Fertility and Infertility — MCQs

Fertility and Infertility Indian Medical PG Practice Questions and MCQs

Question 131: What is the most common time for embryo transfer after IVF?

A. 2 days post-retrieval
B. 3 days post-retrieval (Correct Answer)
C. 4 days post-retrieval
D. 5 days post-retrieval

Explanation: **Explanation:** In In-Vitro Fertilization (IVF), the timing of embryo transfer is critical for synchronizing the embryonic stage with endometrial receptivity. **Why Option B is Correct:** The most common time for embryo transfer is **3 days post-retrieval**, known as the **Cleavage Stage** transfer. At this point, the embryo typically consists of 6 to 8 cells (blastomeres). This timing is traditionally preferred because it minimizes the duration the embryo spends in an artificial culture medium, reducing potential "in-vitro stress," while still allowing the embryologist to assess early developmental milestones and select the healthiest embryos for transfer. **Analysis of Incorrect Options:** * **Option A (2 days):** While transfers can occur at the 4-cell stage, it provides less data on embryo quality compared to Day 3. * **Option C (4 days):** This is the Morula stage. Transfers are rarely performed on Day 4 because it is difficult to distinguish between a healthy compacting morula and one that has arrested. * **Option D (5 days):** This is the **Blastocyst stage**. While blastocyst transfers have higher implantation rates per embryo and are becoming increasingly popular in modern labs, Day 3 remains the most common clinical practice globally due to lower risks of cycle cancellation (as some embryos may not survive to Day 5 in vitro). **High-Yield Clinical Pearls for NEET-PG:** * **Luteal Phase Support:** After retrieval/transfer, progesterone (vaginal or IM) is mandatory to support the endometrium. * **OHSS Risk:** If a patient develops Ovarian Hyperstimulation Syndrome, a "Freeze-all" strategy is used, delaying transfer to a subsequent cycle. * **Number of Embryos:** To prevent multiple gestations, the current trend is **eSET** (elective Single Embryo Transfer), especially in younger patients.

Question 132: What is the commonest cause of anovulatory infertility?

A. Polycystic ovary syndrome (PCOS) (Correct Answer)
B. Tuberculosis (TB)
C. Endometriosis
D. Thyroid dysfunction

Explanation: **Explanation:** **1. Why PCOS is the Correct Answer:** Polycystic Ovary Syndrome (PCOS) is the most common cause of **anovulatory infertility**, accounting for approximately 70–80% of cases. The underlying pathophysiology involves a hormonal imbalance characterized by hyperandrogenism and an increased LH:FSH ratio. This leads to follicular arrest, where multiple small follicles develop but fail to reach the dominant stage required for ovulation, resulting in chronic anovulation. **2. Why Other Options are Incorrect:** * **Tuberculosis (TB):** In India, Genital TB is a major cause of infertility, but it primarily causes **tubal factor infertility** due to chronic salpingitis and tubal blockage (beaded tubes), or uterine factor infertility (Asherman’s syndrome). It does not typically cause primary anovulation. * **Endometriosis:** This primarily causes infertility through **pelvic adhesions**, distorted tubo-ovarian anatomy, and an altered peritoneal microenvironment. While it can affect egg quality, it is not the most common cause of anovulation. * **Thyroid Dysfunction:** Both hypo- and hyperthyroidism can cause menstrual irregularities and anovulation, but they are significantly less prevalent than PCOS in the general infertile population. **Clinical Pearls for NEET-PG:** * **WHO Classification of Anovulation:** PCOS falls under **WHO Group II** (Normogonadotropic normoestrogenic anovulation), which is the most common category. * **First-line treatment for PCOS infertility:** Letrozole (Aromatase inhibitor) is now preferred over Clomiphene Citrate. * **Gold Standard for Tubal Patency:** Hysterosalpingography (HSG) is the screening test, but Laparoscopic Chromopertubation is the gold standard. * **Most common cause of overall female infertility:** Pelvic inflammatory disease (Tubal factor) is a leading cause globally, but for *anovulatory* specifically, it is always PCOS.

