BMJ Sexual & Reproductive Health

Objective: Since 2020, medication abortion provision in the U.S. has been reshaped by changing abortion policies and expanded telehealth access, yet little is known about how medication abortion service delivery has evolved. We examined national trends in service delivery from 2020 to 2025, including changes in abortion facility types, telehealth provision, and gestational limits. Study Design: Using ANSIRHs Abortion Facility Database, a national census of publicly advertising abortion facilities (2020 to 2025), we analyzed trends in medication abortion service delivery. Systematic web searches and mystery shopper calls gathered data on facility types, telehealth provision, and gestational limits. Data analysis included frequencies and comparisons across regions and states. Results: Medication abortion-only facilities increased nationally, from 35% of facilities in 2020 to 65% in 2025, with substantial growth in abortion-restrictive regions such as the Midwest and South. By 2025, 99% of facilities provided medication abortion. Telehealth provision expanded from 7 facilities in 2020 to 606 facilities by 2025, driven by growth in both brick-and-mortar facilities offering telehealth care and new virtual clinics. Overall, 46% of all facilities offered medication abortion by telehealth in 2025. Gestational limits for medication abortion increased nationally, from <1% of facilities offering medication abortion after 11 weeks in 2020 to 38% in 2025. Conclusions: Medication abortion service delivery has adapted to legal and logistical challenges by increasing telehealth options and expanding gestational limits. These changes improve access for abortion seekers, especially those living in restrictive environments. Sustaining abortion access will require ongoing provider adaptation and supportive policy environments.

Background Recent research has documented poor reproductive health among women and people assigned female in England. Access to reproductive health services is hindered by an opaque and fragmented system. Methods We conducted the 2023 Reproductive Health Survey for England, a non-probability online survey, in September and October 2023 (N = 59,332). In this analysis, we examined access to reproductive health services across three domains: heavy menstrual bleeding and severe pain, gynaecological symptoms and conditions and menopause-related symptoms. Weighting the sample to match the 2021 Census age distribution, we assessed differences by ethnic group, subjective financial situation, educational attainment and region across the domains using logistic regression analysis and controlling for age. Results Respondents reported low access to reproductive health services overall, including 34.8% (8,644/24,952) of those with heavy bleeding or severe period pain, 44.7% (6,709/15,569) with menopausal symptoms and 55.3% (21,010/37,411) with gynaecological symptoms or conditions. When controlling for age, there were decreased odds of service access for menopause-related symptoms and increased odds of service access for gynaecological symptoms or conditions among Black ethnic groups. Respondents with a higher education degree had greater access to services for heavy bleeding or severe pain and gynaecological symptoms and conditions. Compared to London, all other regions had lower access to services for heavy bleeding or severe pain. Satisfaction ranged from 16.5% (741/4,666) for polycystic ovary syndrome services to 80.2% (166/207) for reproductive cancer services. Conclusions Access to reproductive health services is poor in England and requires urgent action to address barriers to access.

There are several barriers to uptake of intrauterine devices (IUDs), with the fear of pain during insertion an emerging concern. Using data from an online survey, we sought to understand the experience of women who had undergone IUD insertion, with a particular focus on their expectation compared with their reported experience of pain. We found that, while most participants expected a moderate level of pain at insertion, many reported a high level of pain. Pain relief offered was variable, and, aside from that administered by an anaesthetist, no single method appeared to significantly reduce reported pain.

