Fertility and Infertility — MCQs

A young couple has been unsuccessful in conceiving a child over a 4-month period. The 28-year-old wife has had no abnormalities detected in previous investigations. The husband's semen analysis revealed a low volume and azotemia, with a normal follicle-stimulating hormone (FSH) level. What is the most likely diagnosis?

Q14Easy

All of the following are used in the treatment of infertility, except:

Q15Easy

Aspiration of sperms from testes is done in which procedure?

Q16Medium

According to WHO criteria for semen analysis, which of the following statements is true?

Q17Easy

Antisperm antibody testing is not needed if the sperm are to be used for what procedure?

Q18Easy

What is the gold standard investigation of choice (IOC) for female infertility?

Q19Easy

Intrauterine insemination means placement of:

Q20Medium

Pituitary down-regulation is done in IVF for all the following reasons except?

Fertility and Infertility Indian Medical PG Practice Questions and MCQs

Question 11: What is the mechanism of action of clomiphene citrate used for infertility?

A. Blocks estrogen receptors in the hypothalamus (Correct Answer)
B. Provides negative feedback on the hypothalamic-pituitary-ovarian axis
C. Acts directly on ovarian primordial follicles
D. Increases tubal motility

Explanation: ### Explanation **Correct Option: A (Blocks estrogen receptors in the hypothalamus)** Clomiphene Citrate (CC) is a **Selective Estrogen Receptor Modulator (SERM)**. Its primary mechanism of action is acting as a competitive antagonist to estrogen receptors in the hypothalamus and pituitary gland. By blocking these receptors, CC prevents the brain from sensing circulating estrogen levels (perceived hypoestrogenism). This removes the negative feedback inhibition, leading to an increased secretion of **GnRH** from the hypothalamus and a subsequent rise in **FSH and LH** from the anterior pituitary. The elevated FSH levels stimulate the growth of ovarian follicles, leading to ovulation. **Why other options are incorrect:** * **Option B:** CC actually **interrupts** the negative feedback loop. Providing negative feedback would decrease FSH/LH levels, which would inhibit ovulation (the mechanism of combined oral contraceptives). * **Option C:** CC does not have a direct effect on the ovaries; its action is central (hypothalamic-pituitary axis). The ovarian response is a secondary effect of increased FSH. * **Option D:** CC has no significant effect on tubal motility. In fact, its anti-estrogenic effect can sometimes have a negative impact on cervical mucus (making it thick) and the endometrium. **High-Yield NEET-PG Pearls:** * **First-line drug:** Historically the first-line for WHO Group II ovulation induction (e.g., PCOS), though Letrozole (Aromatase Inhibitor) is now preferred in many guidelines. * **Dosage:** Usually started at 50 mg/day for 5 days, beginning on Day 2, 3, 4, or 5 of the menstrual cycle. * **Side Effects:** Multiple pregnancies (mostly twins, ~8-10%), hot flashes, and ovarian hyperstimulation syndrome (OHSS), though OHSS is less common than with gonadotropins. * **Isomer:** Enclomiphene is the active isomer responsible for the ovulation-inducing effect.

Question 12: What is the typical lifespan of preserved semen for artificial insemination?

A. One year
B. Two years
C. Five years
D. Ten years (Correct Answer)

Explanation: **Explanation:** The correct answer is **Ten years (Option D)**. In the context of assisted reproductive technology (ART) and cryopreservation, human semen is typically stored in liquid nitrogen at a temperature of **-196°C**. At this ultra-low temperature, metabolic activity within the spermatozoa ceases, effectively "pausing" biological time. While theoretically, sperm can remain viable for decades, the standard clinical and legal guideline for the preservation of semen for artificial insemination is **ten years**. This duration is considered safe and effective for maintaining the genetic integrity and motility required for successful fertilization. **Analysis of Incorrect Options:** * **Options A, B, and C (1, 2, and 5 years):** These durations are too short. While semen can certainly be used within these timeframes, they do not represent the established "typical lifespan" or the maximum recommended storage period in clinical practice. Cryopreservation is designed for long-term family planning, especially for patients undergoing gonadotoxic treatments (like chemotherapy), necessitating a longer window than 1–5 years. **High-Yield Clinical Pearls for NEET-PG:** * **Cryoprotectant:** Glycerol is the most commonly used agent to prevent ice crystal formation and cell membrane damage during freezing. * **Storage Medium:** Semen is stored in **liquid nitrogen (-196°C)** or its vapor phase. * **Post-thaw Motility:** Expect a 25–50% reduction in sperm motility after thawing; therefore, pre-freeze semen quality is a critical predictor of success. * **Legal Context:** In many jurisdictions (including the UK’s HFEA and emerging Indian ART guidelines), 10 years is the standard initial limit, though extensions are possible under specific medical circumstances.

