Fertility and Infertility Practice Questions

Q: Fibroids cause infertility and pregnancy wastage because?

They cause endometrial inflammation. **Explanation:** Uterine fibroids (leiomyomas), particularly **submucosal** and **intramural** types that distort the uterine cavity, are significant contributors to infertility and recurrent pregnancy loss. **Why Option B is Correct:** The primary mechanism by which fibroids interfere with implantation and cause pregnancy wastage is by inducing **chronic endometrial inflammation**. The presence of a fibroid leads to: * **Altered Endometrial Receptivity:** Increased production of inflammatory cytokines (e.g., TNF-α, IL-6) and recruitment of macrophages. * **Vascular Changes:** Abnormal venous drainage and focal endometrial thinning/atrophy over the fibroid surface, making the environment hostile for a blastocyst. * **Molecular Changes:** Downregulation of HOXA-10 genes, which are essential for implantation. **Analysis of Incorrect Options:** * **Option A:** Fibroids are estrogen-dependent tumors, but they do not interfere with the Hypothalamic-Pituitary-Ovarian (HPO) axis; therefore, they **do not inhibit ovulation**. * **Option C:** While very large broad ligament fibroids may occasionally displace ovaries, they do not exert a "pressure effect" significant enough to cause infertility. Infertility is primarily a uterine factor issue. * **Option D:** Fibroids **respond** to estrogen (they are hyper-responsive due to increased aromatase activity), but they do not **induce** a systemic hyperestrogenic state. **High-Yield NEET-PG Pearls:** * **Most common fibroid causing infertility:** Submucosal (FIGO Type 0, 1, 2). * **Impact on Tubes:** Large cornual fibroids can cause mechanical obstruction of the fallopian tube ostia. * **Myomectomy Rule:** In infertility, a myomectomy is indicated if the fibroid distorts the cavity or is >4 cm in size. * **Pregnancy Wastage:** Fibroids increase the risk of spontaneous abortion, malpresentation, placental abruption, and postpartum hemorrhage (PPH).

Q: Which of the following locations of tubal obstruction is least amenable to surgical repair?

Interstitial. **Explanation:** The **interstitial (intramural) portion** of the fallopian tube is the segment that traverses the muscular wall of the uterus. Obstruction at this site is the least amenable to surgical repair because it is the narrowest part of the tube (lumen diameter <1 mm) and is encased within the thick myometrium. Surgical access requires a cornual resection and re-anastomosis, which carries a high risk of uterine rupture in subsequent pregnancies and poor patency rates. Today, **IVF** or **hysteroscopic tubal cannulation** are preferred over surgery for interstitial blocks. **Analysis of Other Options:** * **Fimbrial (A):** Obstruction here (e.g., hydrosalpinx) can be treated with fimbrioplasty or neosalpingostomy. While success depends on the health of the mucosa, it is surgically accessible. * **Ampullary (C):** This is the widest part of the tube. While mid-segment blocks are challenging, they are more amenable to end-to-end anastomosis than the intramural segment. * **Isthmic (D):** This is a common site for tubal ligation. It is highly amenable to **microsurgical tubotubal anastomosis**, which boasts the highest success rates among all tubal reconstructive surgeries. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard for Diagnosis:** Hysterosalpingography (HSG) is the initial test; Laparoscopy with Chromopertubation is the gold standard. * **Best Prognosis:** Tubal patency restoration has the best success rate in **Isthmic-Isthmic** anastomosis. * **Most Common Site of Ectopic Pregnancy:** Ampulla. * **Narrowest Part of the Tube:** Interstitial part (0.7 mm).

Q: What is the initial starting dose of clomiphene citrate for infertility?

