Fertility and Infertility — MCQs

Fertility and Infertility Indian Medical PG Practice Questions and MCQs

Question 151: Which of the following is the drug of choice for follicle induction for infertility in PCOS?

A. Clomiphene citrate
B. GnRH agonist
C. Combined oral pills
D. Letrozole (Correct Answer)

Explanation: **Explanation:** **Letrozole** is currently the **first-line drug of choice** for ovulation induction in women with Polycystic Ovary Syndrome (PCOS). It is a third-generation **Aromatase Inhibitor** that works by blocking the conversion of androgens to estrogens. This reduction in systemic estrogen levels removes the negative feedback on the hypothalamus and pituitary, leading to an increase in endogenous **FSH (Follicle Stimulating Hormone)** secretion, which stimulates follicular growth. **Why Letrozole is preferred over Clomiphene Citrate (CC):** * **Higher Live Birth Rates:** Clinical trials (like the Legro study) have proven Letrozole results in higher ovulation and live birth rates in PCOS patients. * **Monofollicular Development:** It has a shorter half-life and does not deplete estrogen receptors, leading to a lower risk of multiple pregnancies compared to CC. * **Endometrial Safety:** Unlike CC, Letrozole does not have an anti-estrogenic effect on the endometrium or cervical mucus, favoring implantation. **Analysis of Incorrect Options:** * **A. Clomiphene Citrate:** Formerly the first-line treatment, it is now considered second-line for PCOS due to its anti-estrogenic side effects on the endometrium and higher rates of "clomiphene resistance." * **B. GnRH Agonists:** These are used for pituitary downregulation during IVF cycles or to treat endometriosis/fibroids; they suppress the ovaries rather than inducing ovulation. * **C. Combined Oral Pills (COCPs):** These are used to manage menstrual irregularity and hirsutism in PCOS but are **contraceptive** in nature and will not help in achieving pregnancy. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism of Letrozole:** Competitive inhibition of the Aromatase enzyme. * **Dose:** Usually 2.5 mg to 5 mg daily for 5 days (starting on Day 2, 3, or 5 of the cycle). * **PCOS Definition:** Most commonly diagnosed using the **Rotterdam Criteria** (2 out of 3: Oligo/anovulation, Hyperandrogenism, and Polycystic ovaries on USG).

Question 152: Ideally, the total motile sperm count in the IUI specimen should be:

A. 10 million/ml or more (Correct Answer)
B. 12 million/ml or more
C. 15 million/ml or more
D. 20 million/ml or more

Explanation: **Explanation:** Intrauterine Insemination (IUI) success is heavily dependent on the quality of the processed semen sample. The **Total Motile Sperm Count (TMSC)**—calculated as the volume of the sample multiplied by the concentration and the percentage of progressive motility—is considered the most reliable predictor of IUI success. **1. Why Option A is Correct:** The consensus in clinical practice and standard textbooks (such as Jeffcoate’s) indicates that a post-wash TMSC of **10 million/ml or more** is ideal for achieving optimal pregnancy rates. While pregnancies can occur with counts as low as 1–5 million, the success rate plateaus once the count exceeds 10 million. Therefore, 10 million/ml is the established threshold for "ideal" outcomes. **2. Why Other Options are Incorrect:** * **Options B & C (12 and 15 million/ml):** While these counts are excellent, they do not represent the minimum "ideal" threshold. Increasing the count beyond 10 million does not significantly increase the clinical pregnancy rate per cycle. * **Option D (20 million/ml):** This is the traditional WHO cut-off for a "normal" sperm concentration in an *unprocessed* (raw) ejaculate, not the specific requirement for a processed IUI specimen. **High-Yield Clinical Pearls for NEET-PG:** * **Minimum Threshold:** If the post-wash TMSC is **<5 million**, the success rate of IUI drops significantly, and IVF/ICSI should be considered. * **Timing:** IUI is ideally performed **36 hours** after hCG trigger (which mimics the LH surge). * **Sperm Survival:** In the female reproductive tract, washed sperm typically survive for 24–48 hours. * **Indication:** The best results for IUI are seen in cases of unexplained infertility, cervical factor infertility, and mild male factor infertility.

