Fertility and Infertility — MCQs

Which investigation would be more appropriate in a 32-year-old nulliparous patient who presents to the gynecology OPD due to inability to conceive, having undergone uterine dilatation and curettage for menorrhagia not controlled medically around 4 years ago, and who is otherwise healthy on general examination?

Q319

Which of the following is a cause of male infertility?

Q320

Cervical hostility is assessed by the following tests, except:

Fertility and Infertility Indian Medical PG Practice Questions and MCQs

Question 311: When is Hysterosalpingography (HSG) ideally performed?

A. Between menstruation and ovulation
B. Just after menstruation (Correct Answer)
C. Just before ovulation
D. At any time

Explanation: ***Just after menstruation*** - HSG is ideally performed in the **early proliferative (follicular) phase**, typically **2-5 days after menstruation ends** or on **cycle days 7-10**. - At this time, the **endometrium is thin**, providing optimal visualization of the uterine cavity and tubal anatomy with minimal discomfort. - This timing avoids disrupting a **potential pregnancy**, as ovulation has not yet occurred and the likelihood of conception is minimal. - Performing the procedure after menstrual flow has ceased also reduces the risk of **infection** and ensures better image quality. *Between menstruation and ovulation* - This timeframe is too broad and vague, spanning approximately **14 days** (the entire follicular phase). - While it technically includes the correct timing, it also encompasses periods when HSG should **not** be performed, such as just before ovulation when fertilization may be imminent. - This option lacks the specificity required for proper clinical timing. *Just before ovulation* - Performing HSG just before ovulation (around day 12-14) carries a significant risk of **disrupting a potential pregnancy** if fertilization has occurred or is about to occur. - The **endometrium** is thicker at this stage in preparation for implantation, which can obscure findings and increase patient discomfort. - This timing also increases the risk of **flushing a fertilized egg** out of the fallopian tube. *At any time* - Performing HSG at any time is not advisable due to multiple risks, including the possibility of performing the procedure on a **pregnant woman**, which can cause harm. - The **uterine lining thickness** varies throughout the cycle, significantly affecting imaging quality and procedural comfort. - Timing during or near menses would result in blood obscuring the contrast and poor visualization.

Question 312: Which part of the female reproductive tract is the most common site of fertilization?

A. Fundus of the uterus
B. Ampulla of the uterine tube (Correct Answer)
C. Fimbriae
D. Infundibulum of the uterine tube

Explanation: ***Ampulla of the uterine tube*** - The **ampulla of the uterine tube** is the widest and longest part of the fallopian tube, making it the most common and typical site for **fertilization** to occur. - After ovulation, the **oocyte** is usually fertilized by sperm in this region before it continues its journey to the uterus. *Fundus of the uterus* - The **fundus of the uterus** is the upper, dome-shaped part of the uterus where the **implantation** of the embryo normally takes place, but not fertilization itself. - Fertilization occurs in the fallopian tube, and the resulting **zygote** then travels to the uterus for implantation. *Fimbriae* - The **fimbriae** are finger-like projections at the end of the fallopian tube that sweep the ovulated oocyte into the infundibulum. - While they are crucial for **oocyte capture**, they do not serve as the site of fertilization. *Infundibulum of the uterine tube* - The **infundibulum** is the funnel-shaped opening of the uterine tube, nearest to the ovary, and is where the oocyte first enters the tube. - While it is the entry point, the oocyte typically travels further into the **ampulla** for fertilization.

