Unexplained 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?
A couple comes for evaluation of infertility. The HSG was normal but semen analysis revealed azoospermia. What is the diagnostic test to differentiate between testicular failure and vas deferens obstruction?
A 23-year-old woman accompanied by her mother-in-law comes to the infertility clinic. She has been having regular intercourse for 6 months but is not able to conceive. What is the next best step?
A 30-year-old woman presents with primary infertility for 2 years. Her menstrual cycles are irregular (35-45 days). Investigations reveal FSH 15 IU/L, AMH 0.5 ng/mL. Semen analysis is normal and HSG shows patent tubes. What is the most appropriate first-line treatment?
Most reliable sign of sexual intercourse in a married woman examined after 48 hours?
A patient with infertility has an ultrasound (USG) suggestive of a uterine anomaly. Which of the following is the best method to confirm the diagnosis?
A young female presents to OPD with a spontaneous abortion and secondary amenorrhea since then. FSH was found to be 6 IU/mL. What is the most probable cause of amenorrhea?
Consider the following statements regarding infertility: 1. Endometrial biopsy provides information regarding ovulatory factor 2. Both tubal and peritoneal factors can be assessed at laparoscopy 3. Unexplained infertility may be due to luteal phase defect Which of the statements given above is/are correct?
A lady on treatment for infertility developed ascites, abdominal pain, and dyspnea. An ultrasound (USG) of the patient was done. What will be the diagnosis?
Minimum sperm count for normal semen analysis according to WHO:
Unexplained Infertility Indian Medical PG Practice Questions and MCQs
Question 1: 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 2: A couple comes for evaluation of infertility. The HSG was normal but semen analysis revealed azoospermia. What is the diagnostic test to differentiate between testicular failure and vas deferens obstruction?
- A. Serum FSH (Correct Answer)
- B. Testicular FNAC
- C. Testosterone levels
- D. Karyotyping
Explanation: ***Serum FSH*** - In **testicular failure**, the pituitary gland tries to compensate for poor sperm production by increasing **follicle-stimulating hormone (FSH)**, leading to **elevated FSH levels**. - In **vas deferens obstruction**, the testes are producing sperm normally, so the pituitary does not need to overstimulate them, resulting in **normal FSH levels**. *Testicular FNAC* - **Fine needle aspiration cytology (FNAC)** of the testis can *confirm* the presence or absence of sperm production but is not the primary diagnostic test to *differentiate* between the two conditions without prior hormonal assessment. - It is an **invasive procedure** typically considered after initial hormone testing and physical examination. *Testosterone levels* - **Testosterone levels** primarily reflect the Leydig cell function and can be normal in both **testicular failure** (especially germ cell-specific failure) and **vas deferens obstruction**. - While low testosterone can indicate Leydig cell dysfunction, it doesn't specifically differentiate between the two causes of azoospermia in all cases. *Karyotyping* - **Karyotyping** is used to detect **chromosomal abnormalities** (e.g., Klinefelter syndrome) that can cause testicular failure. - While important for identifying underlying genetic causes, it does not directly differentiate between existing testicular failure and vas deferens obstruction based on direct physiological function.
Question 3: A 23-year-old woman accompanied by her mother-in-law comes to the infertility clinic. She has been having regular intercourse for 6 months but is not able to conceive. What is the next best step?
- A. Hysterolaparoscopy
- B. Diagnostic hysteroscopy
- C. Reassure and review the couple after 6 months (Correct Answer)
- D. Semen analysis for husband
Explanation: ***Reassure and review the couple after 6 months*** - Infertility is defined as the inability to conceive after **12 months** of regular, unprotected intercourse in women under 35 years old. For women aged 35 or older, this period is 6 months. - Since the patient is 23 years old and has been trying for only 6 months, she does not yet meet the diagnostic criteria for infertility. The appropriate action is to advise them to continue trying and to return for evaluation if conception does not occur after a full year. *Semen analysis for husband* - While a semen analysis is a crucial initial step in an infertility workup, it is premature at this stage given the duration of attempted conception. - It would be appropriate to order this test after the couple has met the criteria for infertility (12 months for women under 35). *Hysterolaparoscopy* - This is an invasive procedure typically reserved for more advanced stages of an infertility workup, especially when suspected pathologies like endometriosis or tubal factor infertility are present. - It is not indicated as an initial step for a couple who has only been trying to conceive for 6 months and does not yet meet the definition of infertility. *Diagnostic hysteroscopy* - A diagnostic hysteroscopy is used to visualize the inside of the uterus to identify intrauterine pathologies that could contribute to infertility. - Like hysterolaparoscopy, it is an invasive diagnostic tool and should only be considered after initial, less invasive investigations have been performed and the couple meets the criteria for infertility.
