Fertility and Infertility Practice Questions

Q: Which of the following methods is the best predictor for ovulation in a female infertility patient during a menstrual cycle?

Hormonal study. **Explanation:** The **Hormonal study**, specifically the measurement of **Serum Progesterone levels** during the mid-luteal phase (Day 21 of a 28-day cycle), is considered the most reliable biochemical predictor of ovulation. A level >3 ng/mL confirms ovulation, while levels >10 ng/mL indicate adequate luteal function. Additionally, the **LH surge** (detected in urine or blood) is the best predictor for the *timing* of upcoming ovulation, occurring 24–36 hours before the egg is released. **Why other options are incorrect:** * **Basal Body Temperature (BBT):** While it shows a biphasic pattern due to progesterone's thermogenic effect, it is retrospective (the rise occurs *after* ovulation) and easily influenced by illness, stress, or sleep patterns, making it less reliable. * **Endometrial Biopsy:** Historically used to identify a "secretory endometrium," it is now rarely used for ovulation timing because it is invasive, expensive, and provides retrospective data. * **Fern Study:** This identifies the "ferning" pattern of cervical mucus under estrogen influence. It disappears after ovulation due to progesterone; however, it is a subjective test and lacks the precision of hormonal assays. **NEET-PG High-Yield Pearls:** * **Gold Standard for Ovulation Monitoring:** Serial Transvaginal Ultrasound (TVUS) to track follicular growth and disappearance (Folliculometry). * **Best Biochemical Marker:** Mid-luteal Serum Progesterone. * **Best Predictor of Ovarian Reserve:** Anti-Müllerian Hormone (AMH) – it is cycle-independent. * **Spinnbarkeit Test:** Refers to the elasticity of cervical mucus; it is maximal just before ovulation (estrogen peak).

Q: A 30-year-old woman is examined for infertility. Hysterosalpingography 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*. **1. Why Mycobacterium tuberculosis is correct:** 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 chronic granulomatous inflammation leads to scarring and strictures. On HSG, these alternating areas of constriction and dilatation create the characteristic **"beaded" appearance**. As the disease progresses, the fimbrial end closes, and the ampulla becomes distended and blunt, known as **"clubbing."** Other HSG signs include a "lead pipe" appearance (rigid tubes) and "tobacco pouch" appearance. **2. Why other options are incorrect:** * **Gonococcus and Chlamydia:** These are the most common causes of Pelvic Inflammatory Disease (PID). While they cause tubal damage and infertility, they typically present with **hydrosalpinx** (thin-walled, fluid-filled tubes) or complete tubal occlusion with a "retort-shaped" appearance, rather than the specific beaded/calcified pattern seen in TB. * **Mycoplasma:** While associated with bacterial vaginosis and sometimes PID, it does not produce the specific chronic granulomatous changes or the "beaded" radiological morphology associated with tuberculosis. **Clinical Pearls for NEET-PG:** * **Most common site** of Genital TB: Fallopian tubes (1st), followed by Endometrium (2nd). * **Gold Standard Diagnosis:** Endometrial biopsy for histopathology (showing giant cells/tubercles) and TB culture (BACTEC). * **Schier's Sign:** A specific HSG finding in TB where there is calcification of the pelvic lymph nodes or the tubes themselves. * **Asherman’s Syndrome:** Genital TB is a leading cause of secondary amenorrhea due to extensive intrauterine synechiae.

Q: Which uterine anomaly is associated with the best fertility outcome?

Arcuate uterus. **Explanation:** The correct answer is **Arcuate uterus**. This question tests the clinical significance of Müllerian duct anomalies on reproductive outcomes. **1. Why Arcuate Uterus is Correct:** The arcuate uterus is considered a mild anatomical variation rather than a true malformation. It is characterized by a small indentation of the fundal endometrium (usually <1 cm). Because the uterine cavity remains largely undistorted and the myometrial structure is intact, it does **not** significantly impair implantation or increase the risk of pregnancy loss. It is associated with the **best fertility outcomes**, often comparable to a normal uterus. **2. Why Other Options are Incorrect:** * **Septate Uterus (C):** This is the most common anomaly and is associated with the **worst reproductive outcomes**. The septum is fibrous and relatively avascular, leading to implantation failure or recurrent early pregnancy loss. (Note: It is also the most common cause of recurrent mid-trimester abortions). * **Bicornuate (A) and Unicornuate Uterus (B):** These are "true" malformations resulting from incomplete fusion or development of Müllerian ducts. They are associated with significantly higher rates of malpresentation, preterm labor, and intrauterine growth restriction (IUGR) due to reduced space and abnormal vascularity. **3. NEET-PG High-Yield Pearls:** * **Most common uterine anomaly:** Septate uterus. * **Anomaly with worst prognosis:** Septate uterus (but it is also the most treatable via hysteroscopic septal resection). * **Renal anomalies:** Most commonly associated with **Unicornuate uterus** (ipsilateral renal agenesis). * **DES exposure:** Classically associated with a **T-shaped uterus**. * **Investigation of choice:** 3D Ultrasound is the gold standard for diagnosis; MRI is also highly accurate.