Question 313: Repeated curettage leads to infertility due to:

A. Uterine fibroids
B. Sheehan's syndrome
C. Endometrial carcinoma
D. Asherman's syndrome (Correct Answer)

Explanation: ***Asherman's syndrome*** - **Asherman's syndrome** is characterized by the formation of **intrauterine adhesions** or **fibrous bands** within the uterine cavity, often resulting from trauma to the endometrium. - **Repeated curettage**, especially following miscarriage or postpartum hemorrhage, is a major cause as it can damage the **basal layer of the endometrium**, preventing its regeneration and leading to scar tissue formation, which can cause infertility. *Uterine fibroids* - **Uterine fibroids** (leiomyomas) are **benign muscular tumors** of the uterus that can cause heavy menstrual bleeding and pelvic pain but do not typically develop due to curettage. - While large or submucosal fibroids can impact fertility, they are not directly caused by repeated curettage or associated with intrauterine adhesions. *Sheehan's syndrome* - **Sheehan's syndrome** is a condition of **hypopituitarism** caused by **ischemic necrosis of the pituitary gland** typically following severe postpartum hemorrhage and hypovolemic shock. - It is unrelated to repeated curettage and presents with hormonal deficiencies (e.g., amenorrhea, lactation failure) rather than uterine scarring. *Endometrial carcinoma* - **Endometrial carcinoma** is a **malignant proliferation of endometrial cells**, most commonly seen in postmenopausal women, and is not a consequence of repeated curettage. - It can cause abnormal uterine bleeding but does not directly lead to infertility through uterine adhesions or scarring from instrumentation.

Question 314: In which scenario should testing for microdeletion of the Y-chromosome be considered for a patient with a normal karyotype?

A. Sperm concentration of 2 million/ml (Correct Answer)
B. Semen volume of 2 ml (normal range)
C. Normal morphology sperms >4% (normal finding)
D. Presence of fructose in semen (normal finding)

Explanation: ***Sperm concentration of 2 million/ml*** - A sperm count of **2 million/ml** indicates severe oligozoospermia, which is a strong clinical indicator for considering Y-chromosome microdeletion testing. - Y-chromosome microdeletions, particularly in the **AZF (Azoospermia Factor) regions**, are a common genetic cause of male infertility, leading to very low or absent sperm counts. *Semen volume of 2 ml (normal range)* - A semen volume of 2 ml falls within the **normal reference range**, suggesting no issues related to seminal vesicle or prostate function. - This finding does not point towards a genetic cause of infertility like a Y-chromosome microdeletion. *Normal morphology sperms >4% (normal finding)* - A percentage of normal morphology sperms greater than 4% is considered **within the normal range** according to strict Kruger criteria. - This finding indicates good sperm quality in terms of shape and structure, and does not suggest a need for Y-chromosome microdeletion testing. *Presence of fructose in semen (normal finding)* - The presence of fructose in semen is a **normal finding**, indicating proper seminal vesicle function and patency of the ejaculatory ducts. - Its presence rules out conditions like ejaculatory duct obstruction or agenesis of the seminal vesicles, and therefore does not indicate a need for Y-chromosome microdeletion testing.

Question 315: A 35-year-old woman presents with primary infertility and a palpable pelvic mass. Her CA-125 level is 15 IU/mL. What is the diagnosis?

A. Endometrioma (Correct Answer)
B. Ovarian cancer
C. Pelvic tuberculosis
D. Borderline ovarian tumor

Explanation: ***Endometrioma*** - A palpable pelvic mass with **primary infertility** and a **normal CA-125** level strongly suggests an endometrioma. - Endometriomas are **cysts formed by endometrial tissue** on the ovaries, commonly causing infertility and pelvic pain. *Ovarian cancer* - Although a pelvic mass and infertility could be present, **ovarian cancer** typically presents with significantly **elevated CA-125** levels, which is not seen here. - Other symptoms may include ascites, weight loss, and severe abdominal pain, which are not mentioned. *Pelvic tuberculosis* - Pelvic tuberculosis can cause **infertility** and a pelvic mass, but it is often associated with characteristic symptoms like **fever, night sweats, and weight loss**, which are absent. - Diagnosis typically involves identifying the **_Mycobacterium tuberculosis_** bacterium. *Borderline ovarian tumor* - Borderline ovarian tumors, like ovarian cancer, are often associated with an **elevated CA-125** level. - They typically have a more **benign clinical course**, but still involve abnormal cell growth that would likely affect CA-125.

