Fertility and Infertility — MCQs

Fertility and Infertility Indian Medical PG Practice Questions and MCQs

Question 141: Tubal patency is checked by all of the following except?

A. Hysterosalpingography
B. Laparoscopy
C. Falloscopy
D. Colposcopy (Correct Answer)

Explanation: **Explanation:** The correct answer is **Colposcopy**. This question tests your ability to differentiate between diagnostic tools for the upper and lower female reproductive tract. **Why Colposcopy is the correct answer:** Colposcopy is a diagnostic procedure used to visualize the **cervix, vagina, and vulva** under magnification. It is primarily used to evaluate abnormal Pap smears and screen for cervical intraepithelial neoplasia (CIN) or malignancy. It does not involve the uterine cavity or the fallopian tubes; therefore, it cannot be used to assess tubal patency. **Evaluation of Incorrect Options:** * **Hysterosalpingography (HSG):** This is the **initial/screening investigation** of choice for tubal patency. It involves injecting radiopaque dye into the uterus and taking X-rays to visualize the spill from the fimbrial ends. * **Laparoscopy (with Chromopertubation):** This is the **Gold Standard** for assessing tubal patency. Methylene blue dye is injected transcervically, and its spill from the tubes is directly visualized via a laparoscope. It also allows for the diagnosis of extrinsic factors like adhesions or endometriosis. * **Falloscopy:** This involves the use of a micro-endoscope to directly visualize the **internal lumen** of the fallopian tubes. It can identify intratubal pathology like debris or scarring. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard for Tubal Patency:** Laparoscopy + Chromopertubation. * **First-line/Screening Test:** Hysterosalpingography (HSG). * **Sonohysterosalpingography (SSG):** Uses saline and ultrasound; it is safer (no radiation) but less accurate than HSG for distal tubal blocks. * **Rubin’s Test:** An obsolete method using $CO_2$ insufflation to check patency (shoulder pain indicates a positive test).

Question 142: What is the accepted minimum period of sexual cohabitation for a couple to be declared infertile in the context of modern life schedules?

A. One year (Correct Answer)
B. One and a half years
C. Two years
D. Three years

Explanation: **Explanation:** In reproductive medicine, **Infertility** is clinically defined as the failure of a couple to achieve a clinical pregnancy after **one year (12 months)** or more of regular, unprotected sexual intercourse. **Why Option A is Correct:** This definition is based on the concept of **fecundability** (the probability of achieving pregnancy in one menstrual cycle). In a healthy couple, approximately 80–85% will conceive within the first year. The one-year threshold is the standard established by the WHO and ACOG to balance the need for medical intervention with the natural biological timeline of human reproduction. **Why Other Options are Incorrect:** * **Options B, C, and D:** While historical definitions sometimes suggested longer periods (especially in older texts or specific demographic studies), modern clinical guidelines have standardized the period to one year. Waiting 1.5 to 3 years would unnecessarily delay the diagnosis of treatable conditions like tubal factor infertility or low ovarian reserve, leading to decreased success rates for ART (Assisted Reproductive Technology). **High-Yield Clinical Pearls for NEET-PG:** * **Primary Infertility:** The couple has never conceived. * **Secondary Infertility:** The couple has conceived at least once before, regardless of the outcome (live birth, miscarriage, or ectopic). * **Exception to the 1-Year Rule:** Evaluation should be initiated after **6 months** if the female partner is **>35 years old**, or immediately if there is a known history of endometriosis, PCOS, or pelvic inflammatory disease. * **Fecundability Rate:** Approximately 20% per month in a healthy young couple.

Question 143: In an infertile woman, endometrial biopsy reveals proliferative changes. Which hormone should be preferred?

