Fertility and Infertility — MCQs

Fertility and Infertility Indian Medical PG Practice Questions and MCQs

Question 21: A patient with infertility, treated with ovulation induction and HCG injection for ovulation, presents to the OPD 5 days later with complaints of abdominal distension with pain, nausea, and vomiting. Ultrasound reveals subclinical ascites. What is the next step in management?

A. Outpatient management with limited activity, daily weight record, and fluid balance monitoring. (Correct Answer)
B. Hospitalization, input-output charting, and IV fluid administration.
C. Hospitalization, albumin infusion, and input-output charting.
D. Paracentesis.

Explanation: **Explanation:** The clinical presentation describes **Ovarian Hyperstimulation Syndrome (OHSS)**, a complication of ovulation induction (usually with gonadotropins) followed by an hCG "trigger." The pathophysiology involves increased vascular permeability leading to a fluid shift from the intravascular to the extravascular space. **1. Why Option A is correct:** OHSS is classified into Mild, Moderate, Severe, and Critical. This patient has **Mild to Moderate OHSS**, characterized by abdominal distension, nausea, and ultrasound evidence of ascites (subclinical). According to standard guidelines (RCOG/ASRM), mild and moderate cases can be managed on an **outpatient basis**. Management focuses on supportive care: oral hydration, limited physical activity (to prevent ovarian torsion), and strict monitoring of daily weight and urine output to detect progression to severe OHSS. **2. Why other options are incorrect:** * **Options B & C:** Hospitalization and IV fluids/Albumin are reserved for **Severe OHSS**. Features of severe OHSS include clinical ascites, pleural effusion, oliguria, hemoconcentration (Hct >45%), or electrolyte imbalances. This patient’s symptoms do not yet meet these criteria. * **Option D:** Paracentesis is indicated only in severe/critical cases for symptomatic relief of tense ascites or compromised respiration. **Clinical Pearls for NEET-PG:** * **Trigger:** hCG is the primary trigger for OHSS due to its long half-life. * **Early vs. Late OHSS:** Early (3–7 days post-hCG) is due to the exogenous hCG injection; Late (12–17 days post-hCG) is due to endogenous hCG from an established pregnancy and is usually more severe. * **Prevention:** Use of GnRH agonists instead of hCG for the ovulation trigger in high-risk patients (e.g., PCOS). * **Key Monitoring:** An increase in body weight is often the first sign of worsening OHSS.

Question 22: Your patient on infertility treatment comes to you for consultation. She feels that the uterine myoma may be responsible for her decreased fertility. Which of the following is NOT a mechanism for decreased fertility in patients with uterine myoma?

A. Impaired tubal motility
B. Distorted uterine cavity
C. Displacement of cervix from vaginal pool of semen
D. Increased vascularity (Correct Answer)

Explanation: **Explanation:** The relationship between uterine myomas (fibroids) and infertility is primarily mechanical and biochemical. The correct answer is **D (Increased vascularity)** because, in the context of myomas, the pathological change is actually **impaired or disordered vascularity** (venous stasis and congestion) rather than a simple increase that supports fertility. In fact, myomas often cause focal endometrial inflammation and abnormal vascular patterns that interfere with embryo implantation. **Why the other options are incorrect (Mechanisms of Infertility in Myoma):** * **A. Impaired tubal motility:** Large or cornual myomas can physically compress the fallopian tubes or distort their anatomy, hindering the transport of the ovum and sperm. * **B. Distorted uterine cavity:** Submucosal and large intramural myomas alter the shape of the cavity, increasing the distance sperm must travel and interfering with the "niche" required for successful implantation. * **C. Displacement of cervix:** Massive fibroids can shift the entire uterus, pulling the cervix away from the posterior vaginal fornix (the seminal pool), thereby reducing the chance of sperm entering the cervical canal. **High-Yield NEET-PG Pearls:** * **Most common fibroid causing infertility:** Submucosal fibroids (FIGO Type 0, 1, 2) have the highest impact on implantation rates. * **Management:** Myomectomy is indicated if the fibroid distorts the cavity (submucosal) or is >4 cm in size in an asymptomatic infertile patient. * **Other mechanisms:** Myomas also cause increased uterine contractility and local release of cytokines/prostaglandins, both of which are detrimental to pregnancy.

