Fertility and Infertility — MCQs

A 41-year-old woman with one healthy child presents with a 3-year history of infertility despite normal menstrual cycles and a biphasic basal body temperature chart. She denies sexually transmitted diseases. A hysterosalpingogram shows patent uterine tubes and a normal uterine cavity. Her husband's semen analysis is normal. In the presence of several normal infertility test results, a laparoscopic examination of the pelvic cavity is scheduled. The physician performing the procedure carefully places the trocar lateral to the rectus abdominis muscle and its sheath to avoid injury to a major artery. What artery is being avoided?

Q35Medium

Varicoceles appear to cause male infertility by which mechanism?

Q36Medium

A 33-year-old woman presents with infertility and dyspareunia. On vaginal examination, tender nodularity is noted along the uterosacral ligaments. What is the most likely diagnosis?

Q37Medium

Semen analysis of a male from an infertile couple shows absence of spermatozoa but presence of fructose. What is the most probable diagnosis?

Q38Medium

Which of the following is true for patients treated with clomiphene?

Q39Easy

What are the functions of the endocervical cell lining?

Q40Easy

Which of the following drugs can affect male fertility?

Fertility and Infertility Indian Medical PG Practice Questions and MCQs

Question 31: A post-coital test shows non-motile sperms in the cervical smear and motile sperms from the posterior fornix. What does this suggest?

A. Faulty coital practice
B. Immunological defect (Correct Answer)
C. Hypospadias
D. Azoospermia

Explanation: **Explanation:** The **Post-Coital Test (PCT)**, or Sims-Huhner test, evaluates the interaction between the cervical mucus and spermatozoa. **Why Option B is Correct:** The presence of motile sperms in the posterior fornix confirms that ejaculation was successful and the semen quality is adequate. However, the finding of **non-motile (or shaking/vibratory) sperms** specifically within the cervical mucus suggests a "hostile" environment. This is the classic presentation of an **immunological defect**, where antisperm antibodies (ASABs) are present in the cervical mucus. These antibodies bind to the sperm, causing them to lose forward progression or become immobilized upon contact with the mucus (the "shaking phenomenon"). **Why Other Options are Incorrect:** * **A. Faulty coital practice:** If coitus were faulty, no sperm would be found in either the posterior fornix or the cervical smear. * **C. Hypospadias:** This condition leads to failure of deposition of semen at the external os; typically, the PCT would show an absence of sperm in the cervical canal. * **D. Azoospermia:** This refers to the total absence of sperm in the ejaculate. The presence of motile sperm in the posterior fornix directly rules this out. **NEET-PG High-Yield Pearls:** * **Timing:** PCT must be performed during the **pre-ovulatory phase** (when estrogen is high and mucus is thin/Spinnbarkeit is high). * **Normal Result:** >5–10 motile sperm per high-power field (HPF) with good forward progression. * **Clinical Utility:** The PCT has largely been replaced by more reliable tests like the **Sperm-Cervical Mucus Contact (SCMC) test** and direct antibody testing (Immunobead assay), as it has high inter-observer variability and poor predictive value for pregnancy.

Question 32: In which of the following conditions is in-vitro fertilisation (IVF) indicated in a 28-year-old female?

A. Anovulatory cycles
B. Tubal block (Correct Answer)
C. Azoospermia
D. Uterine anomalies

Explanation: **Explanation:** **Tubal block** is the classic and most definitive indication for **In-Vitro Fertilization (IVF)**. In cases of bilateral tubal obstruction (e.g., due to Pelvic Inflammatory Disease or previous surgery), the natural site of fertilization—the ampulla of the fallopian tube—is inaccessible. IVF bypasses the tubes entirely by retrieving oocytes directly from the ovaries, fertilizing them in a lab, and transferring the embryo into the uterus. **Analysis of Other Options:** * **Anovulatory cycles (Option A):** The first-line treatment is **Ovulation Induction** using drugs like Clomiphene Citrate or Letrozole. IVF is reserved only if medical induction fails. * **Azoospermia (Option C):** While IVF can be used, the specific procedure required for male factor infertility is **ICSI (Intracytoplasmic Sperm Injection)**. Furthermore, if it is obstructive azoospermia, surgical sperm retrieval is needed; if non-obstructive, donor insemination may be the first step. * **Uterine anomalies (Option D):** Conditions like a septate uterus are managed surgically (Hysteroscopic metroplasty). IVF does not bypass or fix a structural uterine defect that prevents implantation or causes miscarriage. **High-Yield NEET-PG Pearls:** * **Absolute Indication for IVF:** Bilateral tubal block. * **First-line for PCOD/Anovulation:** Letrozole (Aromatase inhibitor). * **Indication for ICSI:** Severe male factor infertility (oligoasthenoteratozoospermia) or failed fertilization in previous IVF cycles. * **Success Rate:** In a 28-year-old (young age), the prognosis for IVF is generally favorable, as ovarian reserve and oocyte quality are typically high.