Question 133: Which of the following is NOT a cause of infertility?

A. Salpingitis
B. Chronic pelvic inflammatory disease
C. Submucosal myomata
D. None of the above (Correct Answer)

Explanation: The correct answer is **None of the above** because all three conditions listed (Salpingitis, Chronic PID, and Submucosal myomata) are well-established causes of female infertility. ### **Explanation of Options:** * **Salpingitis (Option A):** This refers to the inflammation of the fallopian tubes, most commonly due to ascending infections. It leads to infertility by causing structural damage to the endosalpinx, loss of ciliary action, or complete tubal occlusion. * **Chronic Pelvic Inflammatory Disease (Option B):** Chronic PID is a leading cause of tubal factor infertility. It results in the formation of pelvic adhesions, hydrosalpinx, and peritubal scarring, which prevents the fimbria from picking up the oocyte and obstructs sperm transport. * **Submucosal Myomata (Option C):** Uterine fibroids (leiomyomas) that are submucosal in location distort the uterine cavity. They cause infertility by interfering with endometrial receptivity, causing focal inflammation, and physically obstructing the tubal ostia or preventing successful embryo implantation. ### **NEET-PG High-Yield Pearls:** * **Most common cause of female infertility:** Polycystic Ovary Syndrome (PCOS) is the leading cause of *ovulatory* dysfunction, while PID is the leading cause of *tubal* factor infertility. * **Gold Standard Investigation:** **Laparoscopy** is the gold standard for diagnosing tubal and peritoneal factors of infertility. * **Fibroid Impact:** While submucosal fibroids significantly impact fertility, subserosal fibroids generally do not affect conception rates. * **Infection Link:** *Chlamydia trachomatis* is the most common organism responsible for silent salpingitis leading to tubal factor infertility.

Question 134: Clomiphene citrate, used in the initial treatment for most anovulatory infertile women, is:

A. A steroidal triphenylethylene derivative.
B. Given on the 7th day to the 10th day after the onset of spontaneous menses.
C. Can be administered if no follicle is >20mm and the endometrium is <5mm. (Correct Answer)
D. An estrogen antagonist only.

Explanation: **Explanation:** Clomiphene Citrate (CC) is a non-steroidal Selective Estrogen Receptor Modulator (SERM) and the first-line treatment for WHO Group II anovulation (e.g., PCOS). **Why Option C is Correct:** Before starting a CC cycle, a baseline ultrasound is essential to ensure the ovaries are "quiet." The presence of a follicle >20mm suggests a residual cyst or a dominant follicle from a previous cycle, which could lead to hyperstimulation or poor response if CC is administered. Similarly, an endometrium <5mm confirms the absence of pregnancy and that the previous cycle's lining has been shed. **Analysis of Incorrect Options:** * **Option A:** CC is a **non-steroidal** triphenylethylene derivative. Its structure is similar to diethylstilbestrol. * **Option B:** It is typically administered for 5 days, starting early in the cycle (usually **Day 2 to Day 6** or Day 3 to Day 7) to coincide with the rise in endogenous FSH. Starting on Day 7 is too late for effective follicular recruitment. * **Option D:** CC acts as a **competitive antagonist** at the hypothalamus and pituitary (blocking negative feedback of estrogen, thus increasing FSH/LH), but it can have **weak agonistic** effects in other tissues. It is a SERM, not a pure antagonist. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** Blocks estrogen receptors in the hypothalamus $\rightarrow$ perceived low estrogen $\rightarrow$ $\uparrow$ GnRH pulse frequency $\rightarrow$ $\uparrow$ Pituitary FSH production $\rightarrow$ Folliculogenesis. * **Success Rates:** Ovulation occurs in ~80% of cases, but the pregnancy rate is lower (~40%) due to its **anti-estrogenic effect on cervical mucus** and the endometrium. * **Side Effects:** Multiple pregnancies (mostly twins, ~8-10%), hot flashes (most common), and Ovarian Hyperstimulation Syndrome (OHSS - rare). * **Dose:** Starts at 50 mg/day for 5 days; maximum dose is usually 150 mg/day.

