine anomaly is associated with the best fertility outcome?

A. Bicornuate uterus
B. Unicornuate uterus
C. Septate uterus
D. Arcuate uterus (Correct Answer)

Explanation: **Explanation:** The correct answer is **Arcuate uterus**. This question tests the clinical significance of Müllerian duct anomalies on reproductive outcomes. **1. Why Arcuate Uterus is Correct:** The arcuate uterus is considered a mild anatomical variation rather than a true malformation. It is characterized by a small indentation of the fundal endometrium (usually <1 cm). Because the uterine cavity remains largely undistorted and the myometrial structure is intact, it does **not** significantly impair implantation or increase the risk of pregnancy loss. It is associated with the **best fertility outcomes**, often comparable to a normal uterus. **2. Why Other Options are Incorrect:** * **Septate Uterus (C):** This is the most common anomaly and is associated with the **worst reproductive outcomes**. The septum is fibrous and relatively avascular, leading to implantation failure or recurrent early pregnancy loss. (Note: It is also the most common cause of recurrent mid-trimester abortions). * **Bicornuate (A) and Unicornuate Uterus (B):** These are "true" malformations resulting from incomplete fusion or development of Müllerian ducts. They are associated with significantly higher rates of malpresentation, preterm labor, and intrauterine growth restriction (IUGR) due to reduced space and abnormal vascularity. **3. NEET-PG High-Yield Pearls:** * **Most common uterine anomaly:** Septate uterus. * **Anomaly with worst prognosis:** Septate uterus (but it is also the most treatable via hysteroscopic septal resection). * **Renal anomalies:** Most commonly associated with **Unicornuate uterus** (ipsilateral renal agenesis). * **DES exposure:** Classically associated with a **T-shaped uterus**. * **Investigation of choice:** 3D Ultrasound is the gold standard for diagnosis; MRI is also highly accurate.

Question 114: A hysterosalpingogram shows which of the following findings suggestive of a potential cause of infertility?

A. Uterine polyp
B. Bicornuate uterus
C. Genital tuberculosis (Correct Answer)
D. Dermoid cyst

Explanation: ***Genital tuberculosis*** - Shows **pathognomonic HSG findings** including **tobacco-pouch** or **golf-hole uterus** appearance due to endometrial scarring and adhesions. - Demonstrates **beaded tubes**, **pipe-stem tubes**, and **calcifications** in fallopian tubes, indicating chronic tuberculous infection affecting fertility. *Uterine polyp* - Appears as **filling defects** within the uterine cavity on HSG, creating irregular contours but not the classic tuberculous patterns. - Does not cause the characteristic **scarring** and **adhesion patterns** seen with genital tuberculosis. *Bicornuate uterus* - Shows **heart-shaped** or **Y-shaped** uterine cavity with **fundal indentation** greater than 1 cm on HSG. - Represents a **congenital anomaly** without the inflammatory changes and tubal pathology of tuberculosis. *Dermoid cyst* - Is an **ovarian lesion** that cannot be visualized on HSG as this imaging modality only evaluates the **uterine cavity** and **fallopian tubes**. - Would require **ultrasound** or **CT/MRI** for diagnosis, showing characteristic **fat**, **hair**, and **teeth** components.

Question 115: All are side effects of clomiphene citrate except?

A. Ovarian cysts
B. Hot flushes
C. Breast soreness
D. Amenorrhea (Correct Answer)

Explanation: **Explanation:** Clomiphene Citrate (CC) is a Selective Estrogen Receptor Modulator (SERM) and the traditional first-line agent for ovulation induction. It works by binding to estrogen receptors in the hypothalamus, blocking the negative feedback of endogenous estrogen. This leads to an increase in GnRH, FSH, and LH, which stimulates follicular development. **Why Amenorrhea is the Correct Answer:** Amenorrhea (absence of menstruation) is **not** a side effect of Clomiphene. In fact, Clomiphene is used therapeutically to **induce ovulation** and regularize cycles in women with oligomenorrhea or anovulatory cycles (like PCOS). By triggering ovulation, it leads to a subsequent luteal phase and predictable menstrual bleeding if pregnancy does not occur. **Analysis of Incorrect Options:** * **Hot Flushes (Option B):** This is the **most common** side effect (approx. 10%). It occurs due to the anti-estrogenic effect on the hypothalamus, mimicking menopausal vasomotor symptoms. * **Ovarian Cysts (Option A):** Overstimulation of the ovaries can lead to the formation of multiple follicular cysts or, in severe cases, Ovarian Hyperstimulation Syndrome (OHSS), though OHSS is less common with CC than with gonadotropins. * **Breast Soreness (Option C):** This occurs due to the increased levels of endogenous estrogen produced by the multiple developing follicles. **NEET-PG High-Yield Pearls:** * **Mechanism:** Competitive antagonist of estrogen receptors at the hypothalamus. * **Multiple Pregnancy:** Risk is approximately 8–10% (predominantly twins). * **Anti-estrogenic effects:** CC can cause thinning of the endometrium and thickening of cervical mucus, which may create a "discrepancy" between high ovulation rates and lower pregnancy rates. * **Visual Disturbances:** Scintillating scotomas are a rare but specific side effect; if they occur, the drug should be discontinued.

