Fertility and Infertility — MCQs

Fertility and Infertility Indian Medical PG Practice Questions and MCQs

Question 301: Ovarian reserve is best indicated by

A. Follicle-stimulating hormone (FSH)
B. Anti-Müllerian Hormone (AMH) (Correct Answer)
C. Luteinizing hormone (LH)
D. LH/FSH ratio

Explanation: ***Anti-Müllerian Hormone (AMH)*** - **AMH is currently considered the best single biochemical marker** for assessing ovarian reserve - Produced by **granulosa cells of preantral and small antral follicles**, directly reflecting the size of the primordial follicle pool - **Cycle-independent** - can be measured at any time during the menstrual cycle - **More sensitive and specific** than FSH for detecting diminished ovarian reserve - **Minimal inter-cycle and intra-cycle variability**, providing consistent and reliable results - Widely used in **fertility assessment, IVF protocols**, and predicting ovarian response to stimulation *Follicle-stimulating hormone (FSH)* - Elevated **early follicular phase FSH** (measured on day 3) indicates diminished ovarian reserve - Historically the most commonly used marker, but **less sensitive than AMH** - **Cycle-dependent** - must be measured on specific days (day 2-4 of cycle) - A **late marker** - rises only when ovarian reserve is already significantly diminished - Still clinically useful and widely available, but not the "best" indicator *Luteinizing hormone (LH)* - **LH** primarily triggers ovulation and does not directly reflect ovarian reserve - Elevated in conditions like **PCOS** but does not assess the quantity or quality of remaining follicles - Not a reliable indicator of overall ovarian reserve *LH/FSH ratio* - An elevated **LH/FSH ratio** (>2:1 or >3:1) is associated with **Polycystic Ovary Syndrome (PCOS)** - Reflects anovulation and hormonal imbalance, not the number or viability of ovarian follicles - Does not assess ovarian reserve capacity

Question 302: On which day LH & FSH should be measured?

A. 1-3rd day (Correct Answer)
B. 7th day
C. 14th day
D. 10th day

Explanation: ***1-3rd day*** - Measuring **LH** (Luteinizing Hormone) and **FSH** (Follicle-Stimulating Hormone) on cycle days 1-3 provides a baseline assessment of **ovarian reserve** and pituitary function. - At this early follicular phase, hormone levels are relatively stable and reflect the intrinsic **gonadal feedback** mechanisms before significant follicular development begins. *7th day* - By day 7, **follicular development** is usually well underway, and FSH levels might be decreasing as a dominant follicle is selected. - Measuring hormones on this day would not provide an accurate baseline assessment, as the levels are already influenced by **follicular growth**. *14th day* - Day 14 is often associated with the **LH surge** that triggers ovulation, making it unsuitable for a baseline assessment of ovarian reserve. - FSH levels would also be significantly different from the early follicular phase due to the ongoing **ovarian cycle events**. *10th day* - On day 10, **estrogen levels** are typically rising, which would already be providing negative feedback to the pituitary, affecting FSH and LH levels. - This timing would not be ideal for assessing baseline hormone levels for **fertility evaluations**.

Question 303: Most common site of ectopic pregnancy is -

A. Cervical
B. Tubal (Correct Answer)
C. Abdominal
D. Ovarian

Explanation: ***Tubal*** - The **fallopian tubes** are the most common site for ectopic pregnancies, accounting for over **95%** of all cases. - This is because the fertilized ovum typically implants in the tube rather than reaching the uterus. *Abdominal* - **Abdominal ectopic pregnancies** are rare, occurring when the fertilized egg implants in the abdominal cavity. - They account for about **1%** of all ectopic pregnancies and often result in significant maternal complications. *Ovarian* - **Ovarian ectopic pregnancies** are very rare, occurring when the ovum is fertilized within the ovary itself. - They represent less than **1%** of all ectopic cases and can be difficult to diagnose. *Cervical* - **Cervical ectopic pregnancies** involve implantation within the cervical canal. - These are also very rare (less than **1%** of ectopic pregnancies) and are associated with a high risk of severe hemorrhage.

Question 304: Human sperm remains fertile for how many hours in a female genital tract ?

A. 6-8 hrs
B. 12-24 hrs
C. 24-48 hrs
D. Up to 5 days (120 hrs) (Correct Answer)

Explanation: ***Up to 5 days (120 hrs)*** - **Sperm viability** within the female reproductive tract can extend up to **5 days (120 hours)** under optimal conditions. - This extended viability is crucial for fertility, as it allows for fertilization even if ovulation occurs several days after intercourse. *6-8 hrs* - This timeframe is significantly **too short** for typical human sperm viability in the female genital tract. - While some sperm may lose motility or viability relatively quickly, a substantial portion remains viable for much longer. *12-24 hrs* - This represents the average **lifespan of an ovum** (egg) after ovulation, not the typical viability of sperm. - Sperm generally survive longer than an unfertilized egg. *24-48 hrs* - This duration underestimates the maximum potential survival time of human sperm in the female reproductive tract. - While many sperm may be viable within this period, it does not represent the full potential for fertilization.