A. Medroxyprogesterone acetate (Correct Answer)
B. Desogestrel
C. Norethisterone
D. None of the above

Explanation: **Explanation:** The presence of **proliferative changes** on an endometrial biopsy in an infertile woman indicates that the endometrium is under the influence of estrogen but lacks the effect of progesterone. This signifies **anovulation**, as the corpus luteum (which produces progesterone) has not formed. To induce a secretory phase and ensure a regular withdrawal bleed, exogenous progesterone must be administered. **Why Medroxyprogesterone acetate (MPA) is the correct choice:** MPA is a derivative of 17-α-hydroxyprogesterone. In clinical practice, it is the preferred agent for "Progesterone Challenge" or "Medical Curettage" in cases of anovulatory infertility. It effectively converts a proliferative endometrium into a secretory one without having significant androgenic or estrogenic side effects, making it the standard choice for inducing withdrawal bleeding and regulating the cycle in these patients. **Analysis of Incorrect Options:** * **Desogestrel:** This is a third-generation synthetic progestin primarily used in combined oral contraceptive pills (COCPs) or progestogen-only pills (POPs). While it is potent, it is not the first-line choice for simple replacement in anovulatory cycles. * **Norethisterone:** This is a 19-nortestosterone derivative. While it can induce a secretory change, it has significant **androgenic properties** and can be metabolized to estrogen. In the context of infertility, MPA is preferred due to its cleaner profile regarding metabolic and androgenic effects. **NEET-PG High-Yield Pearls:** * **Endometrial Biopsy Timing:** Ideally performed on Day 21–23 of a 28-day cycle (Luteal phase) to check for secretory changes (evidence of ovulation). * **Dating the Endometrium:** Noyes’ criteria are used to date the endometrium; a lag of >2 days is diagnostic of Luteal Phase Defect (LPD). * **Anovulation:** The most common cause of female infertility; characterized by a proliferative endometrium in the second half of the cycle.

Question 144: Kamla, a 30-year-old lady, is examined for infertility by hysterosalpingography, which reveals 'bead-like' fallopian tubes and clubbing of the ampulla. What is the most likely cause?

A. Gonococcus
B. Mycoplasma
C. Chlamydia
D. Mycobacterium tuberculosis (Correct Answer)

Explanation: **Explanation:** The clinical presentation and hysterosalpingography (HSG) findings are classic for **Genital Tuberculosis**, caused by *Mycobacterium tuberculosis*. **Why the Correct Answer is Right:** Genital TB is a significant cause of tubal factor infertility in developing countries. It typically spreads hematogenously to the fallopian tubes (affected in 90-100% of cases). The characteristic HSG findings include: * **Beaded appearance:** Caused by multiple strictures and scarring along the tube. * **Clubbing of the ampulla:** Resulting from fimbriated end occlusion and distal dilatation. * **Lead pipe appearance:** Rigid, straight tubes due to chronic inflammation. * **Tobacco pouch appearance:** Eversion of the fimbriae. **Why Incorrect Options are Wrong:** * **Gonococcus & Chlamydia:** These are the most common causes of Pelvic Inflammatory Disease (PID). While they cause tubal blockage and hydrosalpinx, they typically present with acute symptoms and lead to "fimbriated end block" or "beaded" appearance less frequently than TB. Chlamydia is more associated with "silent" salpingitis and perihepitic adhesions (Fitz-Hugh-Curtis syndrome). * **Mycoplasma:** While it can cause cervicitis or PID, it is a rare cause of the specific chronic architectural distortions (beading and clubbing) seen in this scenario. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Endometrial biopsy for histopathology (showing giant cells/granulomas) and TB-PCR/Culture, ideally performed in the pre-menstrual phase. * **Most common site:** Fallopian tubes (100%) > Endometrium (50%) > Ovaries (20%). * **Schier’s Sign:** Calcified lymph nodes or pelvic calcifications on X-ray, highly suggestive of TB. * **Prognosis:** While antitubercular therapy (ATT) can treat the infection, the structural damage to the tubes is often irreversible, making IVF the preferred fertility treatment.