Question 116: Chlamydia infection can cause infertility due to which of the following complications?

A. Salpingitis (Correct Answer)
B. Endometritis
C. Oophoritis
D. Cervicitis

Explanation: **Explanation:** The primary mechanism by which *Chlamydia trachomatis* causes infertility is through **Salpingitis** (inflammation of the fallopian tubes). Chlamydia is an obligate intracellular pathogen that often causes "silent" or subclinical Pelvic Inflammatory Disease (PID). The chronic inflammatory response leads to scarring, fibrosis, and eventual **tubal occlusion** or loss of ciliary function. This prevents the transport of the ovum and sperm, resulting in tubal factor infertility or an increased risk of ectopic pregnancy. **Analysis of Options:** * **Salpingitis (Correct):** Tubal damage is the most significant cause of permanent infertility following a Chlamydial infection. Even a single episode of PID increases the risk of infertility by approximately 10-12%. * **Endometritis:** While Chlamydia can cause inflammation of the uterine lining, endometritis is usually transient. It does not typically result in permanent infertility unless it progresses to the fallopian tubes. * **Oophoritis:** Inflammation of the ovaries can occur as part of PID, but it is less common than salpingitis and rarely the primary cause of infertility in Chlamydial infections. * **Cervicitis:** This is the most common initial presentation of Chlamydia (mucopurulent discharge). However, as long as the infection is confined to the cervix, it does not cause infertility. Infertility only occurs when the infection ascends to the upper genital tract. **Clinical Pearls for NEET-PG:** * **Fitz-Hugh-Curtis Syndrome:** A complication of Chlamydial PID characterized by perihepatitis and "violin-string" adhesions between the liver capsule and the abdominal wall. * **Gold Standard Diagnosis:** Nucleic Acid Amplification Test (NAAT). * **Treatment:** Azithromycin (1g stat) or Doxycycline (100mg BD for 7 days). Always treat the partner to prevent reinfection. * Chlamydia is the leading cause of **preventable** infertility worldwide.

Question 117: What is asthenozoospermia?

A. Increased abnormal forms of sperm
B. Decreased sperm motility (Correct Answer)
C. Absence of sperms in semen
D. Increased white cells in semen

Explanation: **Explanation:** The term **Asthenozoospermia** is derived from the Greek word *‘sthenos’* (strength), where ‘a-stheno’ implies a lack of strength or movement. According to the WHO criteria (6th Edition, 2021), it is defined as **decreased sperm motility**, specifically when the total motility is <40% or progressive motility is <32%. **Analysis of Options:** * **Option A (Teratozoospermia):** Refers to a high percentage of sperm with abnormal morphology (normal forms <4%). * **Option B (Correct):** Asthenozoospermia specifically denotes impaired motility, which is a critical factor for sperm to traverse the cervical mucus and fertilize the oocyte. * **Option C (Azoospermia):** Refers to the total absence of spermatozoa in the ejaculate. (Note: *Aspermia* is the complete absence of semen). * **Option D (Leukocytospermia/Pyospermia):** Defined as the presence of >1 million white blood cells per ml of semen, often indicating infection. **High-Yield Clinical Pearls for NEET-PG:** * **Oligozoospermia:** Sperm count <15 million/ml. * **Necrozoospermia:** All sperms in the ejaculate are dead (non-viable). * **Globozoospermia:** A rare type of teratozoospermia where sperm have round heads and lack an acrosome ("round-headed sperm"). * **Kallmann Syndrome:** A common cause of hypogonadotropic hypogonadism leading to infertility and anosmia. * **Varicocele:** The most common reversible cause of male infertility, often leading to a "stress pattern" (low count, poor motility, and abnormal forms).

Question 118: A 25-year-old male underwent semen analysis. Results show: sperm count - 15 million/ml; pH - 7.5; volume - 2 ml; no agglutination is seen. Morphology shows 60% normal and 60% motile sperms. What is the most likely diagnosis?