Question 135: The most serious complication of clomiphene therapy for induction of ovulation is:

A. Bone marrow depression
B. Hyperstimulation syndrome (Correct Answer)
C. Secondary amenorrhea
D. Multiple pregnancy

Explanation: **Explanation:** **Clomiphene Citrate (CC)** is a Selective Estrogen Receptor Modulator (SERM) and the most common first-line agent for ovulation induction. It works by inhibiting the negative feedback of estrogen on the hypothalamus, leading to increased FSH and LH secretion, which stimulates follicular development. **Why Option B is Correct:** **Ovarian Hyperstimulation Syndrome (OHSS)** is the most serious and potentially life-threatening complication of any ovulation induction therapy, including clomiphene. It is characterized by massive ovarian enlargement, increased capillary permeability, and fluid shift from the intravascular to the extravascular space (leading to ascites, pleural effusion, and hemoconcentration). While OHSS is more common with injectable gonadotropins, it can occur with clomiphene, especially in patients with Polycystic Ovary Syndrome (PCOS). **Why Other Options are Incorrect:** * **A. Bone marrow depression:** Clomiphene does not have myelosuppressive properties; this is typically seen with cytotoxic chemotherapy. * **C. Secondary amenorrhea:** Clomiphene is used to *treat* anovulatory cycles; it does not cause amenorrhea. However, its anti-estrogenic effect on the endometrium may sometimes lead to thin lining. * **D. Multiple pregnancy:** This is the **most common** complication of clomiphene (occurring in 8–10% of cases, primarily twins), but it is not classified as the "most serious" compared to the systemic risks of OHSS. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** Competitive antagonist of estrogen receptors at the hypothalamus. * **Most Common Side Effect:** Vasomotor flushes (hot flashes). * **Most Common Complication:** Multiple pregnancy (Twins > Triplets). * **Most Serious Complication:** Ovarian Hyperstimulation Syndrome (OHSS). * **Risk Factor for OHSS:** PCOS patients are at the highest risk. * **Dosing:** Usually started at 50 mg/day for 5 days, beginning on Day 2, 3, 4, or 5 of the menstrual cycle.

Question 136: What is the optimal time in a patient's menstrual cycle to perform an endometrial biopsy for evaluation of infertility?

A. Days 12-14
B. Days 17-19
C. Days 20-22 (Correct Answer)
D. Days 3-5

Explanation: **Explanation:** The primary objective of an endometrial biopsy in infertility evaluation is to assess the **"Window of Implantation"** and confirm ovulation. **Why Days 20-22 is correct:** In a standard 28-day cycle, ovulation occurs on Day 14. Following ovulation, the corpus luteum produces progesterone, which transforms the proliferative endometrium into a secretory one. The optimal time for embryo implantation is roughly 6–10 days post-ovulation (Days 20–24 of the cycle). Performing the biopsy on **Days 20-22** (mid-luteal phase) allows the clinician to evaluate the peak secretory changes and diagnose **Luteal Phase Deficiency (LPD)**, where the endometrium lags behind the chronological date by more than 2 days (Noyes’ Criteria). **Analysis of Incorrect Options:** * **Days 12-14 (Option A):** This is the periovulatory period. The endometrium is still in the late proliferative phase under estrogen dominance; it does not reflect progesterone activity or secretory maturity. * **Days 17-19 (Option B):** This is the early luteal phase. While secretory changes have begun, they are not yet at their peak, making it less reliable for dating the "implantation window." * **Days 3-5 (Option D):** This is the early follicular/menstrual phase. The endometrium is shedding, making it unsuitable for assessing fertility or secretory transformation. **NEET-PG High-Yield Pearls:** * **Noyes’ Criteria:** The traditional histological standard used for dating the endometrium. * **Luteal Phase Deficiency (LPD):** Defined as a histological lag of **>2 days** relative to the actual cycle day. * **Current Trend:** While historically common, the routine use of endometrial biopsy for "dating" is declining in favor of serum Progesterone levels (measured on Day 21) due to the biopsy's invasive nature and high inter-observer variability. * **Pre-menstrual Biopsy:** If the goal is specifically to check for endometrial tuberculosis (a common cause of infertility in India), the biopsy is often taken in the late luteal phase (Day 26-28) to maximize the yield of granulomas.