Question 316: Most common cause of first-trimester abortion is:

A. Genetic factors (Correct Answer)
B. Endocrine disorders
C. Immunological disorders
D. Infection

Explanation: ***Genetic factors*** - **Chromosomal abnormalities**, such as aneuploidies (e.g., **trisomy**), account for the majority of first-trimester spontaneous abortions. - These genetic errors often lead to **non-viable embryos**, resulting in early pregnancy loss as a natural selection mechanism. *Endocrine disorders* - While endocrine disorders like **luteal phase defect**, **uncontrolled diabetes**, or **thyroid dysfunction** can contribute to recurrent miscarriages, they are not the most common cause of *first-trimester abortions overall*. - Their impact is often more pronounced in **recurrent pregnancy loss** rather than sporadic first-trimester events. *Immunological disorders* - **Autoimmune disorders** such as **antiphospholipid syndrome** are important causes of **recurrent pregnancy loss** and can lead to first-trimester abortions. - However, they are **less common** than genetic factors as the primary cause of a single, sporadic first-trimester abortion. *Infection* - Certain **TORCH infections** (**T**oxoplasmosis, **O**ther [syphilis, varicella-zoster, parvovirus B19], **R**ubella, **C**ytomegalovirus, **H**erpes simplex virus) can cause miscarriage. - While significant, infections are a **less frequent cause** of first-trimester abortion compared to genetic anomalies.

Question 317: Which of the following methods is considered the best for obtaining a specimen for semen analysis?

A. A specimen obtained by coitus interruptus into a wide vessel
B. A specimen obtained through sexual intercourse with ejaculation into a wide vessel
C. A specimen obtained by masturbation in a clinical setting (Correct Answer)
D. A specimen collected using a condom

Explanation: ***A specimen obtained by masturbation in a clinical setting*** - This method ensures **complete ejaculation** and minimizes the risk of **contamination** or **sperm loss**, providing the most accurate representation of semen quality. - Collection in a clinical setting allows for proper storage conditions and timely analysis, which are crucial for maintaining **sperm viability** and motility. *A specimen obtained by coitus interruptus into a wide vessel* - This method carries a high risk of **losing the initial portion** of the ejaculate, which is typically the **most sperm-rich part**, leading to inaccurate results. - There is also a greater chance of **contamination** from vaginal fluids or external sources, affecting the specimen's integrity. *A specimen obtained through sexual intercourse with ejaculation into a wide vessel* - This method is prone to **contamination** from vaginal secretions and bacteria, which can interfere with accurate semen analysis. - The process may also result in **loss of ejaculate**, particularly the initial portion, impacting the overall volume and sperm concentration measurements. *A specimen collected using a condom* - Most condoms contain **spermicides** that are toxic to sperm, which would severely compromise the viability and motility of the sperm, rendering the analysis invalid. - Even if non-spermicidal condoms are used, the lubricants and materials in the condom might still affect sperm quality and motility, making this an unreliable collection method.

Question 318: Which investigation would be more appropriate in a 32-year-old nulliparous patient who presents to the gynecology OPD due to inability to conceive, having undergone uterine dilatation and curettage for menorrhagia not controlled medically around 4 years ago, and who is otherwise healthy on general examination?