Question 33: All of the following are techniques used for preimplantation genetic testing except?

A. Polar body analysis
B. Blastomere biopsy
C. Trophectoderm biopsy
D. Morula biopsy (Correct Answer)

Explanation: **Explanation:** Preimplantation Genetic Testing (PGT) involves analyzing the genetic material of an embryo before transfer to the uterus. The correct answer is **Morula biopsy** because it is not a standard clinical technique for PGT. **Why Morula Biopsy is the exception:** The morula stage (Day 4, 16–32 cells) is characterized by **compaction**, where cells begin to adhere tightly to one another. Attempting a biopsy at this stage is technically difficult, risks significant damage to the embryo, and provides no clinical advantage over other methods. **Analysis of other options:** * **Polar body analysis:** Performed on the 1st and 2nd polar bodies of the oocyte/zygote. It only provides information on maternal genetic contribution and does not reflect paternal DNA or mitotic errors. * **Blastomere biopsy:** Performed on **Day 3** (6–8 cell stage). One or two cells (blastomeres) are removed. While common in the past, it is associated with higher rates of embryo mosaicism and potential reduction in implantation rates. * **Trophectoderm biopsy:** The current **gold standard**, performed on **Day 5/6 (Blastocyst stage)**. Multiple cells are taken from the outer layer (future placenta), leaving the inner cell mass (future fetus) intact. It provides more DNA and is less traumatic to the embryo. **High-Yield Clinical Pearls for NEET-PG:** * **PGT-A:** Screens for Aneuploidy (most common). * **PGT-M:** Screens for Monogenic/single-gene disorders (e.g., Thalassemia). * **PGT-SR:** Screens for Structural Rearrangements (e.g., translocations). * **Blastocyst stage** is preferred for biopsy because it offers the highest diagnostic accuracy and lowest risk of embryo injury.

Question 34: A 41-year-old woman with one healthy child presents with a 3-year history of infertility despite normal menstrual cycles and a biphasic basal body temperature chart. She denies sexually transmitted diseases. A hysterosalpingogram shows patent uterine tubes and a normal uterine cavity. Her husband's semen analysis is normal. In the presence of several normal infertility test results, a laparoscopic examination of the pelvic cavity is scheduled. The physician performing the procedure carefully places the trocar lateral to the rectus abdominis muscle and its sheath to avoid injury to a major artery. What artery is being avoided?

A. Superior epigastric artery
B. Inferior epigastric artery (Correct Answer)
C. Superficial epigastric artery
D. Superficial circumflex iliac artery

Explanation: ### Explanation **1. Why the Correct Answer is Right:** In laparoscopic surgery, particularly during the placement of secondary trocars, the **inferior epigastric artery (IEA)** is the most significant vascular structure at risk in the anterior abdominal wall. The IEA arises from the **external iliac artery** and ascends superiorly and medially toward the rectus sheath. To avoid injuring this vessel, trocars are typically placed either in the midline (linea alba) or **lateral to the rectus abdominis muscle** (lateral to the lateral umbilical folds). Accidental laceration of the IEA can lead to significant abdominal wall hematomas or intraperitoneal hemorrhage. **2. Analysis of Incorrect Options:** * **A. Superior epigastric artery:** This is a terminal branch of the internal thoracic artery. It enters the rectus sheath from above and stays deep to the muscle. It is rarely injured during lower abdominal trocar placement. * **C. Superficial epigastric artery:** This vessel arises from the femoral artery and runs in the superficial fascia (subcutaneous tissue). While it may be encountered during the skin incision, it is not a "major artery" of the deep abdominal wall and does not dictate the lateral placement relative to the rectus sheath. * **D. Superficial circumflex iliac artery:** This also arises from the femoral artery and travels laterally toward the ASIS. It is located too lateral and superficial to be the primary concern during standard laparoscopic port entry. **3. NEET-PG High-Yield Pearls:** * **Laparoscopic Landmarks:** The inferior epigastric artery is located lateral to the **medial umbilical ligament** (obliterated umbilical artery) and forms the lateral boundary of **Hesselbach’s triangle**. * **Transillumination:** Before secondary port insertion, surgeons often attempt to transilluminate the abdominal wall to visualize the superficial vessels, though the deep IEA cannot always be seen this way. * **Infertility Context:** In a patient with "unexplained infertility" (normal HSG, normal semen analysis, normal ovulation), **Laparoscopy** is the gold standard to diagnose endometriosis or pelvic adhesions that are otherwise occult.

