Effects of marriage equality legislation on sexual health of the US population.

Even though prior research has investigated the relationship between same-sex partnership recognition policies and health outcomes, the impact of same-sex marriage laws on sexually transmitted infections has not received much attention. Using state-level panel data from 2000 to 2019, I show that marriage equality legislation decreases the spread of (shorter-term) syphilis infections and of (longer-term) human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) infections among the general population. Event study analyses correcting for non-staggered treatment implementation confirm these negative effects, but also suggest that standard difference-in-differences models understate the impact of the legislation by up to 8% points. Further analysis supports that these legislation effects operate through three mechanisms: increasing social tolerance, strengthening relationship commitment, and expanding health care access and coverage for HIV/AIDS prevention and treatment. Disaggregating the results by sexual behavior reveals that legal access to same-sex marriage leads to sizable decreases in AIDS rates among men who have sex with men (MSM) (the most at-risk population for an infection). Even though there is economically significant evidence that the legislation improves sexual health of the heterosexual population due to increased utilization of preventive sexual health care, the legislation does not have a direct impact on infection rates for the non-MSM population.

Exploring the knowledge and attitudes of women of reproductive age from the general public towards egg donation and egg sharing: a UK-based study.

STUDY QUESTION: What are the knowledge and views of UK-based women towards egg donation (ED) and egg sharing (ES)? SUMMARY ANSWER: Lacking knowledge of the practices of ED and ES could be an influential factor in donor egg shortages, rather than negative perceptions or lack of donor anonymity and financial incentives. WHAT IS KNOWN ALREADY: The increasing age of women trying to conceive has led to donor egg shortages, with ED and ES failing to meet demand. Indeed, in recent years in the UK, ES numbers have fallen. This results in long waiting lists, forcing patients abroad for fertility treatment to take up cross border reproductive care. Previous research suggests a lack of knowledge of ED among members of the general public; however, no study has yet assessed knowledge or views of ES in the general public. STUDY DESIGN, SIZE, DURATION: Six hundred and thirty-five UK-based women over 18 years were voluntarily recruited from social media community groups by convenience sampling. The recruitment period was from February to April 2020. PARTICIPANTS/MATERIALS, SETTING, METHODS: Participants completed a previously validated questionnaire regarding female fertility, ED and ES, including knowledge, perceptions and approval of the practices and relevant legislation. This included ranking key benefits and issues regarding egg sharing. The questionnaire was completed using the online Qualtrics survey software. Statistical analysis was conducted using SPSS. MAIN RESULTS AND THE ROLE OF CHANCE: Regarding knowledge of ED and ES, 56.3% and 79.8%, respectively had little or no prior knowledge. Upon explanation, most approved of ED (85.8%) and ES (70.4%). A greater proportion of respondents would donate to a family member/friend (49.75%) than to an anonymous recipient (35.80%). Overall, ES was viewed less favourably than ED, with ethical and practical concerns highlighted. Women aged 18-30 years were significantly more likely to approve of egg donation practice compared to those aged >30 years (P < 0.0001). Those against ES found fears of financial coercion or negative psychological wellbeing the most concerning. About 35.8% and 49.7% would personally consider anonymous and known ED, respectively, whilst 56.7% would consider ES. Those answering in favour of egg sharing were significantly more likely to give higher benefit ratings compared to those against the practice (P < 0.001). Most agreed (55.8%) with and were not deterred to donate (60.1%) by the 'Disclosure of Donor Identity' legislation. Only 31.6% agreed with the compensatory cap; however, 52.7% would not be more motivated to donate by an increased cap. LIMITATIONS, REASONS FOR CAUTION: There were several limitations of the study, including the use of convenience sampling and the voluntary nature of participation opening the study up to sampling and participation bias. Finally, closed questions were predominantly used to allow the generation of quantitative data and statistical analysis. However, this approach prevented opinion justification and qualitative analysis, limiting the depth of conclusions drawn. WIDER IMPLICATIONS OF THE FINDINGS: To our knowledge, this is the first study to survey the general public's knowledge and views of ED/ES using a previously validated questionnaire. The conclusion that lack of knowledge could be contributing to the current donor shortfall in the UK demonstrates that campaigns to inform women of the practices are necessary to alleviate donor oocyte shortages. STUDY FUNDING/COMPETING INTEREST(S): No external funds were used for this study. The authors have no conflicts of interest. TRIAL REGISTRATION NUMBER: NA.

