The following statement(s) regarding Veress needle entry technique is/are true?

• a)

  In patients with a BMI >30 it is recommended to insert the Veress needle at an angle of 90 degrees

• b)

  When compared to direct entry technique it is associated with a higher failure rate.

• c)

  When compared to direct entry it is associated with higher rate of extra-peritoneal insufflation and omental injury

• d)

  It is associated with a lower rate of major complications.

• e)

  The most accurate method of detecting correct placement is the insufflator demonstrating flow of CO ₂ with low initial pressure.

To optimize exposure to pelvic organs during laparoscopic procedures in obese patients the following measure(s) is/are appropriate?

• a)

  Consider suspending the bowel to the anterior abdominal wall

• b)

  The following sequence should be performed: 15 mmHg insufflation pressure, 30 degree Trendelenberg, free pelvis, 12 mmHg, 15 degree Trendelenberg

• c)

  Place the patient in Trendelenberg position

• d)

  A low residue diet 5–7 days prior to surgery should be followed

• e)

  The carbon dioxide pressure must be maintained at >20 mmHg throughout the procedure

The following statement(s) regarding laparoscopic surgery in obese patients compared to open procedures is/are true.

• a)

  There is a decreased incidence of post-operative wound infection

• b)

  It reduces thromboembolic complications

• c)

  It is associated with shorter operating time

• d)

  It is associated with increased blood loss

• e)

  It leads to a faster recovery to daily activities

The following statements regarding the obesity epidemic is/are true:

• a)

  Approximately 26% of the UK population is now considered obese

• b)

  The current cost to the NHS of treating obesity related condition is in excess of 10 billion

• c)

  Morbid obesity reduces life expectancy by an average of 3 years

• d)

  A raised waist circumference in women is >102 cm

• e)

  Obesity is associated with an increased risk of endometrial cancer

Studies have shown that the following is/are consistently associated with earlier age at menopause:

• a)

  Obesity

• b)

  Smoking

• c)

  Race

• d)

  Low socioeconomic status

• e)

  Using oral contraceptives

The following is/are true regarding reproductive hormones levels between obese and non-obese women around the time of the final menstrual period:

• a)

  Estradiol is lower in obese premenopausal women

• b)

  FSH is lower in obese premenopausal women

• c)

  Estradiol is lower in obese postmenopausal women

• d)

  FSH is higher in obese postmenopausal women

• e)

  Inhibin B is lower in obese premenopausal women

The following is/are true regarding the effect of menopause on obesity?

• a)

  Weight gain in midlife women has been related mainly to the menopause

• b)

  Body weight increases with age only in obese individuals

• c)

  Menopause is associated with a reduced visceral fat

• d)

  Life style modification with diet and exercise are valid measures to prevent morbidities related to weight gain with ageing.

• e)

  Changes in fat distribution around the menopause are described as a transition from an android to a gynaecoid pattern of fat distribution

The following is/are true regarding the relationship of obesity to cancer development?

• a)

  It is related in approximately 5% of cases

• b)

  It is independent of fat distribution

• c)

  It is most commonly in the breast, uterus and ovary

• d)

  It occurs through different mechanisms including insulin resistance

• e)

  It should be considered a preventable risk factor

Breast cancer is associated with obesity in which of the following situations?

• a)

  In post-menopausal women

• b)

  In pre-menopausal women

• c)

  Independently from body fat distribution

• d)

  Independently from hormonal receptor status

• e)

  Less consistently in HRT users

The following statement(s) is/are true about the medical and surgical treatment of obese patients suffering from female malignancies?

• a)

  Chemotherapy should be capped at a maximum body surface area of 2 m ²

• b)

  Adjuvant therapy with aromatase inhibitors may be less effective in obese women with breast cancer

• c)

  The addition of bevacizumab to chemotherapy in ovarian cancer is highly effective

• d)

  The gold standard of debulking surgery for ovarian cancer is a maximum 1 cm of residual tumour

• e)

  Morbidly obese patients have the same surgical risks as obese patients

The following statement(s) is/are true about endometrial cancer?