Question 4: A 30-year-old woman presents with primary infertility for 2 years. Her menstrual cycles are irregular (35-45 days). Investigations reveal FSH 15 IU/L, AMH 0.5 ng/mL. Semen analysis is normal and HSG shows patent tubes. What is the most appropriate first-line treatment?
- A. Letrozole (Correct Answer)
- B. IVF with donor eggs
- C. Clomiphene citrate
- D. Gonadotropins
Explanation: ***Letrozole*** - This patient has **diminished ovarian reserve (DOR)** evidenced by **FSH 15 IU/L** (borderline elevated) and **AMH 0.5 ng/mL** (significantly low), along with **irregular cycles suggesting anovulation**. - **Letrozole**, an aromatase inhibitor, is the **preferred first-line ovulation induction agent** in patients with DOR who are anovulatory. It works by reducing estrogen production, leading to increased FSH release and follicular development. - **Advantages over clomiphene:** Letrozole has fewer anti-estrogenic effects on the endometrium and cervical mucus, making it superior in DOR patients where endometrial receptivity is crucial. - Given her young age (30 years) and evidence of some ovarian reserve (AMH 0.5, not undetectable), a trial of **2-3 cycles of ovulation induction** before proceeding to IVF is reasonable and cost-effective. *IVF with donor eggs* - This is **premature as first-line therapy**. While the patient has DOR, she still has detectable AMH (0.5 ng/mL), indicating some ovarian function remains. - The **first step** would be attempting conception with her own eggs through ovulation induction, and if that fails, **IVF with autologous (own) eggs** should be tried before considering donor eggs. - Donor egg IVF is typically reserved for patients with **premature ovarian failure**, very advanced age, or after repeated failed IVF cycles with own eggs. *Clomiphene citrate* - While clomiphene is an effective **ovulation induction agent**, it has significant **anti-estrogenic effects** on the endometrium (causing thinning) and cervical mucus (reducing quality). - In patients with **DOR**, where pregnancy rates are already compromised, these anti-estrogenic effects can further reduce success rates. - **Letrozole has been shown to have better pregnancy outcomes** in various populations, including those with DOR, making it the preferred first-line agent. *Gonadotropins* - Injectable gonadotropins (FSH/LH) directly stimulate follicular development and are more potent than oral agents. - However, they carry **higher risks**: multiple gestations (20-30%), ovarian hyperstimulation syndrome (OHSS), and significantly higher cost. - They are typically reserved as **second-line therapy** after failed response to oral ovulation induction agents, or as part of IVF protocols. - Starting with less aggressive, safer oral agents like letrozole is the **standard stepwise approach** in infertility management.
Question 5: Most reliable sign of sexual intercourse in a married woman examined after 48 hours?
- A. Sperm detection (Correct Answer)
- B. Acid phosphatase
- C. Hymenal tears
- D. Vaginal tears
Explanation: ***Sperm detection*** - **Viable sperm** can be detected in the cervical mucus for up to 5 days, and sometimes longer, making it the most reliable indicator of recent intercourse even after 48 hours. - The presence of **spermatozoa**, even non-motile ones, provides direct evidence of male ejaculate in the female genital tract. - Sperm can persist in the vaginal canal for 3-5 days and in cervical mucus for up to 7 days post-intercourse. *Acid phosphatase* - While a component of seminal fluid, **acid phosphatase** degrades rapidly and its detection is generally reliable only within 24-36 hours post-intercourse. - Post 48 hours, the levels of acid phosphatase would likely be too low to be reliably used as conclusive evidence. - It is more useful for recent intercourse detection within 24 hours. *Hymenal tears* - **Hymenal tears** are not a reliable sign of recent intercourse within a marriage context, as some women may not experience tearing, or tears may have healed. - In a married woman, previous intercourse would have likely already altered the hymen, making new tears less indicative of recent activity. - The hymen shows significant variation and may be absent or already disrupted. *Vaginal tears* - **Vaginal tears** are typically associated with forceful or traumatic intercourse, or in cases of sexual assault, rather than consensual marital intercourse. - The absence of vaginal tears does not rule out consensual sexual activity, nor does its presence definitively confirm it in this specific context after 48 hours. - Not a reliable marker for consensual intercourse.
