Fertility and Infertility Practice Questions

Q: Which hormone level is most commonly assessed to evaluate ovarian reserve?

Follicle-Stimulating Hormone (FSH). **Explanation:** **Ovarian reserve** refers to the quantity and quality of the remaining oocytes in the ovaries. As a woman ages, the number of follicles decreases, leading to a decline in **Inhibin B** and **Estradiol** levels. Since these hormones normally provide negative feedback to the pituitary, their decline results in a compensatory rise in **Follicle-Stimulating Hormone (FSH)**. **Why FSH is the Correct Answer:** Basal FSH, measured on **Day 2 or 3** of the menstrual cycle, is the traditional "gold standard" screening test for ovarian reserve. A high FSH level (typically >10-12 mIU/mL) indicates a diminished ovarian reserve (DOR), as the pituitary is "working harder" to stimulate the depleted follicles. **Analysis of Incorrect Options:** * **LH (A):** LH levels are primarily used to detect the mid-cycle surge for ovulation or to diagnose PCOS; they do not independently reflect the oocyte pool. * **LH/FSH Ratio (B):** An elevated ratio (>2:1 or 3:1) is a classic diagnostic marker for **Polycystic Ovary Syndrome (PCOS)**, not ovarian reserve. * **Estradiol (D):** While often measured alongside FSH, isolated estradiol is not a reliable marker. However, a very high early-cycle estradiol (>60-80 pg/mL) can falsely suppress FSH, masking a diminished reserve. **High-Yield NEET-PG Pearls:** * **Most Sensitive/Earliest Marker:** Anti-Müllerian Hormone (**AMH**). Unlike FSH, AMH is cycle-independent (can be tested any day). * **Best Ultrasound Marker:** Antral Follicle Count (**AFC**), measured via TVS. * **Day 3 FSH >20 mIU/mL:** Usually indicates poor response to stimulation and very low pregnancy potential. * **Inhibin B:** Produced by granulosa cells; its decline is one of the earliest biochemical changes in reproductive aging.

Q: Which of the following helps to prevent premature LH surge during oocyte retrieval for in vitro fertilization?

Leuprolide. **Explanation:** In **Controlled Ovarian Hyperstimulation (COH)** for IVF, multiple follicles develop simultaneously, leading to high serum estradiol levels. These high levels can trigger a premature LH surge via positive feedback, causing ovulation before the scheduled oocyte retrieval. To prevent this, the pituitary gland must be suppressed. **Why Leuprolide is correct:** **Leuprolide** is a **GnRH agonist**. When administered continuously (the "long protocol"), it initially causes a "flare" but subsequently leads to the **downregulation and desensitization** of GnRH receptors in the pituitary. This effectively shuts down the production of endogenous LH, preventing a premature surge and allowing the clinician to control the timing of final oocyte maturation. (Note: GnRH antagonists like Cetrorelix are also used for this purpose with a more immediate onset). **Analysis of Incorrect Options:** * **A. HCG:** Human Chorionic Gonadotropin acts as an **LH analog**. It is used as a "trigger" to induce final follicular maturation and ovulation, not to prevent the surge. * **B. Oestrogen:** High levels of estrogen actually *trigger* the LH surge through positive feedback on the pituitary once a threshold is reached. * **C. Progesterone:** While progesterone can inhibit LH in the natural luteal phase, it is not the standard pharmacological agent used for pituitary suppression during the stimulation phase of IVF. **Clinical Pearls for NEET-PG:** * **GnRH Agonists (e.g., Leuprolide):** Cause initial flare followed by downregulation (takes ~7-10 days). * **GnRH Antagonists (e.g., Cetrorelix):** Cause immediate suppression by competitive blockade; no flare effect. * **The "Trigger":** Once follicles reach ~18mm, HCG or a GnRH agonist bolus is given to mimic the LH surge, with retrieval scheduled **34–36 hours** later.

Q: What is the normal sperm concentration in semen analysis?

