Sexually Transmitted Infection Rates and Closure of Family Planning Clinics Because of Abortion Restrictions in Iowa.

This cohort study assesses rates of sexually transmitted infections in Iowa counties before and after closure of family planning health centers and compared with national rates.

Preferences for contraceptive counseling and access among abortion patients at an independent clinic in Texas.

OBJECTIVE: Abortion clinics frequently offer contraceptive counseling, but it is unclear if this is in line with patient preferences or satisfies an unmet need. Our objective was to examine preferences for contraceptive counseling and access among abortion patients in a legally restrictive setting. METHODS: In this cross-sectional study, 181 patients at an abortion clinic in Dallas, Texas completed anonymous, self-administered surveys from June-July 2018. We analyzed data descriptively. RESULTS: 46.5% of patients offered the survey agreed to participate. 33.1% of respondents preferred to obtain birth control from somewhere near their home. 29.3% preferred to obtain birth control from the same physician they visit for other health care needs. 81.8% were uninterested in contraceptive counseling at their abortion visit. Of these, 52.0% did not want to follow up for contraceptive counseling or services. CONCLUSION: Among study participants, most lacked interest in contraceptive counseling at the time of their abortion visit. Those interested in follow up preferred a resource handout over other options, such as a follow-up visit or phone call. PRACTICE IMPLICATIONS: A patient-centered approach elicits patient preferences for contraceptive care and honors them by facilitating access when requested, such as through comprehensive resources and referrals.

Factors associated with abortion at 12 or more weeks gestation after implementation of a restrictive Texas law.

OBJECTIVE: To examine factors associated with obtaining abortion at 12 or more weeks gestation in Texas after implementation of a restrictive law. STUDY DESIGN: In this retrospective cohort study, we collected data from eight Texas abortion clinics that provided services at 12 or more weeks gestation from April 1, 2015 to March 30, 2016, after a restrictive abortion law enacted in November 2013 shuttered many of the state's clinics. We examined factors associated with obtaining in-clinic abortion services between 3-11 versus 12-24 weeks gestation including patient race-ethnicity, income level, and driving distance to the clinic using chi-square tests and calculating odds ratios. We further subcategorized abortion between 15-24 weeks to determine who may be most affected by a Texas law banning dilation and evacuation (D&E). RESULTS: Among 24,555 in-clinic abortions, 19.2% (n = 4,714) occurred at 12 or more weeks gestation. Compared to patients who obtained care between 3-11 weeks, those who obtained care at 12 or more weeks were more likely to be Black than White (OR 1.18; 95% CI 1.05-1.31), live ≤110% of the federal poverty level than have higher income (OR 2.09; 95% CI 1.94-2.26), and drive 50+ miles than 1-24 miles to obtain care (OR 1.25; 95% CI 1.15-1.38). These associations remained for those obtaining care between 15-24 weeks. Even after adjusting for race-ethnicity and driving distance, low-income patients had greater odds of obtaining care in between 15-24 weeks (aOR 1.52; 95% CI 1.21-1.91). CONCLUSIONS: Patients obtaining abortion at 12 or more weeks gestation in Texas are more likely to be Black, low-income, and travel far distances to obtain in-clinic care. IMPLICATIONS: In Texas, patients who are Black, low-income, and travel the farthest are more likely to obtain in-clinic abortion between 15-24 weeks gestation, commonly performed via D&E. If Texas Senate Bill 8 (SB8) banning D&E goes into effect, these patients may be prevented from obtaining care.

Medication abortion use among low-income and rural Texans before and during state-imposed restrictions and after FDA-updated labeling.

