Fertility and Infertility Practice Questions

Q: A couple comes for evaluation of infertility. The HSG was normal but semen analysis revealed azoospermia. What is the diagnostic test to differentiate between testicular failure and vas deferens obstruction?

Serum FSH. ***Serum FSH*** - In **testicular failure**, the pituitary gland tries to compensate for poor sperm production by increasing **follicle-stimulating hormone (FSH)**, leading to **elevated FSH levels**. - In **vas deferens obstruction**, the testes are producing sperm normally, so the pituitary does not need to overstimulate them, resulting in **normal FSH levels**. *Testicular FNAC* - **Fine needle aspiration cytology (FNAC)** of the testis can *confirm* the presence or absence of sperm production but is not the primary diagnostic test to *differentiate* between the two conditions without prior hormonal assessment. - It is an **invasive procedure** typically considered after initial hormone testing and physical examination. *Testosterone levels* - **Testosterone levels** primarily reflect the Leydig cell function and can be normal in both **testicular failure** (especially germ cell-specific failure) and **vas deferens obstruction**. - While low testosterone can indicate Leydig cell dysfunction, it doesn't specifically differentiate between the two causes of azoospermia in all cases. *Karyotyping* - **Karyotyping** is used to detect **chromosomal abnormalities** (e.g., Klinefelter syndrome) that can cause testicular failure. - While important for identifying underlying genetic causes, it does not directly differentiate between existing testicular failure and vas deferens obstruction based on direct physiological function.

Q: Number of oocytes at birth is

2-3 million. ***2-3 million*** - At birth, a female infant's ovaries contain approximately **2-3 million primary oocytes**. - This number represents the peak **oocyte reserve**, which then gradually declines throughout life. *7-10 million* - This range is significantly **higher** than the actual number of oocytes present at birth. - The maximum number of germ cells is reached during **mid-gestation** (around 20 weeks), which is higher than the number at birth. *2-5 million* - While closer, this range extends beyond the generally accepted average, particularly the upper end. - The most precise estimates for oocytes at birth are typically lower. *10-15 million* - This figure is a substantial overestimate of the number of oocytes found in the ovaries at birth. - Such numbers are not physiologically observed at any stage of ovarian development.

Q: Separation of first polar body occurs at the time of:

Ovulation. ***Ovulation*** - The **first polar body is extruded just before ovulation**, when the primary oocyte completes **meiosis I** in response to the LH surge. - This division produces a **secondary oocyte** (containing most of the cytoplasm) and the **first polar body** (a small cell with minimal cytoplasm). - The secondary oocyte is then released at ovulation **with the first polar body already separated** in the perivitelline space. *Fertilization* - At fertilization, the secondary oocyte completes **meiosis II** (not meiosis I). - This produces the mature ovum and the **second polar body** (not the first polar body). - The first polar body was already separated before ovulation occurred. *Menstruation* - Menstruation is the shedding of the endometrial lining that occurs when fertilization does not happen. - This is unrelated to oocyte meiotic divisions or polar body formation. *Oocyte maturation* - While oocyte maturation involves the process of meiosis I completion, this term is too broad. - The **specific timing** of first polar body separation is just **before ovulation** in response to the preovulatory LH surge.

Q: All are steps of GIFT, except:

Fertilization of oocyte in lab. ***Fertilization of oocyte in lab*** - **Gamete intrafallopian transfer (GIFT)** involves the transfer of both sperm and eggs directly into the fallopian tube, where **fertilization occurs naturally** within the body. - The step of **fertilization in the lab** (in vitro fertilization) is characteristic of **IVF**, not GIFT. *Transfer of unfertilized egg into the fallopian tube* - In GIFT, **harvested eggs** (oocytes) are mixed with sperm and then immediately **transferred into the fallopian tube**. - This allows natural fertilization to occur within the woman's body, which is a key distinction of GIFT from IVF. *Ovulation stimulation* - Before GIFT, women undergo **controlled ovarian hyperstimulation** to produce multiple mature follicles and increase the chances of successful egg retrieval. - This process is essential for obtaining a sufficient number of **oocytes** for transfer. *Oocyte retrieval* - Once the follicles are mature, **oocytes are retrieved** from the ovaries, typically through transvaginal ultrasound-guided aspiration. - These retrieved oocytes are then prepared for transfer along with sperm into the fallopian tubes.