• a)

  Only type I endometrial cancers are obesity-related

• b)

  Obesity has a major influence on the risk of recurrence of or death from endometrial cancer

• c)

  The hazard ratio for endometrial cancer is 1.62 per 5 kg/m ² increase in BMI

• d)

  Women with PCOS are at a significantly increased risk of endometrial cancer

• e)

  Metformin is useful in improving prognosis in diabetic patients with endometrial cancer

The following is/are true of obesity in Polycystic Ovary Syndrome (PCOS):

• a)

  Adiposity is thought to play a crucial role in the development of PCOS

• b)

  Adiposity is thought to play a crucial role in the maintenance of PCOS

• c)

  As little as 5% weight loss can significantly improve hormonal abnormalities, menstrual cyclicity and fertility rates in women with PCOS

• d)

  Insulin resistance contributes minimally to the characteristic hyperandrogenism of PCOS

• e)

  A strong association between the degree of adiposity and the severity of PCOS had been demonstrated.

As a front line agent for ovulation induction in polycystic ovary syndrome:

• a)

  Metformin plus clomiphene is superior to either alone

• b)

  Metformin is superior to clomiphene

• c)

  Aromatase inhibitors are superior to both clomiphene and metformin

• d)

  The combination of aromatase inhibitors, clomiphene and metformin is the best current option.

• e)

  Weight loss is superior to all drug options

The following is/are true regarding bariatric surgery:

• a)

  It decreases LH/FSH levels

• b)

  It increases urinary LH and FSH levels

• c)

  It decreases miscarriage rates

• d)

  It increases conception rates

• e)

  It decreases the length of the follicular phase of menstrual cycle

The following is/are true regarding fertility in obese women compared to normal weight women:

• a)

  Obese women require higher doses of gonadotrophins for successful intrauterine insemination

• b)

  BMI was inversely associated with the estradiol (E ₂ ) level per produced pre-ovulatory follicle

• c)

  The number of oocytes retrieved using the trans-vaginal route is lower

• d)

  The risk of euploid miscarriages is higher

• e)

  Increase success with ovulation induction when clomiphene and gonadotrophins are used

Obesity is associated with different hormonal changes that can affect the menstrual cycle. Which of the following hormonal plasma levels is/are seen in obese reproductive ages?

• a)

  Decreased leptin

• b)

  Increased oestrogen

• c)

  Increased insulin

• d)

  Decreased cortisol

• e)

  Increased LH

Regarding medical treatment for menstrual disorders in women:

• a)

  The combined oral contraceptive pill (COCP) is as efficacious in normally weighted and overweight women

• b)

  The progesterone only pill carries more risk than the COCP of venous thromboembolism (VTE) in overweight women

• c)

  The depot progestogen injection, such as DMPA, needs to be given to women with a BMI over 35 more frequently than women with a BMI under 35

• d)

  The progestogen implant (e.g. Nexplanon) is associated with greater weight gain in women who are overweight at the time of fitting the implant

• e)

  The Mirena IUS should be avoided in women with current history of ischaemic heart disease

In regard to investigations and management of menstrual disorders in obese women;

• a)

  An endometrial thickness of greater than 4mm on transvaginal ultrasound should instigate an endometrial sample

• b)

  Symptoms of post-coital bleeding raise the possibility of endometrial hyperplasia

• c)

  It is acceptable to fit a Mirena IUS without an endometrial sample in a 35 year old women presenting with longstanding heavy menstrual bleeding and “no red flag” symptoms

• d)

  Endometrial ablation should not be offered until all other medical treatments have been tried by the patient

• e)

  Endometrial ablation tends to be more effective in obese women than the Mirena IUS

The following statement(s) is/are true about the aetiology or causes of recurrent pregnancy loss (RPL):

• a)

  The incidence of miscarriage depends on women’s age.

• b)

  The live birth rate decreases in keeping with the number of previous miscarriages.

• c)

  Abnormal embryonic karyotype is a predictor of subsequent miscarriage.

• d)

  Uterine anomaly is one of the identifiable causes of RPL.

• e)

  Translocation in either partner is one of the identifiable causes of RPL.

The following statement(s) is/are true about the relationship of RPL and obesity?