Q: A hysterosalpingogram shows which of the following findings suggestive of a potential cause of infertility?

Genital tuberculosis. ***Genital tuberculosis*** - Shows **pathognomonic HSG findings** including **tobacco-pouch** or **golf-hole uterus** appearance due to endometrial scarring and adhesions. - Demonstrates **beaded tubes**, **pipe-stem tubes**, and **calcifications** in fallopian tubes, indicating chronic tuberculous infection affecting fertility. *Uterine polyp* - Appears as **filling defects** within the uterine cavity on HSG, creating irregular contours but not the classic tuberculous patterns. - Does not cause the characteristic **scarring** and **adhesion patterns** seen with genital tuberculosis. *Bicornuate uterus* - Shows **heart-shaped** or **Y-shaped** uterine cavity with **fundal indentation** greater than 1 cm on HSG. - Represents a **congenital anomaly** without the inflammatory changes and tubal pathology of tuberculosis. *Dermoid cyst* - Is an **ovarian lesion** that cannot be visualized on HSG as this imaging modality only evaluates the **uterine cavity** and **fallopian tubes**. - Would require **ultrasound** or **CT/MRI** for diagnosis, showing characteristic **fat**, **hair**, and **teeth** components.

Q: All are side effects of clomiphene citrate except?

Amenorrhea. **Explanation:** Clomiphene Citrate (CC) is a Selective Estrogen Receptor Modulator (SERM) and the traditional first-line agent for ovulation induction. It works by binding to estrogen receptors in the hypothalamus, blocking the negative feedback of endogenous estrogen. This leads to an increase in GnRH, FSH, and LH, which stimulates follicular development. **Why Amenorrhea is the Correct Answer:** Amenorrhea (absence of menstruation) is **not** a side effect of Clomiphene. In fact, Clomiphene is used therapeutically to **induce ovulation** and regularize cycles in women with oligomenorrhea or anovulatory cycles (like PCOS). By triggering ovulation, it leads to a subsequent luteal phase and predictable menstrual bleeding if pregnancy does not occur. **Analysis of Incorrect Options:** * **Hot Flushes (Option B):** This is the **most common** side effect (approx. 10%). It occurs due to the anti-estrogenic effect on the hypothalamus, mimicking menopausal vasomotor symptoms. * **Ovarian Cysts (Option A):** Overstimulation of the ovaries can lead to the formation of multiple follicular cysts or, in severe cases, Ovarian Hyperstimulation Syndrome (OHSS), though OHSS is less common with CC than with gonadotropins. * **Breast Soreness (Option C):** This occurs due to the increased levels of endogenous estrogen produced by the multiple developing follicles. **NEET-PG High-Yield Pearls:** * **Mechanism:** Competitive antagonist of estrogen receptors at the hypothalamus. * **Multiple Pregnancy:** Risk is approximately 8–10% (predominantly twins). * **Anti-estrogenic effects:** CC can cause thinning of the endometrium and thickening of cervical mucus, which may create a "discrepancy" between high ovulation rates and lower pregnancy rates. * **Visual Disturbances:** Scintillating scotomas are a rare but specific side effect; if they occur, the drug should be discontinued.

Q: Chlamydia infection can cause infertility due to which of the following complications?

