Fertility and Infertility — MCQs

Fertility and Infertility Indian Medical PG Practice Questions and MCQs

Question 61: Which of the following is NOT a test for ovulation?

A. Fern test
B. Basal body temperature
C. Hysteroscopy (Correct Answer)
D. LH surge

Explanation: **Explanation:** The assessment of ovulation is a cornerstone of infertility evaluation. To confirm ovulation, a test must detect either the physiological changes preceding it (hormonal surges) or the effects of progesterone produced by the corpus luteum after it occurs. **Why Hysteroscopy is the correct answer:** Hysteroscopy is an endoscopic procedure used to visualize the **endocervical canal and uterine cavity**. While it is the "gold standard" for diagnosing structural intrauterine pathologies (like polyps, submucosal fibroids, or synechiae), it provides no information regarding the functional status of the ovaries or the occurrence of ovulation. **Analysis of other options:** * **Fern Test:** This assesses cervical mucus. Under the influence of estrogen (pre-ovulatory), mucus shows "ferning." After ovulation, **progesterone** inhibits this pattern, causing "smearing" or cellular patterns. The disappearance of ferning is an indirect sign that ovulation has occurred. * **Basal Body Temperature (BBT):** Progesterone is thermogenic. A rise in BBT by 0.4–0.8°F in the second half of the cycle (biphasic curve) indicates the presence of a functioning corpus luteum, confirming ovulation. * **LH Surge:** The Luteinizing Hormone surge (detected in urine or blood) occurs 24–36 hours before ovulation. It is the most reliable predictor of impending oocyte release. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard for Ovulation:** The only 100% certain sign of ovulation is **pregnancy** or the recovery of an oocyte. * **Best Biochemical Test:** Mid-luteal **Serum Progesterone** (measured on Day 21 of a 28-day cycle). A value >3 ng/mL suggests ovulation; >10 ng/mL is optimal. * **Best Imaging:** Serial **Transvaginal Sonography (TVS)** (Folliculometry) to observe follicle disappearance and the appearance of free fluid in the Pouch of Douglas. * **Endometrial Biopsy:** Historically used to show "secretory endometrium," but no longer recommended for routine ovulation testing due to its invasive nature.

Question 62: Which of the following drugs is used for ovulation induction?

A. Mifepristone
B. Clomiphene citrate (Correct Answer)
C. Levonorgestrel
D. Oral contraceptive pills

Explanation: **Explanation:** **Correct Answer: B. Clomiphene citrate** **Mechanism of Action:** Clomiphene citrate is a **Selective Estrogen Receptor Modulator (SERM)** and is considered the first-line pharmacological agent for ovulation induction, particularly in patients with WHO Group II anovulation (e.g., PCOS). It acts as a competitive antagonist to estrogen receptors in the hypothalamus. By blocking the negative feedback of endogenous estrogen, it tricks the brain into perceiving low estrogen levels. This leads to an increased secretion of **GnRH**, which subsequently increases **FSH and LH** production from the anterior pituitary, stimulating follicular development in the ovaries. **Analysis of Incorrect Options:** * **A. Mifepristone:** A progesterone receptor antagonist used primarily for medical termination of pregnancy (MTP) and emergency contraception. * **C. Levonorgestrel:** A potent progestogen used in emergency contraceptive pills (ECPs), hormonal IUDs (Mirena), and progestogen-only pills. It inhibits ovulation rather than inducing it. * **D. Oral Contraceptive Pills (OCPs):** These contain estrogen and progestogen which suppress FSH and LH via negative feedback, thereby inhibiting ovulation. They are used for contraception and cycle regulation. **High-Yield Clinical Pearls for NEET-PG:** * **Administration:** Usually given as 50 mg/day for 5 days, starting on Day 2, 3, 4, or 5 of the menstrual cycle. * **Side Effects:** Multiple pregnancies (approx. 8-10%, mostly twins), hot flashes, and Ovarian Hyperstimulation Syndrome (OHSS). * **Anti-estrogenic effect:** It can cause thinning of the endometrium and thickening of cervical mucus, which may lead to a "conception gap" (ovulation occurs, but pregnancy does not). * **Letrozole (Aromatase Inhibitor):** Now often preferred over Clomiphene in PCOS patients due to higher live birth rates and better endometrial thickness.

