Fertility and Infertility Practice Questions

Q: Tubal patency is checked by all of the following except?

Colposcopy. **Explanation:** The correct answer is **Colposcopy**. This question tests your ability to differentiate between diagnostic tools for the upper and lower female reproductive tract. **Why Colposcopy is the correct answer:** Colposcopy is a diagnostic procedure used to visualize the **cervix, vagina, and vulva** under magnification. It is primarily used to evaluate abnormal Pap smears and screen for cervical intraepithelial neoplasia (CIN) or malignancy. It does not involve the uterine cavity or the fallopian tubes; therefore, it cannot be used to assess tubal patency. **Evaluation of Incorrect Options:** * **Hysterosalpingography (HSG):** This is the **initial/screening investigation** of choice for tubal patency. It involves injecting radiopaque dye into the uterus and taking X-rays to visualize the spill from the fimbrial ends. * **Laparoscopy (with Chromopertubation):** This is the **Gold Standard** for assessing tubal patency. Methylene blue dye is injected transcervically, and its spill from the tubes is directly visualized via a laparoscope. It also allows for the diagnosis of extrinsic factors like adhesions or endometriosis. * **Falloscopy:** This involves the use of a micro-endoscope to directly visualize the **internal lumen** of the fallopian tubes. It can identify intratubal pathology like debris or scarring. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard for Tubal Patency:** Laparoscopy + Chromopertubation. * **First-line/Screening Test:** Hysterosalpingography (HSG). * **Sonohysterosalpingography (SSG):** Uses saline and ultrasound; it is safer (no radiation) but less accurate than HSG for distal tubal blocks. * **Rubin’s Test:** An obsolete method using $CO_2$ insufflation to check patency (shoulder pain indicates a positive test).

Q: Kamla, a 30-year-old lady, is examined for infertility by hysterosalpingography, which reveals 'bead-like' fallopian tubes and clubbing of the ampulla. What is the most likely cause?

Mycobacterium tuberculosis. **Explanation:** The clinical presentation and hysterosalpingography (HSG) findings are classic for **Genital Tuberculosis**, caused by *Mycobacterium tuberculosis*. **Why the Correct Answer is Right:** Genital TB is a significant cause of tubal factor infertility in developing countries. It typically spreads hematogenously to the fallopian tubes (affected in 90-100% of cases). The characteristic HSG findings include: * **Beaded appearance:** Caused by multiple strictures and scarring along the tube. * **Clubbing of the ampulla:** Resulting from fimbriated end occlusion and distal dilatation. * **Lead pipe appearance:** Rigid, straight tubes due to chronic inflammation. * **Tobacco pouch appearance:** Eversion of the fimbriae. **Why Incorrect Options are Wrong:** * **Gonococcus & Chlamydia:** These are the most common causes of Pelvic Inflammatory Disease (PID). While they cause tubal blockage and hydrosalpinx, they typically present with acute symptoms and lead to "fimbriated end block" or "beaded" appearance less frequently than TB. Chlamydia is more associated with "silent" salpingitis and perihepitic adhesions (Fitz-Hugh-Curtis syndrome). * **Mycoplasma:** While it can cause cervicitis or PID, it is a rare cause of the specific chronic architectural distortions (beading and clubbing) seen in this scenario. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Endometrial biopsy for histopathology (showing giant cells/granulomas) and TB-PCR/Culture, ideally performed in the pre-menstrual phase. * **Most common site:** Fallopian tubes (100%) > Endometrium (50%) > Ovaries (20%). * **Schier’s Sign:** Calcified lymph nodes or pelvic calcifications on X-ray, highly suggestive of TB. * **Prognosis:** While antitubercular therapy (ATT) can treat the infection, the structural damage to the tubes is often irreversible, making IVF the preferred fertility treatment.

Q: Which one of the following procedures is used for severe male factor infertility?

