Fertility and Infertility — MCQs

Fertility and Infertility Indian Medical PG Practice Questions and MCQs

Question 41: What is the most reversible form of infertility?

A. Anovulation (Correct Answer)
B. Endometriosis
C. Tubal factor
D. Oligospermia

Explanation: **Explanation:** **Anovulation** is considered the most reversible form of infertility because it is primarily a functional disorder rather than a structural one. In most cases, the ovaries contain healthy oocytes, but the hormonal axis (Hypothalamic-Pituitary-Ovarian) is disrupted. With the administration of **ovulation induction agents** (such as Clomiphene Citrate or Letrozole), the success rate for achieving ovulation is as high as 70-80%, making it the most treatable cause of infertility. **Why other options are incorrect:** * **Endometriosis:** This is a progressive, chronic inflammatory disease. While medical and surgical interventions (laparoscopy) can improve fertility, the recurrence rate is high, and the pelvic environment often remains hostile to conception. * **Tubal Factor:** This involves structural damage or blockage (e.g., post-PID or hydrosalpinx). Reversing tubal damage requires complex microsurgery with variable success rates, or bypassing the tubes entirely via IVF. * **Oligospermia:** Male factor infertility is often idiopathic or genetic. While lifestyle changes or varicocelectomy may help, many cases require advanced Assisted Reproductive Technology (ART) like ICSI, which is a management strategy rather than a "reversal" of the underlying pathology. **NEET-PG High-Yield Pearls:** * **First-line drug for ovulation induction:** Letrozole (Aromatase inhibitor) is now preferred over Clomiphene Citrate, especially in PCOS. * **Most common cause of anovulatory infertility:** Polycystic Ovary Syndrome (PCOS). * **WHO Group II:** The most common category of anovulation (Normogonadotropic normoestrogenic). * **Success Rate:** Ovulation induction in PCOS patients has a cumulative pregnancy rate approaching that of the general population.

Question 42: Which of the following investigations is used to check fallopian tube patency?

A. Hysterosalpingography
B. Laparoscopy
C. Hysteroscopy
D. All of the above (Correct Answer)

Explanation: **Explanation:** Fallopian tube patency is a critical component of the infertility workup, as the tubes are the site of fertilization. While different methods offer varying levels of detail, all three listed investigations can be used to assess whether the tubes are open. * **Hysterosalpingography (HSG):** This is the **initial screening test** for tubal patency. It involves injecting a radiopaque dye into the uterus under fluoroscopy. If the tubes are patent, the dye spills into the peritoneal cavity. It is excellent for identifying proximal tubal blocks and contour abnormalities. * **Laparoscopy (with Chromopertubation):** This is the **Gold Standard** for assessing tubal patency. Methylene blue dye is injected transcervically, and the surgeon directly visualizes the dye spilling from the fimbrial ends. It has the added advantage of diagnosing extrinsic factors like peritubal adhesions or endometriosis. * **Hysteroscopy:** While primarily used to visualize the uterine cavity, hysteroscopy can assess patency via **hysteroscopic tubal cannulation** or by observing air bubbles/fluid entering the ostia. It is often combined with laparoscopy for a comprehensive evaluation. **High-Yield NEET-PG Pearls:** * **Gold Standard for Tubal Patency:** Laparoscopy + Chromopertubation. * **Best Initial Test:** Hysterosalpingography (HSG). * **Sonohysterosalpingography (SSG):** Uses ultrasound and saline; it is a radiation-free alternative to HSG. * **Timing:** HSG should be performed in the **pre-ovulatory phase** (Day 6 to Day 10) to avoid interfering with a potential pregnancy and to ensure the endometrium is thin.

Question 43: A patient presents with infertility without a significant clinical problem. What is the most likely diagnosis?