Question 145: Which one of the following procedures is used for severe male factor infertility?

A. Gamete Intrafallopian Transfer (GIFT)
B. Zygote Intrafallopian Transfer (ZIFT)
C. Intracytoplasmic Sperm Injection (ICSI) (Correct Answer)
D. In Vitro Fertilization (IVF)

Explanation: **Explanation:** **Intracytoplasmic Sperm Injection (ICSI)** is the treatment of choice for severe male factor infertility. The underlying medical concept involves the mechanical bypass of natural fertilization barriers; a single viable sperm is directly injected into the cytoplasm of a mature oocyte (MII stage). This overcomes issues where sperm cannot penetrate the zona pellucida due to **severe oligospermia** (low count), **asthenospermia** (poor motility), or **teratospermia** (abnormal morphology). **Analysis of Incorrect Options:** * **IVF (In Vitro Fertilization):** Conventional IVF requires a minimum concentration of motile sperm (approx. 50,000–100,000 per egg) to achieve spontaneous fertilization in a dish. It is ineffective if sperm parameters are severely compromised. * **GIFT (Gamete Intrafallopian Transfer):** Both eggs and sperm are placed into the fallopian tube. It requires at least one functional tube and adequate sperm quality, as fertilization occurs *in vivo*. * **ZIFT (Zygote Intrafallopian Transfer):** Fertilization occurs in vitro, and the zygote is transferred to the fallopian tube. Like IVF, it still relies on relatively healthy sperm for initial fertilization unless combined with ICSI. **High-Yield Clinical Pearls for NEET-PG:** * **Indications for ICSI:** Sperm count <5 million/ml, <5% motility, obstructive/non-obstructive azoospermia (using TESA/PESA), or previous IVF failure. * **Prerequisite:** The oocyte must be in the **Metaphase II (MII)** stage (identified by the presence of the first polar body). * **Success Rate:** Fertilization rates with ICSI are approximately 70-80%, independent of sperm quality. * **Azoospermia:** In cases of azoospermia, ICSI is the only way to achieve biological parenthood using surgically retrieved sperm.

Question 146: What is the most common type of twin pregnancy following assisted reproductive technology?

A. Monozygotic twin
B. Acardiac twin
C. Dizygotic twin (Correct Answer)
D. Conjoined twin

Explanation: **Explanation:** The correct answer is **Dizygotic twin (Option C)**. **Why Dizygotic twin is correct:** Assisted Reproductive Technology (ART), specifically In Vitro Fertilization (IVF) and Ovulation Induction (OI), significantly increases the risk of multiple gestations. The primary reason for the high incidence of twins in ART is the **transfer of multiple embryos** into the uterus during an IVF cycle or the **stimulation of multiple follicles** using gonadotropins or clomiphene citrate. Since these twins arise from two separate eggs fertilized by two separate sperm, they are genetically distinct and classified as dizygotic (fraternal) twins. **Why other options are incorrect:** * **Monozygotic twin (Option A):** While ART does slightly increase the risk of monozygotic (identical) twinning compared to natural conception (likely due to zona pellucida manipulation), dizygotic twins remain far more common due to the practice of multi-embryo transfer. * **Acardiac twin (Option B):** This is a rare, severe complication of monochorionic multiple pregnancies (Twin Reversed Arterial Perfusion sequence). It is a specific pathology, not a "type" of pregnancy common to ART. * **Conjoined twin (Option D):** These occur due to the incomplete division of a single zygote after 13 days of fertilization. They are extremely rare and not the standard outcome of ART. **NEET-PG High-Yield Pearls:** * **Most common twin overall (Natural & ART):** Dizygotic twins. * **Most common type of Monozygotic twin:** Monochorionic Diamniotic (60-70%). * **The "T-sign" on ultrasound:** Indicates Monochorionic twins. * **The "Lambda (λ) sign" or "Twin Peak sign":** Indicates Dichorionic twins (all dizygotic twins are dichorionic). * **Vanishing Twin Syndrome:** The spontaneous loss of one fetus in a multi-gestational pregnancy, often seen in ART-related early ultrasounds.