Question 63: Artificial insemination with husband's semen is indicated in all the following situations, EXCEPT:

A. Oligospermia
B. Impotency
C. Antisperm antibodies in the cervical mucous
D. Azoospermia (Correct Answer)

Explanation: **Explanation:** The core principle of **Artificial Insemination with Husband’s semen (AIH)** is the use of the husband's own biological material to achieve conception. For AIH to be successful, the husband must have viable spermatozoa in his ejaculate. **Why Azoospermia is the correct answer:** **Azoospermia** is defined as the total absence of spermatozoa in the ejaculate. Since AIH relies entirely on the husband's sperm, it is physically impossible to perform this procedure if no sperm is present. In cases of obstructive or non-obstructive azoospermia, the alternatives are either surgical sperm retrieval (like TESA/MESA) followed by ICSI, or **Artificial Insemination with Donor semen (AID)**. **Analysis of incorrect options:** * **Oligospermia:** AIH is a primary indication here. The semen is processed (washed and concentrated) to increase the density of motile sperm before being deposited directly into the uterus (IUI), bypassing the vaginal acidity. * **Impotency:** In cases of erectile dysfunction or ejaculatory failure where the husband is still producing sperm, semen can be collected (via vibratory stimulation or electroejaculation) and used for AIH. * **Antisperm antibodies in cervical mucus:** By using the Intrauterine Insemination (IUI) technique of AIH, the sperm is deposited directly into the uterine cavity, effectively "bypassing" the hostile cervical mucus containing the antibodies. **High-Yield Clinical Pearls for NEET-PG:** * **IUI Timing:** Usually performed 36 hours after hCG "trigger" injection. * **Semen Processing:** Essential in AIH to remove prostaglandins, which can cause severe uterine contractions if injected directly. * **Success Rate:** Approximately 10–15% per cycle; usually, 3–6 cycles are attempted before moving to IVF.

Question 64: What is the cause of infertility in hypothyroidism?

A. Decrease in prolactin
B. Increase in prolactin (Correct Answer)
C. Both
D. None

Explanation: **Explanation:** The correct answer is **B. Increase in prolactin**. **Pathophysiology:** In primary hypothyroidism, low levels of circulating thyroid hormones (T3 and T4) trigger a feedback mechanism that increases the secretion of **Thyrotropin-Releasing Hormone (TRH)** from the hypothalamus. TRH acts as a potent stimulator for both the thyrotrophs (releasing TSH) and the lactotrophs in the anterior pituitary. Consequently, elevated TRH leads to **hyperprolactinemia**. High prolactin levels interfere with the pulsatile secretion of **Gonadotropin-Releasing Hormone (GnRH)** from the hypothalamus. This disruption inhibits the release of LH and FSH, leading to anovulation, luteal phase defects, and ultimately, infertility. **Analysis of Options:** * **Option A (Decrease in prolactin):** This is incorrect. Low prolactin is not associated with hypothyroidism; rather, the loss of negative feedback in hypothyroidism specifically drives prolactin levels upward. * **Option C & D:** These are incorrect based on the established hormonal axis described above. **High-Yield Clinical Pearls for NEET-PG:** * **First-line Investigation:** In a patient presenting with galactorrhea and infertility, always check **TSH** levels first to rule out primary hypothyroidism before considering a prolactinoma. * **Treatment:** Infertility caused by hypothyroidism is often reversible. Treating the underlying condition with **Levothyroxine** typically normalizes TRH and prolactin levels, restoring regular ovulatory cycles. * **Associated Symptoms:** Patients may also present with menstrual irregularities like **menorrhagia** (most common) or oligomenorrhea.