50 mg/day. **Explanation:** **Clomiphene Citrate (CC)** is the traditional first-line pharmacological agent for ovulation induction, particularly in women with WHO Group II ovulatory dysfunction (e.g., Polycystic Ovary Syndrome). **Why 50 mg/day is correct:** The standard protocol for Clomiphene Citrate initiation is a starting dose of **50 mg per day for 5 consecutive days**, typically beginning on Day 2, 3, 4, or 5 of the menstrual cycle. This dose is chosen because it is the lowest effective dose that achieves ovulation in approximately 50% of patients while minimizing the risk of side effects like multiple pregnancies and Ovarian Hyperstimulation Syndrome (OHSS). If ovulation is not achieved at 50 mg, the dose is increased in subsequent cycles in increments of 50 mg (up to a maximum of 150 mg). **Why other options are incorrect:** * **30 mg, 40 mg, and 60 mg/day:** These are not standard manufactured strengths or recommended starting doses. Clomiphene is commercially available in **50 mg tablets**. Starting at doses lower than 50 mg is generally sub-therapeutic, and starting higher increases the risk of anti-estrogenic effects on the endometrium and cervical mucus. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism of Action:** It is a **Selective Estrogen Receptor Modulator (SERM)**. It acts as a competitive antagonist to estrogen receptors in the hypothalamus, blocking negative feedback. This leads to increased GnRH secretion, which stimulates the pituitary to release more **FSH and LH**, promoting follicular growth. * **Success Rates:** Ovulation occurs in ~70-80% of cases, but the pregnancy rate is lower (~30-40%) due to its anti-estrogenic effect on the endometrium. * **Side Effects:** Most common is **vasomotor flushes** (hot flashes). The most serious is **OHSS** (though less common than with gonadotropins). * **Multiple Pregnancy:** There is a 5-10% risk, predominantly twins.

Q: Treatment with clomiphene citrate should be limited to how many ovulatory cycles?

6. **Explanation:** **Clomiphene Citrate (CC)** is a Selective Estrogen Receptor Modulator (SERM) and the traditional first-line agent for ovulation induction in WHO Group II anovulation (e.g., PCOS). **Why 6 cycles?** The correct answer is **6 cycles** because clinical data shows that approximately **75-80% of pregnancies** occurring with CC treatment happen within the first six ovulatory cycles. Continuing treatment beyond this point offers a significantly diminishing return on the pregnancy rate. Furthermore, prolonged use (typically defined as >12 cycles) has been historically linked to a theoretical increased risk of borderline ovarian tumors, though the primary reason for the 6-cycle limit is **clinical futility**. If a patient has not conceived after 6 ovulatory cycles, they are classified as "clomiphene failures," and the treatment strategy should be escalated to gonadotropins or IVF. **Analysis of Incorrect Options:** * **A (3 cycles):** While some clinicians evaluate progress early, 3 cycles are insufficient to declare treatment failure, as many patients conceive between cycles 3 and 6. * **C & D (10 & 12 cycles):** Continuing CC for 10-12 cycles is avoided due to the lack of additional efficacy and the potential anti-estrogenic effects of CC on the cervical mucus and endometrium, which may actually hinder implantation over time. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism of Action:** Blocks estrogen receptors in the hypothalamus, inhibiting negative feedback and increasing endogenous **GnRH, FSH, and LH** pulses. * **Dosage:** Usually started at **50 mg/day** for 5 days (Day 2-6 or 3-7 of the cycle). Max dose is 150 mg. * **Side Effects:** Multiple pregnancies (approx. 8-10%, mostly twins), hot flashes, and Ovarian Hyperstimulation Syndrome (OHSS - though less common than with gonadotropins). * **Monitoring:** Ovulation is typically expected 5–10 days after the last pill.

Q: Considering the demands of modern life schedules, what is the accepted minimum period of unprotected sexual cohabitation for a couple to be considered infertile?

One year. **Explanation:** Infertility is clinically defined as the failure to achieve a clinical pregnancy after **12 months (one year)** or more of regular, unprotected sexual intercourse. This definition is based on the concept of **fecundability**—the probability of achieving pregnancy in a single menstrual cycle. In a healthy couple, the cumulative pregnancy rate is approximately 80-85% within the first year. Therefore, the one-year mark serves as the standard threshold to initiate medical investigations. **Analysis of Options:** * **Option A (One Year):** This is the globally accepted standard by WHO and ACOG. It balances the natural time required for conception with the need for timely medical intervention. * **Option B, C, and D:** These durations (1.5 to 3 years) are considered unnecessarily long. Delaying evaluation for this length of time can lead to a decline in ovarian reserve, especially in older patients, reducing the success rate of future treatments. **High-Yield Clinical Pearls for NEET-PG:** * **Age Exception:** If the female partner is **>35 years old**, the period of unprotected cohabitation required for an infertility diagnosis is reduced to **6 months**. * **Primary vs. Secondary:** Primary infertility refers to a couple who has never achieved pregnancy; Secondary infertility refers to those who have had at least one prior pregnancy (regardless of the outcome). * **Fecundability Rate:** The average monthly chance of conception for a healthy couple is about **20%**. * **Immediate Evaluation:** Investigation should start immediately (without waiting a year) if there is a known history of endometriosis, PCOS, tubal disease, or male factor infertility.

Q: Which of the following is NOT an essential criterion according to WHO for normal semen analysis?