Question 137: What is the first test for a couple presenting with infertility?

A. Post coital test
B. Chromosomal studies
C. Sperm penetration test
D. Husband's semen analysis (Correct Answer)

Explanation: **Explanation:** In the evaluation of an infertile couple, the **Husband’s Semen Analysis** is the mandatory first-line investigation. This is because male factor infertility contributes to approximately 40–50% of cases. The test is prioritized because it is **non-invasive, inexpensive, and provides immediate, definitive information** regarding the male partner's fertility status before the female partner undergoes more invasive or expensive procedures. **Analysis of Options:** * **A. Post-coital test (Sims-Huhner test):** Historically used to assess sperm-cervical mucus interaction, it is now considered obsolete and is no longer recommended by WHO or ASRM due to poor predictive value and lack of standardization. * **B. Chromosomal studies:** These are specialized tests (Karyotyping) indicated only if there is a history of recurrent pregnancy loss, severe oligospermia (<5 million/ml), or suspected genetic syndromes (e.g., Klinefelter syndrome). They are never a primary screening tool. * **C. Sperm penetration test:** This is a functional assay (e.g., Hamster zona-free ovum test) used to evaluate the ability of sperm to undergo capacitation and fertilize. It is a tertiary-level investigation used in specific cases of unexplained infertility, not a screening test. **NEET-PG High-Yield Pearls:** * **Semen Collection:** Requires 2–7 days of abstinence. The sample should be delivered to the lab within 1 hour. * **WHO 2021 (6th Ed) Criteria:** Lower reference limit for volume is 1.4 mL, total motility is 42%, and normal morphology (Kruger’s strict criteria) is 4%. * **Sequence of Investigation:** Always start with Semen Analysis (Male) → Confirmation of Ovulation (Female) → Tubal Patency tests like HSG (Female).

Question 138: Which of the following findings characterize lower reference limits in a normal semen sample?

A. Volume > 2 mL
B. Sperm concentration of 40 million per mL
C. 30% normal sperm morphology
D. 32% progressive sperm motility (Correct Answer)

Explanation: **Explanation:** The assessment of male fertility is based on the **WHO Laboratory Manual for the Examination and Processing of Human Semen (5th Edition, 2010)**, which established the current lower reference limits (5th centiles) for semen parameters. **Why Option D is Correct:** According to WHO 2010 criteria, the lower reference limit for **progressive motility** (sperm moving actively in a linear or large circle) is **32%**. Total motility (progressive + non-progressive) should be at least 40%. **Analysis of Incorrect Options:** * **A. Volume:** The lower reference limit is **1.5 mL**, not 2 mL. (Note: The older 1999 criteria used 2 mL, but current standards have lowered this). * **B. Sperm Concentration:** The lower limit is **15 million per mL**. A concentration of 40 million is well within the normal range but does not represent the "lower reference limit." * **C. Morphology:** Using Kruger’s strict criteria, the lower reference limit for normal forms is only **4%**. The 30% value is outdated (from the 1992 criteria). **High-Yield Clinical Pearls for NEET-PG:** * **Total Sperm Number:** ≥ 39 million per ejaculate. * **Vitality:** ≥ 58% live spermatozoa. * **pH:** ≥ 7.2. * **Azoospermia:** Absence of sperm in ejaculate. * **Oligozoospermia:** Sperm concentration < 15 million/mL. * **Asthenozoospermia:** Progressive motility < 32%. * **Teratozoospermia:** Normal forms < 4%. * **Update Note:** While the WHO 6th Edition (2021) exists, NEET-PG questions primarily focus on the **5th Edition (2010)** standards. Always prioritize 1.5 mL, 15 million/mL, 32% motility, and 4% morphology.