A systematic review exploring the patient decision-making factors and attitudes towards pre-implantation genetic testing for aneuploidy and gender selection.

INTRODUCTION: Pre-implantation genetic testing for aneuploidy (PGT-A) is in high demand worldwide, with ongoing debate among medical societies as to which patient groups it should be offered. The psychological aspects for patients regarding its use, lag behind the genomic technological advances, leaving couples with limited decision-making support. The development of this technology also leads to the possibility for its utilization in gender selection. Despite the controversy surrounding these issues, very few studies have investigated the psychological aspects of patients using PGT-A. MATERIAL AND METHODS: This systematic review provides an up-to-date analysis of the psychosocial aspects surrounding PGT for aneuploidy and sex selection, as well as decision-making factors. A systematic search of English peer-reviewed journals of three computerized databases were undertaken following PRISMA guidelines. The qualitative data were extracted using thematic analysis. PROSPERO Registration number: CRD42019126439. RESULTS: The main outcome measures were patients' motivations, decision-making factors, attitudes and experiences surrounding the use of PGT for aneuploidy and sex selection. Ten studies were included, four for PGT-A and six for sex selection. Attitudes towards PGT-A were positive, with the main motivating factors being decreasing miscarriage rate, reducing the risk of termination of pregnancy and reducing the time to pregnancy. Consistently raised concerns regarding PGT-A were the financial burden and moral beliefs. The vast majority of patients felt sufficiently knowledgeable to make the decision; however, studies did reveal that a minority mis-interpreted certain potential benefits of PGT-A. Studies investigating PGT for sex selection predominantly reported the main motivation was to achieve gender balance within the family dynamic, with most studies finding no difference between couples using PGT for gender selection to have male or female offspring. CONCLUSIONS: Although this systematic review was limited by the small number of studies investigating this topic, a significant minority of patients appeared to misunderstand certain benefits and limitations of PGT-A. Fertility clinics must ensure they provide adequate counseling to all patients using PGT-A. With the use of PGT-A on the rise globally, there is a need to develop decision support tools for couples who have an increasing number of genetic testing options becoming available to them.

Exploring women's attitudes, knowledge, and intentions to use oocyte freezing for non-medical reasons: A systematic review.

INTRODUCTION: Women are postponing childbearing and preventing age-related fertility decline with oocyte freezing for non-medical reasons (OFNMR). The objective of this systematic evaluation was to gain an understanding of women's attitudes and knowledge of, and intentions to use OFNMR among users of OFNMR and the general public. MATERIAL AND METHODS: A systematic search of MEDLINE, EMBASE, and PyschINFO databases was undertaken, for studies that examined the psychosocial attitudes among women toward OFNMR. The search was limited to English language and no time restriction was set for publications. Extracted data were analyzed using thematic analysis and the study was performed according to PRISMA guidelines with prospective PROSPERO registration (CRD4201912578). RESULTS: Overall, 35 studies met the inclusion criteria. Studies were broadly categorized into studies investigating users or potential users of OFNMR, and studies examining the views of members of the general public. Users of OFNMR have good knowledge of age-related fertility decline and awareness of the OFNMR procedure. Lack of partner was identified as the most common motivating factor to undertake OFNMR, with cost as a predominant concern. Knowledge among the general public of OFNMR is highly variable. Underestimation of age-related fertility decline is common among the general public. Intentions of women to use OFNMR also varied drastically between studies. CONCLUSIONS: Women are predominantly motivated to freeze eggs by the lack of a suitable partner, but cost is a significant barrier. Increasing the number of women pursuing OFNMR at an earlier stage may positively impact upon the risk of future involuntary childlessness. Better information should be made available to both women and men about their fertility and options to inform their reproductive decision-making.

Number and function of uterine natural killer cells in recurrent miscarriage and implantation failure: a systematic review and meta-analysis.