Intracytoplasmic Sperm Injection (ICSI). **Explanation:** **Intracytoplasmic Sperm Injection (ICSI)** is the treatment of choice for severe male factor infertility. The underlying medical concept involves the mechanical bypass of natural fertilization barriers; a single viable sperm is directly injected into the cytoplasm of a mature oocyte (MII stage). This overcomes issues where sperm cannot penetrate the zona pellucida due to **severe oligospermia** (low count), **asthenospermia** (poor motility), or **teratospermia** (abnormal morphology). **Analysis of Incorrect Options:** * **IVF (In Vitro Fertilization):** Conventional IVF requires a minimum concentration of motile sperm (approx. 50,000–100,000 per egg) to achieve spontaneous fertilization in a dish. It is ineffective if sperm parameters are severely compromised. * **GIFT (Gamete Intrafallopian Transfer):** Both eggs and sperm are placed into the fallopian tube. It requires at least one functional tube and adequate sperm quality, as fertilization occurs *in vivo*. * **ZIFT (Zygote Intrafallopian Transfer):** Fertilization occurs in vitro, and the zygote is transferred to the fallopian tube. Like IVF, it still relies on relatively healthy sperm for initial fertilization unless combined with ICSI. **High-Yield Clinical Pearls for NEET-PG:** * **Indications for ICSI:** Sperm count <5 million/ml, <5% motility, obstructive/non-obstructive azoospermia (using TESA/PESA), or previous IVF failure. * **Prerequisite:** The oocyte must be in the **Metaphase II (MII)** stage (identified by the presence of the first polar body). * **Success Rate:** Fertilization rates with ICSI are approximately 70-80%, independent of sperm quality. * **Azoospermia:** In cases of azoospermia, ICSI is the only way to achieve biological parenthood using surgically retrieved sperm.

Q: What is the most common type of twin pregnancy following assisted reproductive technology?

Dizygotic twin. **Explanation:** The correct answer is **Dizygotic twin (Option C)**. **Why Dizygotic twin is correct:** Assisted Reproductive Technology (ART), specifically In Vitro Fertilization (IVF) and Ovulation Induction (OI), significantly increases the risk of multiple gestations. The primary reason for the high incidence of twins in ART is the **transfer of multiple embryos** into the uterus during an IVF cycle or the **stimulation of multiple follicles** using gonadotropins or clomiphene citrate. Since these twins arise from two separate eggs fertilized by two separate sperm, they are genetically distinct and classified as dizygotic (fraternal) twins. **Why other options are incorrect:** * **Monozygotic twin (Option A):** While ART does slightly increase the risk of monozygotic (identical) twinning compared to natural conception (likely due to zona pellucida manipulation), dizygotic twins remain far more common due to the practice of multi-embryo transfer. * **Acardiac twin (Option B):** This is a rare, severe complication of monochorionic multiple pregnancies (Twin Reversed Arterial Perfusion sequence). It is a specific pathology, not a "type" of pregnancy common to ART. * **Conjoined twin (Option D):** These occur due to the incomplete division of a single zygote after 13 days of fertilization. They are extremely rare and not the standard outcome of ART. **NEET-PG High-Yield Pearls:** * **Most common twin overall (Natural & ART):** Dizygotic twins. * **Most common type of Monozygotic twin:** Monochorionic Diamniotic (60-70%). * **The "T-sign" on ultrasound:** Indicates Monochorionic twins. * **The "Lambda (λ) sign" or "Twin Peak sign":** Indicates Dichorionic twins (all dizygotic twins are dichorionic). * **Vanishing Twin Syndrome:** The spontaneous loss of one fetus in a multi-gestational pregnancy, often seen in ART-related early ultrasounds.

Q: A female patient presents with complaints of infertility. Hysterosalpingography (HSG) findings are described as follows. What is the most likely diagnosis?

Unicornuate uterus. ***Unicornuate uterus*** - HSG shows a characteristic **single banana-shaped uterine cavity** with only **one fallopian tube** visible, representing incomplete development of one Müllerian duct. - Associated with **increased infertility** and **pregnancy complications** due to reduced uterine volume and potential **renal anomalies** on the same side. *Septate uterus* - HSG demonstrates a **normal external uterine contour** with an **internal septum** dividing the cavity, creating two compartments. - The **intercornual angle is acute ( 90°)** and a **fundal indentation** visible externally. - Both **fallopian tubes are present** and the external contour shows a **heart-shaped** appearance, contrasting with the single cavity in unicornuate uterus. *Uterus didelphys* - HSG shows **complete duplication** with **two separate uterine cavities** and **two cervices**, requiring separate contrast injections. - Represents **complete non-fusion** of Müllerian ducts, unlike the partial development seen in unicornuate uterus.