Q: Asthenospermia means:

Reduction in motility of sperms. ***Reduction in motility of sperms*** - **Astheno** refers to weakness or lack of strength, while **spermia** relates to sperm. Therefore, asthenospermia means reduced sperm motility. - This condition is a significant cause of **male infertility**, as sperm with poor motility struggle to reach and fertilize an egg. *Reduction in number of sperms* - A reduction in the number of sperms is termed **oligospermia**. - While both can affect fertility, **oligospermia** specifically refers to concentration, whereas asthenospermia refers to movement. *Absence of semen* - The absence of semen is known as **aspermia**, which means no ejaculate is produced. - This is distinct from issues with sperm quality or quantity within the semen. *Absence of sperms* - The complete absence of sperm in the ejaculate is called **azoospermia**. - This condition implies a total lack of sperm, unlike asthenospermia which indicates the presence of sperm but with impaired movement.

Q: Fructose absence in semen analysis suggests:

Seminal vesicles agenesis. ***Seminal vesicles agenesis*** - The **seminal vesicles** produce the majority of **fructose** in semen, which serves as the primary energy source for sperm. - Complete or partial absence of fructose indicates issues with seminal vesicle function or development, such as **agenesis**. *Bilateral vas deferens obstruction* - While it causes **azoospermia** (absence of sperm), a bilateral vas deferens obstruction generally does **not affect fructose production** by the seminal vesicles. - In such a scenario, most ejaculate volume originating from the seminal vesicles and prostate would still be present, including fructose. *Testicular failure* - **Testicular failure** primarily affects **sperm production** (spermatogenesis) and **testosterone synthesis**. - It does not directly impact the **fructose content** of the seminal fluid, as fructose is produced by the seminal vesicles, not the testes. *Prostatic urethral obstruction* - A **prostatic urethral obstruction** can affect ejaculate volume and flow but does not directly influence the **fructose content**, which is contributed by the seminal vesicles. - The prostate contributes **citric acid** and **prostate-specific antigen**, not fructose.

Q: 26 yr lady with delayed cycles presents to the infertility clinic. After diagnosing her to be a case anovulation of 'Normogonadotropic Hypogonadism' type she was put on human menopausal gonadotropin (HMG) for ovulation induction from the second day of her menstrual period. She was 'Triggered' for follicular rupture with Human chorionic gonadotropin (hCG) and on the 19th day of this cycle she developed dyspnoea, reduced urine output, abdominal bloating and pain. What condition is this patient likely suffering from?

Ovarian hyperstimulation syndrome. ***Ovarian hyperstimulation syndrome*** - The patient's history of **ovulation induction** using **HMG** followed by an **hCG trigger** and subsequent symptoms of **dyspnea**, **reduced urine output**, **abdominal bloating**, and pain strongly indicate **ovarian hyperstimulation syndrome (OHSS)**. - **hCG** exacerbates OHSS by increasing vascular permeability, leading to fluid shifts into the third space and resulting in effusions (e.g., ascites, pleural effusion) and hemoconcentration. *Ruptured ectopic pregnancy* - While an **ectopic pregnancy** can cause abdominal pain, it typically presents with a **positive pregnancy test** and **vaginal bleeding**, which are not mentioned. - Dyspnea and reduced urine output are not typical initial symptoms of ruptured ectopic pregnancy; rather, **hypovolemic shock** would be expected. *Theca lutein cysts* - **Theca lutein cysts** are usually **asymptomatic** and benign, often resolving spontaneously. - Although associated with high **hCG levels**, they typically do not cause the acute, severe systemic symptoms like dyspnea and reduced urine output seen in this patient. *Ruptured corpus luteum cyst* - A **ruptured corpus luteum cyst** can cause sudden abdominal pain due to **hemoperitoneum**, but it usually does not lead to severe systemic symptoms like significant dyspnea or reduced urine output unless there is massive hemorrhage. - The clinical picture with **dyspnea** and **reduced urine output** points more towards systemic fluid shifts rather than localized bleeding alone.

Q: A 24-year-old woman with a married life of 4 years visits an infertility clinic with a history of recurrent abortion. On further workup, she is found to have a septate uterus. Which surgery has the best reproductive outcome?