Greater than or equal to 15 million/ml. The correct answer is **B. Greater than or equal to 15 million/ml**. ### **Explanation** The reference values for semen analysis are based on the **WHO Laboratory Manual for the Examination and Processing of Human Semen (5th Edition, 2010)**, which remains the standard for most competitive exams like NEET-PG. According to these criteria, the lower reference limit for **sperm concentration** is **15 million spermatozoa per ml**. * **Sperm Concentration:** Refers to the number of sperm per unit volume (ml). * **Total Sperm Number:** Refers to the total count in the entire ejaculate (Lower limit: **39 million per ejaculate**). ### **Why other options are incorrect:** * **Option A:** Less than 15 million/ml is defined as **Oligozoospermia**, indicating a sub-fertile state. * **Option C:** 20 million/ml was the cutoff used in the older WHO 4th Edition (1999). While still seen in some clinical practices, it is no longer the standard for current examinations. * **Option D:** 25 million/ml is well above the minimum threshold for normalcy and does not represent a standard diagnostic cutoff. ### **High-Yield Clinical Pearls (WHO 5th Edition Criteria):** * **Volume:** ≥ 1.5 ml * **Total Motility (PR + NP):** ≥ 40% (Progressive Motility: ≥ 32%) * **Morphology (Kruger’s strict criteria):** ≥ 4% normal forms * **Vitality (Live sperm):** ≥ 58% * **pH:** ≥ 7.2 * **Azoospermia:** Absence of sperm in the ejaculate. * **Asthenozoospermia:** Reduced sperm motility. * **Teratozoospermia:** Increased abnormal forms of sperm.

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

Clomiphene citrate. **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.

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

Azoospermia. **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.

Q: Intrauterine insemination is indicated in all except?

Sperm count 5-10 million/ml. **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 1

If a lifestyle factor causing infertility in a young male is identified, which of the following lifestyle modifications will have no effect?

Accepted Answer

Vegetarian diet

Answer

Weight gain

Answer

Less exercise

Answer

Weight loss

Question 2

Which hormone level is most commonly assessed to evaluate ovarian reserve?

Accepted Answer

Follicle-Stimulating Hormone (FSH)

Answer

Luteinizing Hormone (LH)

Answer

LH/FSH ratio

Answer

Estradiol

Question 3

A patient experiencing infertility, treated with ovulation induction and an ovulation trigger with HCG injection, tests positive for pregnancy on the first day of her missed period. On the same day, she presents to the emergency department with complaints of abdominal distension, vomiting, and difficulty in breathing. Her blood pressure is 110/60 mmHg and pulse rate is 98/min. What is the most probable cause of her symptoms?

Accepted Answer

Ovarian Hyperstimulation Syndrome

Answer

Choriocarcinoma

Answer

Molar pregnancy

Answer

Ruptured ectopic pregnancy

Question 4

Which of the following helps to prevent premature LH surge during oocyte retrieval for in vitro fertilization?

Accepted Answer

Leuprolide

Answer

HCG

Answer

Oestrogen

Answer

Progesterone

Question 5

What is the normal sperm concentration in semen analysis?

Accepted Answer

Greater than or equal to 15 million/ml

Answer

Less than 15 million/ml

Answer

Greater than or equal to 20 million/ml

Answer

Greater than or equal to 25 million/ml

Question 6

A 26-year-old patient has had three consecutive spontaneous abortions early in her pregnancy. As part of an evaluation for this problem, which of the following tests would be least useful?

Accepted Answer

Testing for TORCH infections, Postcoital test

Answer

Hysterosalpingogram, Testing for TORCH infections, Postcoital test

Answer

Hysterosalpingogram, Testing for TORCH infections

Answer

Postcoital test only

Question 7

Which of the following is NOT a test for ovulation?

Accepted Answer

Hysteroscopy

Answer

Fern test

Answer

Basal body temperature

Answer

LH surge

Question 8

Which of the following drugs is used for ovulation induction?

Accepted Answer

Clomiphene citrate

Answer

Mifepristone

Answer

Levonorgestrel

Answer

Oral contraceptive pills

Question 9

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

Accepted Answer

Azoospermia

Answer

Oligospermia

Answer

Impotency

Answer

Antisperm antibodies in the cervical mucous

Question 10

Intrauterine insemination is indicated in all except?

Accepted Answer

Sperm count 5-10 million/ml

Answer

Hypospadias

Answer

Antisperm antibodies in cervix

Answer

Retrograde ejaculation

Fertility and Infertility — MCQs

Fertility and Infertility — MCQs

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