BACKGROUND: In 2013, the Texas legislature passed House Bill 2, restricting use of medication abortion to comply with Food and Drug Administration labeling from 2000. The Food and Drug Administration updated its labeling for medication abortion in 2016, alleviating some of the burdens imposed by House Bill 2. OBJECTIVE: Our objective was to identify the impact of House Bill 2 on medication abortion use by patient travel distance to an open clinic and income status. MATERIALS AND METHODS: In this retrospective study, we collected patient zip code, county of residence, type of abortion, family size, and income data on all patients who received an abortion (medication or aspiration) from 7 Texas abortion clinics in 3 time periods: pre-House Bill 2 (July 1, 2012-June 30, 2013), during House Bill 2 (April 1, 2015-March 30, 2016), and post-Food and Drug Administration labeling update (April 1, 2016-March 30, 2017). Patient driving distance to the clinic where care was obtained was categorized as 1-24, 25-49, 50-99, or 100+ miles. Patient county of residence was categorized by availability of a clinic during House Bill 2 (open clinic), county with a House Bill 2-related clinic closure (closed clinic), or no clinic any time period. Patient income was categorized as ≤110% federal poverty level (low-income) and >110% federal poverty level. Change in medication abortion use in the 3 time periods by patient driving distance, residence in a county with an open clinic, and income status were evaluated using χ2 tests and logistic regression. We used geospatial mapping to depict the spatial distribution of patients who obtained a medication abortion in each time period. RESULTS: Among 70,578 abortion procedures, medication abortion comprised 26%, 7%, and 29% of cases pre-House Bill 2, during House Bill 2, and post-Food and Drug Administration labeling update, respectively. During House Bill 2, patients traveling 100+ miles compared to 1- 24 miles were less likely to use medication abortion (odds ratio, 0.21; 95% confidence interval, 0.15, 0.30), as were low-income compared to higher-income patients (odds ratio, 0.76; 95% confidence interval, 0.68, 0.85), and low-income, distant patients (adjusted odds ratio, 0.14; 95% confidence interval, 0.08, 0.25). Similarly, post-Food and Drug Administration labeling update, rebound in medication abortion use was less pronounced for patients traveling 100+ miles compared to 1-24 miles (odds ratio, 0.82; 95% confidence interval, 0.74, 0.91), low-income compared to higher-income patients (odds ratio, 0.77; 95% confidence interval, 0.72, 0.81), and low-income, distant patients (adjusted odds ratio, 0.80; 95% confidence interval, 0.68, 0.94). Post-Food and Drug Administration labeling update, patients residing in counties with House Bill 2-related clinic closures were less likely to receive medication abortion as driving distance increased (52% traveling 25-49 miles, 41% traveling 50-99 miles, and 26% traveling 100+ miles, P < .05). Geospatial mapping demonstrated that patients traveled from all over the state to receive medication abortion pre-House Bill 2 and post-Food and Drug Administration labeling update, whereas during House Bill 2, only those living in or near a county with an open clinic obtained medication abortion. CONCLUSION: Texas state law drastically restricted access to medication abortion and had a disproportionate impact on low-income patients and those living farther from an open clinic. After the Food and Drug Administration labeling update, medication abortion use rebounded, but disparities in use remained.

"Every Person's Just Different": Women's Experiences with Counseling for Early Pregnancy Loss Management.

BACKGROUND: Women have strong preferences for their choice of early pregnancy loss (EPL) management. However, current practice patterns suggest that some women may not be offered counseling about the full range of management options. To develop a foundation for quality counseling about EPL treatment, we elicited patients' perspectives regarding their preferences and values for communication during this decision-making process. METHODS: Twenty-one individual interviews were conducted with women who recently experienced EPL. Interviews discussed their experiences surrounding EPL diagnosis, counseling for and support during treatment decision making, and management outcomes, and concluded with questions seeking feedback on a decision tool. Interview transcripts were coded in an iterative and collaborative process by two authors, using constructivist grounded theory analysis. RESULTS: Women in our study overwhelmingly preferred having options for EPL management rather than being prescribed a single treatment by their provider. Women reported a wide variety of personal priorities that influence decision making for EPL management. They valued providers who engaged in a balanced conversation about these priorities and medical recommendations. Participants stressed the importance of candid counseling about treatment options and expressed frustration with delayed news delivery for EPL diagnosis. CONCLUSIONS: A patient-centered approach to EPL management includes unbiased counseling about the full range of options available. Women may perceive communication during EPL diagnosis as a critical time to initiate these discussions. Women are often weighing personal priorities to make decisions about EPL management and use of a decision aid may offer a systematic approach to identifying women's preferences for treatment.

Early pregnancy failure management among family physicians.