Question 6: A patient with infertility has an ultrasound (USG) suggestive of a uterine anomaly. Which of the following is the best method to confirm the diagnosis?
- A. Hysterosalpingography (HSG)
- B. Transvaginal Sonography (TVS)
- C. Hysteroscopy + Laparoscopy (Correct Answer)
- D. Laparoscopy
Explanation: ***Hysteroscopy + Laparoscopy*** - This combination allows for a comprehensive evaluation: **hysteroscopy** visualizes the uterine cavity to confirm the type of anomaly (e.g., septum), while **laparoscopy** assesses the external uterine contour and overall pelvic anatomy. - It is considered the **gold standard** for diagnosing complex uterine anomalies as it provides the most detailed information for both diagnosis and surgical planning. *Hysterosalpingography (HSG)* - HSG can delineate the **uterine cavity morphology** and patency of fallopian tubes. - However, it is an **X-ray based test** and does not provide information about the external contour of the uterus, which is crucial for differentiating anomalies like a bicornuate from a septate uterus. *Transvaginal Sonography (TVS)* - While TVS is an excellent initial screening tool and can suggest a uterine anomaly, it often **lacks the definitive resolution** to precisely classify the anomaly, especially differentiating between septate and bicornuate uteri. - Its accuracy can be **operator-dependent** and limited in visualizing the external uterine contour. *Laparoscopy* - Laparoscopy alone provides an excellent view of the **external uterine contour** and pelvic organs. - However, it **does not visualize the internal uterine cavity**, which is essential for identifying and classifying anomalies such as a uterine septum.
Question 7: A young female presents to OPD with a spontaneous abortion and secondary amenorrhea since then. FSH was found to be 6 IU/mL. What is the most probable cause of amenorrhea?
- A. Ovarian failure
- B. Pituitary failure
- C. Ongoing pregnancy
- D. Uterine synechiae (Correct Answer)
Explanation: ***Uterine synechiae*** - A history of **spontaneous abortion** can lead to **uterine synechiae (Asherman's syndrome)** due to instrumentation (D&C) or infection. - **Normal FSH levels** (6 IU/mL) rule out ovarian failure and pituitary failure as primary causes, pointing towards an **outflow tract obstruction**. - Asherman's syndrome is characterized by intrauterine adhesions that physically obstruct menstrual flow. *Ovarian failure* - Would present with **elevated FSH levels** (typically > 20-40 IU/mL) due to lack of negative feedback from the ovaries. - The FSH level of 6 IU/mL is within the normal premenopausal range, contradicting ovarian failure. *Pituitary failure* - Would lead to **low FSH levels** (typically < 5 IU/mL) along with other symptoms of hypopituitarism. - While FSH of 6 IU/mL is in lower normal range, the specific history of post-abortion amenorrhea makes uterine causes more likely. *Ongoing pregnancy* - Would be associated with a **positive pregnancy test** (elevated β-hCG) and other early pregnancy symptoms. - The history states amenorrhea is "since" the abortion, indicating the pregnancy has ended, not ongoing.
Question 8: Consider the following statements regarding infertility: 1. Endometrial biopsy provides information regarding ovulatory factor 2. Both tubal and peritoneal factors can be assessed at laparoscopy 3. Unexplained infertility may be due to luteal phase defect Which of the statements given above is/are correct?