BACKGROUND: Uterine natural killer cells (uNK) are the most abundant lymphocytes found in the decidua during implantation and in first trimester pregnancy. They are important for early placental development, especially trophoblast invasion and transformation of the spiral arteries. However, inappropriate uNK function has been implicated in reproductive failure, such as recurrent miscarriage (RM) or recurrent implantation failure (RIF). Previous studies have mainly focussed on peripheral NK cells (pNK), despite the well-documented differences in pNK and uNK phenotype and function. In recent years, there has been an explosion of studies conducted on uNK, providing a more suitable representation of the immune environment at the maternal-foetal interface. Here, we summarize the evidence from studies published on uNK in women with RM/RIF compared with controls. OBJECTIVE AND RATIONALE: The objectives of this systematic review and meta-analysis are to evaluate: differences in uNK level in women with RM/RIF compared with controls; pregnancy outcome in women with RM/RIF stratified by high and normal uNK levels; correlation between uNK and pNK in women with RM/RIF; and differences in uNK activity in women with RM/RIF compared with controls. SEARCH METHODS: MEDLINE, EMBASE, Web of Science and Cochrane Trials Registry were searched from inception up to December 2020 and studies were selected in accordance with PRISMA guidelines. Meta-analyses were performed for uNK level, pregnancy outcome and uNK/pNK correlation. Narrative synthesis was conducted for uNK activity. Risk of bias was assessed by ROBINS-I and publication bias by Egger's test. OUTCOMES: Our initial search yielded 4636 articles, of which 60 articles were included in our systematic review. Meta-analysis of CD56+ uNK level in women with RM compared with controls showed significantly higher levels in women with RM in subgroup analysis of endometrial samples (standardized mean difference (SMD) 0.49, CI 0.08, 0.90; P = 0.02; I2 88%; 1100 women). Meta-analysis of CD56+ uNK level in endometrium of women with RIF compared with controls showed significantly higher levels in women with RIF (SMD 0.49, CI 0.01, 0.98; P = 0.046; I2 84%; 604 women). There was no difference in pregnancy outcome in women with RM/RIF stratified by uNK level, and no significant correlation between pNK and uNK levels in women with RM/RIF. There was wide variation in studies conducted on uNK activity, which can be broadly divided into regulation and receptors, uNK cytotoxicity, cytokine secretion and effect of uNK on angiogenesis. These studies were largely equivocal in their results on cytokine secretion, but most studies found lower expression of inhibitory receptors and increased expression of angiogenic factors in women with RM. WIDER IMPLICATIONS: The observation of significantly increased uNK level in endometrium of women with RM and RIF may point to an underlying disturbance of the immune milieu culminating in implantation and/or placentation failure. Further research is warranted to elucidate the underlying pathophysiology. The evidence for measuring pNK as an indicator of uNK behaviour is sparse, and of limited clinical use. Measurement of uNK level/activity may be more useful as a diagnostic tool, however, a standardized reference range must be established before this can be of clinical use.

Uterine NK cells underexpress KIR2DL1/S1 and LILRB1 in reproductive failure.

A significant proportion of recurrent miscarriage, recurrent implantation failure and infertility are unexplained, and these conditions have been proposed to have an etiology of immunological dysfunction at the maternal-fetal interface. Uterine Natural Killer cells (uNK) comprise three subsets and are the most numerous immune cells found in the uterine mucosa at the time of implantation. They are thought to play an important role in successful pregnancy by regulation of extravillous trophoblast (EVT) invasion and spiral artery remodelling. Here, we examine the frequency, phenotype and function of uNK1-3 from the uterine mucosa of 16 women with unexplained reproductive failure compared to 11 controls with no reproductive problems, during the window of implantation. We report that KIR2DL1/S1 and LILRB1 expression is lower in the reproductive failure group for both uNK (total uNK, uNK 2 and 3) and pNK. We also show that degranulation activity is significantly reduced in total uNK, and that TNF-α production is lower in all uNK subsets in the reproductive failure group. Taken together, our findings suggest that reproductive failure is associated with global reduction in expression of uNK receptors important for interaction with HLA-C and HLA-G on EVT during early pregnancy, leading to reduced uNK activation. This is the first study to examine uNK subsets during the window of implantation in women with reproductive failure and will serve as a platform to focus on particular aspects of phenotype and function of uNK subsets in future studies. Further understanding of uNK dysregulation is important to establish potential diagnostic and therapeutic targets in the population of women with unexplained reproductive failure.

Impact of socioeconomic and transport indicators on road safety during the crisis period in Europe.