Question 23: A patient's semen analysis reveals normal semen volume and the presence of fructose. Where is the likely site of a block if the patient has azoospermia?

A. Testicular
B. Below the level of seminal vesicles
C. Above the level of seminal vesicles (Correct Answer)
D. Pituitary

Explanation: **Explanation:** The presence of **fructose** in the semen is the key diagnostic marker in this case. Fructose is produced and secreted exclusively by the **seminal vesicles**. 1. **Why Option C is Correct:** If the semen analysis shows azoospermia (absence of sperm) but contains fructose and has a normal volume, it indicates that the seminal vesicles are functioning and their ducts are patent. Therefore, the obstruction must be located **above (proximal to)** the level where the seminal vesicle ducts join the vas deferens to form the ejaculatory ducts. Common sites include the epididymis or the proximal vas deferens. 2. **Why Incorrect Options are Wrong:** * **Option B (Below the level of seminal vesicles):** An obstruction at the level of the ejaculatory ducts or the prostate would block the secretions of the seminal vesicles. This would result in **fructose-negative** semen, low semen volume (<1.5 ml), and acidic pH. * **Option A (Testicular):** While testicular failure causes azoospermia, the question specifically asks for the "site of a block" (obstructive azoospermia). Testicular causes are typically non-obstructive. * **Option D (Pituitary):** Pituitary failure leads to hypogonadotropic hypogonadism. While this causes azoospermia, it is a hormonal issue, not a physical "block" in the ductal system. **NEET-PG High-Yield Pearls:** * **Fructose Test:** Used to differentiate between obstructive causes of azoospermia. * **Congenital Bilateral Absence of Vas Deferens (CBAVD):** Often associated with Cystic Fibrosis (CFTR mutation); presents with low volume, acidic, fructose-negative semen because the seminal vesicles are also typically absent or atrophic. * **Normal Semen pH:** 7.2–8.0 (Alkaline). If pH is acidic (<7.0) and fructose is absent, suspect ejaculatory duct obstruction.

Question 24: Infertility in women with endometriosis is most likely due to which of the following?

A. Tubal obstruction (Correct Answer)
B. Ovulatory dysfunction
C. Defect in implantation
D. Anti-sperm antibodies

Explanation: **Explanation:** Infertility is a common complication of endometriosis, affecting approximately 30–50% of women with the condition. The primary mechanism for infertility, especially in moderate to severe cases (Stage III and IV), is **mechanical distortion of pelvic anatomy**. **1. Why Tubal Obstruction is the Correct Answer:** Endometriosis leads to chronic pelvic inflammation, which results in the formation of dense **pelvic adhesions**. These adhesions cause structural damage, such as: * **Tubal blockage/obstruction:** Preventing the sperm and egg from meeting. * **Distortion of tubo-ovarian anatomy:** Interfering with the "fimbrial pick-up" mechanism of the oocyte. * **Fixed retroverted uterus:** Further complicating natural conception. While peritoneal factors (cytokines) play a role in mild cases, mechanical obstruction remains the most definitive and "most likely" cause in the context of established infertility. **2. Analysis of Incorrect Options:** * **B. Ovulatory dysfunction:** While some women with endometriosis may have Luteinized Unruptured Follicle (LUF) syndrome, most patients have regular ovulatory cycles. It is not the primary cause. * **C. Defect in implantation:** Though inflammatory cytokines (IL-6, TNF-α) may theoretically reduce endometrial receptivity, this is a secondary factor compared to the gross anatomical disruption. * **D. Anti-sperm antibodies:** These are more commonly associated with immunological infertility or post-vasectomy states in men; they are not a hallmark of endometriosis. **Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Laparoscopy ("Powder-burn" or "Gunshot" lesions). * **ASRM Staging:** Based on the size and depth of implants and the severity of adhesions. * **Management:** For infertility in Stage III/IV, **Surgical laparoscopy** (to restore anatomy) or **IVF** are the treatments of choice. Medical management (GnRH agonists, OCPs) treats pain but **does not** improve fertility.