Question 147: A female patient presents with complaints of infertility. Hysterosalpingography (HSG) findings are described as follows. What is the most likely diagnosis?

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

Explanation: ***Unicornuate uterus*** - HSG shows a characteristic **single banana-shaped uterine cavity** with only **one fallopian tube** visible, representing incomplete development of one Müllerian duct. - Associated with **increased infertility** and **pregnancy complications** due to reduced uterine volume and potential **renal anomalies** on the same side. *Septate uterus* - HSG demonstrates a **normal external uterine contour** with an **internal septum** dividing the cavity, creating two compartments. - The **intercornual angle is acute (<90°)** and both fallopian tubes are present, unlike the single tube in unicornuate uterus. *Bicornuate uterus* - HSG reveals **two separate uterine horns** with an **obtuse intercornual angle (>90°)** and a **fundal indentation** visible externally. - Both **fallopian tubes are present** and the external contour shows a **heart-shaped** appearance, contrasting with the single cavity in unicornuate uterus. *Uterus didelphys* - HSG shows **complete duplication** with **two separate uterine cavities** and **two cervices**, requiring separate contrast injections. - Represents **complete non-fusion** of Müllerian ducts, unlike the partial development seen in unicornuate uterus.

Question 148: A nullipara is being investigated for infertility and has a history of successfully treated pulmonary tuberculosis. If genital tuberculosis is the cause of her infertility, which organ is most likely to be affected?

A. Tubes (Correct Answer)
B. Uterus
C. Cervix
D. Vagina

Explanation: **Explanation:** Genital tuberculosis (GTB) is a significant cause of secondary and primary infertility in developing countries. It is almost always secondary to an extra-genital focus, most commonly the lungs, from which the bacilli spread to the pelvic organs via the **hematogenous route**. **1. Why the Fallopian Tubes are the correct answer:** The fallopian tubes are the **most common site** of genital tuberculosis, being affected in **90–100%** of cases. Because the tubes have a high vascularity and a narrow lumen, the tubercle bacilli easily lodge in the endosalpinx. This leads to chronic salpingitis, characteristic "beaded tubes," and eventually, tubal occlusion or "tobacco pouch" appearance, leading to infertility. **2. Why the other options are incorrect:** * **Uterus (Endometrium):** This is the second most common site, affected in about **50–60%** of cases. It is almost always secondary to tubal involvement (descending infection). * **Cervix:** Involved in only **5–15%** of cases. It usually presents as an erosive or hypertrophic lesion mimicking malignancy. * **Vagina/Vulva:** These are the rarest sites, affected in **<1%** of cases, as the squamous epithelium is relatively resistant to the bacilli. **Clinical Pearls for NEET-PG:** * **Order of Frequency:** Fallopian Tubes (100%) > Uterus (50%) > Ovaries (25%) > Cervix (5%). * **Hysterosalpingography (HSG) Findings:** Look for "Beaded tubes," "Golf-hole ostia," or "Lead pipe" appearance. * **Asherman’s Syndrome:** Severe TB endometritis can lead to uterine synechiae (Netter's Syndrome), causing secondary amenorrhea. * **Gold Standard Diagnosis:** Endometrial biopsy/aspirate for TB-PCR or culture (taken in the pre-menstrual phase).

Question 149: A couple has been having unprotected intercourse for one year without conceiving and presents to an infertility clinic. The woman has a normal menstrual cycle. Semen analysis shows abnormal sperm morphology, low count, and normal volume. What is the best next step?