Volume >1 mL. The correct answer is **B (Volume >1 mL)** because, according to the **WHO 6th Edition (2021)** and the widely tested **WHO 5th Edition (2010)** guidelines, the lower reference limit for semen volume is **1.5 mL**, not 1 mL. A volume below 1.5 mL is termed hypospermia and may indicate retrograde ejaculation, ductal obstruction, or androgen deficiency. ### Analysis of Incorrect Options: * **A. Sperm count >15 million/mL:** This is a correct WHO criterion. A concentration below this threshold is defined as **oligozoospermia**. * **C. Sperm with normal morphology >4%:** According to **Kruger’s strict criteria**, a sample is considered normal if at least 4% of sperm have ideal head, midpiece, and tail structures. Values below this are termed **teratozoospermia**. * **D. Motility >32%:** The WHO defines normal total motility as ≥40%, but specifically requires **progressive motility (PR) to be ≥32%**. Failure to meet this is termed **asthenozoospermia**. ### High-Yield Clinical Pearls for NEET-PG: * **Azoospermia:** Total absence of spermatozoa in the ejaculate. * **Aspermia:** Complete absence of semen. * **Vitality:** At least **58%** of sperm should be alive (tested via Eosin-Nigrosin stain). * **pH:** Should be **≥7.2** (alkaline). Acidic pH suggests bilateral absence of vas deferens or seminal vesicle obstruction. * **Liquefaction time:** Usually occurs within **15–30 minutes** at room temperature.

Question 1

Fibroids cause infertility and pregnancy wastage because?

Accepted Answer

They cause endometrial inflammation

Answer

They inhibit normal ovulation

Answer

They exert a pressure effect on the ovaries

Answer

They induce a hyperestrogenic state

Question 2

Which of the following locations of tubal obstruction is least amenable to surgical repair?

Accepted Answer

Interstitial

Answer

Fimbrial

Answer

Ampullary

Answer

Isthmic

Question 3

Which of the following procedures is associated with the maximum chance of re-canalization during surgery for reversal of tubal ligation?

Accepted Answer

Isthmic-isthmic anastomosis

Answer

Isthmic-ampullary anastomosis

Answer

Ampullary-ampullary anastomosis

Answer

Cornual obstruction

Question 4

On which day of a normal 28-day menstrual cycle should a hysterosalpingogram be performed for a woman with a 5-day menstrual period?

Accepted Answer

Day 8

Answer

Day 4

Answer

Day 14

Answer

Day 21

Question 5

Recurrent miscarriage is defined as?

Accepted Answer

Three or more consecutive pregnancy losses at <= 20 weeks or with a fetal weight < 500 grams

Answer

One or more consecutive pregnancy losses at <= 20 weeks or with a fetal weight < 500 grams

Answer

Two or more consecutive pregnancy losses at <= 20 weeks or with a fetal weight < 500 grams

Answer

Four or more consecutive pregnancy losses at <= 20 weeks or with a fetal weight < 500 grams

Question 6

What is the initial starting dose of clomiphene citrate for infertility?

Accepted Answer

50 mg/day

Answer

30 mg/day

Answer

40 mg/day

Answer

60 mg/day

Question 7

Treatment with clomiphene citrate should be limited to how many ovulatory cycles?

Accepted Answer

6

Answer

3

Answer

10

Answer

12

Question 8

Considering the demands of modern life schedules, what is the accepted minimum period of unprotected sexual cohabitation for a couple to be considered infertile?

Accepted Answer

One year

Answer

One and a half years

Answer

Two years

Answer

Three years

Question 9

A 38-year-old female presents to the infertility clinic complaining of inability to conceive. Semen analysis results are as follows: Semen volume: 2 cc, Sperm density: 20 x 10^6/cc, Sperm motility: 50%, Sperm morphology (strict criteria): 14%, Sperm viability: 40%, White blood cells: [value not specified]. Hysterosalpingography was performed on a patient with recurrent abortions, revealing the finding shown. The condition marked by the black arrow is due to the mal-development of which structure?

Accepted Answer

Structure A

Answer

Structure B

Answer

Structure D

Answer

Structure C

Question 10

Which of the following is NOT an essential criterion according to WHO for normal semen analysis?

Accepted Answer

Volume >1 mL

Answer

Sperm count >15 million/mL

Answer

Sperm with normal morphology (strict criteria) >4%

Answer

Motility >32% with rapidly progressive motility

Fertility and Infertility — MCQs

Fertility and Infertility — MCQs

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