Question 65: What is the optimal timing for performing a hysterosalpingography (HSG)?

A. Just before menstruation
B. During menstruation
C. Between the end of menstruation and ovulation (Correct Answer)
D. On the 28th day of the menstrual cycle

Explanation: **Explanation:** The optimal timing for performing a **Hysterosalpingography (HSG)** is during the **early follicular phase**, specifically between **Day 7 and Day 10** of a 28-day menstrual cycle (after menstruation has ceased but before ovulation). **Why Option C is Correct:** 1. **Avoidance of Pregnancy:** Performing the procedure before ovulation ensures there is no early undiagnosed pregnancy, preventing potential radiation exposure to a developing embryo or accidental flushing of a fertilized ovum into the peritoneal cavity. 2. **Optimal Visualization:** During this phase, the endometrium is thin. A thin lining allows for better visualization of the uterine cavity and prevents false-positive results where thick, secretory endometrium might mimic polyps or cause tubal ostia occlusion. **Why Other Options are Incorrect:** * **Option A & D (Late Cycle/Pre-menstrual):** There is a high risk of performing the procedure on an early pregnancy. Additionally, the thickened secretory endometrium can block the tubal ostia, leading to a false diagnosis of tubal obstruction. * **Option B (During Menstruation):** Performing HSG during menses increases the risk of **venous intravasation** (contrast entering the uterine venous plexus) and potentially predisposes the patient to endometriosis or pelvic infection. **High-Yield Clinical Pearls for NEET-PG:** * **Primary Indication:** Evaluation of tubal patency and uterine cavity architecture in infertility. * **Contraindications:** Pregnancy, acute pelvic inflammatory disease (PID), and active uterine bleeding. * **Therapeutic Effect:** HSG has a "flushing effect" that may enhance fertility for 3–6 months post-procedure by clearing minor tubal debris or mucus plugs. * **Water-soluble vs. Oil-based:** Water-soluble contrast is preferred for better mucosal detail and faster absorption, though oil-based contrast is associated with slightly higher pregnancy rates.

Question 66: Intrauterine insemination is indicated in all except?

A. Hypospadias
B. Sperm count 5-10 million/ml (Correct Answer)
C. Antisperm antibodies in cervix
D. Retrograde ejaculation

Explanation: **Explanation:** Intrauterine Insemination (IUI) is a fertility procedure where processed and concentrated motile sperm are placed directly into the uterine cavity. It is primarily indicated when there is a mechanical or anatomical barrier to sperm reaching the cervix, or when cervical factors impede sperm motility. **Why Option B is the Correct Answer:** IUI requires a minimum threshold of sperm quality to be effective. For a successful IUI, the **Total Motile Sperm Count (TMSC)** after processing should ideally be **>5 million**. If the initial sperm count is as low as 5-10 million/ml, the post-wash recovery of motile sperm often falls below the threshold required for reasonable success rates. In such cases of significant oligospermia, **In Vitro Fertilization (IVF)** or **Intracytoplasmic Sperm Injection (ICSI)** is indicated rather than IUI. **Analysis of Other Options:** * **Hypospadias (A):** This anatomical defect prevents the proper deposition of semen into the vaginal vault during intercourse. IUI bypasses this mechanical issue. * **Antisperm antibodies in cervix (C):** Hostile cervical mucus or antibodies can trap or kill sperm. IUI bypasses the cervical barrier entirely, delivering sperm directly to the uterus. * **Retrograde Ejaculation (D):** Sperm is retrieved from the patient's urine, processed, and then used for IUI, making it a standard indication for this condition. **High-Yield Clinical Pearls for NEET-PG:** * **Ideal TMSC for IUI:** >5–10 million (Success rates drop significantly if <1 million). * **Most common indication for IUI:** Unexplained infertility and mild male factor infertility. * **Prerequisite:** At least one patent fallopian tube (confirmed via HSG or Laparoscopy) is mandatory for IUI. * **Success Rate:** Approximately 10-15% per cycle.