Question 13: A young couple has been unsuccessful in conceiving a child over a 4-month period. The 28-year-old wife has had no abnormalities detected in previous investigations. The husband's semen analysis revealed a low volume and azotemia, with a normal follicle-stimulating hormone (FSH) level. What is the most likely diagnosis?

A. Bilateral testicular atrophy
B. Congenital absence of the vas deferens (Correct Answer)
C. Hydrocele
D. Varicocele

Explanation: **Explanation:** The clinical presentation of **low semen volume** and **azoospermia** (absence of sperm) in the presence of **normal FSH levels** is a classic indicator of **obstructive azoospermia**. 1. **Why Option B is Correct:** Congenital Bilateral Absence of the Vas Deferens (CBAVD) results in an obstruction where sperm cannot reach the ejaculate. Since the seminal vesicles are often also absent or atrophic in these cases (as they develop from the same Wolffian duct), the semen volume is characteristically low (<1.5 ml) and acidic. FSH levels remain normal because spermatogenesis in the testes is typically preserved; the issue is purely structural/transport-related. 2. **Why Incorrect Options are Wrong:** * **Bilateral Testicular Atrophy:** This would result in primary testicular failure (non-obstructive azoospermia), which is characterized by **elevated FSH levels** due to the loss of negative feedback from inhibin and testosterone. * **Hydrocele:** This is a collection of fluid in the tunica vaginalis. While it causes scrotal swelling, it does not typically cause azoospermia or low semen volume. * **Varicocele:** This is a dilation of the pampiniform plexus. While it is a common cause of male infertility (due to increased scrotal temperature), it usually presents with **oligospermia** (low count) or poor motility, not complete azoospermia with low volume. **Clinical Pearls for NEET-PG:** * **CBAVD Association:** Strongly associated with mutations in the **CFTR gene** (Cystic Fibrosis). Always screen for CFTR mutations in these patients. * **FSH as a Marker:** In male infertility, a normal FSH suggests obstructive azoospermia, while a high FSH suggests primary testicular failure (Sertoli cell dysfunction). * **Fructose Test:** Semen in CBAVD is typically **fructose-negative** because fructose is produced in the seminal vesicles, which are usually absent.

Question 14: All of the following are used in the treatment of infertility, except:

A. Luteinizing hormone (LH)
B. Prolactin (Correct Answer)
C. Gonadotropin-releasing hormone (GnRH)
D. Clomiphene

Explanation: **Explanation:** The correct answer is **Prolactin**. In the context of infertility, Prolactin is not a treatment; rather, **hyperprolactinemia** is a significant cause of infertility. High levels of prolactin inhibit the pulsatile secretion of GnRH from the hypothalamus, leading to decreased FSH and LH levels, which results in anovulation and amenorrhea. Therefore, the treatment for infertility in such cases involves prolactin *antagonists* (like Bromocriptine or Cabergoline) to lower prolactin levels, not the hormone itself. **Analysis of Incorrect Options:** * **Luteinizing hormone (LH):** Purified LH or Recombinant LH is used in ovulation induction, particularly in patients with hypogonadotropic hypogonadism or to trigger the "LH surge" for oocyte maturation in IVF cycles. * **GnRH:** Pulsatile administration of GnRH is used to induce ovulation in women with hypothalamic amenorrhea. Conversely, GnRH analogs are used in ART cycles to prevent premature LH surges. * **Clomiphene:** This is a Selective Estrogen Receptor Modulator (SERM) and is the first-line drug for ovulation induction in patients with PCOS (WHO Group II infertility). It works by blocking estrogen receptors in the hypothalamus, increasing endogenous FSH and LH production. **Clinical Pearls for NEET-PG:** * **Drug of Choice for Hyperprolactinemia:** Cabergoline (preferred over Bromocriptine due to better efficacy and fewer side effects). * **Clomiphene Citrate:** Acts primarily by increasing the **pulse frequency** of GnRH. * **Luteal Phase Support:** Progesterone is the hormone of choice to support the endometrium after ovulation induction or embryo transfer.

