Fertility and Infertility — MCQs

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?

Q250

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?

Fertility and Infertility Indian Medical PG Practice Questions and MCQs

Question 241: 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?

A. Serum FSH (Correct Answer)
B. Testicular FNAC
C. Testosterone levels
D. Karyotyping

Explanation: ***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.

Question 242: Number of oocytes at birth is

A. 7-10 million
B. 2-5 million
C. 10-15 million
D. 2-3 million (Correct Answer)

Explanation: ***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.

Question 243: Separation of first polar body occurs at the time of:

A. Ovulation (Correct Answer)
B. Menstruation
C. Fertilization
D. Oocyte maturation

Explanation: ***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.

Question 244: All are steps of GIFT, except:

A. Transfer of unfertilized egg into the fallopian tube
B. Fertilization of oocyte in lab (Correct Answer)
C. Ovulation stimulation
D. Oocyte retrieval

Explanation: ***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.

Question 245: Asthenospermia means:

A. Reduction in motility of sperms (Correct Answer)
B. Reduction in number of sperms
C. Absence of semen
D. Absence of sperms

Explanation: ***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.

Question 246: Regarding medical treatment of ectopic pregnancy, all are true except:

A. Best prognostic indicator for success is initial HCG levels
B. Perform baseline CBC, LFT, KFT
C. Initial beta HCG is an indicator for the number of doses required (Correct Answer)
D. Failure rates increase if cardiac activity is present

Explanation: ***Initial beta HCG is an indicator for the number of doses required*** - The initial **beta-HCG level** is a strong predictor of methotrexate treatment success, but it does **not delineate the number of doses** required. - The decision for single-dose vs. multi-dose methotrexate regimen is typically based on factors like initial HCG levels, size of ectopic mass, and physician preference, not predetermined by HCG for dose count. *Best prognostic indicator for success is initial HCG levels* - An initial **HCG level below 5000 mIU/mL** is the most significant positive prognostic indicator for successful medical management of ectopic pregnancy with methotrexate. - Higher HCG levels are associated with a **reduced success rate** and may necessitate surgical intervention. *Perform baseline CBC, LFT, KFT* - **Baseline complete blood count (CBC)**, **liver function tests (LFTs)**, and **kidney function tests (KFTs)** are essential before methotrexate treatment to assess for contraindications. - Methotrexate is **hepatotoxic** and **nephrotoxic**, and can cause myelosuppression, making these blood tests crucial for patient safety. *Failure rates increase if cardiac activity is present* - The presence of **fetal cardiac activity** within the ectopic pregnancy is a key predictor of failure with medical management and often a contraindication to methotrexate, favoring surgical intervention. - An embryo with cardiac activity indicates a **larger, more viable pregnancy**, which is less likely to respond to methotrexate and carries a higher risk of rupture.

Question 247: Fructose absence in semen analysis suggests:

A. Bilateral vas deferens obstruction
B. Testicular failure
C. Seminal vesicles agenesis (Correct Answer)
D. Prostatic urethral obstruction

Explanation: ***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.

Question 248: All are signs / features of ectopic pregnancy on USG except –

A. Hyperechoic rim
B. Echogenic mass with multicystic spaces within endometrial cavity (Correct Answer)
C. Adnexal mass
D. Pseudo sac

Explanation: **Echogenic mass with multicystic spaces within endometrial cavity** - This description is characteristic of a **hydatidiform mole**, a form of gestational trophoblastic disease, not an ectopic pregnancy. - A **hydatidiform mole** typically presents with an enlarged uterus and an echogenic, multicystic mass (often described as a "snowstorm" appearance) within the **endometrial cavity**. *Hyperechoic rim* - A **hyperechoic rim (or decidual reaction)** around an adnexal mass can be a sign of an ectopic pregnancy, representing the decidualized tissue surrounding the gestational sac. - This is part of the "ring of fire" sign on Doppler ultrasound, indicating increased vascularity around the ectopic gestational sac. *Adenexal mass* - The presence of an **adnexal mass** separate from the ovary, especially if it contains a gestational sac or yolk sac, is a primary ultrasonographic feature of an **ectopic pregnancy**. - This mass represents the ectopic implantation site, most commonly in the **fallopian tube**. *Pseudo sac* - A **pseudo sac (or pseudo gestational sac)** is a collection of intrauterine fluid that can mimic a gestational sac but lacks an embryo or yolk sac. - It is a common finding in **ectopic pregnancies** and results from decidual reactions within the uterus in response to elevated hCG levels from the ectopic pregnancy.

Question 249: 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?

A. Ruptured ectopic pregnancy
B. Ruptured corpus luteum cyst
C. Ovarian hyperstimulation syndrome (Correct Answer)
D. Theca lutein cysts

Explanation: ***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.

Question 250: 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?

A. Tompkins procedure
B. Hysteroscopic surgery (Correct Answer)
C. Jones procedure
D. Strassman procedure

Explanation: ***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.

Practice by Chapter

Reproductive Physiology

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Evaluation of the Infertile Couple

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Male Factor Infertility

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Female Factor Infertility

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Ovulatory Disorders

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Tubal and Peritoneal Factors

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Uterine Factors

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Unexplained Infertility

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Assisted Reproductive Technologies

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Psychological Aspects of Infertility

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