- A. 1 and 3 only
- B. 1, 2 and 3 (Correct Answer)
- C. 2 and 3 only
- D. 1 and 2 only
Explanation: ***Correct: 1, 2 and 3*** - **Statement 1** - **Endometrial biopsy** was historically used to assess the histological changes in the endometrium that correlate with the hormonal environment (progesterone effect), indirectly confirming **ovulation** and luteal phase adequacy. *Note: Current guidelines (ASRM) no longer recommend routine endometrial biopsy for infertility evaluation, as serum progesterone and ultrasound monitoring are preferred.* - **Statement 2** - **Laparoscopy with chromopertubation** is the gold standard for direct visualization of the fallopian tubes (assessing patency, hydrosalpinx, adhesions) and peritoneal factors such as **endometriosis**, pelvic adhesions, or sequelae of pelvic inflammatory disease. This statement is definitively correct. - **Statement 3** - **Unexplained infertility** may be attributed to subtle factors including **luteal phase defect** (LPD). *Note: The concept of LPD is controversial in modern reproductive medicine, with current evidence not strongly supporting it as a distinct diagnosis. Unexplained infertility is more commonly attributed to subtle sperm dysfunction, oocyte quality issues, or immunological factors.* *Incorrect: 1 and 3 only* - This option incorrectly excludes statement 2, which is clearly correct. **Laparoscopy** is a fundamental diagnostic tool for evaluating both tubal patency and peritoneal factors in the infertility workup. *Incorrect: 2 and 3 only* - This option incorrectly excludes statement 1. While endometrial biopsy is not routinely recommended in current practice, it was a recognized method for assessing ovulatory function and luteal phase adequacy at the time of this examination (2019). *Incorrect: 1 and 2 only* - This option incorrectly excludes statement 3. In the context of this 2019 examination, luteal phase defect was considered a potential cause of unexplained infertility, even though this concept is now controversial in modern reproductive medicine.
Question 9: A lady on treatment for infertility developed ascites, abdominal pain, and dyspnea. An ultrasound (USG) of the patient was done. What will be the diagnosis?
- A. Theca lutein cysts
- B. Mucinous cystadenoma
- C. Polycystic Ovary Syndrome (PCOS)
- D. Ovarian Hyperstimulation Syndrome (OHSS) (Correct Answer)
Explanation: ***Ovarian Hyperstimulation Syndrome (OHSS)*** - The clinical presentation of infertility treatment followed by **ascites, abdominal pain, and dyspnea** is highly suggestive of OHSS. The ultrasound image shows **enlarged ovaries with multiple follicular cysts**, which is characteristic of severe OHSS. - OHSS is a potentially serious complication of **ovarian stimulation** during infertility treatment, where excessive ovarian response leads to systemic changes from increased vascular permeability. *Theca lutein cysts* - These cysts typically develop due to **excessive stimulation by hCG**, often seen with gestational trophoblastic disease or multiple pregnancies. - While they can be large and multiple, they are not typically associated with the rapid onset of severe systemic symptoms like **ascites and dyspnea** in the context of infertility treatment directly. *Mucinous cystadenoma* - This is a type of **benign ovarian tumor** that can grow very large and cause abdominal distension, but it is not typically associated with infertility treatment or the acute systemic symptoms of ascites and dyspnea as seen here. - Imaging would typically show a **multilocular cyst with internal septations**, not the numerous small follicular cysts seen in the image. *Polycystic Ovary Syndrome (PCOS)* - PCOS is a common cause of infertility, characterized by **anovulation, hyperandrogenism, and polycystic ovaries** on ultrasound (multiple small follicles in a string-of-pearls pattern). - While the ultrasound shares some similarities with multiple follicles, PCOS does not cause the acute symptoms of **ascites, abdominal pain, and dyspnea** that are directly linked to the rapid onset of severe OHSS.
Question 10: Minimum sperm count for normal semen analysis according to WHO:
- A. 10 million/mL
- B. 2 million/mL
- C. 15 million/mL (Correct Answer)
- D. 5 million/mL
Explanation: ***15 million/mL*** - According to the **World Health Organization (WHO)** guidelines, a **minimum sperm concentration of 15 million/mL** is considered normal for a semen analysis. - This threshold is used to define **normozoospermia**, which indicates a healthy sperm count. *10 million/mL* - This value is **below the WHO reference range** for normal sperm concentration and would be considered **oligozoospermia**. - A sperm count of 10 million/mL suggests a **reduced likelihood of natural conception**. *2 million/mL* - A sperm count of 2 million/mL is significantly low and indicates **severe oligozoospermia**, which is associated with a very **low probability of natural conception**. - This value is far below the normal range defined by WHO. *5 million/mL* - This concentration is also below the normal WHO threshold, indicating **oligozoospermia**. - While higher than 2 million/mL, it still falls within the range suggesting **reduced fertility potential**.
Want unlimited practice?
Get full access to all questions, explanations, and performance tracking.
Start For Free