Question 35: Varicoceles appear to cause male infertility by which mechanism?

A. Interfering with sperm production
B. Blocking epididymal sperm motility activation
C. Increasing the likelihood of sperm antibody formation (Correct Answer)
D. Interfering with sperm movement through cervical mucus

Explanation: **Explanation:** The relationship between varicoceles and male infertility is multifactorial, but according to standard textbooks (like Jeffcoate’s and Novak’s), the primary immunological mechanism is the **disruption of the blood-testis barrier**. **1. Why Option C is Correct:** A varicocele causes venous stasis and increased hydrostatic pressure, which can lead to the breakdown of the blood-testis barrier. This exposes sequestered sperm antigens to the systemic circulation, triggering the production of **anti-sperm antibodies (ASA)**. These antibodies can cause sperm agglutination and inhibit the acrosome reaction, significantly impairing fertility. **2. Why Other Options are Incorrect:** * **Option A:** While varicoceles do cause hyperthermia and oxidative stress (which affect spermatogenesis), the question asks for the specific mechanism often highlighted in competitive exams regarding the "likelihood" of a specific pathology. In the context of this specific MCQ, the immunological factor is the prioritized answer. * **Option B:** Epididymal maturation is affected by the microenvironment, but "blocking activation" is not the primary pathophysiological hallmark of a varicocele. * **Option D:** While anti-sperm antibodies *can* interfere with cervical mucus penetration, this is a secondary effect. The primary mechanism caused by the varicocele itself is the *formation* of those antibodies. **Clinical Pearls for NEET-PG:** * **Most common cause** of surgically reversible male infertility. * **Side:** More common on the **left side** (due to the left testicular vein entering the left renal vein at a right angle). * **Diagnosis:** Gold standard is **Color Doppler Ultrasound** (vein diameter >2-3 mm with reflux on Valsalva). * **Semen Analysis:** Classically shows **Stress Pattern** (low motility, low count, and increased abnormal forms/tapered heads). * **Surgery:** Indicated if the varicocele is palpable, the couple has documented infertility, and the female partner is fertile.

Question 36: A 33-year-old woman presents with infertility and dyspareunia. On vaginal examination, tender nodularity is noted along the uterosacral ligaments. What is the most likely diagnosis?

A. Adenomyosis
B. Diethylstilbestrol (DES)-related disease
C. Subserosal fibroids
D. Endometriosis (Correct Answer)

Explanation: **Explanation:** The clinical presentation of **infertility, dyspareunia, and tender nodularity along the uterosacral ligaments** is a classic triad for **Endometriosis**. In this condition, functional endometrial tissue exists outside the uterine cavity. The uterosacral ligaments are one of the most common sites for deep infiltrating endometriosis; the "nodularity" felt on examination represents ectopic tissue and associated fibrosis, which becomes exquisitely tender due to cyclical bleeding and inflammation. **Analysis of Options:** * **Adenomyosis (A):** While it causes dysmenorrhea and infertility, it typically presents with a **globular, symmetrically enlarged, and soft (boggy) uterus**. It does not typically cause isolated uterosacral nodularity. * **DES-related disease (B):** Exposure to Diethylstilbestrol in utero is associated with structural anomalies like a **T-shaped uterine cavity**, cervical ridges, and clear cell adenocarcinoma, rather than tender pelvic nodules. * **Subserosal fibroids (C):** These may cause pelvic pressure or an irregular uterine contour, but they are generally **firm, non-tender**, and do not specifically target the uterosacral ligaments or typically cause deep dyspareunia unless degenerating. **NEET-PG High-Yield Pearls:** * **Gold Standard Diagnosis:** Laparoscopy (visual confirmation with biopsy). * **Commonest Site:** The ovary (often presenting as a "Chocolate cyst" or Endometrioma). * **Powder-burn Appearance:** Classic laparoscopic finding of peritoneal implants. * **Sampson’s Theory:** Retrograde menstruation is the most widely accepted theory for its pathogenesis. * **Markers:** CA-125 may be elevated but is non-specific (used for monitoring, not diagnosis).