A. Fibroid uterus
B. T.B. endometrium (Correct Answer)
C. Carcinoma cervix
D. None of the above

Explanation: **Explanation:** In the context of the NEET-PG exam, the phrase **"infertility without a significant clinical problem"** is a classic descriptor for **Genital Tuberculosis (TB)**. In many developing countries, including India, pelvic TB is a leading cause of secondary and primary infertility. The disease is often "silent"—the patient may have no systemic symptoms (like fever or weight loss) and no obvious clinical findings on physical examination, yet the fallopian tubes and endometrium are damaged, preventing conception. **Why the options are right/wrong:** * **T.B. Endometrium (Correct):** Genital TB often presents solely as infertility. The infection typically starts in the fallopian tubes (100% of cases) and spreads to the endometrium (50-60%). It can cause tubal blockage or Asherman-like intrauterine adhesions without causing pain or menstrual irregularities in the early stages. * **Fibroid Uterus:** While common, fibroids are usually symptomatic, presenting with heavy menstrual bleeding (menorrhagia), pelvic pain, or a palpable mass on examination. Small intramural fibroids often do not cause infertility. * **Carcinoma Cervix:** This is a malignancy that typically presents with post-coital bleeding, foul-smelling discharge, or an obvious growth on the cervix. It is not a primary cause of infertility in an otherwise asymptomatic patient. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site** for Genital TB: Fallopian tubes (specifically the ampulla). * **Most common symptom** of Genital TB: Infertility. * **Most common menstrual abnormality** in Genital TB: Oligomenorrhea or Amenorrhea (due to endometrial destruction/Asherman’s Syndrome). * **Gold Standard Diagnosis:** Endometrial biopsy for histopathology (showing granulomas) and TB-PCR/Culture. * **Characteristic finding on HSG:** "Beaded tube," "Lead pipe appearance," or "Tobacco pouch" appearance.

Question 44: What is the percentage of female infertility cases attributed to tubal factors?

A. 7%
B. 19%
C. 26% (Correct Answer)
D. 40%

Explanation: **Explanation:** Infertility is defined as the inability to conceive after one year of regular, unprotected intercourse. In female factor infertility, the etiology is broadly categorized into ovulatory dysfunction, tubal/peritoneal factors, and uterine/cervical factors. **Why 26% is correct:** According to standard textbooks (like Williams Gynecology and Jeffcoate’s) and data from the Practice Committee of the American Society for Reproductive Medicine (ASRM), **tubal factors** account for approximately **25–30%** of female infertility cases. This makes it the second most common cause of female infertility after ovulatory disorders. Tubal damage is most frequently a result of Pelvic Inflammatory Disease (PID), endometriosis, or previous pelvic surgeries. **Analysis of Incorrect Options:** * **A (7%):** This is too low. While uterine factors (like fibroids or polyps) account for about 5–10% of cases, tubal patency is a much more frequent clinical issue. * **B (19%):** This figure is closer to the prevalence of endometriosis-related infertility but underestimates the total burden of tubal-only pathology. * **D (40%):** This is the approximate percentage for **ovulatory dysfunction** (the leading cause of female infertility) or the overall contribution of **male factors** to a couple's infertility. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Laparoscopy and Chromopertubation is the gold standard for diagnosing tubal patency and pelvic adhesions. * **Screening Test of Choice:** Hysterosalpingography (HSG) is the initial screening test, usually performed in the proliferative phase (Day 7–10). * **Most Common Cause of Tubal Block:** In India, **Genital Tuberculosis** is a significant specific cause, while globally, **Chlamydia trachomatis** is the most common infectious cause of PID leading to tubal factor infertility.

Question 45: Which of the following describes in vitro fertilization?