A. Perform hysterosalpingography (HSG) in the woman
B. Check luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels
C. Repeat semen analysis (Correct Answer)
D. Get a scrotal ultrasound done

Explanation: ### Explanation **Correct Option: C. Repeat semen analysis** The diagnosis of male factor infertility should never be based on a single abnormal semen analysis. Sperm parameters exhibit significant physiological variability due to factors like recent illness, stress, or duration of abstinence. According to WHO guidelines, if the initial semen analysis is abnormal, it must be **repeated after 2–4 weeks** (ideally 3 months to cover a full spermatogenic cycle) to confirm the findings before initiating invasive or expensive investigations. **Why other options are incorrect:** * **A. Perform HSG:** While evaluating tubal patency is part of the basic infertility workup, the immediate priority is to confirm the male factor abnormality already identified. * **B. Check LH and FSH levels:** Hormonal evaluation in males is indicated only after a persistent abnormality is confirmed on a repeat semen analysis, especially if the count is <5–10 million/ml. * **D. Get a scrotal ultrasound:** This is not a routine screening tool. It is indicated only if a physical exam suggests a varicocele, mass, or if there is obstructive azoospermia. --- ### High-Yield NEET-PG Pearls * **Definition of Infertility:** Failure to conceive after **1 year** of regular unprotected intercourse (or **6 months** if the woman is >35 years). * **Semen Collection:** Requires **2–7 days** of abstinence. The sample should be collected by masturbation and delivered to the lab within **1 hour**. * **WHO 2021 (6th Ed) Lower Reference Limits:** * **Volume:** 1.4 ml * **Total Count:** 39 million per ejaculate (Concentration: 16 million/ml) * **Motility:** 42% total (30% progressive) * **Morphology:** 4% (Kruger’s strict criteria) * **Oligoasthenoteratozoospermia (OAT):** A condition where all three parameters (count, motility, and morphology) are abnormal.

Question 150: Which of the following is a marker of ovarian reserve, estimated for infertility?

A. Antral follicle size
B. LH/FSH ratio
C. Inhibin A
D. Anti-Müllerian hormone (Correct Answer)

Explanation: **Explanation:** **Anti-Müllerian Hormone (AMH)** is currently considered the most reliable biochemical marker for ovarian reserve. It is produced by the granulosa cells of pre-antral and small antral follicles. Its levels are independent of the hypothalamic-pituitary-ovarian axis, meaning it remains relatively constant throughout the menstrual cycle. This allows for testing on any day of the cycle, making it superior to other markers. A low AMH level indicates a depleted primordial follicle pool. **Analysis of Incorrect Options:** * **Antral Follicle Size:** While **Antral Follicle Count (AFC)**—the total number of follicles measuring 2–10 mm—is a gold standard marker for ovarian reserve, the *size* of an individual follicle is used to monitor ovulation induction, not to estimate the total reserve. * **LH/FSH Ratio:** An elevated LH/FSH ratio (>2:1 or 3:1) is a classic diagnostic feature of **Polycystic Ovary Syndrome (PCOS)**, but it does not accurately reflect the quantitative egg reserve. * **Inhibin A:** This is a marker of corpus luteum function and is used in the **Quadruple Screen** for Down Syndrome. **Inhibin B**, however, is the form secreted by early follicles and was previously used for reserve testing, though it is now largely replaced by AMH. **High-Yield Clinical Pearls for NEET-PG:** * **Best Biochemical Marker:** AMH (earliest marker to decline with age). * **Best Imaging/Biophysical Marker:** Antral Follicle Count (AFC) via Transvaginal Ultrasound (TVS). * **Day 3 FSH:** High levels (>10-12 mIU/mL) indicate poor ovarian reserve, but it is less sensitive than AMH as it fluctuates cycle-to-cycle. * **AMH Levels:** <1 ng/mL suggests diminished ovarian reserve; >3.5 ng/mL is often seen in PCOS.

Practice by Chapter

Reproductive Physiology

Practice Questions

Evaluation of the Infertile Couple

Practice Questions

Male Factor Infertility

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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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