Fertility and Infertility Practice Questions

Q: In long protocol In Vitro Fertilization (IVF), on which day is GnRH agonist typically started?

Day 21 of the previous cycle. **Explanation:** In IVF, the **Long Protocol** (also known as the "Down-regulation protocol") is the most traditional and widely used method for controlled ovarian hyperstimulation. **1. Why Day 21 of the previous cycle is correct:** The primary goal of the long protocol is to achieve complete suppression of the pituitary gland before starting gonadotropins. The GnRH agonist is initiated in the **mid-luteal phase** (typically **Day 21**) of the cycle preceding the IVF stimulation. * **Mechanism:** Initial administration causes a "flare effect" (release of FSH/LH), but continuous administration leads to down-regulation and desensitization of GnRH receptors. This prevents a premature LH surge during the subsequent stimulation phase, ensuring that the follicles grow synchronously and do not ovulate before egg retrieval. **2. Analysis of Incorrect Options:** * **Day 1 of the previous cycle:** Starting this early is unnecessary and would interfere with the previous cycle's physiology without providing additional benefit for down-regulation. * **Day 1 of the IVF cycle:** This is characteristic of the **Short Protocol** (Flare Protocol). Here, the agonist is started on Day 2 to utilize the initial "flare" of endogenous FSH to help recruit follicles. * **Day 21 of the IVF cycle:** By this time, the cycle is usually complete (egg retrieval occurs around Day 14). **3. High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard:** The Long Protocol is considered the gold standard for patients with normal ovarian reserve. * **Down-regulation check:** Successful down-regulation is confirmed by an ultrasound showing a thin endometrium (<5mm) and no ovarian cysts, and serum Estradiol levels <50 pg/mL. * **Antagonist Protocol:** Unlike agonists, GnRH **antagonists** (e.g., Cetrorelix) are started in the *late follicular phase* (Day 6 or when the lead follicle is 14mm) and provide immediate LH suppression.

Q: Tuberculosis endometritis causes infertility by which of the following mechanisms?

Destroying the endometrium and causing tubal blockage. **Explanation:** Genital Tuberculosis (GTB) is a significant cause of secondary infertility in developing countries. The correct answer is **A** because TB affects the female reproductive tract in a descending fashion, primarily targeting the fallopian tubes and the endometrium. 1. **Mechanism of Infertility:** * **Tubal Factor (Most Common):** The fallopian tubes are affected in almost 100% of cases. Chronic inflammation leads to hydrosalpinx, "beaded" appearance, and eventually complete tubal blockage or "pipestem" tubes. * **Endometrial Factor:** The endometrium is involved in about 50-60% of cases. Chronic tubercular endometritis leads to the destruction of the basal layer of the endometrium, resulting in intrauterine adhesions (**Asherman’s Syndrome** or Netter’s Syndrome). This renders the endometrium non-receptive to implantation. **Analysis of Incorrect Options:** * **Option B:** While tubal blockage is a major factor, it is incomplete because it ignores the significant role of endometrial destruction (Asherman’s), which is a hallmark of TB infertility. * **Options C & D:** TB is a chronic inflammatory disease; it does not typically interfere with the Hypothalamic-Pituitary-Ovarian axis to cause **anovulation**. Ovulation usually remains preserved unless there is rare, extensive ovarian involvement. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Fallopian tube (100%) > Endometrium (50-60%) > Ovaries (20-30%). * **Gold Standard Diagnosis:** Endometrial biopsy for Histopathology (showing giant cells/granulomas) and Culture (Lowenstein-Jensen medium). * **Hysterosalpingography (HSG) findings:** "Beaded tube," "Golf-hole ostia," or "Lead pipe/Pipestem appearance." * **Prognosis:** Even after successful Antitubercular Therapy (ATT), the conception rate remains low due to permanent structural damage to the cilia and endometrium.

Q: Which of the following is NOT a treatment for cervical infertility?