Question 67: In a post-coital test, which of the following factors is assessed?

A. Cervical factor (Correct Answer)
B. Vaginal factor
C. Uterine factor
D. Psychological factor

Explanation: **Explanation:** The **Post-Coital Test (PCT)**, also known as the **Sims-Huhner test**, is a traditional clinical investigation used to evaluate the interaction between the spermatozoa and the cervical mucus. **1. Why Cervical Factor is Correct:** The primary objective of the PCT is to assess the **Cervical Factor** of infertility. It evaluates the quality of the cervical mucus (Spinnbarkeit and ferning) and the ability of the sperm to penetrate, survive, and maintain motility within that mucus. A positive test (finding >5–10 motile sperm per high-power field) indicates that the cervical mucus is receptive and the sperm are capable of reaching the upper reproductive tract. **2. Why Other Options are Incorrect:** * **Vaginal Factor:** While the vagina is the site of deposition, its acidic environment is naturally hostile to sperm. The PCT specifically looks at the transition into the alkaline, protective cervical mucus. * **Uterine Factor:** The PCT does not provide information regarding the uterine cavity, endometrial receptivity, or anatomical abnormalities like fibroids or septums. * **Psychological Factor:** This refers to emotional or mental states, which cannot be assessed via a microscopic examination of cervical secretions. **Clinical Pearls for NEET-PG:** * **Timing:** The test must be performed during the **pre-ovulatory phase** (Day 12–14 of a 28-day cycle) when estrogen levels are highest, making the mucus thin and watery. * **Technique:** It is performed **2 to 12 hours** after unprotected intercourse. * **Current Status:** The PCT has largely been replaced in modern infertility workups by more reliable tests like the Semen Analysis and Anti-Sperm Antibody assays due to its high false-positive rate and poor reproducibility. * **Insurmountable Mucus:** If sperm are seen "shaking" but not progressing, it suggests the presence of **antisperm antibodies**.

Question 68: Fibroids cause infertility and pregnancy wastage because?

A. They inhibit normal ovulation
B. They cause endometrial inflammation (Correct Answer)
C. They exert a pressure effect on the ovaries
D. They induce a hyperestrogenic state

Explanation: **Explanation:** Uterine fibroids (leiomyomas), particularly **submucosal** and **intramural** types that distort the uterine cavity, are significant contributors to infertility and recurrent pregnancy loss. **Why Option B is Correct:** The primary mechanism by which fibroids interfere with implantation and cause pregnancy wastage is by inducing **chronic endometrial inflammation**. The presence of a fibroid leads to: * **Altered Endometrial Receptivity:** Increased production of inflammatory cytokines (e.g., TNF-α, IL-6) and recruitment of macrophages. * **Vascular Changes:** Abnormal venous drainage and focal endometrial thinning/atrophy over the fibroid surface, making the environment hostile for a blastocyst. * **Molecular Changes:** Downregulation of HOXA-10 genes, which are essential for implantation. **Analysis of Incorrect Options:** * **Option A:** Fibroids are estrogen-dependent tumors, but they do not interfere with the Hypothalamic-Pituitary-Ovarian (HPO) axis; therefore, they **do not inhibit ovulation**. * **Option C:** While very large broad ligament fibroids may occasionally displace ovaries, they do not exert a "pressure effect" significant enough to cause infertility. Infertility is primarily a uterine factor issue. * **Option D:** Fibroids **respond** to estrogen (they are hyper-responsive due to increased aromatase activity), but they do not **induce** a systemic hyperestrogenic state. **High-Yield NEET-PG Pearls:** * **Most common fibroid causing infertility:** Submucosal (FIGO Type 0, 1, 2). * **Impact on Tubes:** Large cornual fibroids can cause mechanical obstruction of the fallopian tube ostia. * **Myomectomy Rule:** In infertility, a myomectomy is indicated if the fibroid distorts the cavity or is >4 cm in size. * **Pregnancy Wastage:** Fibroids increase the risk of spontaneous abortion, malpresentation, placental abruption, and postpartum hemorrhage (PPH).