A. Normospermia
B. Oligospermia (Correct Answer)
C. Azoospermia
D. Aspermia

Explanation: ### Explanation The diagnosis is based on the **WHO 2010/2021 criteria** for semen analysis. In this case, the patient’s sperm count is **15 million/ml**, which falls below the lower reference limit. **1. Why Oligospermia is correct:** * **Oligospermia** is defined as a total sperm count of less than 15 million/ml (or less than 39 million per ejaculate). * In this scenario, while the volume (2 ml), motility (60%), and morphology (60%) are within normal limits, the concentration is at the borderline/low threshold. According to standard nomenclature, any value below 15 million/ml is classified as oligospermia. **2. Why other options are incorrect:** * **Normospermia:** Refers to a normal semen analysis where all parameters (count ≥15 million/ml, motility ≥40%, morphology ≥4% Kruger’s criteria) are met. * **Azoospermia:** Refers to the total absence of spermatozoa in the ejaculate after centrifugation. * **Aspermia:** Refers to the complete absence of semen (no ejaculate volume), often seen in retrograde ejaculation or ductal obstruction. **3. High-Yield NEET-PG Clinical Pearls:** * **Asthenozoospermia:** <40% total motility or <32% progressive motility. * **Teratozoospermia:** <4% normal forms (using strict Kruger criteria). * **Necrozoospermia:** All sperms in the ejaculate are dead. * **Globozoospermia:** A rare condition where sperm heads are round and lack an acrosome (associated with infertility). * **Initial Investigation:** Semen analysis is the first-line investigation for male factor infertility and should be repeated after 4–12 weeks if the first sample is abnormal.

Question 119: What is the incidence of infertility in reproductive-age couples?

A. 0-5%
B. 5-10%
C. 10-20% (Correct Answer)
D. 25-30%

Explanation: **Explanation:** Infertility is defined as the inability of a couple to achieve pregnancy after **12 months** of regular, unprotected intercourse. Globally and in India, the prevalence of infertility among reproductive-age couples is consistently cited between **10% and 15%**, with some studies extending the range up to **20%** depending on the population and environmental factors. Therefore, **10-20%** is the most accurate statistical range for medical examinations. **Analysis of Options:** * **0-5% (Option A):** This is significantly lower than the actual prevalence. Even in highly fertile populations, the rate of primary and secondary infertility exceeds this range. * **5-10% (Option B):** While some specific regions may report lower figures, this range underestimates the global burden of infertility, which has been rising due to delayed childbearing and lifestyle factors. * **25-30% (Option D):** This is an overestimation of the general population's infertility rate. However, this figure may represent the risk of infertility in specific high-risk subgroups (e.g., women over age 40). **High-Yield Clinical Pearls for NEET-PG:** * **Fecundability:** The probability of achieving pregnancy in a single menstrual cycle (approx. **20-25%** in healthy couples). * **Fecundity:** The probability of achieving a live birth in a single cycle. * **Causes:** Male factors account for ~30-40%, female factors for ~40-50%, and unexplained factors for ~10-20%. * **Primary vs. Secondary:** Primary infertility refers to couples who have never conceived; secondary refers to those who have conceived at least once before.

Question 120: Which hormone best indicates ovarian reserve?

A. Luteinizing hormone (LH)
B. Follicle-stimulating hormone (FSH) (Correct Answer)
C. LH/FSH ratio
D. Estrogen

Explanation: **Explanation:** Ovarian reserve refers to the quantity and quality of the remaining oocytes in the ovaries. **Follicle-stimulating hormone (FSH)** is the most widely used biochemical marker for assessing this reserve. As the pool of primordial follicles declines with age or premature ovarian failure, there is a decrease in the production of **Inhibin B** and **Estradiol**. This loss of negative feedback on the pituitary gland leads to a compensatory rise in serum FSH levels. Therefore, a high basal FSH level (typically measured on Day 2 or 3 of the menstrual cycle) is a reliable indicator of diminished ovarian reserve. **Analysis of Incorrect Options:** * **Luteinizing Hormone (LH):** While LH is essential for ovulation and androgen production, its basal levels do not reliably reflect the oocyte pool. * **LH/FSH Ratio:** An elevated LH/FSH ratio (typically >2:1 or 3:1) is a classic biochemical marker for **Polycystic Ovary Syndrome (PCOS)**, not a measure of declining ovarian reserve. * **Estrogen (Estradiol):** While Day 3 Estradiol is often measured alongside FSH, it is less specific. High early-cycle estrogen can actually "mask" a high FSH by providing false negative feedback, making it a secondary marker rather than the primary indicator. **NEET-PG High-Yield Pearls:** * **Best Single Marker:** While this question identifies FSH, modern clinical practice considers **Anti-Müllerian Hormone (AMH)** the most sensitive and reliable marker because it is cycle-independent. * **Best Imaging Marker:** **Antral Follicle Count (AFC)** via transvaginal ultrasound is the gold standard for morphological assessment of reserve. * **Day of Testing:** Basal FSH must be tested on **Day 2-4** of the cycle to be valid. * **Cut-off:** FSH levels **>10-12 mIU/mL** generally suggest a poor response to ovarian stimulation.

Practice by Chapter

Reproductive Physiology

Practice Questions

Evaluation of the Infertile Couple

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Male Factor Infertility

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Female Factor Infertility

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Ovulatory Disorders

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Tubal and Peritoneal Factors

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Uterine Factors

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Unexplained Infertility

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Assisted Reproductive Technologies

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Psychological Aspects of Infertility

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