A. Method to judge the time of ovulation so that coitus can result in fertilization
B. Use of hormones to promote fertilization in the fallopian tubes
C. Removing mature ova, fertilizing it with sperm, and implanting back in the uterus (Correct Answer)
D. Artificial insemination

Explanation: **Explanation:** **In Vitro Fertilization (IVF)** is a type of Assisted Reproductive Technology (ART) where fertilization occurs outside the human body. The process involves controlled ovarian hyperstimulation to produce multiple follicles, followed by the ultrasound-guided retrieval of **mature oocytes**. These are then fertilized with sperm in a laboratory dish (in vitro). Once embryos reach the cleavage or blastocyst stage, they are **transferred back into the uterus** for implantation. **Analysis of Options:** * **Option A:** Describes **Natural Family Planning** or the "Calendar Method," which relies on tracking the menstrual cycle to identify the fertile window. * **Option B:** Refers to **Ovulation Induction (OI)** or Superovulation. While hormones are used in IVF, the actual fertilization in this option occurs naturally within the fallopian tubes (in vivo). * **Option D:** **Artificial Insemination (e.g., IUI)** involves placing processed sperm directly into the uterus, bypassing the cervix, but fertilization still occurs inside the woman's body. **High-Yield NEET-PG Pearls:** * **Indications:** Bilateral tubal block (most common), severe male factor infertility, and unexplained infertility. * **Step-by-Step:** 1. Pituitary suppression → 2. Controlled Ovarian Stimulation → 3. HCG "Trigger" (for final maturation) → 4. Oocyte retrieval (34–36 hours post-HCG) → 5. Fertilization → 6. Embryo Transfer. * **Complication:** The most serious complication of the stimulation phase is **Ovarian Hyperstimulation Syndrome (OHSS)**. * **Luteal Support:** Progesterone is mandatory after embryo transfer to support the endometrium.

Question 46: In semen banks, semen is preserved at low temperatures using which cryoprotectant?

A. Dry ice
B. Glycerol (Correct Answer)
C. Liquid nitrogen
D. Liquid oxygen

Explanation: **Explanation:** The correct answer is **Glycerol**. **1. Why Glycerol is the correct answer:** Cryopreservation of spermatozoa requires a **cryoprotectant** to prevent cellular damage during the freezing and thawing process. Glycerol is the most commonly used intracellular cryoprotectant for human semen. It works by lowering the freezing point and increasing the viscosity of the medium. Most importantly, it permeates the cell membrane and binds with water molecules, preventing the formation of **intracellular ice crystals**, which would otherwise rupture the sperm cell membrane and organelles. **2. Analysis of Incorrect Options:** * **Dry ice (Solid $CO_2$):** While it provides a cold environment ($-78.5^\circ C$), it is not a cryoprotectant. It was historically used for transport but is insufficient for long-term preservation of viability. * **Liquid Nitrogen ($-196^\circ C$):** This is the **medium/refrigerant** used for storage, not the cryoprotectant itself. Semen straws are submerged in liquid nitrogen or stored in its vapor phase for long-term cryopreservation. * **Liquid Oxygen:** This is highly combustible and biologically reactive; it is never used for cryopreservation. **3. High-Yield Clinical Pearls for NEET-PG:** * **Storage Temperature:** Semen is stored at **$-196^\circ C$** in liquid nitrogen. * **Cryoprotectants:** These are classified into **permeating** (e.g., Glycerol, DMSO) and **non-permeating** (e.g., Sucrose, Egg yolk, Skim milk). * **Vitrification:** A "flash-freezing" technique that avoids ice crystal formation by turning the medium into a glass-like solid. * **Post-thaw motility:** Typically, 50% or more of the initial motility should be maintained for a sample to be considered high quality after thawing.

Question 47: A semen analysis of a male partner in an infertile couple shows low volume with azoospermia and absent fructose. Serum FSH levels are normal. What is the most probable diagnosis?