Question 153: Which type of leiomyoma has the best prognosis for reversibility?

A. Isthmic type (Correct Answer)
B. Isthmic-ampullary type
C. Ampullary-foreacial type
D. Ampullary-fimbrial type

Explanation: **Explanation:** The question refers to the classification of **tubal leiomyomas** (rare benign tumors of the fallopian tube) and their impact on tubal patency and fertility. **1. Why the Isthmic type is correct:** The **isthmus** is the narrowest, thickest-walled part of the fallopian tube. While a leiomyoma here can cause mechanical obstruction, it is the most surgically accessible site. Because the isthmus has a well-defined muscular coat and a straight course, a **tubal myomectomy** or segmental resection followed by **re-anastomosis** (tubal reconstruction) has the highest success rate. The structural integrity of the tube is easier to restore here compared to the more complex distal segments, leading to the best prognosis for reversing infertility. **2. Analysis of Incorrect Options:** * **B. Isthmic-ampullary type:** This involves the transition zone. Surgery at the junction of two different luminal diameters is technically more challenging than a pure isthmic repair, increasing the risk of postoperative stenosis. * **C & D. Ampullary-foreacial/Fimbrial types:** The ampulla is the widest part of the tube where fertilization occurs, and the fimbriae are essential for ovum pickup. Leiomyomas in these regions often distort the delicate mucosal folds (endosalpinx) or destroy the fimbrial mechanism. Damage to the fimbriae is generally irreversible and carries the poorest prognosis for natural conception. **Clinical Pearls for NEET-PG:** * **Most common site for Tubal Ectopic:** Ampulla (70%). * **Narrowest part of the Fallopian tube:** Interstitial (Intramural) part. * **Site of Fertilization:** Ampulla. * **Best prognosis for Tubal Reconstructive Surgery:** Isthmic-isthmic anastomosis (often following previous tubal ligation).

Question 154: All of the following are causative factors for infertility in Pelvic Inflammatory Disease (PID) except?

A. Cornual block
B. Loss of cilia of the fallopian tubes
C. Loss of peristalsis of the fallopian tubes
D. Anovulation (Correct Answer)

Explanation: **Explanation:** **1. Why Anovulation is the Correct Answer:** Pelvic Inflammatory Disease (PID) is primarily an inflammatory and infectious process affecting the upper genital tract. The infertility associated with PID is **mechanical and structural** in nature, rather than hormonal. PID causes damage to the fallopian tubes and pelvic peritoneum, but it does **not** typically interfere with the Hypothalamic-Pituitary-Ovarian (HPO) axis. Therefore, ovulation usually remains intact, making "Anovulation" the exception. **2. Analysis of Incorrect Options:** * **Cornual Block (A):** Ascending infection (commonly *Chlamydia* or *Gonorrhea*) causes endosalpingitis. This leads to fibrosis and scarring, which can physically obstruct the fallopian tubes at the proximal (cornual) or distal ends. * **Loss of Cilia (B):** The inflammatory process destroys the delicate ciliated epithelium of the fallopian tubes. Since cilia are essential for transporting the ovum toward the uterus, their loss results in infertility or ectopic pregnancy. * **Loss of Peristalsis (C):** Chronic inflammation leads to transmural scarring and pelvic adhesions (peritubal adhesions). This stiffens the tubal wall and fixes the tube in place, impairing the normal peristaltic contractions required for gamete transport. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of tubal factor infertility:** PID (specifically *Chlamydia trachomatis* due to its often silent, destructive nature). * **Fitz-Hugh-Curtis Syndrome:** A complication of PID involving perihepatitis ("violin-string" adhesions). * **Risk of Infertility:** The risk of tubal infertility increases with each episode of PID (approx. 12% after one episode, 25% after two, and 50% after three). * **Gold Standard Investigation:** Laparoscopy is the gold standard for diagnosing tubal patency and pelvic adhesions in chronic PID.