Hysteroscopic surgery. ***Hysteroscopic surgery*** - This minimally invasive procedure involves resecting the **septum** using a hysteroscope, which is associated with excellent reproductive outcomes, often achieving **term pregnancy rates of 70-80%**. - It is preferred because it avoids hysterotomy (incision into the uterus), preserving uterine integrity and reducing the risk of future complications during pregnancy and delivery. *Tompkins procedure* - This procedure involves a **laparotomy and longitudinal incision** into the uterus to excise the septum, followed by closure. - While effective, it is a more invasive open surgical approach, leading to a **longer recovery time** and potentially compromising uterine integrity, increasing the risk of future uterine rupture. *Jones procedure* - The Jones procedure is also an **abdominal metroplasty** that involves excising a wedge of tissue from the fundus of the uterus, typically used for **bicornuate uteri**. - It is **highly invasive** and not the preferred method for a septate uterus due to its extensive nature and associated risks. *Strassman procedure* - The Strassman procedure is primarily used for the surgical correction of a **bicornuate uterus** or **uterus didelphys**, involving unification of the two uterine horns. - This procedure is also an **open abdominal surgery** with significant recovery time and risks, and is not applicable for a septate uterus, where the issue is a fibrous or muscular wall within a single uterine cavity.

Question 1

A couple comes for evaluation of infertility. The HSG was normal but semen analysis revealed azoospermia. What is the diagnostic test to differentiate between testicular failure and vas deferens obstruction?

Accepted Answer

Serum FSH

Answer

Testicular FNAC

Answer

Testosterone levels

Answer

Karyotyping

Question 2

Number of oocytes at birth is

Accepted Answer

2-3 million

Answer

7-10 million

Answer

2-5 million

Answer

10-15 million

Question 3

Separation of first polar body occurs at the time of:

Accepted Answer

Ovulation

Answer

Menstruation

Answer

Fertilization

Answer

Oocyte maturation

Question 4

All are steps of GIFT, except:

Accepted Answer

Fertilization of oocyte in lab

Answer

Transfer of unfertilized egg into the fallopian tube

Answer

Ovulation stimulation

Answer

Oocyte retrieval

Question 5

Asthenospermia means:

Accepted Answer

Reduction in motility of sperms

Answer

Reduction in number of sperms

Answer

Absence of semen

Answer

Absence of sperms

Question 6

Regarding medical treatment of ectopic pregnancy, all are true except:

Accepted Answer

Initial beta HCG is an indicator for the number of doses required

Answer

Best prognostic indicator for success is initial HCG levels

Answer

Perform baseline CBC, LFT, KFT

Answer

Failure rates increase if cardiac activity is present

Question 7

Fructose absence in semen analysis suggests:

Accepted Answer

Seminal vesicles agenesis

Answer

Bilateral vas deferens obstruction

Answer

Testicular failure

Answer

Prostatic urethral obstruction

Question 8

All are signs / features of ectopic pregnancy on USG except –

Accepted Answer

Echogenic mass with multicystic spaces within endometrial cavity

Answer

Hyperechoic rim

Answer

Adnexal mass

Answer

Pseudo sac

Question 9

26 yr lady with delayed cycles presents to the infertility clinic. After diagnosing her to be a case anovulation of 'Normogonadotropic Hypogonadism' type she was put on human menopausal gonadotropin (HMG) for ovulation induction from the second day of her menstrual period. She was 'Triggered' for follicular rupture with Human chorionic gonadotropin (hCG) and on the 19th day of this cycle she developed dyspnoea, reduced urine output, abdominal bloating and pain. What condition is this patient likely suffering from?

Accepted Answer

Ovarian hyperstimulation syndrome

Answer

Ruptured ectopic pregnancy

Answer

Ruptured corpus luteum cyst

Answer

Theca lutein cysts

Question 10

A 24-year-old woman with a married life of 4 years visits an infertility clinic with a history of recurrent abortion. On further workup, she is found to have a septate uterus. Which surgery has the best reproductive outcome?

Accepted Answer

Hysteroscopic surgery

Answer

Tompkins procedure

Answer

Jones procedure

Answer

Strassman procedure

Fertility and Infertility — MCQs

Fertility and Infertility — MCQs

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