A. Prostatic infection
B. Mumps orchitis
C. Block in the efferent duct system (Correct Answer)
D. Hypothalamic dysfunction

Explanation: **Explanation:** The clinical presentation of **azoospermia** (absence of sperm) combined with **low semen volume** and **absent fructose** in the presence of **normal FSH levels** is a classic indicator of an obstructive pathology, specifically a blockage in the efferent duct system (ejaculatory ducts or seminal vesicles). **1. Why Option C is Correct:** * **Fructose Source:** Fructose is produced exclusively by the **seminal vesicles**. Its absence in the ejaculate indicates either congenital bilateral absence of the vas deferens (CBAVD) or a distal obstruction (ejaculatory duct obstruction). * **Semen Volume:** Since seminal vesicle fluid constitutes about 60-70% of the total ejaculate volume, an obstruction here leads to low volume. * **Normal FSH:** FSH is a marker of germ cell health. Normal FSH levels suggest that spermatogenesis is occurring normally within the testes, confirming that the azoospermia is **obstructive** rather than secretory. **2. Why Other Options are Incorrect:** * **Prostatic Infection:** While it may affect sperm motility or cause leukocytospermia, it does not typically cause azoospermia or the total absence of fructose. * **Mumps Orchitis:** This causes primary testicular failure (secretory azoospermia). In such cases, **FSH would be elevated** due to the loss of negative feedback from inhibin B, and fructose would be present (as seminal vesicles are unaffected). * **Hypothalamic Dysfunction:** This results in hypogonadotropic hypogonadism. Both **FSH and LH would be low**, leading to secondary testicular failure. **NEET-PG High-Yield Pearls:** * **Fructose Test:** Used to differentiate between obstructive and non-obstructive azoospermia. * **Normal FSH + Azoospermia:** Highly suggestive of **Obstructive Azoospermia**. * **Elevated FSH + Azoospermia:** Suggestive of **Non-Obstructive (Secretory) Azoospermia** (e.g., Klinefelter syndrome, Sertoli-cell-only syndrome). * **Acidic pH + Low Volume + Absent Fructose:** Classic triad for Ejaculatory Duct Obstruction or CBAVD.

Question 48: What is the cause of infertility in KÃ¤gener syndrome?

A. Oligospermia
B. Asthenospermia (Correct Answer)
C. Undescended testis
D. Epididymis obstruction

Explanation: **Explanation:** **Kartagener Syndrome** is a subset of **Primary Ciliary Dyskinesia (PCD)**, characterized by the clinical triad of situs inversus, chronic sinusitis, and bronchiectasis. The underlying pathology is a structural defect in the **dynein arms** of cilia and flagella. 1. **Why Asthenospermia is correct:** The tail of a spermatozoon is a modified flagellum with a "9+2" microtubule arrangement, identical to respiratory cilia. In Kartagener syndrome, the deficiency of dynein arms results in **impaired motility**. While the sperm count (oligospermia) and morphology are typically normal, the sperm are unable to swim effectively to reach the oocyte. This state of reduced or absent motility is termed **Asthenospermia**. 2. **Why other options are incorrect:** * **Oligospermia:** Sperm production in the testes is generally normal because spermatogenesis is not dependent on ciliary function. * **Undescended testis:** This is an anatomical developmental defect (cryptorchidism) not associated with microtubule or dynein arm dysfunction. * **Epididymis obstruction:** While PCD can occasionally affect the efferent ductules, the primary and classic cause of infertility in these patients is the functional defect in sperm motility, not a physical blockage. **High-Yield Clinical Pearls for NEET-PG:** * **Inheritance:** Autosomal Recessive. * **Diagnosis:** Screening via nasal nitric oxide levels; definitive diagnosis via electron microscopy (showing absent dynein arms). * **Female Infertility:** Women with Kartagener syndrome may also face subfertility due to impaired ciliary action in the **fallopian tubes**, which hinders ovum transport. * **Management:** Infertility in males is best treated with **ICSI (Intracytoplasmic Sperm Injection)**, as motility is not required for successful fertilization in vitro.

Question 49: What is the most common cause of bilateral cornual block observed on hysterosalpingography?