Question 305: What is the most common site for ectopic pregnancies?

A. Isthmus
B. Ampulla (Correct Answer)
C. Fimbriae
D. Interstitial/Cornual

Explanation: ***Ampulla*** - The **ampulla** of the fallopian tube is the most common site for ectopic pregnancies, accounting for about **70-80% of all cases**. - Its **wider lumen** and **tortuous path** can delay the ovum's transit, increasing the likelihood of implantation there. *Isthmus* - The **isthmus** is the second most common site for ectopic pregnancies, accounting for about **12% of cases**. - Pregnancies in this narrow, muscular part of the tube are more prone to **early rupture** due to limited distensibility. *Fimbriae* - **Fimbrial** ectopic pregnancies are rare, accounting for approximately **5% of cases**. - These occur when the fertilized egg implants on the **finger-like projections** at the end of the fallopian tube. *Interstitial/Cornual* - **Interstitial** or **cornual** pregnancies are uncommon but serious, making up about **2-4% of ectopic pregnancies**. - They occur in the portion of the fallopian tube that passes through the **muscular wall of the uterus** and carry a higher risk of hemorrhage due to rich vascularity.

Question 306: Blastocyst makes contact with endometrium on ?

A. < 3 days
B. 5 - 7 days (Correct Answer)
C. 8 - 11 days
D. 15-16 days

Explanation: ***5-7 days*** - The **blastocyst makes initial contact** (apposition) with the **endometrium** around **day 5-6 after fertilization**. - **Implantation**, which includes adhesion and invasion, typically begins around day 6 and is complete by day 10. - This timeframe allows the blastocyst to travel from the fallopian tube to the uterus and for the uterine lining to be optimally prepared. *< 3 days* - Within the first few days after fertilization, the zygote is still undergoing **cleavage** and development into a **morula**, then a young blastocyst, while traveling down the fallopian tube. - It has not yet reached the uterus or developed sufficiently to interact with the endometrium. *8-11 days* - By 8-11 days, the process of implantation is usually **well underway or completed**, with the blastocyst already invading the endometrial wall. - Initial contact and attachment occur prior to this period. *15-16 days* - This timeframe is well beyond the typical window for initial blastocyst contact and implantation. - By 15-16 days post-fertilization, the embryo would be undergoing **gastrulation** and early organogenesis, assuming successful implantation.

Question 307: The thickness of the endometrium at the time of implantation is:

A. 7 - 10 mm (Correct Answer)
B. 20 - 30 mm
C. 30 - 40 mm
D. 3 - 4 mm

Explanation: ***7 - 10 mm*** - At the time of **implantation** (day 6-10 post-fertilization, around day 20-24 of the menstrual cycle), the endometrium is in the **mid-secretory phase** and measures **7-10 mm** in thickness. - This is the **optimal thickness** for successful embryo implantation, characterized by a receptive endometrium with **decidualization**, **spiral artery development**, and **glycogen-rich glandular secretions**. - Endometrial thickness <7 mm is associated with **poor implantation rates** and reduced pregnancy success. *3 - 4 mm* - An endometrial thickness of 3-4 mm is **too thin** for successful implantation. - This thickness is typically seen in the **early proliferative phase** (immediately after menstruation), not during the implantation window. - Thin endometrium (<7 mm) is associated with **poor receptivity** and lower pregnancy rates in both natural conception and assisted reproduction. *20 - 30 mm* - An endometrial thickness of 20-30 mm is **abnormally thick** and not conducive to normal implantation. - Such thickness may indicate **endometrial hyperplasia**, **polyps**, or other pathological conditions requiring investigation. *30 - 40 mm* - An endometrial thickness of 30-40 mm is **severely abnormal** and would likely prevent successful implantation. - This extreme thickness suggests significant pathology such as **endometrial hyperplasia** or **malignancy** and requires urgent evaluation.

Question 308: What are the primary indications for in vitro fertilization (IVF)?