Question 155: What is the process by which a "test tube baby" is produced?

A. Sperm and ovum are directly implanted into the fallopian tube.
B. Sperm and ovum are fertilized in a test tube and then implanted. (Correct Answer)
C. A fetus is grown entirely in a test tube.
D. Only sperm is transferred.

Explanation: **Explanation:** The term "test tube baby" refers to a child conceived via **In Vitro Fertilization (IVF)**. In this process, mature oocytes are surgically retrieved from the ovaries after controlled ovarian stimulation. These oocytes are then fertilized by sperm in a controlled laboratory setting (the "test tube" or Petri dish). Once fertilization occurs and the embryo reaches the cleavage or blastocyst stage, it is transferred into the mother's uterus for implantation and subsequent gestation. **Analysis of Options:** * **Option A (Incorrect):** This describes **GIFT (Gamete Intrafallopian Transfer)**. In GIFT, fertilization occurs *in vivo* (inside the body) rather than in a lab. * **Option B (Correct):** Accurately describes the IVF process where fertilization is extracorporeal, followed by embryo transfer. * **Option C (Incorrect):** This is a biological impossibility with current technology. Ectogenesis (growth outside the womb) is not practiced; the uterus is required for gestation. * **Option D (Incorrect):** This describes **IUI (Intrauterine Insemination)**, where processed sperm is placed directly into the uterus to facilitate natural fertilization. **NEET-PG High-Yield Pearls:** * **First IVF Baby:** Louise Brown (1978); in India, it was Kanupriya Agarwal (Durga). * **Indication:** IVF is the gold standard for bilateral tubal block, severe endometriosis, and unexplained infertility. * **ICSI (Intracytoplasmic Sperm Injection):** A specialized form of IVF used for severe male factor infertility where a single sperm is injected directly into the ooplasm. * **OHSS (Ovarian Hyperstimulation Syndrome):** The most serious complication of the ovulation induction phase of IVF.

Question 156: With Intracytoplasmic sperm injection (ICSI), which of the following steps in fertilization is skipped?

A. Sperm-oocyte binding
B. Zona reaction
C. Acrosome reaction (Correct Answer)
D. Cortical reaction

Explanation: **Explanation:** In **Intracytoplasmic Sperm Injection (ICSI)**, a single viable sperm is directly injected into the cytoplasm of a mature oocyte (MII stage) using a micropipette. This procedure bypasses the natural barriers of the egg. **Why Acrosome Reaction is the correct answer:** The **acrosome reaction** is a physiological process where the sperm releases enzymes (like hyaluronidase and acrosin) to penetrate the *zona pellucida*. Since ICSI involves mechanical insertion of the sperm directly into the ooplasm, the sperm does not need to penetrate the zona pellucida or the oocyte membrane on its own. Therefore, the acrosome reaction is bypassed/skipped. **Analysis of Incorrect Options:** * **A. Sperm-oocyte binding:** While the physical "binding" to the zona is bypassed, the question specifically targets the physiological biochemical reactions. However, the acrosome reaction is the most definitive "skipped" step in the sequence of fertilization events. * **B & D. Zona and Cortical reactions:** These reactions occur *after* a sperm enters the egg to prevent polyspermy (hardening of the zona). Even in ICSI, once the sperm is injected, the oocyte undergoes activation, which includes the cortical reaction to complete the second meiotic division. **High-Yield NEET-PG Pearls:** * **Indications for ICSI:** Severe male factor infertility (oligozoospermia, asthenozoospermia), obstructive azoospermia (PESA/TESA), and previous IVF failure. * **Oocyte Stage:** ICSI is performed only on **Metaphase II (MII)** oocytes (identified by the presence of the first polar body). * **Success Rate:** Fertilization rates with ICSI are approximately 70-80%. * **Key Difference:** IVF requires thousands of motile sperm; ICSI requires only one viable sperm per egg.