Clomiphene citrate. **Explanation:** **Cervical infertility** occurs when the cervical mucus is hostile to sperm (due to antisperm antibodies) or when the mucus is insufficient/thick, preventing sperm from entering the upper reproductive tract. **Why Clomiphene Citrate is the Correct Answer:** Clomiphene citrate is an **ovulation-inducing agent**, not a treatment for cervical factors. In fact, Clomiphene has a known **anti-estrogenic effect** on the cervix. It often causes the cervical mucus to become thick, scanty, and "hostile," which can actually *contribute* to cervical infertility rather than treating it. Therefore, it is contraindicated as a solution for this specific condition. **Analysis of Other Options:** * **Condom for 3 months:** This is a classic treatment for **immunological cervical infertility**. By using condoms, the woman’s system is no longer exposed to specific sperm antigens, allowing the titer of antisperm antibodies in the cervical mucus to decrease. * **Intrauterine Insemination (IUI):** This is the **gold standard** treatment. IUI bypasses the "cervical barrier" entirely by depositing washed, concentrated sperm directly into the uterine cavity. * **GIFT:** Similar to IUI, GIFT bypasses the cervix by placing gametes directly into the fallopian tubes, effectively overcoming any cervical hostility. **NEET-PG High-Yield Pearls:** * **Post-Coital Test (Huhner Test):** Historically used to diagnose cervical infertility (performed 2–12 hours after intercourse during the mid-ovulatory phase). A "poor" result shows <5–10 motile sperm per high-power field. * **Hostile Mucus:** Often seen in patients on Clomiphene; switching to Letrozole (an aromatase inhibitor) is preferred as it does not deplete estrogen receptors in the cervix. * **First-line treatment:** For most cases of persistent cervical factor infertility, **IUI** is the preferred clinical approach.

Q: A 32-year-old woman has had three pregnancies, all ending in stillbirths in the first trimester. On physical examination, she and her only spouse for all pregnancies have no abnormalities. Which of the following laboratory tests is most appropriate to perform on this woman for elucidating potential causes for recurrent fetal loss?

Karyotyping. **Explanation:** The clinical presentation of three consecutive pregnancy losses (recurrent pregnancy loss, RPL) necessitates an investigation into parental genetic factors. **Why Karyotyping is Correct:** Approximately 2–5% of couples with recurrent pregnancy loss have a major structural chromosomal abnormality, most commonly a **balanced reciprocal or Robertsonian translocation**. While the parent is phenotypically normal (as seen in this case), their gametes can lead to unbalanced chromosomal arrangements in the fetus, resulting in miscarriage or stillbirth. Conventional **G-banded Karyotyping** is the gold standard initial test for both partners to identify these structural rearrangements. **Analysis of Incorrect Options:** * **A. Genome-wide association study (GWAS):** This is a research tool used to identify genetic variations (SNPs) associated with complex diseases across a population; it is not a diagnostic tool for individual clinical evaluation of RPL. * **B. Fluorescence in situ hybridization (FISH):** While FISH can detect specific microdeletions or aneuploidies, it is "targeted." It would miss the broad range of structural translocations that a global karyotype can detect. * **D. PCR analysis:** PCR is used to amplify specific DNA sequences (e.g., for single-gene disorders like Thalassemia). It cannot detect the large-scale structural chromosomal shifts responsible for most genetic causes of RPL. **Clinical Pearls for NEET-PG:** * **Definition of RPL:** Traditionally 3 or more consecutive losses; however, ASRM now defines it as **2 or more** clinical pregnancy losses. * **Most common genetic cause of RPL:** Parental balanced translocation. * **Most common cause of sporadic miscarriage:** Fetal chromosomal aneuploidy (Trisomy 16 is the most common specific trisomy). * **Other RPL investigations:** Uterine anatomy (HSG/Hysteroscopy), Antiphospholipid Syndrome (APLA) screening, and Thyroid profile.