Q: A couple has been having unprotected intercourse for one year without conceiving and presents to an infertility clinic. The woman has a normal menstrual cycle. Semen analysis shows abnormal sperm morphology, low count, and normal volume. What is the best next step?

Repeat semen analysis. ### Explanation **Correct Option: C. Repeat semen analysis** The diagnosis of male factor infertility should never be based on a single abnormal semen analysis. Sperm parameters exhibit significant physiological variability due to factors like recent illness, stress, or duration of abstinence. According to WHO guidelines, if the initial semen analysis is abnormal, it must be **repeated after 2–4 weeks** (ideally 3 months to cover a full spermatogenic cycle) to confirm the findings before initiating invasive or expensive investigations. **Why other options are incorrect:** * **A. Perform HSG:** While evaluating tubal patency is part of the basic infertility workup, the immediate priority is to confirm the male factor abnormality already identified. * **B. Check LH and FSH levels:** Hormonal evaluation in males is indicated only after a persistent abnormality is confirmed on a repeat semen analysis, especially if the count is 35 years). * **Semen Collection:** Requires **2–7 days** of abstinence. The sample should be collected by masturbation and delivered to the lab within **1 hour**. * **WHO 2021 (6th Ed) Lower Reference Limits:** * **Volume:** 1.4 ml * **Total Count:** 39 million per ejaculate (Concentration: 16 million/ml) * **Motility:** 42% total (30% progressive) * **Morphology:** 4% (Kruger’s strict criteria) * **Oligoasthenoteratozoospermia (OAT):** A condition where all three parameters (count, motility, and morphology) are abnormal.

Q: Which of the following is a marker of ovarian reserve, estimated for infertility?

Anti-Müllerian hormone. **Explanation:** **Anti-Müllerian Hormone (AMH)** is currently considered the most reliable biochemical marker for ovarian reserve. It is produced by the granulosa cells of pre-antral and small antral follicles. Its levels are independent of the hypothalamic-pituitary-ovarian axis, meaning it remains relatively constant throughout the menstrual cycle. This allows for testing on any day of the cycle, making it superior to other markers. A low AMH level indicates a depleted primordial follicle pool. **Analysis of Incorrect Options:** * **Antral Follicle Size:** While **Antral Follicle Count (AFC)**—the total number of follicles measuring 2–10 mm—is a gold standard marker for ovarian reserve, the *size* of an individual follicle is used to monitor ovulation induction, not to estimate the total reserve. * **LH/FSH Ratio:** An elevated LH/FSH ratio (>2:1 or 3:1) is a classic diagnostic feature of **Polycystic Ovary Syndrome (PCOS)**, but it does not accurately reflect the quantitative egg reserve. * **Inhibin A:** This is a marker of corpus luteum function and is used in the **Quadruple Screen** for Down Syndrome. **Inhibin B**, however, is the form secreted by early follicles and was previously used for reserve testing, though it is now largely replaced by AMH. **High-Yield Clinical Pearls for NEET-PG:** * **Best Biochemical Marker:** AMH (earliest marker to decline with age). * **Best Imaging/Biophysical Marker:** Antral Follicle Count (AFC) via Transvaginal Ultrasound (TVS). * **Day 3 FSH:** High levels (>10-12 mIU/mL) indicate poor ovarian reserve, but it is less sensitive than AMH as it fluctuates cycle-to-cycle. * **AMH Levels:** 3.5 ng/mL is often seen in PCOS.