Question 157: What is the prevalence of endometriosis in women with unexplained infertility?

A. 10-20%
B. 20-30%
C. 30-40%
D. 40-50% (Correct Answer)

Explanation: **Explanation:** **Understanding the Concept:** Endometriosis is one of the most common underlying pathologies in women presenting with infertility. In cases labeled as "unexplained infertility"—where standard evaluations (semen analysis, ovulation monitoring, and tubal patency tests) are normal—diagnostic laparoscopy often reveals occult endometriosis. Studies and standard textbooks (like Williams Gynecology) indicate that **40-50%** of these women have endometriosis, most commonly Stage I (minimal) or Stage II (mild). The condition impairs fertility through pelvic inflammation, altered peritoneal fluid composition, and impaired oocyte quality, even in the absence of structural tubal blockage. **Analysis of Options:** * **A (10-20%):** This represents the prevalence of endometriosis in the **general population** of reproductive-age women. * **B & C (20-40%):** While endometriosis is found in roughly 25-35% of *all* infertile women, these ranges underestimate the specific subset of **unexplained infertility**, where the prevalence is significantly higher upon laparoscopic investigation. * **D (40-50%):** This is the correct clinical estimate. Laparoscopy remains the "gold standard" for diagnosing these occult cases that are missed by ultrasound. **NEET-PG High-Yield Pearls:** * **Gold Standard Diagnosis:** Laparoscopy with biopsy is the definitive method for diagnosing endometriosis. * **Commonest Site:** The **ovary** is the most common site for endometriosis. * **Infertility Mechanism:** In minimal/mild disease, infertility is due to an altered peritoneal microenvironment; in severe disease, it is due to distorted pelvic anatomy (tubo-ovarian relationship). * **Management:** For unexplained infertility associated with minimal endometriosis, the treatment of choice is often Superovulation with Intrauterine Insemination (IUI) or IVF.

Question 158: What is the required number of sperms per oocyte for fertilization in in-vitro fertilization?

A. 100
B. 1000
C. 10000
D. 100000 (Correct Answer)

Explanation: ### Explanation In conventional **In-Vitro Fertilization (IVF)**, fertilization occurs by placing a specific concentration of motile sperm in a culture dish alongside the retrieved oocytes. The goal is to mimic natural selection while ensuring a high probability of successful penetration of the zona pellucida. **1. Why 100,000 is Correct:** The standard protocol for conventional IVF requires approximately **50,000 to 100,000 motile spermatozoa per oocyte**. This concentration is optimal because it provides enough acrosomal enzymes (like hyaluronidase) to disperse the cumulus cells surrounding the egg, yet is not so high that it increases the risk of **polyspermy** (fertilization by more than one sperm), which results in non-viable embryos. **2. Analysis of Incorrect Options:** * **A (100) & B (1000):** These concentrations are far too low. At these levels, the probability of a sperm successfully navigating the cumulus-oocyte complex and penetrating the zona pellucida is negligible, leading to total fertilization failure. * **C (10,000):** While some labs may achieve fertilization at this lower threshold, it is generally considered suboptimal for conventional IVF and carries a higher risk of failed fertilization. **3. High-Yield Clinical Pearls for NEET-PG:** * **ICSI (Intracytoplasmic Sperm Injection):** If the sperm count is significantly lower than the required 100,000/oocyte (severe oligospermia) or if there is poor motility (asthenozoospermia), ICSI is indicated. In ICSI, only **one single live sperm** is required per oocyte. * **Normal Semen Analysis (WHO 2021):** * Volume: ≥ 1.4 mL * Concentration: ≥ 16 million/mL * Total Motility: ≥ 42% * Morphology: ≥ 4% (Kruger’s criteria) * **Fertilization Check:** Fertilization is confirmed 16–18 hours after insemination by the presence of **two pronuclei (2PN)** and two polar bodies.

Question 159: According to WHO criteria, which of the following is NOT true in a normal person?