Q: Intrauterine insemination (IUI) is indicated for all except:

Unexplained infertility. **Explanation:** Intrauterine Insemination (IUI) is a fertility procedure where processed sperm is placed directly into the uterus, bypassing the cervical barrier. While IUI is commonly used in clinical practice for various conditions, this question tests the **primary/absolute indications** versus conditions where its efficacy is less definitive or where it serves as a secondary option. **Why "Unexplained Infertility" is the correct answer:** In the context of strict indications, IUI alone is not the primary treatment for unexplained infertility. Evidence suggests that IUI without ovarian stimulation (Natural Cycle IUI) offers no significant benefit over timed intercourse for these couples. The standard of care for unexplained infertility is **Superovulation (SO) + IUI** or IVF. Therefore, among the choices provided, it is the least "direct" indication for IUI as a standalone procedure. **Analysis of Incorrect Options:** * **Male Factor Infertility:** This is a primary indication. IUI helps by concentrating motile sperm and placing them closer to the fallopian tubes, overcoming mild to moderate oligospermia or asthenospermia. * **Erectile Dysfunction (ED):** IUI is indicated when vaginal intercourse is not possible due to ED, premature ejaculation, or retrograde ejaculation, provided the semen parameters are adequate. * **Cervical Factor Infertility:** IUI is the treatment of choice here as it directly bypasses hostile cervical mucus or anatomical cervical defects that prevent sperm penetration. **High-Yield Clinical Pearls for NEET-PG:** * **Prerequisites for IUI:** At least one patent fallopian tube (confirmed by HSG/Laparoscopy) and a minimum Total Motile Sperm Count (TMSC) of 5–10 million. * **Timing:** IUI is typically performed 34–36 hours after hCG "trigger" injection. * **Success Rate:** Approximately 10–15% per cycle; usually, 3–6 cycles are attempted before moving to IVF.

Q: A woman with infertility presents with bilateral cornual block on hysterosalpingography (HSG). What is the next best investigation for management?

Laparoscopy and chromotubation. **Explanation:** The correct answer is **Laparoscopy and chromotubation**. **1. Why Laparoscopy and Chromotubation is the correct answer:** Hysterosalpingography (HSG) has a high false-positive rate for proximal (cornual) tubal occlusion, often caused by **tubal spasms** during the procedure or debris/mucus plugs. Laparoscopy with chromotubation is the **gold standard** for evaluating tubal patency. It allows for a definitive diagnosis by bypassing the effects of pain-induced spasms (as it is done under general anesthesia) and provides a direct visual assessment of the pelvic anatomy, including endometriosis or adhesions that HSG might miss. **2. Why other options are incorrect:** * **Tuboplasty (A):** Surgical repair is only considered after a definitive diagnosis of permanent anatomical blockage is made. It is not an investigation. * **In vitro fertilization (B):** While IVF is the definitive treatment for bilateral tubal block, it is premature to proceed to expensive ART without confirming that the block is real and not just a spasm. * **Hydrotubation (C):** This is an outdated, blind procedure with low diagnostic accuracy and a high risk of infection; it has been largely replaced by HSG and laparoscopy. **Clinical Pearls for NEET-PG:** * **Gold Standard for Tubal Patency:** Laparoscopy and chromotubation. * **First-line Investigation for Infertility:** Semen analysis (Male); HSG (Female - Tubal factor). * **Cornual Spasm:** The most common cause of a "false" bilateral cornual block on HSG. * **Management Flow:** If HSG shows cornual block $\rightarrow$ Repeat with selective salpingography or proceed to Laparoscopy. If Laparoscopy confirms irreversible block $\rightarrow$ IVF is the treatment of choice.

Q: What is the gold standard investigation for uterine cavity evaluation?