The risk of being involved in a road crash is typically influenced by mobility, which in turn is influenced by various socioeconomic indicators. This study aims to investigate the impact of socioeconomic and transport indicators on road safety during the economic crisis period in Europe. A database containing Human Development Index (HDI), suicides, passenger-kilometers and road fatalities per population was developed. Linear Mixed Models were applied for all the examined countries and the different groups that were selected for the period 2006-2015. The results led to the conclusion that HDI has the most important impact and its increase leads to road fatalities decrease. Moreover, the evolution of human development affects the outcomes of road crashes more than suicides and passenger-kilometers travelled. After the end of the crisis, the impact of human development is even higher. Concerning passenger-kilometers travelled, there is an increase in the relative impact on road fatalities after the end of the crisis.

A review on the motivations, decision-making factors, attitudes and experiences of couples using pre-implantation genetic testing for inherited conditions.

BACKGROUND: In pre-implantation genetic testing (PGT), fertile couples undergo IVF with genetic testing of embryos to avoid conceptions with a genetic condition. There is an exponentially increasing uptake with over 600 applications listed by the Human Fertilisation and Embryology Authority in the UK. The psychological aspects of the decision-making process and the experience of PGT, however, are relatively underevaluated, with the potential to leave patients unsupported in their journeys. OBJECTIVE AND RATIONALE: In this review, we aim to comprehensively report on every aspect of couples' experiences of PGT. We consider what motivates users, the practical and ethical decisions involved and how couples navigate the decision-making process. Additionally, we report on the social and psychological impact on couples who are actively undergoing or have completed the PGT process. SEARCH METHODS: A systematic search of English peer-reviewed journals of three computerized databases was undertaken following PRISMA guidelines. Studies that examined the motivations, attitudes, decision-making factors and experiences of patients who have been actively engaged in the PGT process were included. No restrictions were placed on study design or date of publication. Studies examining patients using PGT in a hypothetical context or solely using PGT for aneuploidy were excluded. Qualitative data were extracted using thematic analysis. OUTCOMES: The main outcomes were patient motivations, deciding factors and attitudes, as well as the patient experience of coming to a decision and going through PGT.Patients were primarily motivated by the desire to have a healthy child and to avoid termination of pregnancy. Those with a sick child or previous experience of termination were more likely to use PGT. Patients also felt compelled to make use of the technology available, either from a moral responsibility to do so or to avoid feelings of guilt if not. The main factors considered when deciding to use PGT were the need for IVF and the acceptability of the technology, the financial cost of the procedure and one's ethical standpoint on the creation and manipulation of embryos. There was a general consensus that PGT should be applied to lethal or severe childhood disease but less agreement on use for adult onset or variable expression conditions. There was an agreement that it should not be used to select for aesthetic traits and a frustration with the views of PGT in society. We report that couples find it difficult to consider all of the benefits and costs of PGT, resulting in ambivalence and prolonged indecision. After deciding on PGT use, we found that patients find the process extremely impractical and psychologically demanding. WIDER IMPLICATIONS: This review aimed to summarize the current knowledge on how patients decide to use and experience PGT and to make suggestions to incorporate the findings into clinical practice. We cannot stress enough the importance of holistic evaluation of patients and thorough counselling prior to and during PGT use from a multidisciplinary team that includes geneticists, IVF clinicians, psychologists and also patient support groups. Large prospective studies using a validated psychological tool at various stages of the PGT process would provide an invaluable database for professionals to better aid patients in their decision-making and to improve the patient experience.

Investigation of traffic and safety behavior of pedestrians while texting or web-surfing.