A. Sperm count >20 million/ml
B. Aggressive forward motility in >25% of sperms
C. Normal morphology in >15% of sperms (strict criteria)
D. Ejaculated volume >1 ml (Correct Answer)

Explanation: ### Explanation This question tests knowledge of the **WHO Laboratory Manual for the Examination and Processing of Human Semen**. It is important to note that the WHO updated its criteria in 2010 (5th Edition) and 2021 (6th Edition). In the context of NEET-PG, examiners often test the **WHO 2010 (5th Edition)** criteria, which are the current standard for most clinical examinations. #### Why Option D is the Correct Answer According to WHO 2010 criteria, the lower reference limit for **ejaculate volume is ≥1.5 ml**. Therefore, the statement "Ejaculated volume >1 ml" is technically incorrect/incomplete as per the strict threshold, making it the "NOT true" option among the choices provided. #### Analysis of Other Options * **Option A (Sperm count >20 million/ml):** This is considered normal. The WHO 2010 cutoff for sperm concentration is **≥15 million/ml**. Since 20 million is above this threshold, it falls within the normal range. * **Option B (Aggressive forward motility >25%):** Normal motility (Grade A+B or Progressive Motility) should be **≥32%**. However, in many older classifications and specific clinical contexts, 25% aggressive linear motility was a benchmark. In the context of this MCQ, it is generally accepted as a "normal" parameter compared to the volume error. * **Option C (Normal morphology >15%):** While the WHO 2010 "Strict Criteria" (Kruger’s) lowered the normal limit to **≥4%**, older standards used 15%. In many exams, >15% is still cited as the traditional "normal" threshold for morphology. #### High-Yield Clinical Pearls (WHO 2010 Criteria) * **Volume:** ≥1.5 ml * **Total Sperm Number:** ≥39 million per ejaculate * **Concentration:** ≥15 million/ml * **Total Motility (PR + NP):** ≥40% * **Progressive Motility (PR):** ≥32% * **Vitality:** ≥58% live sperms * **Morphology:** ≥4% (Strict/Kruger criteria) * **pH:** ≥7.2

Question 160: Which form of infertility in women has the best prognosis and is most reversible?

A. Tubal block
B. Anovulation (Correct Answer)
C. Oligospermia
D. Endometritis

Explanation: **Explanation:** **Anovulation** is considered the most treatable and reversible cause of female infertility, carrying the best prognosis. This is because the underlying issue—the failure to release an oocyte—can often be corrected through medical intervention. With the use of **Ovulation Induction (OI)** agents such as Clomiphene Citrate (the traditional first-line) or Letrozole (now preferred in PCOS), successful ovulation can be achieved in up to 70-80% of patients, leading to high cumulative pregnancy rates. **Analysis of Incorrect Options:** * **Tubal Block:** This represents structural damage. While surgical tuboplasty exists, success rates are low, and the risk of ectopic pregnancy is high. Most cases require expensive assisted reproductive technologies (ART) like IVF. * **Oligospermia:** This is a cause of *male* factor infertility. While treatable via IUI or ICSI, it does not address female fertility prognosis and often requires long-term management. * **Endometritis:** Chronic inflammation of the uterine lining impairs implantation. While treatable with antibiotics, it can lead to permanent synechiae (Asherman syndrome) or irreversible damage to the receptive environment of the uterus. **High-Yield Clinical Pearls for NEET-PG:** * **WHO Group II (PCOS)** is the most common cause of anovulatory infertility. * **Letrozole** (Aromatase Inhibitor) is currently the **drug of choice** for ovulation induction in PCOS due to higher live birth rates and lower risks of multiple gestations compared to Clomiphene. * In patients with **Hypogonadotropic Hypogonadism (WHO Group I)**, the treatment of choice is pulsatile GnRH or Gonadotropins.

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

Practice Questions

Ovulatory Disorders

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Tubal and Peritoneal Factors

Practice Questions

Uterine Factors

Practice Questions

Unexplained Infertility

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Assisted Reproductive Technologies

Practice Questions

Psychological Aspects of Infertility

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