Question 15: Aspiration of sperms from testes is done in which procedure?

A. TESA (Correct Answer)
B. MESA
C. ZIFT
D. GIFT

Explanation: **Explanation:** The correct answer is **TESA (Testicular Sperm Aspiration)**. This procedure involves the direct aspiration of sperm from the **testicular parenchyma** using a fine needle. It is primarily indicated for patients with obstructive azoospermia or non-obstructive azoospermia where mature sperm are not found in the ejaculate. **Analysis of Options:** * **TESA (Correct):** As the name implies, sperm is aspirated directly from the **Testes**. It is a minimally invasive technique used to retrieve immature sperm for use in ICSI (Intracytoplasmic Sperm Injection). * **MESA (Microsurgical Epididymal Sperm Aspiration):** This involves collecting sperm from the **Epididymis**, not the testes. It is performed under a microscope and typically yields a higher concentration of mature, motile sperm compared to testicular extraction. * **ZIFT (Zygote Intra-Fallopian Transfer):** This is an assisted reproductive technique where a **fertilized egg (zygote)** is transferred into the fallopian tube. It is not a sperm retrieval method. * **GIFT (Gamete Intra-Fallopian Transfer):** This involves transferring **unfertilized eggs and washed sperm** into the fallopian tube so fertilization can occur *in vivo*. **High-Yield Clinical Pearls for NEET-PG:** * **PESA (Percutaneous Epididymal Sperm Aspiration):** Similar to MESA but done blindly without a microscope. * **TESE (Testicular Sperm Extraction):** Involves a **biopsy/tissue sample** of the testes rather than simple needle aspiration. * **ICSI Requirement:** Since sperm retrieved via TESA/MESA are often immature or have poor motility, they **must** be used in conjunction with **ICSI**, as they cannot fertilize an egg via standard IVF. * **Indication:** These procedures are the gold standard for **Obstructive Azoospermia** (e.g., Congenital Bilateral Absence of Vas Deferens).

Question 16: According to WHO criteria for semen analysis, which of the following statements is true?

A. Progressive motility >15%
B. Normal morphology >25%
C. Volume of 2-5ml
D. Sperm count >39 million (Correct Answer)

Explanation: The World Health Organization (WHO) updated its criteria for semen analysis in the **6th Edition (2021)** manual. Understanding these lower reference limits is crucial for diagnosing male factor infertility. ### **Explanation of the Correct Answer** **Option D (Sperm count >39 million)** is correct because it represents the **Total Sperm Number** per ejaculate. It is calculated by multiplying the sperm concentration by the total volume. According to the WHO 6th edition, the lower reference limit for total sperm number is **39 million per ejaculate**. ### **Analysis of Incorrect Options** * **Option A (Progressive motility >15%):** This is incorrect. The lower reference limit for **progressive motility** (PR) is **32%**. The total motility (Progressive + Non-progressive) should be at least 40%. * **Option B (Normal morphology >25%):** This is incorrect. Using Tygerberg’s strict criteria, the lower reference limit for **normal morphology** is only **4%**. A value of 25% is significantly higher than the minimum requirement. * **Option C (Volume of 2-5ml):** While 2-5ml is a common average, the WHO lower reference limit for **semen volume** is **1.4 ml** (updated from 1.5 ml in the 5th edition). ### **High-Yield Clinical Pearls for NEET-PG** * **Sperm Concentration:** The lower limit is **16 million/ml** (previously 15 million/ml). * **Vitality:** At least **54%** of sperms should be alive (dye exclusion test). * **Azoospermia vs. Oligozoospermia:** Azoospermia is the total absence of sperm; Oligozoospermia is <16 million/ml. * **Asthenozoospermia:** Reduced motility (<32% progressive motility). * **Teratozoospermia:** Poor morphology (<4% normal forms). * **Leukocytospermia:** Presence of >1 million WBCs/ml, indicating infection.