• a)

  The percentage of women with one or more miscarriage rose from 10.7% with normal body mass index (BMI) to 13.6% in obese women

• b)

  Maternal obesity (BMI ≥ 30 kg/m ² ) was an independent risk factor in couples with unexplained RPL

• c)

  Obese women have an increased frequency of euploid miscarriage

• d)

  There are a lot of manuscripts describing the relationship between RPL and obesity

• e)

  Being underweight is an independent risk factor in patients with RPL

Patients with a history of RPL have a further risk of several diseases including which of the following?

• a)

  RPL was found to be an independent risk factor for long-term maternal cardiovascular complications

• b)

  Obesity influences both RPL and cardiovascular disease

• c)

  Patients with unexplained recurrent miscarriage had a significantly higher risk of coeliac disease compared to the general population

• d)

  RPL was found to be associated with the occurrence of gastric ulcer, gastritis, fatty liver, and atopic dermatitis

• e)

  Weight loss is effective for reduction of further miscarriage

Adipose tissue characteristics and secretory function in obese women with PCOS have differences between BMI-matched normal women in terms of which of the following?

• a)

  Fat distribution

• b)

  Adipocyte characteristics

• c)

  Leptin levels in the circulation

• d)

  Adiponectin levels in the circulation

• e)

  Resistin levels in the circulation

Obesity may amplify which of the following parameters in PCOS?

• a)

  Hyperandrogenism

• b)

  SHBG production

• c)

  Hypersecretion of LH

• d)

  Hyperinsulinemia

• e)

  Visfatin levels

In obese women with PCOS and anovulatory infertility, the following treatments should be considered:

• a)

  Clomiphene citrate administration as first-line treatment

• b)

  Diet and life-style changes for 6 months before any medical treatment

• c)

  Laparoscopic ovarian drilling before starting clomiphene treatment

• d)

  Metformin for ovulation induction instead of clomiphene citrate

• e)

  In vitro fertilization as first-line treatment

The recommended methods for weight loss in obese women with PCOS include which of the following?

• a)

  Exercise and lifestyle changes

• b)

  Administration of only metformin for several months

• c)

  Administration of only anti-obesity drugs

• d)

  Administration of the oral contraceptive pill

• e)

  Bariatric surgery

A 35 year-old male presents to an infertility clinic with his wife. The couple have been unsuccessful in achieving a pregnancy for 15 months despite routine unprotected sexual intercourse. The wife’s infertility work-up has been unremarkable. The patient is tested for signs of metabolic syndrome. The following is/are consistent with ATPIII criteria for metabolic syndrome in this male patient?

• a)

  HDL of 38 mg/dL

• b)

  Triglycerides 175 mg/dL

• c)

  Random blood glucose of 150 mg/dL

• d)

  Waist circumference of 95 cm

• e)

  Blood pressure of 145/90 mmHg

A male patient with metabolic syndrome presents for infertility evaluation. His wife’s infertility work-up has been unremarkable. He is hesitant to pursue assisted reproductive therapy and wants to know if there is anything he can to enhance his chances of achieving a successful pregnancy. The following have been demonstrated to improve male infertility in randomized clinical trials?

• a)

  Metformin

• b)

  Simvastatin

• c)

  Weight loss

• d)

  Scrotal lipectomy

• e)

  Anti-oxidants

Diabetes has been linked to male infertility through which of the following mechanisms?

• a)

  Hypogonadism

• b)

  Depression

• c)

  Erectile dysfunction

• d)

  Retrograde ejaculation

• e)

  Testicular abscesses

The following statement(s) is/are true regarding obesity and sexual behavior?

• a)

  Adult obese women have been found to have riskier sexual behaviours than their normal weight counterparts

• b)

  Adolescent obese women have been found to have riskier sexual behaviours than their normal weight counterparts

• c)

  As BMI increases the likelihood of having more than one sexual partner in the last year decreases

• d)

  Obese women with a sexual partner report more frequent episodes of sexual intercourse than their normal weight counterparts

• e)

  There is no difference in sexual orientation between obese and normal weight women

The World Health Organization provides the following recommendations for contraceptive use in obese women:

• a)

  Combined hormonal contraceptives: category 2

• b)

  Intrauterine device, either hormonal or copper: category 1

• c)

  Depot medroxyprogesterone acetate in adolescents: category 1

• d)

  Depot medroxyprogesterone acetate in adult women: category 1

• e)

  Contraceptive implant: category 1