Question 139: What is the best treatment for women with bilateral tubal blockage who wish to become pregnant?

A. In Vitro Fertilization (IVF) (Correct Answer)
B. Intrauterine Insemination (IUI)
C. Surrogacy
D. Ovulation induction with IUI

Explanation: **Explanation:** The fundamental requirement for natural conception or Intrauterine Insemination (IUI) is at least one patent and functional fallopian tube to facilitate the meeting of the sperm and the oocyte. In cases of **bilateral tubal blockage** (tubal factor infertility), the physiological site of fertilization is completely bypassed. **1. Why IVF is the Correct Answer:** In Vitro Fertilization (IVF) is the gold standard and definitive treatment for bilateral tubal disease. In IVF, oocytes are retrieved directly from the ovaries and fertilized with sperm in a laboratory setting (extracorporeal fertilization). The resulting embryo is then transferred directly into the uterine cavity, completely circumventing the need for fallopian tubes. **2. Why Other Options are Incorrect:** * **Intrauterine Insemination (IUI) & Ovulation Induction (Options B & D):** These methods rely on the fallopian tubes to pick up the egg and allow it to meet the sperm. If both tubes are blocked, the sperm can never reach the egg, making these treatments futile. * **Surrogacy (Option C):** This is indicated for women with uterine factors (e.g., absent uterus, severe Asherman syndrome) or medical contraindications to pregnancy. It is not the first-line treatment for tubal blockage, as the patient can still carry a pregnancy using her own uterus via IVF. **Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Hysterosalpingography (HSG) is the initial screening test for tubal patency, but **Laparoscopic Chromopertubation** is the "Gold Standard" for diagnosis. * **Hydrosalpinx:** If a blocked tube is dilated with fluid (hydrosalpinx), the success rate of IVF decreases. In such cases, **salpingectomy** or tubal clipping is recommended before proceeding with IVF. * **Historical Context:** The first IVF baby (Louise Brown) was born to a mother with tubal factor infertility.

Question 140: Endometrial biopsy for infertility is best taken on which day of the menstrual cycle?

A. Day 5 to 7
B. Day 12 to 14
C. Day 23 to 26 (Correct Answer)
D. Day 9 to 11

Explanation: **Explanation:** The primary objective of an endometrial biopsy in infertility is to assess the **adequacy of the luteal phase** and confirm **ovulation**. **Why Day 23 to 26 is correct:** In a standard 28-day cycle, ovulation occurs around Day 14. Following ovulation, the corpus luteum produces progesterone, which transforms the proliferative endometrium into a secretory one. A biopsy taken during the **late luteal phase (Day 23–26)** allows the pathologist to observe maximal secretory changes. By comparing the histological "dating" of the endometrium (using Noyes’ criteria) with the actual chronological day of the cycle, clinicians can diagnose **Luteal Phase Deficiency (LPD)**—a condition where the endometrium is out of sync, potentially preventing successful implantation. **Analysis of Incorrect Options:** * **Day 5 to 7 (Option A):** This is the early proliferative phase. The endometrium is thin and regenerating; it provides no information about ovulation or progesterone effect. * **Day 12 to 14 (Option B):** This is the periovulatory period. The endometrium is still proliferative (influenced by estrogen), making it impossible to assess the luteal function. * **Day 9 to 11 (Option D):** This is the mid-proliferative phase, used primarily to check for estrogenic response, not for infertility workups regarding implantation. **Clinical Pearls for NEET-PG:** * **Gold Standard for Ovulation:** While biopsy was traditional, the current "gold standard" to confirm ovulation is **Transvaginal Sonography (TVS)** for follicular tracking. * **Timing:** Ideally, the biopsy is performed 2–3 days before the expected onset of menstruation. * **Noyes’ Criteria:** The classic histological method used to date the endometrium. * **Alternative:** A mid-luteal (Day 21) serum progesterone level >3 ng/mL is a simpler, non-invasive way to confirm ovulation.

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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