Fertility and Infertility Practice Questions

Q: What is a marker of low ovarian reserve in a premenopausal female?

Low Anti-Müllerian hormone levels. **Explanation:** **Anti-Müllerian Hormone (AMH)** is considered the most sensitive and reliable biochemical marker for assessing ovarian reserve. It is produced by the granulosa cells of pre-antral and small antral follicles. Because its levels are independent of the hypothalamic-pituitary-ovarian axis, AMH remains relatively constant throughout the menstrual cycle, making it a superior "anytime" test compared to FSH. Low levels of AMH directly correlate with a depleted pool of primordial follicles. **Analysis of Incorrect Options:** * **Small antral follicle size:** It is the **Antral Follicle Count (AFC)**—the total number of follicles (2–10 mm)—that marks ovarian reserve, not the size of the follicles themselves. A low AFC is a hallmark of decreased reserve. * **Raised LH/FSH ratio:** This is a classic biochemical feature of **Polycystic Ovary Syndrome (PCOS)**, where the ratio is often >2:1 or 3:1. In low ovarian reserve, FSH typically rises higher than LH. * **Decreased inhibin A:** While **Inhibin B** (produced by early antral follicles) decreases in low ovarian reserve, Inhibin A is a marker of corpus luteum function and dominant follicle maturity; it is not a primary screening tool for ovarian reserve. **NEET-PG High-Yield Pearls:** * **Best Biochemical Marker:** AMH (earliest marker to change). * **Best Imaging/Biophysical Marker:** Antral Follicle Count (AFC) via TVS. * **Day 3 FSH:** Levels >10–12 mIU/mL suggest poor ovarian reserve (less sensitive than AMH). * **AMH Values:** 3.5 ng/mL suggests PCOS.

Q: What is the commonest cause of anovulatory infertility?

Polycystic ovary syndrome (PCOS). **Explanation:** **1. Why PCOS is the Correct Answer:** Polycystic Ovary Syndrome (PCOS) is the most common cause of **anovulatory infertility**, accounting for approximately 70–80% of cases. The underlying pathophysiology involves a hormonal imbalance characterized by hyperandrogenism and an increased LH:FSH ratio. This leads to follicular arrest, where multiple small follicles develop but fail to reach the dominant stage required for ovulation, resulting in chronic anovulation. **2. Why Other Options are Incorrect:** * **Tuberculosis (TB):** In India, Genital TB is a major cause of infertility, but it primarily causes **tubal factor infertility** due to chronic salpingitis and tubal blockage (beaded tubes), or uterine factor infertility (Asherman’s syndrome). It does not typically cause primary anovulation. * **Endometriosis:** This primarily causes infertility through **pelvic adhesions**, distorted tubo-ovarian anatomy, and an altered peritoneal microenvironment. While it can affect egg quality, it is not the most common cause of anovulation. * **Thyroid Dysfunction:** Both hypo- and hyperthyroidism can cause menstrual irregularities and anovulation, but they are significantly less prevalent than PCOS in the general infertile population. **Clinical Pearls for NEET-PG:** * **WHO Classification of Anovulation:** PCOS falls under **WHO Group II** (Normogonadotropic normoestrogenic anovulation), which is the most common category. * **First-line treatment for PCOS infertility:** Letrozole (Aromatase inhibitor) is now preferred over Clomiphene Citrate. * **Gold Standard for Tubal Patency:** Hysterosalpingography (HSG) is the screening test, but Laparoscopic Chromopertubation is the gold standard. * **Most common cause of overall female infertility:** Pelvic inflammatory disease (Tubal factor) is a leading cause globally, but for *anovulatory* specifically, it is always PCOS.

Q: Time of ovulation is detected by all EXCEPT:

Urine FSH. **Explanation:** The detection of ovulation is crucial for fertility monitoring. The correct answer is **Urine FSH** because, while FSH levels do rise slightly during the mid-cycle surge, they are not used clinically to predict or confirm the exact timing of ovulation. **Why the other options are used to detect ovulation:** * **Urine LH (Option A):** This is the "Gold Standard" for home prediction. The LH surge occurs approximately 24–36 hours before ovulation. Detecting the LH peak in urine is the most reliable way to identify the upcoming fertile window. * **Serum Progesterone (Option C):** Progesterone is secreted by the Corpus Luteum *after* ovulation. A mid-luteal phase serum progesterone level (measured on Day 21 of a 28-day cycle) >3 ng/mL is a definitive retrospective indicator that ovulation has occurred. * **Basal Body Temperature (Option D):** Under the influence of thermogenic progesterone, the BBT rises by 0.5–1.0°F after ovulation. While it cannot predict ovulation, it is a useful tool to confirm that ovulation has taken place. **High-Yield NEET-PG Pearls:** 1. **Spinnbarkeit Phenomenon:** Just before ovulation, cervical mucus becomes thin, watery, and stretchy (resembling egg white) due to high estrogen. 2. **Fern Test:** Estrogen causes "ferning" patterns in cervical mucus; this disappears after ovulation due to progesterone. 3. **Mittelschmerz:** Pelvic pain experienced by some women mid-cycle at the time of follicular rupture. 4. **Ultrasonography:** Serial TVS (Transvaginal Sonography) showing the disappearance of a dominant follicle is the most accurate way to confirm ovulation.

Q: What is the first test for a couple presenting with infertility?

Husband's semen analysis. **Explanation:** In the evaluation of an infertile couple, the **Husband’s Semen Analysis** is the mandatory first-line investigation. This is because male factor infertility contributes to approximately 40–50% of cases. The test is prioritized because it is **non-invasive, inexpensive, and provides immediate, definitive information** regarding the male partner's fertility status before the female partner undergoes more invasive or expensive procedures. **Analysis of Options:** * **A. Post-coital test (Sims-Huhner test):** Historically used to assess sperm-cervical mucus interaction, it is now considered obsolete and is no longer recommended by WHO or ASRM due to poor predictive value and lack of standardization. * **B. Chromosomal studies:** These are specialized tests (Karyotyping) indicated only if there is a history of recurrent pregnancy loss, severe oligospermia (<5 million/ml), or suspected genetic syndromes (e.g., Klinefelter syndrome). They are never a primary screening tool. * **C. Sperm penetration test:** This is a functional assay (e.g., Hamster zona-free ovum test) used to evaluate the ability of sperm to undergo capacitation and fertilize. It is a tertiary-level investigation used in specific cases of unexplained infertility, not a screening test. **NEET-PG High-Yield Pearls:** * **Semen Collection:** Requires 2–7 days of abstinence. The sample should be delivered to the lab within 1 hour. * **WHO 2021 (6th Ed) Criteria:** Lower reference limit for volume is 1.4 mL, total motility is 42%, and normal morphology (Kruger’s strict criteria) is 4%. * **Sequence of Investigation:** Always start with Semen Analysis (Male) → Confirmation of Ovulation (Female) → Tubal Patency tests like HSG (Female).

Q: Which of the following findings characterize lower reference limits in a normal semen sample?

32% progressive sperm motility. **Explanation:** The assessment of male fertility is based on the **WHO Laboratory Manual for the Examination and Processing of Human Semen (5th Edition, 2010)**, which established the current lower reference limits (5th centiles) for semen parameters. **Why Option D is Correct:** According to WHO 2010 criteria, the lower reference limit for **progressive motility** (sperm moving actively in a linear or large circle) is **32%**. Total motility (progressive + non-progressive) should be at least 40%. **Analysis of Incorrect Options:** * **A. Volume:** The lower reference limit is **1.5 mL**, not 2 mL. (Note: The older 1999 criteria used 2 mL, but current standards have lowered this). * **B. Sperm Concentration:** The lower limit is **15 million per mL**. A concentration of 40 million is well within the normal range but does not represent the "lower reference limit." * **C. Morphology:** Using Kruger’s strict criteria, the lower reference limit for normal forms is only **4%**. The 30% value is outdated (from the 1992 criteria). **High-Yield Clinical Pearls for NEET-PG:** * **Total Sperm Number:** ≥ 39 million per ejaculate. * **Vitality:** ≥ 58% live spermatozoa. * **pH:** ≥ 7.2. * **Azoospermia:** Absence of sperm in ejaculate. * **Oligozoospermia:** Sperm concentration < 15 million/mL. * **Asthenozoospermia:** Progressive motility < 32%. * **Teratozoospermia:** Normal forms < 4%. * **Update Note:** While the WHO 6th Edition (2021) exists, NEET-PG questions primarily focus on the **5th Edition (2010)** standards. Always prioritize 1.5 mL, 15 million/mL, 32% motility, and 4% morphology.