Salpingitis. **Explanation:** The primary mechanism by which *Chlamydia trachomatis* causes infertility is through **Salpingitis** (inflammation of the fallopian tubes). Chlamydia is an obligate intracellular pathogen that often causes "silent" or subclinical Pelvic Inflammatory Disease (PID). The chronic inflammatory response leads to scarring, fibrosis, and eventual **tubal occlusion** or loss of ciliary function. This prevents the transport of the ovum and sperm, resulting in tubal factor infertility or an increased risk of ectopic pregnancy. **Analysis of Options:** * **Salpingitis (Correct):** Tubal damage is the most significant cause of permanent infertility following a Chlamydial infection. Even a single episode of PID increases the risk of infertility by approximately 10-12%. * **Endometritis:** While Chlamydia can cause inflammation of the uterine lining, endometritis is usually transient. It does not typically result in permanent infertility unless it progresses to the fallopian tubes. * **Oophoritis:** Inflammation of the ovaries can occur as part of PID, but it is less common than salpingitis and rarely the primary cause of infertility in Chlamydial infections. * **Cervicitis:** This is the most common initial presentation of Chlamydia (mucopurulent discharge). However, as long as the infection is confined to the cervix, it does not cause infertility. Infertility only occurs when the infection ascends to the upper genital tract. **Clinical Pearls for NEET-PG:** * **Fitz-Hugh-Curtis Syndrome:** A complication of Chlamydial PID characterized by perihepatitis and "violin-string" adhesions between the liver capsule and the abdominal wall. * **Gold Standard Diagnosis:** Nucleic Acid Amplification Test (NAAT). * **Treatment:** Azithromycin (1g stat) or Doxycycline (100mg BD for 7 days). Always treat the partner to prevent reinfection. * Chlamydia is the leading cause of **preventable** infertility worldwide.

Q: A 25-year-old male underwent semen analysis. Results show: sperm count - 15 million/ml; pH - 7.5; volume - 2 ml; no agglutination is seen. Morphology shows 60% normal and 60% motile sperms. What is the most likely diagnosis?

Oligospermia. ### Explanation The diagnosis is based on the **WHO 2010/2021 criteria** for semen analysis. In this case, the patient’s sperm count is **15 million/ml**, which falls below the lower reference limit. **1. Why Oligospermia is correct:** * **Oligospermia** is defined as a total sperm count of less than 15 million/ml (or less than 39 million per ejaculate). * In this scenario, while the volume (2 ml), motility (60%), and morphology (60%) are within normal limits, the concentration is at the borderline/low threshold. According to standard nomenclature, any value below 15 million/ml is classified as oligospermia. **2. Why other options are incorrect:** * **Normospermia:** Refers to a normal semen analysis where all parameters (count ≥15 million/ml, motility ≥40%, morphology ≥4% Kruger’s criteria) are met. * **Azoospermia:** Refers to the total absence of spermatozoa in the ejaculate after centrifugation. * **Aspermia:** Refers to the complete absence of semen (no ejaculate volume), often seen in retrograde ejaculation or ductal obstruction. **3. High-Yield NEET-PG Clinical Pearls:** * **Asthenozoospermia:** <40% total motility or <32% progressive motility. * **Teratozoospermia:** <4% normal forms (using strict Kruger criteria). * **Necrozoospermia:** All sperms in the ejaculate are dead. * **Globozoospermia:** A rare condition where sperm heads are round and lack an acrosome (associated with infertility). * **Initial Investigation:** Semen analysis is the first-line investigation for male factor infertility and should be repeated after 4–12 weeks if the first sample is abnormal.

Q: Which hormone best indicates ovarian reserve?

Follicle-stimulating hormone (FSH). **Explanation:** Ovarian reserve refers to the quantity and quality of the remaining oocytes in the ovaries. **Follicle-stimulating hormone (FSH)** is the most widely used biochemical marker for assessing this reserve. As the pool of primordial follicles declines with age or premature ovarian failure, there is a decrease in the production of **Inhibin B** and **Estradiol**. This loss of negative feedback on the pituitary gland leads to a compensatory rise in serum FSH levels. Therefore, a high basal FSH level (typically measured on Day 2 or 3 of the menstrual cycle) is a reliable indicator of diminished ovarian reserve. **Analysis of Incorrect Options:** * **Luteinizing Hormone (LH):** While LH is essential for ovulation and androgen production, its basal levels do not reliably reflect the oocyte pool. * **LH/FSH Ratio:** An elevated LH/FSH ratio (typically >2:1 or 3:1) is a classic biochemical marker for **Polycystic Ovary Syndrome (PCOS)**, not a measure of declining ovarian reserve. * **Estrogen (Estradiol):** While Day 3 Estradiol is often measured alongside FSH, it is less specific. High early-cycle estrogen can actually "mask" a high FSH by providing false negative feedback, making it a secondary marker rather than the primary indicator. **NEET-PG High-Yield Pearls:** * **Best Single Marker:** While this question identifies FSH, modern clinical practice considers **Anti-Müllerian Hormone (AMH)** the most sensitive and reliable marker because it is cycle-independent. * **Best Imaging Marker:** **Antral Follicle Count (AFC)** via transvaginal ultrasound is the gold standard for morphological assessment of reserve. * **Day of Testing:** Basal FSH must be tested on **Day 2-4** of the cycle to be valid. * **Cut-off:** FSH levels **>10-12 mIU/mL** generally suggest a poor response to ovarian stimulation.