Question 69: Which of the following locations of tubal obstruction is least amenable to surgical repair?

A. Fimbrial
B. Interstitial (Correct Answer)
C. Ampullary
D. Isthmic

Explanation: **Explanation:** The **interstitial (intramural) portion** of the fallopian tube is the segment that traverses the muscular wall of the uterus. Obstruction at this site is the least amenable to surgical repair because it is the narrowest part of the tube (lumen diameter <1 mm) and is encased within the thick myometrium. Surgical access requires a cornual resection and re-anastomosis, which carries a high risk of uterine rupture in subsequent pregnancies and poor patency rates. Today, **IVF** or **hysteroscopic tubal cannulation** are preferred over surgery for interstitial blocks. **Analysis of Other Options:** * **Fimbrial (A):** Obstruction here (e.g., hydrosalpinx) can be treated with fimbrioplasty or neosalpingostomy. While success depends on the health of the mucosa, it is surgically accessible. * **Ampullary (C):** This is the widest part of the tube. While mid-segment blocks are challenging, they are more amenable to end-to-end anastomosis than the intramural segment. * **Isthmic (D):** This is a common site for tubal ligation. It is highly amenable to **microsurgical tubotubal anastomosis**, which boasts the highest success rates among all tubal reconstructive surgeries. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard for Diagnosis:** Hysterosalpingography (HSG) is the initial test; Laparoscopy with Chromopertubation is the gold standard. * **Best Prognosis:** Tubal patency restoration has the best success rate in **Isthmic-Isthmic** anastomosis. * **Most Common Site of Ectopic Pregnancy:** Ampulla. * **Narrowest Part of the Tube:** Interstitial part (0.7 mm).

Question 70: What are the common causes of infertility?

A. Chlamydia
B. Gonorrhea
C. Mycoplasma
D. All of the above (Correct Answer)

Explanation: **Explanation:** Infertility is frequently a sequela of **Pelvic Inflammatory Disease (PID)**, which leads to tubal factor infertility through salpingitis, tubal scarring, and fimbrial damage. * **Chlamydia trachomatis (Option A):** This is the most common bacterial cause of sexually transmitted infections (STIs) and PID worldwide. It is often "silent" or subclinical, leading to delayed diagnosis and significant tubal damage (distal tubal occlusion). * **Neisseria gonorrhoeae (Option B):** A major pathogen responsible for acute PID. It causes intense inflammatory responses in the fallopian tubes, leading to pyosalpinx and subsequent tubal factor infertility. * **Mycoplasma genitalium (Option C):** Emerging evidence identifies *Mycoplasma* (and *Ureaplasma*) as significant contributors to cervicitis and PID. It is increasingly recognized as an independent risk factor for female infertility and may also affect male fertility by impacting sperm motility. Since all three pathogens are established causes of pelvic inflammation and subsequent reproductive tract damage, **Option D** is the correct answer. **Clinical Pearls for NEET-PG:** * **Gold Standard for Tubal Patency:** Hysterosalpingography (HSG) is the initial screening test, but **Laparoscopy with Chromopertubation** is the gold standard. * **Fitz-Hugh-Curtis Syndrome:** A complication of PID (primarily Chlamydia) involving perihepatitis and "violin-string" adhesions. * **Most Common Cause of Infertility in India:** While infections (tubal factor) are highly prevalent, **Polycystic Ovary Syndrome (PCOS)** is the most common cause of anovulatory infertility. * **Treatment:** PID is managed with broad-spectrum antibiotics (e.g., Ceftriaxone + Doxycycline + Metronidazole) to prevent the long-term risk of infertility and ectopic pregnancy.

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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