Question 25: What is the optimal timing for an endometrial biopsy in the investigation of infertility?

A. The first day of menstruation
B. One week after the onset of menstruation
C. Just before the expected date of the next menstruation (Correct Answer)
D. The 15th day after the onset of menstruation

Explanation: **Explanation:** The primary objective of an endometrial biopsy in infertility workup is to assess **luteal phase adequacy** and confirm **ovulation**. **Why Option C is Correct:** The biopsy is ideally performed during the **late secretory phase**, specifically 2–3 days before the expected onset of menstruation (typically days 24–26 of a 28-day cycle). At this stage, the endometrium has been exposed to progesterone from the corpus luteum for the maximum duration. This allows the pathologist to "date" the endometrium using **Noyes’ criteria**. If the histological age lags behind the chronological cycle day by more than 2 days, it indicates a Luteal Phase Defect (LPD), which can be a cause of infertility or recurrent miscarriage. **Analysis of Incorrect Options:** * **Option A & B:** During or shortly after menstruation, the endometrium is either shedding or in the early proliferative phase. These stages do not reflect the progesterone influence required to confirm ovulation. * **Option D:** The 15th day is the early secretory phase (just after ovulation). The characteristic morphological changes required for accurate dating are not yet fully developed. **NEET-PG High-Yield Pearls:** * **Gold Standard:** While biopsy was historically the gold standard for LPD, **Mid-luteal serum progesterone levels** (measured on Day 21) are now more commonly used as a non-invasive alternative. A level >3 ng/ml confirms ovulation; >10 ng/ml suggests adequate luteal function. * **Site of Biopsy:** Usually taken from the **fundus** (anterior or posterior wall) as this area is most responsive to hormonal changes. * **Pre-procedure:** Always rule out pregnancy (via a urine pregnancy test) before performing a late-luteal biopsy to avoid disrupting a potential early implantation.

Question 26: An infertile couple enquires about modalities of assisted reproduction. Which of the following is not an assisted reproductive technology?

A. IVF
B. GIFT
C. ZIFT
D. Artificial insemination (Correct Answer)

Explanation: The distinction between Assisted Reproductive Technology (ART) and other fertility treatments is a high-yield concept for NEET-PG. ### **Explanation** According to the **CDC and WHO definitions**, **Assisted Reproductive Technology (ART)** includes all fertility treatments in which **both eggs and embryos are handled outside the body**. **Why Artificial Insemination (AI/IUI) is the correct answer:** Artificial Insemination, such as Intrauterine Insemination (IUI), involves the deposition of processed sperm into the female reproductive tract. Since the **oocytes are not handled** and fertilization occurs **in vivo** (inside the fallopian tube), it does not meet the technical definition of ART. **Why the other options are incorrect:** * **IVF (In-Vitro Fertilization):** The gold standard of ART where eggs are extracted, fertilized by sperm in a lab, and the resulting embryo is transferred to the uterus. * **GIFT (Gamete Intrafallopian Transfer):** Eggs and sperm are collected and immediately placed into the fallopian tube. Although fertilization is in vivo, it is considered ART because the oocytes are handled outside the body. * **ZIFT (Zygote Intrafallopian Transfer):** A hybrid of IVF and GIFT where fertilization happens in the lab, and the zygote is transferred into the fallopian tube. ### **High-Yield Clinical Pearls** * **Success Rates:** IVF generally has higher success rates per cycle compared to IUI. * **ICSI (Intracytoplasmic Sperm Injection):** The most common ART procedure used for **male factor infertility** (low sperm count/motility). * **OHSS (Ovarian Hyperstimulation Syndrome):** The most serious complication associated with the controlled ovarian stimulation used in ART. * **Legal Note:** In India, the **ART (Regulation) Act, 2021** provides the legal framework for these procedures, distinguishing between ART banks and clinics.