Objective: More and more pedestrians use mobile phones in their daily traffic activities by the roadside or even when crossing the street. The objective of this research is to examine pedestrians' traffic and safety behavior while texting or web-surfing, when crossing signalized intersections.Methods: In order to compare the behavior of distracted and non-distracted pedestrians, an experimental process through video recording was carried out in real road conditions, in three signalized intersections in the center of Athens in Greece. Demographic and behavioral characteristics were observed, including use of mobile device. For the statistical analysis, two multiple linear regression models were developed to investigate the association of pedestrians' speed and distraction caused by mobile phone use. Additionally, binary logistic regression models were developed in order to determine the influence of distraction on pedestrians' safety characteristics and more specifically on near misses with oncoming vehicles.Results: Observers recorded crossing behaviors for 2,280 pedestrians and noticed that nearly one-fifth (16.6%) of them performed a phone-distracting activity while crossing. Distractions included texting or web-surfing (6.3%), listening to music (5.4%) and using a handheld phone (4.9%). Τhis research indicated that distraction caused by texting or web-surfing had a negative impact on pedestrians' main traffic and safety characteristics. Results pointed out that in high pedestrian traffic, distracted pedestrians who were texting or web-surfing on their mobile phone present lower speed than non-distracted pedestrians, regardless of their age, as they may be not aware of traffic conditions due to distraction and therefore, they have higher crossing times. Furthermore, their probability of a near miss increases with increasing pedestrian volume as the more pedestrians who occupy the pedestrian crossing the more difficult is for them to observe carefully the rest traffic.Conclusions: Mobile phones are integral to contemporary daily life and their use and penetration is increasing rapidly as well. For this reason, it is crucial to investigate the impacts of distracted walking on pedestrians' traffic and safety behavior. Various measures and strategies should be implemented and further research should be conducted as texting and web-surfing distraction is associated with a rather high risk.

How old are your eggs?

PURPOSE OF REVIEW: It is estimated that 10% of women experience a rapid decline in their ovarian reserve from the early 30s. This is called 'early ovarian ageing'. With the development of the so-called 'ovarian reserve tests', it was hoped that it would be possible to assess each woman's ovarian biological age and screen for 'early ovarian ageing' in the general population. This review examines the progress that has been made in this area. RECENT FINDINGS: Almost the entire literature on ovarian reserve tests refers to women having IVF, rather than women in the general population. Recent systematic reviews have shown that the currently known 'ovarian reserve' tests are reasonably good at predicting the number of eggs that are collected following ovarian stimulation with gonadotrophins in the context of an IVF cycle. They show very poor correlation with live-birth rates. The reason is that they cannot directly assess oocyte quality. SUMMARY: Screening for 'early ovarian ageing' in the general population is desirable but still not possible. Therefore, postponing childbearing to the late 30s remains a risky gamble. Advice to individual women should be given by specialist reproductive endocrinologists, though home-testing is not advisable.

Investigating the effect of an abnormal cervico-vaginal and endometrial microbiome on assisted reproductive technologies: A systematic review.

The female reproductive tract has an active microbiome, and it is suggested that these microbes could influence the outcome of assisted reproductive technologies (ART). This systematic review aimed to assess the vaginal/uterine microbiome, specifically with regard to improving the outcome of ART. English peer-reviewed journals were searched for studies investigating the vaginal/uterine micriobiome and female reproductive tract, using PRISMA guidelines. Twenty-six studies were included, 19 studying the vaginal and seven investigating the uterine microbiome. Studies using culture-based technologies found an abnormal vaginal microbiome AVM was not associated with ART outcome. However, studies using sequence-based technologies found an abnormal vaginal microbiome had a negative effect on ART. An abnormal uterine microbiome impacted ART outcome in all of the studies which used culture-based methods and the most extensive of the two studies using metagenomic sequencing. This review has revealed a lack of translational data relating an abnormal vaginal/uterine microbiome to ART outcomes, with inconsistencies between the results of the different studies. Therefore the nature of the relationship between the vaginal/uterine microbiome and fertility remains unknown. As we better characterize this relationship using modern metagenomic techniques, the potential to manipulate the female reproductive tract microbiome to improve ART could be a reality.

Does cyberbullying impact youth suicidal behaviors?

Even though several youth fatal suicides have been linked with school victimization, there is lack of evidence on whether cyberbullying victimization causes students to adopt suicidal behaviors. To investigate this issue, I use exogenous state-year variation in cyberbullying laws and information on high school students from the Youth Risk Behavioral Survey within a bivariate probit framework, and complement these estimates with matching techniques. I find that cyberbullying has a strong impact on all suicidal behaviors: it increases suicidal thoughts by 14.5 percentage points and suicide attempts by 8.7 percentage points. Even if the focus is on statewide fatal suicide rates, cyberbullying still leads to significant increases in suicide mortality, with these effects being stronger for men than for women. Since cyberbullying laws have an effect on limiting cyberbullying, investing in cyberbullying-preventing strategies can improve individual health by decreasing suicide attempts, and increase the aggregate health stock by decreasing suicide rates.