Q: What is the best treatment for women with bilateral tubal blockage who wish to become pregnant?

In Vitro Fertilization (IVF). **Explanation:** The fundamental requirement for natural conception or Intrauterine Insemination (IUI) is at least one patent and functional fallopian tube to facilitate the meeting of the sperm and the oocyte. In cases of **bilateral tubal blockage** (tubal factor infertility), the physiological site of fertilization is completely bypassed. **1. Why IVF is the Correct Answer:** In Vitro Fertilization (IVF) is the gold standard and definitive treatment for bilateral tubal disease. In IVF, oocytes are retrieved directly from the ovaries and fertilized with sperm in a laboratory setting (extracorporeal fertilization). The resulting embryo is then transferred directly into the uterine cavity, completely circumventing the need for fallopian tubes. **2. Why Other Options are Incorrect:** * **Intrauterine Insemination (IUI) & Ovulation Induction (Options B & D):** These methods rely on the fallopian tubes to pick up the egg and allow it to meet the sperm. If both tubes are blocked, the sperm can never reach the egg, making these treatments futile. * **Surrogacy (Option C):** This is indicated for women with uterine factors (e.g., absent uterus, severe Asherman syndrome) or medical contraindications to pregnancy. It is not the first-line treatment for tubal blockage, as the patient can still carry a pregnancy using her own uterus via IVF. **Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Hysterosalpingography (HSG) is the initial screening test for tubal patency, but **Laparoscopic Chromopertubation** is the "Gold Standard" for diagnosis. * **Hydrosalpinx:** If a blocked tube is dilated with fluid (hydrosalpinx), the success rate of IVF decreases. In such cases, **salpingectomy** or tubal clipping is recommended before proceeding with IVF. * **Historical Context:** The first IVF baby (Louise Brown) was born to a mother with tubal factor infertility.

Question 1

What is the method of choice to monitor ovulation in a patient being treated with clomiphene for infertility?

Accepted Answer

Serial ultrasound

Answer

Chest X-ray

Answer

Serial HCG

Answer

None

Question 2

What is a marker of low ovarian reserve in a premenopausal female?

Accepted Answer

Low Anti-Müllerian hormone levels

Answer

Small antral follicle size

Answer

Raised LH/FSH ratio

Answer

Decreased inhibin A

Question 3

What is the commonest cause of anovulatory infertility?

Accepted Answer

Polycystic ovary syndrome (PCOS)

Answer

Tuberculosis (TB)

Answer

Endometriosis

Answer

Thyroid dysfunction

Question 4

Time of ovulation is detected by all EXCEPT:

Accepted Answer

Urine FSH

Answer

Urine LH

Answer

Serum progesterone

Answer

Basal body temperature

Question 5

Clomiphene citrate, used in the initial treatment for most anovulatory infertile women, is:

Accepted Answer

Can be administered if no follicle is >20mm and the endometrium is <5mm.

Answer

A steroidal triphenylethylene derivative.

Answer

Given on the 7th day to the 10th day after the onset of spontaneous menses.

Answer

An estrogen antagonist only.

Question 6

The most serious complication of clomiphene therapy for induction of ovulation is:

Accepted Answer

Hyperstimulation syndrome

Answer

Bone marrow depression

Answer

Secondary amenorrhea

Answer

Multiple pregnancy

Question 7

What is the optimal time in a patient's menstrual cycle to perform an endometrial biopsy for evaluation of infertility?

Accepted Answer

Days 20-22

Answer

Days 12-14

Answer

Days 17-19

Answer

Days 3-5

Question 8

What is the first test for a couple presenting with infertility?

Accepted Answer

Husband's semen analysis

Answer

Post coital test

Answer

Chromosomal studies

Answer

Sperm penetration test

Question 9

Which of the following findings characterize lower reference limits in a normal semen sample?

Accepted Answer

32% progressive sperm motility

Answer

Volume > 2 mL

Answer

Sperm concentration of 40 million per mL

Answer

30% normal sperm morphology

Question 10

What is the best treatment for women with bilateral tubal blockage who wish to become pregnant?

Accepted Answer

In Vitro Fertilization (IVF)

Answer

Intrauterine Insemination (IUI)

Answer

Surrogacy

Answer

Ovulation induction with IUI

Fertility and Infertility — MCQs

Fertility and Infertility — MCQs

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