Question 27: What is the probability of a normally fertile couple conceiving a child within one menstrual cycle?

A. 80%
B. 25% (Correct Answer)
C. 60%
D. 45%

Explanation: **Explanation:** The probability of a normally fertile couple conceiving in a single menstrual cycle is known as **Fecundability**. For a healthy couple in their peak reproductive years (early 20s) having regular unprotected intercourse, the fecundability rate is approximately **20–25%**. While humans are relatively inefficient breeders compared to other mammals, the cumulative probability of conception increases over time: about 70% conceive within 6 months, 85% within 12 months, and 95% by 24 months. **Analysis of Options:** * **Option A (80%):** This is incorrect for a single cycle. However, 80–85% is the cumulative pregnancy rate after **one year** of regular unprotected intercourse. * **Option B (25%):** **Correct.** This represents the maximum biological potential for conception per cycle (fecundability). * **Option C (60%):** This is incorrect for a single cycle. Approximately 60–70% of couples will have conceived by the end of **six months**. * **Option D (45%):** This value does not correspond to standard clinical milestones in fertility statistics. **Clinical Pearls for NEET-PG:** * **Fecundability:** Probability of pregnancy in one cycle (~25%). * **Fecundity:** The ability to achieve a live birth within one menstrual cycle. * **Infertility Definition:** Failure to conceive after **12 months** of regular unprotected intercourse (or 6 months if the female partner is >35 years). * **Peak Fertility:** Occurs during the "fertile window," which includes the 5 days preceding ovulation and the day of ovulation itself. * **Age Factor:** Fecundability declines significantly after age 35 due to decreased oocyte quantity and quality.

Question 28: A 30-year-old lady is examined for infertility. Hysterosalpingography reveals 'bead-like' fallopian tubes and clubbing of the ampulla. What is the most likely cause?

A. Neisseria gonorrhoeae
B. Mycoplasma species
C. Chlamydia trachomatis
D. Mycobacterium tuberculosis (Correct Answer)

Explanation: **Explanation:** The clinical presentation and hysterosalpingography (HSG) findings are classic for **Genital Tuberculosis (GTB)**. In India and other developing nations, Mycobacterium tuberculosis is a leading cause of tubal factor infertility. **1. Why Mycobacterium tuberculosis is correct:** Genital TB typically spreads hematogenously to the fallopian tubes (affected in 90-100% of cases). The chronic granulomatous inflammation leads to specific radiological signs on HSG: * **Beaded appearance:** Caused by multiple strictures and scarring along the tube. * **Clubbing of the ampulla:** Resulting from fimbrial phimosis and distal occlusion. * **Other high-yield HSG signs:** "Lead pipe" tubes (rigid tubes), "Tobacco pouch" appearance, and **Asherman’s syndrome** (due to endometrial involvement). **2. Why other options are incorrect:** * **Chlamydia trachomatis & Neisseria gonorrhoeae:** These are the most common causes of Pelvic Inflammatory Disease (PID) worldwide. While they cause tubal blockages and hydrosalpinx, they typically result in thin-walled, dilated tubes rather than the characteristic "beaded" or "calcified" appearance seen in TB. * **Mycoplasma species:** These are associated with bacterial vaginosis and subacute PID but rarely cause the extensive structural tubal destruction or specific beaded morphology associated with tuberculosis. **NEET-PG High-Yield Pearls:** * **Gold Standard Diagnosis for GTB:** Endometrial biopsy for histopathology (granulomas) and TB-PCR/Culture (taken in the pre-menstrual phase). * **Most common site of Genital TB:** Fallopian tube (1st), followed by Endometrium (2nd). * **Schick’s Sign:** A radiological sign in GTB where there is calcification of pelvic lymph nodes or the fallopian tubes. * **Prognosis:** Even after successful Antitubercular Therapy (ATT), the conception rate remains low due to permanent tubal damage and endometrial scarring.

Question 29: Apart from ovulation induction, clomiphene citrate can be tried for which of the following disorders?