Question 37: Semen analysis of a male from an infertile couple shows absence of spermatozoa but presence of fructose. What is the most probable diagnosis?

A. Prostatic infection
B. Mumps orchitis
C. Block in efferent duct system (Correct Answer)
D. All of the above

Explanation: **Explanation:** The presence of **fructose** in semen is a critical diagnostic marker in the evaluation of azoospermia (absence of spermatozoa). Fructose is produced and secreted exclusively by the **seminal vesicles**. 1. **Why the correct answer is right:** In this scenario, the presence of fructose confirms that the seminal vesicles are present and their ducts are patent. Since there are no spermatozoa (azoospermia) but fructose is present, the obstruction or pathology must be located **proximal** to the point where the seminal vesicles join the vas deferens (i.e., the ejaculatory duct). The **efferent duct system** (including the rete testis and epididymis) is located before this junction. Therefore, a block in the efferent ducts prevents sperm from reaching the ejaculate while allowing seminal vesicle fluid (and fructose) to pass through. 2. **Why incorrect options are wrong:** * **Prostatic infection:** While this can affect sperm motility or cause leukocytospermia, it does not typically cause a complete absence of spermatozoa. * **Mumps orchitis:** This leads to testicular atrophy and primary testicular failure (non-obstructive azoospermia). While sperm would be absent, this is a functional failure of production, not a diagnostic match specifically highlighted by the "presence of fructose" logic used to differentiate types of obstructive azoospermia. **High-Yield Clinical Pearls for NEET-PG:** * **Azoospermia + Fructose Negative:** Suggests Congenital Bilateral Absence of Vas Deferens (CBAVD) or Ejaculatory Duct Obstruction (since seminal vesicles are often absent or blocked). * **CBAVD** is strongly associated with mutations in the **CFTR gene** (Cystic Fibrosis). * **Normal Semen pH:** 7.2–8.0 (Alkaline). If the ejaculate is acidic and fructose-negative, it points toward seminal vesicle obstruction or agenesis.

Question 38: Which of the following is true for patients treated with clomiphene?

A. Decreased risk of ovarian carcinoma
B. Causes decreased sexuality if given in males
C. Increased risk of ovarian hyperstimulation and polycystic ovaries (Correct Answer)
D. Risk of ectopic pregnancy

Explanation: **Explanation:** **Clomiphene Citrate (CC)** is a Selective Estrogen Receptor Modulator (SERM) and the traditional first-line agent for ovulation induction. It acts as a competitive antagonist to estrogen receptors in the hypothalamus, blocking negative feedback. This leads to an increase in GnRH, FSH, and LH, stimulating follicular development. **Why Option C is Correct:** By increasing endogenous FSH levels, clomiphene often stimulates the growth of multiple follicles rather than a single dominant one. This exaggerated response can lead to **Ovarian Hyperstimulation Syndrome (OHSS)**, although the risk is significantly lower (approx. 1%) compared to gonadotropin therapy. Furthermore, prolonged use or high doses can lead to the formation of multiple **theca-lutein cysts**, mimicking or exacerbating a polycystic ovarian morphology. **Why Other Options are Incorrect:** * **Option A:** There is no evidence that CC decreases the risk of ovarian carcinoma. In fact, historical concerns (though largely debated) suggested a slight increase in risk with prolonged use (>12 cycles) due to "incessant ovulation." * **Option B:** In males, CC is used off-label for idiopathic oligospermia. It increases testosterone levels by stimulating the pituitary-gonadal axis, which generally **improves** rather than decreases libido/sexuality. * **Option C:** While CC increases the risk of **multiple gestations** (approx. 8-10%, mostly twins), it does not inherently increase the risk of ectopic pregnancy compared to the baseline risk in the infertile population. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** Competitive inhibition of estrogen receptors at the hypothalamus. * **Side Effects:** Hot flashes (most common), visual disturbances (scotomas), and thinning of the endometrium (due to anti-estrogenic effect). * **Monitoring:** Usually started on Day 2, 3, 4, or 5 of the cycle for 5 days. * **Success Rate:** Ovulation occurs in ~80%, but pregnancy occurs in only ~40% (the "Ocular-Endometrial Discrepancy").