BACKGROUND AND OBJECTIVES: Family physicians, as primary care providers for reproductive-aged women, frequently initiate or refer patients for management of early pregnancy failure (EPF). Safe and effective options for EPF treatment include expectant management, medical management with misoprostol, and aspiration in the office or operating room. Current practice does not appear to reflect patient preferences or to utilize the most cost-effective treatments. We compared characteristics and practice patterns among family physicians who do and do not provide multiple options for EPF care. METHODS: We performed a secondary analysis of a national survey of women's health providers to describe demographic and practice characteristics among family physicians who care for women with EPF. We used multivariate logistic regression to identify correlates of providing more than one option for EPF management. RESULTS: The majority of family physicians provide only one option for EPF; expectant management was most frequently used among our survey respondents. Misoprostol and office-based aspiration were rarely used. Providing more than one option for EPF management was associated with more years in practice, smaller county population, larger proportions of Medicaid patients, intrauterine contraception provision, and prior training in office-based aspiration. CONCLUSIONS: Family physicians are capable of providing a comprehensive range of options for EPF management in the outpatient setting but few providers currently do so. To create a more patient-centered and cost-effective model of care for EPF, additional resources should be directed at education, skills training, and system change initiatives to prepare family physicians to offer misoprostol and office-based aspiration to women with EPF.

Counseling women with early pregnancy failure: utilizing evidence, preserving preference.

OBJECTIVES: To apply principles of shared decision-making to EPF management counseling. To present a patient treatment priority checklist developed from review of available literature on patient priorities for EPF management. METHODS: Review of evidence for patient preferences; personal, emotional, physical and clinical factors that may influence patient priorities for EPF management; and the clinical factors, resources, and provider bias that may influence current practice. RESULTS: Women have strong and diverse preferences for EPF management and report higher satisfaction when treated according to these preferences. However, estimates of actual treatment patterns suggest that current practice does not reflect the evidence for safety and acceptability of all options, or patient preferences. Multiple practice barriers and biases exist that may be influencing provider counseling about options for EPF management. CONCLUSION: Choosing management for EPF is a preference-sensitive decision. A patient-centered approach to EPF management should incorporate counseling about all treatment options. PRACTICE IMPLICATIONS: Providers can integrate a counseling model into EPF management practice that utilizes principles of shared decision-making and an organized method for eliciting patient preferences, priorities, and concerns about treatment options.

Derivation of major yolk proteins from parental vitellogenins and alternative processing during oocyte maturation in Fundulus heteroclitus.

Various Coomassie blue-staining yolk proteins (YPs) present in oocytes and eggs of Fundulus heteroclitus, a teleost that produces low hydrated, demersal eggs (benthophil species), were subjected to N-terminal microsequencing. Four YPs were N-terminally blocked, while five yielded sequence information. Of the latter, four corresponded to internal sequences of vitellogenin 1 (Vg1), whereas a fifth band corresponded to the N-terminal sequence of Vg2. Phosphorylated YPs (phosvitins and phosvettes) derived from the polyserine domain of Vg were not successfully sequenced. The major N-terminally blocked 122-and 103-kDa YPs both represented the lipovitellin heavy chain of Vg1 (LvH1), and thus most of the oocyte YPs were derived from Vg1. During oocyte maturation in vivo and in vitro, the LvH1 122 is degraded, concomitant with an increased enzymatic activity of cathepsin B, while the 45-kDa YP is converted to a 42-kDa YP. The LvH1 122 was found to contain a consensus site for proteolytic degradation (PEST) near its C-terminus, which is missing from its stable, but truncated twin sequence, LvH1 103. We suggest that this site becomes exposed to cathepsin B during the hydration process that accompanies oocyte maturation and renders the LvH1 122 susceptible to proteolysis. PEST sites are found in Vg sequences from other benthophil fish, whereas, interestingly, they are missing in marine teleosts that spawn highly hydrated, pelagic eggs (pelagophil species), displaying a different pattern of Vg incorporation into YPs and LvH1 and LvH2 processing to that found in F. heteroclitus. Thus, different models of Vg/YP precursor/product relationship and further processing during oocyte maturation and hydration are proposed for pelagophil and benthophil teleosts.

Fundulus heteroclitus gonadotropins.5: Small scale chromatographic fractionation of pituitary extracts into components with different steroidogenic activities using homologous bioassays.