Q: What is the best investigation to assess tubal patency?

Laparoscopic chromtubation. **Explanation:** **Laparoscopic Chromopertubation (Chromotubation)** is considered the **Gold Standard** investigation for assessing tubal patency. During this procedure, a dye (usually Methylene Blue) is injected through the cervix, and its spillage from the fimbrial ends of the fallopian tubes is directly visualized using a laparoscope. Its superiority lies in its ability to simultaneously diagnose peritubal adhesions, endometriosis, or pelvic inflammatory disease (PID) that might be causing infertility despite "patent" tubes. **Analysis of Options:** * **Rubin's Test:** This is an obsolete historical test involving the insufflation of $CO_2$ into the uterus. It has a high false-negative rate and provides no information about which tube is blocked or the status of the pelvic anatomy. * **Hysterosalpingography (HSG):** While HSG is the **best initial/screening test** for tubal patency due to its non-invasive nature, it carries a higher rate of false positives (due to cornual spasms) compared to laparoscopy. * **Laparotomy:** This involves a large surgical incision to open the abdomen. It is an invasive therapeutic procedure, not a primary diagnostic investigation for tubal patency. **Clinical Pearls for NEET-PG:** * **Gold Standard for Tubal Patency:** Laparoscopic Chromopertubation. * **Best Screening/First-line Test:** HSG (performed in the pre-ovulatory phase, Day 7–10). * **Therapeutic benefit of HSG:** The flushing action of the dye (especially oil-based) can sometimes clear minor debris, slightly increasing pregnancy rates post-procedure. * **Contraindication for HSG/Chromopertubation:** Active pelvic infection or pregnancy.

Question 1

Which of the following methods is the best predictor for ovulation in a female infertility patient during a menstrual cycle?

Accepted Answer

Hormonal study

Answer

Basal body temperature

Answer

Endometrial biopsy

Answer

Fern study

Question 2

A 30-year-old woman is examined for infertility. Hysterosalpingography 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 3

Which uterine anomaly is associated with the best fertility outcome?

Accepted Answer

Arcuate uterus

Answer

Bicornuate uterus

Answer

Unicornuate uterus

Answer

Septate uterus

Question 4

A hysterosalpingogram shows which of the following findings suggestive of a potential cause of infertility?

Accepted Answer

Genital tuberculosis

Answer

Uterine polyp

Answer

Bicornuate uterus

Answer

Dermoid cyst

Question 5

All are side effects of clomiphene citrate except?

Accepted Answer

Amenorrhea

Answer

Ovarian cysts

Answer

Hot flushes

Answer

Breast soreness

Question 6

Chlamydia infection can cause infertility due to which of the following complications?

Accepted Answer

Salpingitis

Answer

Endometritis

Answer

Oophoritis

Answer

Cervicitis

Question 7

A 25-year-old male underwent semen analysis. Results show: sperm count - 15 million/ml; pH - 7.5; volume - 2 ml; no agglutination is seen. Morphology shows 60% normal and 60% motile sperms. What is the most likely diagnosis?

Accepted Answer

Oligospermia

Answer

Normospermia

Answer

Azoospermia

Answer

Aspermia

Question 8

Which hormone best indicates ovarian reserve?

Accepted Answer

Follicle-stimulating hormone (FSH)

Answer

Luteinizing hormone (LH)

Answer

LH/FSH ratio

Answer

Estrogen

Question 9

Fallopian tube dysmotility is seen in which of the following conditions?

Accepted Answer

Klinefelter syndrome

Answer

Noonan syndrome

Answer

Turner syndrome

Answer

Marfan syndrome

Question 10

What is the best investigation to assess tubal patency?

Accepted Answer

Laparoscopic chromtubation

Answer

Rubin's test

Answer

Hysterosalpingography (HSG)

Answer

Laparotomy

Fertility and Infertility — MCQs

Fertility and Infertility — MCQs

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