Background Fertility rates in Australia have been declining over recent decades, reaching a record low total fertility rate of 1.48 births per woman in 2024. Concurrently, vasectomy remains widely accessible and increasingly normalised as a permanent contraceptive option. Despite extensive commentary on falling birth rates, no contemporary Australian study has examined vasectomy rates relative to birth rates over time. We aimed to compare population level vasectomy and birth rates across Australian jurisdictions and age groups. Study design Nationwide retrospective time-series study. Retrospective population-based study using Medicare Benefits Schedule item 37623 to identify vasectomy procedures performed between July 2015 and December 2024. Rates were calculated per 100,000 male population using quarterly Australian Bureau of Statistics (ABS) population estimates and summarised as rolling 12-month averages. Birth rates were derived using matched ABS data for women across equivalent age strata (18-24, 25-34, 35-44 years). Results: Vasectomy rates increased nationally from 32 per 100,000 in 2016 to 55 per 100,000 in 2023 before declining modestly in 2024. Birth rates declined from 5,200 to 3,800 per 100,000 over the same period. Trends were consistent across states and age groups, with the greatest vasectomy uptake in men aged 35-44 years. Conclusion: Australia is undergoing a demographic shift characterised by rising vasectomy uptake and declining fertility. While vasectomy rates remain lower than birth rates, their convergence signals changing reproductive intentions and contraceptive behaviours. Ongoing monitoring of permanent and long-acting contraception is essential to understand evolving population dynamics and inform reproductive health policy.

Objective: To address the need for improved measurement of the ways contraception impacts the baseline menstrual cycle (i.e., contraceptive-induced menstrual changes; CIMCs) by assembling an interdisciplinary, global research collective to rigorously develop a person-centered measure for CIMCs in multiple languages. As the first step, this paper reports on our conceptual model development, which is the foundation for ongoing measure development. Study design: We conducted 18 focus groups with 106 people experiencing CIMCs while using hormonal or intrauterine contraception in Durban, South Africa, Santo Domingo, Dominican Republic, and Portland Oregon, United States. We used a virtual affinity mapping approach to analyze qualitative data, which was the basis of our conceptual model along with relevant theory and related models in the literature. Results: The conceptual model of experiences with CIMCs depicts the baseline menstrual cycle, including CIMCs and conceptually-linked effects and the impacts and perceptions of those CIMCs. We found key domains of changes in pain, bleeding volume, bleeding patterns, and characteristics of blood. Conclusion: Our CIMC conceptual model will inform development of a measure with evidence of validation across three language and global contexts. Adoption of a person-centered, standardized CIMC measurement across trials will improve knowledge and decision-making between methods.

Introduction Perinatal Empowerment is widely referenced in maternity care research, yet its use often lacks clear conceptual definitions and validated measures. Existing instruments do not capture the multidimensional nature of perinatal empowerment, including both external dimensions (e.g., gender equity, resource access), and internal dimensions (e.g., confidence, agency and informed decision making). This gap has limited the ability to rigorously evaluate how healthcare experiences shape empowerment during pregnancy, birth, and the postpartum period. Aim To develop a valid and reliable instrument that measures dimensions of perinatal empowerment, both external and internal. Methods Instrument development followed the seven-step MEASURE framework. Initial item generation was guided by a concept analysis, a scoping review of existing instruments, and feedback from international midwifery experts. A preliminary 51-item instrument underwent expert content validity review, resulting in 48 items, which were then pilot-tested with six pregnant and postnatal women. A large-scale validation study was conducted via an international online survey (N=155). Psychometric testing included exploratory factor analysis (EFA), reliability assessment using Cronbachs , known-groups validity testing, and regression analyses adjusting for potential confounders. Results EFA supported two overarching dimensions--external and internal empowerment--with six factors across 30 final items (18 external, 12 internal). Sampling adequacy was high, and item loadings exceeded recommended thresholds. Internal consistency was strong for both dimensions (=0.88 external; =0.87 internal). Women receiving midwifery continuity of care reported significantly higher empowerment scores across total, external, and internal dimensions compared with other care models (p<.001). Differences between primiparous and multiparous women were not statistically significant. Conclusion The MPower instrument represents a conceptually grounded, psychometrically robust measure of multidimensional perinatal empowerment in high-income settings. Further validation in more diverse populations is needed to refine the instrument and expand its applicability across clinical and research contexts.