A. Tuberculosis
B. Endometriosis
C. Physiological spasm (Correct Answer)
D. Pelvic inflammatory disease

Explanation: **Explanation:** The correct answer is **Physiological Spasm**. **1. Why Physiological Spasm is the correct answer:** Hysterosalpingography (HSG) involves the injection of radio-opaque contrast into the uterine cavity. The cornua (the junction of the fallopian tube and uterus) is the narrowest part of the tube and is surrounded by smooth muscle. The irritation caused by the contrast medium or the pressure of the injection often triggers a **transient physiological spasm** of these muscles. This prevents the contrast from entering the tubes, mimicking a bilateral block. It is the most frequent cause of "apparent" cornual obstruction seen on an initial HSG. **2. Why other options are incorrect:** * **Tuberculosis (A):** While Genital TB is a major cause of tubal infertility in developing countries, it typically presents with features like "beaded tubes," "tobacco pouch" appearance, or distal hydrosalpinx. It causes organic (permanent) blocks rather than the more common transient functional blocks. * **Endometriosis (B):** This usually causes peritubal adhesions and distal tubal distortion rather than isolated bilateral cornual occlusion. * **Pelvic Inflammatory Disease (D):** PID is a leading cause of organic tubal blockage, but it most commonly results in distal tubal occlusion (fimbrial block) and hydrosalpinx. **3. Clinical Pearls for NEET-PG:** * **Management of Spasm:** If a cornual block is suspected on HSG, antispasmodics (like Glucagon or Buscopan) or selective tubal cannulation under fluoroscopy can be used to differentiate spasm from a true organic block. * **Gold Standard:** Laparoscopy with chromopertubation remains the gold standard to confirm tubal patency and rule out false positives caused by HSG spasms. * **Water-soluble vs. Oil-based contrast:** Water-soluble contrast is preferred for HSG as it provides better mucosal detail and carries a lower risk of embolism.

Question 50: Tubal patency can be checked by all EXCEPT:

A. Hysterosalpingography
B. Laparoscopic chromotubation
C. Post coital test (Correct Answer)
D. Sonosalpingography

Explanation: **Explanation:** The assessment of tubal patency is a fundamental step in the evaluation of female infertility. The correct answer is **Post-coital test (PCT)** because it evaluates the interaction between sperm and cervical mucus, not the anatomical patency of the fallopian tubes. **Why Post-coital test (PCT) is the correct answer:** The PCT (Sims-Huhner test) is performed 2–12 hours after intercourse during the mid-ovulatory phase. It assesses the quality of cervical mucus and the ability of sperm to survive and migrate through it. It does not provide any information regarding the fallopian tubes. Note: In modern clinical practice, PCT has largely been replaced by semen analysis and anti-sperm antibody testing due to its low predictive value. **Why the other options are incorrect:** * **Hysterosalpingography (HSG):** The traditional first-line screening test for tubal patency. It involves injecting radiopaque dye into the uterus under fluoroscopy to visualize the uterine cavity and bilateral spill from the tubes. * **Laparoscopic Chromotubation:** Considered the **Gold Standard** for assessing tubal patency. Methylene blue or indigo carmine dye is injected transcervically while visualizing the fimbrial ends via laparoscopy. It also allows for the diagnosis of peritubal adhesions or endometriosis. * **Sonosalpingography (SSG):** Also known as "Sion Test," it uses saline infusion and transvaginal ultrasound to detect "spill" in the Pouch of Douglas. It is a safe, radiation-free bedside procedure. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard for Tubal Patency:** Laparoscopy and Chromotubation. * **First-line Investigation:** HSG (usually done on Day 7–10 of the cycle). * **Rubin’s Test:** An obsolete test using $CO_2$ insufflation to check patency (shoulder pain indicates a positive result). * **Hysterosalpingo-contrast-sonography (HyCoSy):** A specialized SSG using contrast agents (e.g., Echovist) for better visualization.

Practice by Chapter

Reproductive Physiology

Practice Questions

Evaluation of the Infertile Couple

Practice Questions

Male Factor Infertility

Practice Questions

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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