A. Laparoscopy
B. Hysterosalpingography (Correct Answer)
C. CT scan of abdomen and pelvis
D. X-ray of pelvis

Explanation: ***Hysterosalpingography*** - This procedure uses **X-rays** and **contrast dye** to visualize the inside of the uterus and fallopian tubes, which is crucial for assessing **tubal patency** and uterine cavity abnormalities. - Given the patient's history of **dilatation and curettage (D&C)**, there is a risk of **Asherman's syndrome** (intrauterine adhesions), which hysterosalpingography can effectively diagnose. *Laparoscopy* - While laparoscopy can provide a direct visual assessment of pelvic organs and tubal patency, it is a **more invasive** surgical procedure with associated risks. - It is typically reserved for cases where less invasive tests like hysterosalpingography are inconclusive or suggest abnormalities requiring surgical intervention. *CT scan of abdomen and pelvis* - A CT scan is primarily used for evaluating **soft tissue structures** and detecting tumors or masses, but it is not the most appropriate initial investigation for assessing uterine cavity or fallopian tube patency in fertility workup. - It involves significant radiation exposure and provides **limited detail** compared to hysterosalpingography for the specific concerns in this patient. *X-ray of pelvis* - A standard X-ray of the pelvis offers a general view of **bone structures** and gross abnormalities but provides no information about the patency of the fallopian tubes or the morphology of the uterine cavity. - It is completely unsuitable for evaluating the causes of infertility related to uterine or tubal factors.

Question 319: Which of the following is a cause of male infertility?

A. Idiopathic
B. Yq11 microdeletion
C. Varicocele
D. All of the options (Correct Answer)

Explanation: ***All of the options*** - **Idiopathic**, **varicocele**, and **Yq11 microdeletion** are all recognized causes of male infertility, making this the most comprehensive and correct answer. - Male infertility can stem from a variety of factors, including genetic, structural, hormonal, and unexplained (idiopathic) causes. *Idiopathic* - Refers to cases where no specific cause for infertility can be identified despite thorough investigation, accounting for a significant proportion of male infertility. - This diagnosis is made by **exclusion** after ruling out other known causes. *Varicocele* - A common and treatable cause of male infertility, characterized by **dilated veins in the pampiniform plexus** of the scrotum. - Varicoceles can impair sperm production and function due to **increased scrotal temperature** and oxidative stress. *Yq11 microdeletion* - Refers to deletions in the **azoospermia factor (AZF) region** on the long arm of the Y chromosome, which are genetic causes of severe spermatogenic failure. - These deletions disrupt genes essential for sperm production, leading to conditions ranging from **oligozoospermia** (low sperm count) to **azoospermia** (absence of sperm).

Question 320: Cervical hostility is assessed by the following tests, except:

A. Hysterosalpingography (HSG) (Correct Answer)
B. Post coital test
C. Spinbarkeit
D. Miller-Kurzkrok test

Explanation: ***Hysterosalpingography (HSG)*** - **Hysterosalpingography (HSG)** is an imaging procedure used primarily to evaluate the patency of the fallopian tubes and the shape of the uterine cavity. - It does **not** assess cervical mucus quality, sperm-cervical mucus interaction, or any other component of cervical hostility. - HSG is used for tubal factor infertility assessment, not cervical factor assessment. *Spinbarkeit* - **Spinbarkeit** refers to the stretchability or elasticity of cervical mucus, which is a key physical property evaluated to assess cervical mucus quality. - This test assesses the ability of cervical mucus to stretch (normally 6-10 cm at ovulation), indicating adequate estrogen effect and favorable conditions for sperm penetration. - It is a direct measure of cervical mucus receptivity and is used to evaluate cervical factors in infertility. *Post coital test* - The **post coital test** (PCT), or Sims-Huhner test, directly evaluates the interaction between sperm and cervical mucus after intercourse. - It assesses sperm survival and motility within the cervical canal, making it a direct measure of cervical hostility. - The test examines whether cervical mucus is hospitable or hostile to sperm migration. *Miller-Kurzrok test* - The **Miller-Kurzrok test** is an in vitro test that assesses sperm-cervical mucus interaction by observing sperm penetration into a sample of cervical mucus on a slide. - This test is specifically designed to identify potential cervical factors affecting sperm motility and penetration. - It directly evaluates cervical hostility by testing the compatibility between sperm and cervical mucus.

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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