Adolescents with Down syndrome face unique menstrual health challenges, yet their experiences remain under-researched. This study aimed to describe the menstruation experiences of adolescents with Down syndrome and their caregivers, in the UK, to inform the development of tailored, evidence-based interventions for this population. Guided by an advisory group of caregivers and young people with Down syndrome, this mixed-methods study (September 2024 -July 2025) involved a national online survey of primary caregivers (N=143) and participatory interviews with adolescents (n=6), mothers (n=11) and healthcare and education professionals (n=8). Quantitative data were analysed descriptively according to support needs (high vs low), and qualitative data were analysed thematically. The median age of menarche (12 years) aligned with the general population. While adolescents generally coped better with menarche than caregivers anticipated, 91% of 120 caregivers of adolescents who had reached menarche had ongoing menstruation concerns. While products like period underwear ("magic pants") improved independence and simplified care, key remaining concerns include: heavy periods (48%); personal care (45%); menstrual pain (45%); and the communication of pain (26%). The impact on adolescent wellbeing was greater for those with greater support needs. Additionally, 33% of caregivers felt "overwhelmed" by menstrual-related care. Decision-making for hormonal intervention was a source of heavy responsibility for caregivers. There is substantial demand for accessible educational and practical resources to support menstruation. Menstrual health is a highly individualised experience for adolescents with Down syndrome. Significant unmet needs persist, particularly for those with higher support needs. Successful outcomes require supporting caregivers through provision of accurate information that dispels pre-menarche anxiety alongside accessible and appropriate guidance to foster young peoples independence, choice and autonomy. Future interventions must be co-developed with the Down syndrome community to ensure safe, dignified menstruation. FundingDowns Syndrome Research Foundation UK

Background Parental health before pregnancy influences maternal and child outcomes. Primary care professionals, including general practitioners [GPs], midwives, and naturopaths, can provide preconception care, yet many report limited knowledge and difficulty accessing relevant information. This study described Australian GPs, midwives, and naturopaths preconception health literacy, including knowledge and ability to access information. Methods Between July and September 2022, Australian GPs, midwives, and naturopaths completed a 32-item online cross-sectional survey. Participants were recruited through professional associations, and data were analysed using descriptive and inferential statistics Results Participants (N=373) included naturopaths (40.7%), GPs (32.4%), and midwives (26.8%). Reported barriers to clinician health literacy including lack of preconception care resources (25.5%), and limited clinician knowledge (23.6%). The proportion identifying limited clinician knowledge differed significantly between professions (GP: 31.4%; midwives: 23.0%; naturopaths: 17.8%; p=0.030). The highest level of accurate knowledge regarding preconception exposures was for pre-pregnancy obesity (82.7%), while low birth weight was the most accurately identified preconception outcomes (83.7%). Incorrect responses were most common for maternal multivitamin use as an exposure (28.3%) and childhood leukaemia as an outcome (26.3%). Differences between professions were strongest for infant outcomes, with moderate associations observed for shoulder dystocia (V=.2355), precipitous labour (V=.2173), macrosomia (V=.2060), labour dystocia (V=.2018) and cryptorchidism (V=.2018). Discussion Preconception health literacy varies across primary care professions. Clinicians require greater access to targeted resources and education tailored to their differing scopes of practice and experience. Improving clinician preconception health literacy may strengthen consistent evidence-based care and support better maternal, child, and long-term family health outcomes.

Background: Unintended pregnancies can introduce stress and shift life trajectories. Social support may buffer these effects, yet its influence during an unintended pregnancy and into the early parenthood period is not clear. This study aimed to understand the types and gaps of social support experienced throughout this period. Methods: This study utilized interview data under the RISE UP study in The Hague, the Netherlands. 13 mothers and 8 partners who experienced an unintended pregnancy participated in semi structured interviews between 2024 and 2025. Interviews were thematically analyzed using House's social support framework. Results: Different types of support were highlighted across the entire timeline from pregnancy to early parenthood, underlining its dynamic nature. Emotional and instrumental support stood out the most throughout. A key form of emotional support was knowing that support is available, even if not needed immediately. Conclusions: Perceived support during unintended pregnancy is shaped more by contextual factors than by pregnancy intention. While emotional and instrumental support are valued throughout, their form differs by the family's unique circumstances, emphasizing the need for tailored support across the perinatal and postpartum periods.