Fractionation and characterization of gonadotropins (GtH) from Fundulus heteroclitus pituitary extracts were carried out using a biocompatible liquid chromatographic procedure (Pharmacia FPLC system). Chromatographic fractions were monitored for gonadotropic activities (induction of oocyte maturation and steroid production) using homologous follicle bioassays in vitro. Size-exclusion chromatography eluted gonadotropic activity in one major protein peak (Mr approximately 30,000). Anion-exchange and hydrophobic-interaction chromatography (HIC) yielded two distinct peaks of 17beta-estradiol (E2)- and 17alpha-hydroxy,20beta-dihydroprogesterone (DHP)-promoting activity with associated oocyte maturation. Two-dimensional chromatography (chromatofocusing followed by HIC) resolved pituitary extracts into two active fractions; both induced E2 synthesis, but one was relatively poor in eliciting DHP and testosterone production. Thus, using homologous bioassays, at least two quantitatively different gonadotropic (steroidogenic) activities: an E2-promoting gonadotropin (GtH I-like) and a DHP-promoting gonadotropin (GtH II-like), which has a lower isoelectric point but greater hydrophobicity than the former, can be distinguished from F. heteroclitus pituitaries by a variety of chromatographic procedures. This study complements previous biochemical and molecular data in F. heteroclitus and substantiates the duality of GtH function in a multiple-spawning teleost.

Sexually transmitted infections and increased risk of co-infection with human immunodeficiency virus.

The incidence of trichomoniasis (Trichomonas vaginalis) in the United States is estimated at 5 million cases annually; chlamydia (Chlamydia trachomatis) at 3 million; gonorrhea (Neisseria gonorrhoeae), 650,000; and syphilis (Treponema pallidum), 70,000. However, most sexually transmitted infections (STIs) are asymptomatic-contributing to underdiagnosis estimated at 50% or more. Diagnosis of an STI signals sexual health risk because an STI facilitates the transmission and acquisition of other STIs, including human immunodeficiency virus (HIV). In fact, comorbid STIs increase patients' susceptibility of acquiring and transmitting HIV by two- to fivefold. Several studies have shown that aggressive STI prevention, testing, and treatment reduces the transmission of HIV. The authors discuss common clinical presentations, screening, diagnosis, and treatment for trichomoniasis, chlamydia, gonorrhea, syphilis, and herpes simplex virus.

Stages of oocyte development in the zebrafish, Brachydanio rerio.

Oocyte development has been divided into five stages in the zebrafish Brachydanio rerio, based on morphological criteria and on physiological and biochemical events. In stage I (primary growth stage), oocytes reside in nests with other oocytes (Stage IA) and then within a definitive follicle (Stage IB), where they greatly increase in size. In stage II (cortical alveolus stage), oocytes are distinguished by the appearance of variably sized cortical alveoli and the vitelline envelope becomes prominent. In stage III (vitellogenesis), yolk proteins appear in oocytes and yolk bodies with crystalline yolk accrue during this major growth stage. Ooctes develop the capacity to respond in vitro to the steroid 17α, 20ß-dihydroxy-4-pregnen-3-one (DHP) by undergoing oocyte maturation. In stage IV (oocyte maturation), oocytes increase slightly in size, become translucent, and their yolk becomes non-crystalline as they undergo final meiotic maturation in vivo (and in response to DHP in vitro). In stage V (mature egg), eggs (approx. 0.75 mm) are ovulated into the ovarian lumen and are capable of fertilization. This staging series lays the foundation for future studies on the cellular processes occurring during oocyte development in zebrafish and should be useful for experimentation that requires an understanding of stage-specific events. © 1993 Wiley-Liss, Inc.

Ovary of the seahorse, Hippocampus erectus.

The ovary of the seahorse, Hippocampus erectus, is a cylindrical tube bounded by an outer layer consisting of a mesothelium and muscular wall and by an inner luminal epithelium, with a single row of developing follicles sandwiched between the two layers. Follicles are produced by a germinal ridge, which contains oogonia, early oocytes, and prefollicle cells, and which runs along the length of the ovary. The germinal ridge is an outpocketing of the luminal epithelium, as indicated by a continuous underlying basal lamina. Prefollicle cells invest diplotene oocytes and the complex eventually pinches off the germinal ridge as a primordial follicle surrounded by a basal lamina derived from the germinal ridge. Subsequent investment of the primordial follicle by elements of the theca complete the process of folliculogenesis. H. erectus has two ovaries and each ovary has two dorsally located germinal ridges. Thus, in each ovary the derived follicular lamina is bilaterally symmetrical: two temporally and spatially arranged sequences of developing follicles are produced, with the largest follicles found along the ventral midline of the ovary. The advantages of developmental, kinetic, and systemic analyses of these unusual ovaries are indicated.