Question 17: Antisperm antibody testing is not needed if the sperm are to be used for what procedure?

A. Intracytoplasmic sperm injection (ICSI) (Correct Answer)
B. Gamete intrafallopian transfer (GIFT)
C. Zygote intrafallopian transfer (ZIFT)
D. In vitro fertilization (IVF)

Explanation: **Explanation:** The presence of **Antisperm Antibodies (ASA)**—whether on the sperm surface or in the cervical mucus—interferes with fertility by causing sperm agglutination, inhibiting motility, or preventing the sperm from binding to and penetrating the *zona pellucida* of the oocyte. **Why ICSI is the Correct Answer:** Intracytoplasmic Sperm Injection (ICSI) is a specialized form of micromanipulation where a single sperm is directly injected into the cytoplasm of the oocyte. Because this process **bypasses all natural barriers** to fertilization (such as cervical mucus, the cumulus oophorus, and the zona pellucida), the presence of antibodies on the sperm head or tail becomes irrelevant. The mechanical injection ensures fertilization regardless of the sperm's immunological status. **Why Other Options are Incorrect:** * **IVF (In Vitro Fertilization):** In conventional IVF, sperm and eggs are placed in a dish, and the sperm must still bind to and penetrate the egg naturally. High titers of ASA can significantly reduce fertilization rates in IVF. * **GIFT & ZIFT:** These are older assisted reproductive techniques where gametes (GIFT) or zygotes (ZIFT) are placed into the fallopian tubes. Since GIFT requires the sperm to fertilize the egg naturally within the tube, ASA would still hinder the process. **High-Yield Clinical Pearls for NEET-PG:** * **Screening Test:** The **Immunobead test** and **Mixed Antiglobulin Reaction (MAR) test** are the gold standards for detecting ASA. * **Indications for ICSI:** Apart from ASA, ICSI is the treatment of choice for severe male factor infertility (oligozoospermia, asthenozoospermia) and prior IVF failure. * **ASA in Men:** Often occurs due to a breach in the **blood-testis barrier** (e.g., post-vasectomy, testicular trauma, or infection).

Question 18: What is the gold standard investigation of choice (IOC) for female infertility?

A. Laparoscopy
B. Transvaginal ultrasonography
C. Hysteroscopy
D. Laparoscopy and hysteroscopy (Correct Answer)

Explanation: **Explanation:** The evaluation of female infertility requires a comprehensive assessment of the pelvic anatomy, specifically the uterus, fallopian tubes, and the peritoneal environment. **Why Option D is correct:** The combination of **Laparoscopy and Hysteroscopy** is considered the "Gold Standard" because it allows for a simultaneous, direct visual inspection of both the internal uterine cavity and the external pelvic structures. * **Laparoscopy** (with chromopertubation) is the gold standard for assessing **tubal patency** and diagnosing peritoneal factors like **endometriosis** or pelvic adhesions. * **Hysteroscopy** is the gold standard for evaluating the **uterine cavity** for septa, polyps, or submucosal fibroids. Performing them together provides a complete anatomical survey in a single procedure. **Why other options are incorrect:** * **A. Laparoscopy:** While excellent for tubal and peritoneal factors, it cannot visualize the internal architecture of the uterine cavity. * **B. Transvaginal Ultrasonography (TVS):** This is the **first-line (screening) investigation** for infertility. It is excellent for follicular monitoring and diagnosing PCOS or fibroids but lacks the definitive accuracy of direct visualization. * **C. Hysteroscopy:** Alone, it only evaluates the uterine cavity and cannot assess tubal patency or the presence of endometriosis. **High-Yield Clinical Pearls for NEET-PG:** * **Screening/First-line IOC:** Transvaginal Ultrasound (TVS). * **Initial test for Tubal Patency:** Hysterosalpingography (HSG). * **Gold Standard for Tubal Patency:** Laparoscopy + Chromopertubation (using Methylene blue dye). * **Gold Standard for Uterine Morphology:** Hysteroscopy. * **Best time for HSG:** Pre-ovulatory phase (Day 7 to Day 10 of the cycle).