Hysteroscopy. **Explanation:** **Hysteroscopy** is considered the **gold standard** for evaluating the uterine cavity because it allows for direct visualization of the endometrium and the internal architecture of the uterus. Unlike indirect imaging, it provides real-time assessment of the size, shape, and vascularity of any intrauterine pathology (such as polyps, submucosal fibroids, or synechiae) and offers the unique advantage of "see-and-treat"—allowing for simultaneous diagnosis and operative intervention (biopsy or resection). **Analysis of Incorrect Options:** * **Ultrasonography (USG):** Usually the first-line screening tool. While excellent for assessing the myometrium and ovaries, its sensitivity for small intrauterine lesions is lower than hysteroscopy. * **Saline Infusion Sonography (SIS):** Better than a routine USG for detecting intracavitary lesions as the saline distends the cavity. However, it remains an indirect method and cannot provide a definitive histological diagnosis or immediate treatment. * **Hysterosalpingography (HSG):** Primarily used to assess **tubal patency**. While it can show filling defects in the uterus, it has a high false-positive rate and cannot distinguish between different types of intrauterine masses. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard for Tubal Patency:** Laparoscopic Chromopertubation. * **Best time for Hysteroscopy:** Early follicular phase (Day 6 to Day 10), when the endometrium is thinnest. * **Distension Media:** CO2 (diagnostic), Normal Saline (bipolar cautery), or Glycine (monopolar cautery). * **HSG Timing:** Performed in the pre-ovulatory phase (Day 7 to Day 10) to avoid interfering with a potential pregnancy and to ensure the endometrium is thin.

Question 1

In long protocol In Vitro Fertilization (IVF), on which day is GnRH agonist typically started?

Accepted Answer

Day 21 of the previous cycle

Answer

Day 1 of the previous cycle

Answer

Day 1 of the IVF cycle

Answer

Day 21 of the IVF cycle

Question 2

What is the recommended treatment for a patient with infertility and an 8 cm endometriotic cyst?

Accepted Answer

Proceed with surgery first, followed by infertility treatment.

Answer

Perform IUI as early as possible to utilize remaining fertility potential.

Answer

Administer Danazol first, followed by IUI or IVF.

Answer

Induce ovulation and monitor the fertile period.

Question 3

Which of the following is the single most important parameter in semen analysis to assess chances of conception in an infertile male?

Accepted Answer

Morphology

Answer

Motility

Answer

Volume

Answer

Sperm count

Question 4

Tuberculosis endometritis causes infertility by which of the following mechanisms?

Accepted Answer

Destroying the endometrium and causing tubal blockage

Answer

Causing tubal blockage

Answer

Causing anovulation and causing tubal blockage

Answer

Causing anovulation and ciliary dysmotility

Question 5

Which of the following is NOT a treatment for cervical infertility?

Accepted Answer

Clomiphene citrate

Answer

Condom for 3 months

Answer

Intrauterine insemination (IUI)

Answer

Gamete intrafallopian transfer (GIFT)

Question 6

A 32-year-old woman has had three pregnancies, all ending in stillbirths in the first trimester. On physical examination, she and her only spouse for all pregnancies have no abnormalities. Which of the following laboratory tests is most appropriate to perform on this woman for elucidating potential causes for recurrent fetal loss?

Accepted Answer

Karyotyping

Answer

Genome-wide association study

Answer

Fluorescence in situ hybridization

Answer

PCR analysis

Question 7

Which is the most common uterine malformation associated with infertility?

Accepted Answer

Septate

Answer

Bicornuate

Answer

Unicornuate

Answer

Didelphys

Question 8

Intrauterine insemination (IUI) is indicated for all except:

Accepted Answer

Unexplained infertility

Answer

Male factor infertility

Answer

Erectile dysfunction

Answer

Cervical factor infertility

Question 9

A woman with infertility presents with bilateral cornual block on hysterosalpingography (HSG). What is the next best investigation for management?

Accepted Answer

Laparoscopy and chromotubation

Answer

Tuboplasty

Answer

In vitro fertilization (IVF)

Answer

Hydrotubation

Question 10

What is the gold standard investigation for uterine cavity evaluation?

Accepted Answer

Hysteroscopy

Answer

Ultrasonography

Answer

Saline sonography

Answer

Hysterosalpingography

Fertility and Infertility — MCQs

Fertility and Infertility — MCQs

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