A. Uterine factor
B. Tubal blocks (Correct Answer)
C. None of the options
D. Male factor (sperm count 12 million/ml)

Explanation: ***Tubal blocks*** - **Tubal blockages**, whether bilateral or severe unilateral, prevent the natural meeting of sperm and egg, making IVF an essential treatment to bypass this anatomical obstruction. - This is the **primary and classic indication** for IVF, as it allows fertilization to occur externally before embryo transfer to the uterus. - Tubal factor infertility was the original indication for which IVF was developed. *Uterine factor* - **Severe uterine factors**, such as significant structural abnormalities or severe intrauterine adhesions, are generally considered contraindications or make IVF less successful. - While IVF can bypass some reproductive challenges, it cannot overcome significant issues with the uterine environment needed for implantation and pregnancy maintenance. *None of the options* - This option is incorrect because **tubal blocks** are a well-recognized and primary indication for IVF. - IVF effectively addresses reproductive challenges linked to tubal patency issues. *Male factor (sperm count 12 million/ml)* - A sperm count of 12 million/mL represents **oligozoospermia** (normal >15 million/mL per WHO criteria). - While male factor infertility is an indication for assisted reproduction, **ICSI (Intracytoplasmic Sperm Injection)** rather than conventional IVF is typically the preferred treatment for significant male factor. - Treatment choice depends on comprehensive semen analysis including motility, morphology, and overall fertility assessment of both partners.

Question 309: Which of the following is the least invasive assisted reproductive technique?

A. GIFT
B. ZIFT
C. IVF
D. Intra-Uterine Insemination (Correct Answer)

Explanation: ***Intra-Uterine Insemination (IUI)*** - **IUI** involves directly placing **sperm** into the **uterus**, bypassing the cervix after sperm washing, making it the least invasive method among the options. - It is often used for mild male factor infertility, unexplained infertility, or when a woman has cervical mucus issues. *GIFT (Gamete Intra-Fallopian Transfer)* - **GIFT** is more invasive as it requires a **laparoscopic procedure** to place both **sperm** and **eggs** directly into the fallopian tube. - While fertilization occurs *in vivo* (in the body), the surgical aspect makes it more invasive than IUI. *ZIFT (Zygote Intra-Fallopian Transfer)* - **ZIFT** involves **IVF** to fertilize eggs in the lab, but then requires a **laparoscopic procedure** to place the resulting **zygotes** (early embryos) into the fallopian tube. - The combination of *in vitro* fertilization and surgical placement makes it more invasive than IUI. *IVF (In Vitro Fertilization)* - **IVF** involves **oocyte retrieval** (a transvaginal ultrasound-guided procedure) and **fertilization in vitro** (in the lab), followed by **embryo transfer** into the uterus. - While embryo transfer is less invasive than laparoscopic procedures, the initial oocyte retrieval makes IVF generally more invasive than IUI.

Question 310: When is Hysterosalpingography (HSG) ideally performed?

A. Between menstruation and ovulation
B. Just after menstruation (Correct Answer)
C. Just before ovulation
D. At any time

Explanation: ***Just after menstruation*** - HSG is ideally performed in the **early proliferative (follicular) phase**, typically **2-5 days after menstruation ends** or on **cycle days 7-10**. - At this time, the **endometrium is thin**, providing optimal visualization of the uterine cavity and tubal anatomy with minimal discomfort. - This timing avoids disrupting a **potential pregnancy**, as ovulation has not yet occurred and the likelihood of conception is minimal. - Performing the procedure after menstrual flow has ceased also reduces the risk of **infection** and ensures better image quality. *Between menstruation and ovulation* - This timeframe is too broad and vague, spanning approximately **14 days** (the entire follicular phase). - While it technically includes the correct timing, it also encompasses periods when HSG should **not** be performed, such as just before ovulation when fertilization may be imminent. - This option lacks the specificity required for proper clinical timing. *Just before ovulation* - Performing HSG just before ovulation (around day 12-14) carries a significant risk of **disrupting a potential pregnancy** if fertilization has occurred or is about to occur. - The **endometrium** is thicker at this stage in preparation for implantation, which can obscure findings and increase patient discomfort. - This timing also increases the risk of **flushing a fertilized egg** out of the fallopian tube. *At any time* - Performing HSG at any time is not advisable due to multiple risks, including the possibility of performing the procedure on a **pregnant woman**, which can cause harm. - The **uterine lining thickness** varies throughout the cycle, significantly affecting imaging quality and procedural comfort. - Timing during or near menses would result in blood obscuring the contrast and poor visualization.

Practice by Chapter

Reproductive Physiology

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Evaluation of the Infertile Couple

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Male Factor Infertility

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Female Factor Infertility

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Ovulatory Disorders

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Tubal and Peritoneal Factors

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Uterine Factors

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Unexplained Infertility

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Assisted Reproductive Technologies

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Psychological Aspects of Infertility

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