Objective To evaluate the feasibility, safety, patient acceptance, and preliminary clinical relevance of automated self-operated transvaginal ultrasound for ovarian stimulation monitoring. Design Prospective observational pilot study. Subjects Ten women undergoing ovarian stimulation for in vitro fertilization or fertility preservation at a single high-volume private IVF center. Exposure Participants performed investigational self-operated transvaginal ultrasound examinations immediately following standard monitoring visits. Patients inserted and stabilized the ultrasound probe while ovarian and endometrial imaging was acquired through controlled motorized probe rotation without real-time anatomical guidance. Main Outcome Measure(s) The primary outcome was feasibility, defined as the generation of evaluable imaging datasets suitable for ovarian stimulation monitoring. Secondary outcomes included bilateral ovarian visualization, procedural safety, patient-reported outcomes, follicular assessment, and agreement of endometrial thickness measurements with standard transvaginal ultrasound. Result(s) Nineteen investigational scan attempts were performed, yielding 18 evaluable datasets (94.7%). Bilateral ovarian visualization was achieved in 16 of 18 evaluable examinations (88.9%), whereas partial ovarian visualization occurred in 2 examinations (11.1%). No adverse events, adverse device effects, vaginal injury, bleeding, or infection were observed. Patient-reported outcomes demonstrated high procedural acceptability, with all participants expressing willingness to reuse the system. Compared with standard transvaginal ultrasound monitoring, investigational self-operated acquisition significantly improved overall examination experience (Wilcoxon p=0.002). Investigational imaging demonstrated clinically relevant agreement with standard transvaginal ultrasound for follicular categorization and endometrial assessment. Counts of follicles [&ge;]14 mm correlated strongly with mature oocyte recovery for both investigational and standard ultrasound measurements (Spearman {rho}=0.83 and {rho}=0.80, respectively). Endometrial thickness measurements also demonstrated strong correlation between modalities (Spearman {rho}=0.91). Conclusion(s) This prospective pilot study demonstrates the feasibility of automated self-operated transvaginal ultrasound during ovarian stimulation monitoring. Investigational imaging generated clinically relevant monitoring information without observed safety concerns and was associated with high patient acceptance. These findings support further investigation of patient-operated acquisition strategies and standardized imaging workflows in reproductive medicine.

Objectives: To evaluate if direct access to a Pregnancy Early Access Center (PEACE) improves the timeliness and efficiency of pregnancy loss care. Methods: We conducted a retrospective cohort study of patients diagnosed with EPL from January 2017 to December 2022 within a single healthcare system. We included EPL patients treated with procedural or medication management who had been assessed for a related early pregnancy complaint in the thirty days prior. The exposure was direct utilization of PEACE (yes/no) between first EPL symptom visit and EPL management. The primary outcome was "care latency" defined as days from initial presentation for concerning early pregnancy symptoms to initiation of active management. Secondary outcomes included "care continuity," the number of care teams encountered, "care efficiency," the number of patient encounters, and the type of EPL management received. Results: The evaluable cohort included 2151 individuals, with 36.5% patients of Black race and 30.3% publicly insured. A total of 885 (41.1%) received any EPL care at PEACE and 246 (11.4%) initiated their care at PEACE. Patients initiating care through PEACE experienced a 5-day reduction in care latency compared to patients who did not access PEACE. Adjusting for age, race, and insurance type, patients whose index EPL visit was with PEACE initiated their treatment twice as quickly as those who never saw PEACE (aHR 2.36 [95% CI, 2.05-2.71]). Care efficiency (median 2 [1-3] encounters) and care continuity (median 4.5 [4-7] care teams) were also improved by an index visit with PEACE when compared with controls (3 [2-4] and 6 [4-8] p<0.01), respectively). Conclusions: The Pregnancy Early Access Center (PEACE) model is associated with reduced care latency and improved efficiency and continuity when compared with routine care. PEACE reduces barriers to timely, patient-centered early pregnancy care.