Question 39: What are the functions of the endocervical cell lining?

A. Cilia are directed downwards
B. Provides nutrition to sperms
C. Allows capacitation of sperms
D. All of the above (Correct Answer)

Explanation: The endocervical canal is lined by a single layer of tall columnar epithelium, which plays a critical role in sperm transport and survival. **Explanation of the Correct Answer:** The correct answer is **D (All of the above)** because the endocervical lining acts as a biological filter and reservoir for spermatozoa: 1. **Ciliary Action (Option A):** The endocervical cells possess cilia that beat in a **downward direction** (towards the vagina). This creates a fluid current that helps orient the sperm to swim upstream (rheotaxis) toward the uterine cavity. 2. **Nutritional Support (Option B):** The cervical mucus, secreted by these cells, is rich in carbohydrates (glucose), amino acids, and electrolytes. This provides the necessary energy substrate for sperm to survive for up to 48–72 hours within the cervical crypts. 3. **Capacitation (Option C):** As sperm pass through the cervical mucus, the process of **capacitation** begins. This involves the removal of glycoprotein coats and seminal plasma proteins from the sperm head, making them capable of fertilizing an oocyte. **Clinical Pearls for NEET-PG:** * **Insulin-like Growth Factors:** Cervical mucus contains IGFs which enhance sperm motility. * **Spinnbarkeit Effect:** Under estrogen influence (ovulation), the mucus becomes thin, watery, and stretchy, facilitating sperm penetration. * **The "Filter" Function:** The endocervix filters out morphologically abnormal sperm and prevents the entry of vaginal bacteria into the upper genital tract. * **Cervical Crypts:** These act as a "reservoir," releasing sperm in waves over several days to increase the chances of fertilization.

Question 40: Which of the following drugs can affect male fertility?

A. Marijuana
B. Silodocin
C. Dutasteride
D. All the above (Correct Answer)

Explanation: **Explanation:** Male infertility can be induced by various pharmacological agents through mechanisms involving hormonal disruption, impaired spermatogenesis, or ejaculatory dysfunction. * **Marijuana (Option A):** Cannabinoids act on the hypothalamic-pituitary-gonadal (HPG) axis. Chronic use suppresses the release of GnRH, leading to decreased LH and FSH levels. This results in **reduced testosterone production** and impaired spermatogenesis (decreased sperm count and motility). * **Silodocin (Option B):** This is a highly selective **alpha-1A adrenergic receptor antagonist** used for Benign Prostatic Hyperplasia (BPH). It causes relaxation of the smooth muscles in the vas deferens and seminal vesicles, leading to **retrograde ejaculation** or "dry orgasm," which is a significant cause of reversible male infertility. * **Dutasteride (Option C):** As a **5-alpha reductase inhibitor**, it prevents the conversion of testosterone to the more potent dihydrotestosterone (DHT). Clinical studies show that it can lead to a significant **reduction in total sperm count, semen volume, and sperm motility** in some men. **High-Yield Clinical Pearls for NEET-PG:** * **Spironolactone & Ketoconazole:** Both can cause infertility and gynecomastia by inhibiting androgen synthesis and displacing testosterone from SHBG. * **Sulfasalazine:** A classic "high-yield" drug that causes reversible impairment of sperm count and motility (switch to Mesalamine to restore fertility). * **Anabolic Steroids:** Cause profound infertility via negative feedback on the HPG axis, leading to azoospermia and testicular atrophy. * **Cytotoxic drugs:** Cyclophosphamide is the most notorious for causing permanent germ cell depletion.

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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