The Influence of Yolk Protein Proteolysis on Hydration in the Oocytes of Fundulus heteroclitus: (oocyte hydration/meiotic maturation/proteolysis/yolk proteins/teleost).

Growth in oocytes of many marine teleosts can be attributed to a combination of yolk accumulation during the vitellogenic phase of development and water uptake during meiotic maturation. In the salt marsh fish, Fundulus heteroclitus, hydration associated with maturation gives rise to a greater than two-fold increase in oocyte volume. It has been proposed that a concurrent proteolysis of specific yolk proteins may be the mechanism driving this water uptake. To test this hypothesis, we used various in vitro culture techniques to block or significantly reduce oocyte hydration while allowing meiotic maturation to continue, then examined yolk proteins by SDS-polyacrylamide gel electrophoresis. We were able to dissociate yolk proteolysis from both hydration and nuclear maturation stimulated by a maturation-inducing steroid, 17α-hydroxy- 20ß-dihydroprogesterone. It therefore appears that the proteolysis of specific yolk proteins observed in maturing oocytes of marine teleosts is an independent developmental event, and is not directly involved in the hydration mechanism.

Stages of oocyte development in the pipefish, Syngnathus scovelli.

Oocyte development occurs in a temporal and spatial pattern in the ovary of the pipefish, Syngnathus scovelli. Cytological observations combined with [3 H]thymidine uptake and cell culture were used as criteria to identify six stages of oocyte development in this species. Stage I-Oogonia, found within the germinal ridge. Stage II-Oocytes in primary growth, subdivided into (1) chromatin-nucleolus oocytes in early prophase I of meiosis, also found within the germinal ridge, and (2) perinucleolar oocytes, which possess multiple nucleoli and are within definitive follicles (the Balbiani vitelline body is the main cytoplasmic component in these latter oocytes). Stage III-Oocytes distinguished by the appearance of cortical alveoli, the vitelline envelope, and lipid. Stage IV-Vitellogenic oocytes, which accumulate yolk proteins and possess primary, transitional, and mature yolk spheres. Stage V-Maturational oocytes, which are competent to undergo final meiotic maturation in vivo and in response to the steroid 17 α-hydroxy-20ß-dihydroprogesterone in vitro. Stage VI-Ovulated mature eggs, which are present in the ovary lumen and are capable of being fertilized. These studies provide a staging series for oogenesis and oocyte development in the pipefish and relate these stages to the unusual ovary in this animal.

Ovary of the pipefish, Syngnathus scovelli.

Gross dissection, light microscopy, and transmission electron microscopy were used to generate a detailed understanding of the ovarian anatomy of the pipefish, Syngnathus scovelli. The ovary is a cylindrical tube bounded by an outer layer consisting of a smooth muscle wall and an inner layer of luminal epithelium, with follicles sandwiched between the two layers. A remarkable feature of this ovary is a sequential pattern of follicle development. This pattern begins at the germinal ridge with a gradient of follicles of increasing developmental age extending to the mature edge. The germinal ridge is an outpocketed region of the luminal epithelium containing early germinal cells and somatic prefollicular cells. Therefore, the germinal ridge and luminal epithelium share the same ovarian compartment and follicle formation occurs within this compartment. The mature edge is defined as the site of oocyte maturation and ovulation. The outer ovarian wall contains unmyelinated nerve fibers throughout. Longitudinally oriented unmyelinated nerves are also observed near the smooth muscle bundles associated with the mature edge. Oocytes near the mature edge are polarized such that the germinal vesicle (nucleus) is generally oriented toward the luminal epithelium. The sandwichlike organization of the ovary results in follicles that have a shared theca. An extensive lymphatic network is also interspersed among the follicles. Thus, the exceptional features of the pipefish ovary make it particularly well suited for the examination of early events in oogenesis. Specifically, we characterize pipefish folliculogenesis in detail.