Niger has the worlds highest adolescent fertility rate. Social network (SN) approaches to family planning may improve intervention impact through diffusion beyond direct beneficiaries. We tested a social network modification of a community-based family planning intervention to increase contraceptive use compared to standard implementation and control.Three-arm cluster-randomized trial in 56 rural villages in Maradi, Niger. Eligible participants were adolescent wives (AW) aged 15-19 with 0-1 children and their husbands. Villages were randomized using covariate-constrained randomization (Minirand): standard Kulawa (100% coverage), SN modification (50% coverage pairing AW-mother-in-law dyads with adopt-a-friend diffusion), or control. Interventions were delivered over 12 months. Blinding of participants and implementers was infeasible; analysts were blinded. Primary outcome was current contraceptive use assessed at endline and analyzed using intention-to-treat difference-in-differences logistic regression adjusting for clustering; no missing data were imputed. ClinicalTrials.gov NCT05777473; trial closed to enrollment.From May 1 to September 30, 2022, 1,538 female AW were enrolled (517 control, 532 Kulawa, 489 Kulawa SN); 1,396 (90.8%) completed endline (May-August 2024). Compared to control, the SN arm significantly increased contraceptive use (AOR 2.36, 95% CI 1.27-4.44); the standard arm showed no significant effect (AOR 1.36, 95% CI 0.76-2.41). Within SN villages, both non-participants (AOR 2.66, 95% CI 1.25-5.70) and direct participants (AOR 2.10, 95% CI 0.99-4.44) showed increased use versus control, demonstrating behavioral diffusion. No intervention-related adverse events were observed in any arm. An SN approach targeting AWs, husbands, mothers-in-law, and adopted friends achieved greater effects than standard implementation despite 50% lower coverage, with evidence of diffusion to non-participants. Leveraging social networks may improve impact of family planning programs in high-fertility settings.

Introduction:Relational dynamics between partners within a couple planning pregnancy are critical to their preconception health behaviour change and are largely underexamined. Given the need for both reproductive partners to engage in beneficial preconception health behaviours and the influence couples have on each others behaviour, this study examines the concordance between pregnancy planning and preconception health behaviours and health information-seeking within reproductive partner dyads. Methods:A retrospective observational study was undertaken utilizing data from two online cross-sectional 80-item surveys administered simultaneously between December 2020 and September 2021. Eligible study participants were females or birthing people aged 18-49 living in Australia during any stage of pregnancy, and reproductive partners of those that met these criteria. The survey items covered sociodemographic characteristics, level of pregnancy planning, preconception health behaviours, health information seeking, and health history. Cohens kappa (K) (categorical variables) and interclass correlation coefficients (ICC) (continuous variables) were used to identify agreement within the couples. Results:Eighty matched dyads of pregnant females and non-pregnant partners were included. Concordance in pregnancy planning was fair (K=0.27) and was primarily seen in couples where both partners reported the pregnancy as planned (42.5%) or ambivalent (18.8%). Couples had very low similarity (ICC:0.22) in weekday alcohol consumption 3 months preconception (pregnant females: 1.2 standard drinks per day (SD1.7); non-pregnant partners: 2.5/day (SD3.5)). Approximately one quarter (26.3%) of couples reported similarities in partners attempting and succeeding in preconception health information-seeking 12 months before pregnancy. There was greater concordance in not discussing preconception health topics with GPs, including topics explicitly covered within clinical guidelines. Conclusion:There is notable discordance in couples preparation for pregnancy in many behaviours relevant to positive pregnancy outcomes, and in their health service engagement and experience. There is a clear need to provide care to both reproductive partners to ensure the best possible outcome for the future generations.