Question 19: Intrauterine insemination means placement of:

A. Semen
B. Washed semen (Correct Answer)
C. Millions of sperms
D. Fertilized ova

Explanation: **Explanation:** **Intrauterine Insemination (IUI)** is a fertility procedure where processed sperm is placed directly into the uterine cavity. **Why "Washed Semen" is the Correct Answer:** Raw semen contains not only spermatozoa but also seminal plasma, which is rich in **prostaglandins**, inflammatory proteins, and potential bacteria. If raw semen is injected directly into the uterus, the prostaglandins can trigger severe, painful uterine contractions and potentially cause an anaphylactic reaction or pelvic infection. "Washing" is a laboratory process (using techniques like density gradient centrifugation or swim-up) that separates motile sperm from the seminal fluid, debris, and non-motile cells, making it safe for intrauterine placement. **Analysis of Incorrect Options:** * **A. Semen:** As explained, raw semen is contraindicated for intrauterine placement due to the risk of prostaglandin-induced cramping and infection. * **C. Millions of sperms:** While IUI does involve millions of sperm, this is a quantitative description rather than the procedural definition. The critical medical requirement is the *processing* (washing) of the sample. * **D. Fertilized ova:** This refers to **Embryo Transfer (ET)**, which is a component of In-Vitro Fertilization (IVF), not IUI. **High-Yield Clinical Pearls for NEET-PG:** * **Timing:** IUI is ideally performed **36 hours** after an hCG "trigger" injection (which mimics the LH surge). * **Prerequisite:** At least one **patent fallopian tube** is mandatory for IUI to be successful. * **Sperm Count:** For a successful IUI outcome, the post-wash Total Motile Sperm Count (TMSC) should ideally be **>5–10 million**. * **Indications:** Unexplained infertility, mild male factor infertility, and cervical factor infertility.

Question 20: Pituitary down-regulation is done in IVF for all the following reasons except?

A. To prevent ovarian hyperstimulation syndrome
B. To prevent endogenous LH surges
C. To prevent premature ovulation
D. To cause oocyte maturation and ovulation (Correct Answer)

Explanation: **Explanation:** In In Vitro Fertilization (IVF), pituitary down-regulation is achieved using **GnRH agonists or antagonists**. The primary goal is to suppress the patient's endogenous hormonal control to allow the clinician to take full command of the follicular cycle. **Why Option D is the Correct Answer:** Pituitary down-regulation **does not** cause oocyte maturation or ovulation. In fact, it suppresses the natural LH surge required for these processes. Oocyte maturation and "triggering" of ovulation are achieved by administering an external bolus of **hCG (Human Chorionic Gonadotropin)** or a GnRH agonist (if an antagonist protocol was used), which mimics the natural LH surge. **Analysis of Other Options:** * **Option B & C:** These are the primary goals of down-regulation. By suppressing the pituitary, we prevent a **premature LH surge**. Without this, the follicles might rupture (premature ovulation) before they can be surgically retrieved, leading to a cancelled cycle. * **Option A:** Down-regulation (specifically using GnRH antagonists) allows for the use of a GnRH agonist trigger instead of hCG. This significantly reduces the risk of **Ovarian Hyperstimulation Syndrome (OHSS)**, making it a protective strategy. **High-Yield Clinical Pearls for NEET-PG:** * **Long Protocol:** Starts GnRH agonist in the mid-luteal phase (Day 21) of the previous cycle. * **Short/Antagonist Protocol:** Preferred in PCOS patients to minimize OHSS risk. * **The "Trigger":** hCG is the gold standard for final oocyte maturation because its alpha subunit is identical to LH, but it has a much longer half-life. * **Down-regulation** ensures synchronous follicular growth, allowing multiple eggs to be harvested simultaneously.

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

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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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