A. Oligospermia (Correct Answer)
B. Erectile dysfunction
C. Asherman's syndrome
D. Carcinoma endometrium

Explanation: **Explanation:** **Clomiphene Citrate (CC)** is a Selective Estrogen Receptor Modulator (SERM). While primarily known for female ovulation induction, it is also used off-label in male infertility. **Why Oligospermia is correct:** In men, Clomiphene acts by blocking estrogen receptors at the level of the hypothalamus and pituitary gland. This inhibits the negative feedback loop of estrogen, leading to an increased secretion of **GnRH, FSH, and LH**. * **FSH** stimulates the Sertoli cells to support spermatogenesis. * **LH** stimulates Leydig cells to produce endogenous **testosterone**. This hormonal surge can improve sperm count and concentration in men with idiopathic oligospermia, provided they have a functional hypothalamic-pituitary-gonadal axis. **Why other options are incorrect:** * **B. Erectile Dysfunction:** This is primarily a vascular or neurological issue (treated with PDE5 inhibitors like Sildenafil), not a gonadotropin deficiency. * **C. Asherman’s Syndrome:** This involves intrauterine adhesions (structural defect). CC cannot restore the endometrium; treatment requires hysteroscopic adhesiolysis. * **D. Carcinoma Endometrium:** CC is actually **contraindicated** or used with extreme caution in estrogen-dependent tumors because its long-term use can potentially have a proliferative effect on the endometrium. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism of Action:** Competitive antagonist of estrogen receptors in the hypothalamus (increases GnRH pulse frequency). * **Side Effects:** Multiple pregnancies (mostly twins), hot flashes, and **ovarian hyperstimulation syndrome (OHSS)** (though less common than with gonadotropins). * **Dose for Ovulation:** Usually 50 mg/day for 5 days (Day 2 to Day 6 or Day 3 to Day 7 of the cycle). * **Anti-estrogenic effect:** It can cause thinning of the cervical mucus and endometrium, which may sometimes lead to a "conception-ovulation gap."

Question 30: A 32-year-old male presents at an infertility clinic with a history of azoospermia on semen analysis. His serum FSH is increased and testosterone levels are decreased. What is the most likely site of the problem in this case?

A. Testicular (Correct Answer)
B. Post-testicular
C. Hypothalamus
D. Pituitary

Explanation: **Explanation:** The clinical presentation of **azoospermia** associated with **increased FSH** and **decreased testosterone** indicates **Primary Hypogonadism (Hypergonadotropic Hypogonadism)**. **1. Why Testicular is correct:** In this case, the pathology lies within the testes (the primary organ). When the testes fail to produce testosterone (Leydig cell dysfunction) and inhibin (Sertoli cell dysfunction), the negative feedback mechanism to the brain is lost. Consequently, the pituitary gland secretes compensatory high levels of FSH and LH to stimulate the failing gonads. This hormonal profile (High FSH/LH, Low Testosterone) is a hallmark of primary testicular failure, such as in Klinefelter syndrome or post-mumps orchitis. **2. Why other options are incorrect:** * **Hypothalamus (C) and Pituitary (D):** These represent **Secondary Hypogonadism (Hypogonadotropic Hypogonadism)**. If the defect were at the level of the brain, the FSH and LH would be low or inappropriately normal in the presence of low testosterone. * **Post-testicular (B):** This refers to obstructive azoospermia (e.g., Congenital Absence of Vas Deferens). In these cases, the testicular production of hormones is intact; therefore, FSH, LH, and testosterone levels remain **normal**. **High-Yield Clinical Pearls for NEET-PG:** * **FSH** is the most sensitive marker for spermatogenesis; elevated FSH usually indicates significant germ cell depletion. * **Normal FSH + Azoospermia** = Likely Obstructive (Post-testicular) cause. * **High FSH + Azoospermia** = Likely Non-obstructive (Testicular) cause. * **Low FSH + Azoospermia** = Pre-testicular (Hypothalamic/Pituitary) cause.

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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