Q: Ideally, the total motile sperm count in the IUI specimen should be:

10 million/ml or more. **Explanation:** Intrauterine Insemination (IUI) success is heavily dependent on the quality of the processed semen sample. The **Total Motile Sperm Count (TMSC)**—calculated as the volume of the sample multiplied by the concentration and the percentage of progressive motility—is considered the most reliable predictor of IUI success. **1. Why Option A is Correct:** The consensus in clinical practice and standard textbooks (such as Jeffcoate’s) indicates that a post-wash TMSC of **10 million/ml or more** is ideal for achieving optimal pregnancy rates. While pregnancies can occur with counts as low as 1–5 million, the success rate plateaus once the count exceeds 10 million. Therefore, 10 million/ml is the established threshold for "ideal" outcomes. **2. Why Other Options are Incorrect:** * **Options B & C (12 and 15 million/ml):** While these counts are excellent, they do not represent the minimum "ideal" threshold. Increasing the count beyond 10 million does not significantly increase the clinical pregnancy rate per cycle. * **Option D (20 million/ml):** This is the traditional WHO cut-off for a "normal" sperm concentration in an *unprocessed* (raw) ejaculate, not the specific requirement for a processed IUI specimen. **High-Yield Clinical Pearls for NEET-PG:** * **Minimum Threshold:** If the post-wash TMSC is **<5 million**, the success rate of IUI drops significantly, and IVF/ICSI should be considered. * **Timing:** IUI is ideally performed **36 hours** after hCG trigger (which mimics the LH surge). * **Sperm Survival:** In the female reproductive tract, washed sperm typically survive for 24–48 hours. * **Indication:** The best results for IUI are seen in cases of unexplained infertility, cervical factor infertility, and mild male factor infertility.

Question 1

Tubal patency is checked by all of the following except?

Accepted Answer

Colposcopy

Answer

Hysterosalpingography

Answer

Laparoscopy

Answer

Falloscopy

Question 2

In an infertile woman, endometrial biopsy reveals proliferative changes. Which hormone should be preferred?

Accepted Answer

Medroxyprogesterone acetate

Answer

Desogestrel

Answer

Norethisterone

Answer

None of the above

Question 3

Kamla, a 30-year-old lady, is examined for infertility by hysterosalpingography, which reveals 'bead-like' fallopian tubes and clubbing of the ampulla. What is the most likely cause?

Accepted Answer

Mycobacterium tuberculosis

Answer

Gonococcus

Answer

Mycoplasma

Answer

Chlamydia

Question 4

Which one of the following procedures is used for severe male factor infertility?

Accepted Answer

Intracytoplasmic Sperm Injection (ICSI)

Answer

Gamete Intrafallopian Transfer (GIFT)

Answer

Zygote Intrafallopian Transfer (ZIFT)

Answer

In Vitro Fertilization (IVF)

Question 5

What is the most common type of twin pregnancy following assisted reproductive technology?

Accepted Answer

Dizygotic twin

Answer

Monozygotic twin

Answer

Acardiac twin

Answer

Conjoined twin

Question 6

A female patient presents with complaints of infertility. Hysterosalpingography (HSG) findings are described as follows. What is the most likely diagnosis?

Accepted Answer

Unicornuate uterus

Answer

Septate uterus

Answer

Bicornuate uterus

Answer

Uterus didelphys

Question 7

A couple has been having unprotected intercourse for one year without conceiving and presents to an infertility clinic. The woman has a normal menstrual cycle. Semen analysis shows abnormal sperm morphology, low count, and normal volume. What is the best next step?

Accepted Answer

Repeat semen analysis

Answer

Perform hysterosalpingography (HSG) in the woman

Answer

Check luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels

Answer

Get a scrotal ultrasound done

Question 8

Which of the following is a marker of ovarian reserve, estimated for infertility?

Accepted Answer

Anti-Müllerian hormone

Answer

Antral follicle size

Answer

LH/FSH ratio

Answer

Inhibin A

Question 9

Which of the following is the drug of choice for follicle induction for infertility in PCOS?

Accepted Answer

Letrozole

Answer

Clomiphene citrate

Answer

GnRH agonist

Answer

Combined oral pills

Question 10

Ideally, the total motile sperm count in the IUI specimen should be:

Accepted Answer

10 million/ml or more

Answer

12 million/ml or more

Answer

15 million/ml or more

Answer

20 million/ml or more

Fertility and Infertility — MCQs

Fertility and Infertility — MCQs

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