Is AMH Level, Independent of Age, a Predictor of Live Birth in IVF?

BACKGROUND: Although anti-mullerian hormone (AMH) level is known to predict ovarian reserve, there is conflicting evidence regarding the association between AMH and clinical pregnancy or live birth (LB). AIM: Our aim is to establish if there is any association between AMH and LB considering the effects of age and other relevant confounding factors in predicting LB. SETTINGS AND DESIGN: 200 in-vitro fertilisation (IVF) cycles were retrospectively analysed in a tertiary fertility centre. MATERIALS AND METHODS: From the database, data regarding the women's age, AMH level, IVF/intracytoplasmic sperm injection, the factors of infertility, protocols, median AMH level and live birth rates (LBRs) were compared between the groups with and without LB in four age groups. The influences of age and AMH in predicting LB were analysed. Statistical analysis was performed using the Statistical Package for the Social Sciences version 21 software (SPSS Inc., Chicago, IL, United States). RESULTS AND CONCLUSION: There were no significant differences in any of the confounding factors analysed between the groups with and without LB. In the higher two age groups, median AMH levels in the group with LB were higher than that in the group without LB. The odds of having a LB was significantly higher in the younger three age groups, and when AMH level was >20 pmol/l. AMH was not found to be the IVF outcome defining factor in younger women, but was relevant in those above 35 years. Older women with significantly higher AMH level had significantly higher LBR than their peers with low AMH level. Thus AMH does have a role in counselling women when predicting live birth from IVF, although age of women plays a major role in determining success from IVF treatment.

What is the role of assisted reproduction technology in the management of age-related infertility?

Although in the UK the upper age limit for National Health Service (NHS) provision of in vitro fertilisation (IVF) is 39 years of age there has been an increase in number of women having fertility treatment in their 40s. However, the success rates of IVF and intra-uterine insemination (IUI) in this group remain low. Human Fertilisation and Embryology Authority (HFEA) data from 2006 showed that the live-birth rate from IVF in the UK was 11% in the age group 40-42, 4.6% in the age group 43-44 and less than 4% in women over 44. We performed a literature search for studies using terms and combinations of terms in online databases and published meta-analyses reporting the outcome of interventions in older women. This review showed that assisted reproduction technologies (ARTs) continue to have low live-birth rates in women over 40. Trials showed that assisted hatching may increase the chance of pregnancy in women with poor history. Blastocyst transfer is associated with better outcome, whereas application of pre-implantation genetic screening (PGS) in older women has not increased the success rates. It appears that, with the exception of egg-donation, ART has no answer yet to age-related decline of female fertility.

The effectiveness of IVF in unexplained infertility: a systematic Cochrane review. 2002,.

BACKGROUND: IVF is an accepted treatment for unexplained infertility. The objective of this review was to determine whether, for unexplained infertility, IVF improves the probability of live birth compared with: (i) expectant management; (ii) clomiphene citrate (CC); (iii) intrauterine insemination (IUI); (iv) IUI with controlled ovarian stimulation; and (v) gamete intra-Fallopian transfer (GIFT). METHODS: This was based on a Cochrane review. Randomized controlled trials (RCTs) which compared the effectiveness of IVF with expectant management, CC, IUI with or without controlled ovarian stimulation and GIFT were included. Patients included couples with unexplained infertility. Live birth rate per woman/couple was the main outcome measure. RESULTS: Nine RCT were identified. Five RCTs were included in the final meta-analysis. There were no comparative data for CC and live birth rates for expectant management or GIFT. There was no significant difference in clinical pregnancy rates between IVF and expectant management. There was no evidence of a difference in live birth rates between IVF and IUI either without (OR 1.96, 95% CI 0.88 to 4.36) or with (OR 1.15, 95% CI 0.55 to 2.42) ovarian stimulation. Clinical pregnancy rates with IVF were significantly higher compared with GIFT (OR 2.14, 95% CI 1.08 to 4.22) as were the multiple pregnancy rates (OR 6.25, 95% CI 1.70 to 23.00). Clinical heterogeneity was present among the studies. There was no evidence of statistical heterogeneity. CONCLUSIONS: The effectiveness of IVF in unexplained infertility remains unproven. Larger trials with adequate power are warranted.