Introduction: The preconception period (i.e. the weeks and months before pregnancy) is a critical window during which parental health behaviours can influence pregnancy outcomes and the childs long-term health. Modifiable factors such as nutrition, physical activity, substance use, and environmental exposures play a key role, yet womens ability to adopt and sustain healthy behaviours is shaped by complex psychological, social and environmental influences. This study applies the Theory of Planned Behaviour to identify the beliefs underpinning womens preconception behaviours, with the aim of informing support for effective and sustained health behaviour change. Methods: An Australian national retrospective cross-sectional survey of pregnant women (18-49 years), recruited through social media platforms. The 92-item survey captured respondent socio-demographics, pregnancy status and health conditions, health behaviours, and beliefs regarding preconception health behaviours. Respondents level of pregnancy planning was categorised using the London Measure of Unplanned Pregnancy (LMUP). Items regarding preconception beliefs were structured in accordance with the Theory of Planned Behaviour, with a focus on regular exercise, healthy diet, and alcohol avoidance. These beliefs variables were analysed using structured equation modelling to identify paths between latent variables and the items used to estimate each concept. Results: The study was completed by 430 pregnant women of whom 72.7% had a planned pregnancy. Most had a partner, were university educated and in good health. Structural equation modelling showed intention strongly predicted exercise ({beta}=0.65), healthy diet ({beta}=0.54) and alcohol avoidance ({beta}=0.64). Perceived control and partner norms influenced intentions, whereas health professional norms had limited effect. Positive beliefs were associated with folate supplement use and smoking cessation. Conclusion: These findings highlight intention as a key driver of preconception health behaviours, with perceived control and partner influences playing a more significant role than individual beliefs or health professional input. Effective interventions should therefore address structural barriers and actively involve partners, while respecting womens autonomy. Overall, couples-focused, multi-level strategies are likely essential to support meaningful and sustained preconception health behaviour change.

IntroductionObstetric litigation is the largest single category of NHS clinical negligence by cost. The last systematic analysis of NHS obstetric litigation data was published in 2012 [1]. Despite major national safety programmes, annual costs have continued to escalate. This study aims to update the analysis and consider ethical and resource implications. MethodsFOI claims data were obtained from NHS Resolution for 2015/16-2024/25, supplemented by cerebral palsy and brain damage (CP/BD) data for the most recent six years. Activity-weighted HRG unit costs for 2024/25 and 2023/24 were used to compare planned vaginal birth (PVB) and planned caesarean section (PCS) pathway costs, incorporating indemnity attribution by cause-code proportion. The consent architecture was reviewed against Montgomery v Lanarkshire Health Board [2015] UKSC 11. ResultsOver the period, 11,881 claims were notified (approximately one per 500 England NHS births); 7,216 were settled, with total damages of {pound}5,974 million, rising approximately 85% in real terms. Four intrapartum monitoring failure codes and seven labour-exclusive delivery complication codes together accounted for {pound}2,776 million paid (55.9% of all obstetric damages). CP/BD claims represented 16.6% of volume but 77.7% of obstetric damages over 2019/20-2024/25, at an average of {pound}3.58 million per claim. Activity-weighted HRG analysis at 2024/25 tariff showed PCS at {pound}6,202 versus PVB at {pound}6,339 per birth. ConclusionsObstetric litigation costs continue to escalate, driven overwhelmingly by labour-attributable harm. NHS England data show, for the first time, PCS tariff costs below PVB. Including indemnity under the primary eleven-code attribution, total system cost excess of PVB reaches approximately {pound}1,032-{pound}3,082 per birth (2024/25 cash to actuarial basis). Consent architecture for planned mode of delivery raises a potential inconsistency with Montgomery. Key messagesO_ST_ABSWhat is already known on this topicC_ST_ABSObstetric litigation is the largest single category of NHS clinical negligence by cost, driven overwhelmingly by intrapartum harm, yet no systematic analysis of cause-code data has been published since 2012. What this study addsTen years of NHS Resolution FOI data show that eleven labour-exclusive cause codes account for 55.9% of obstetric damages; NHS England tariff data show, for the first time, that planned caesarean section ({pound}6,202) is less costly than the planned vaginal birth pathway ({pound}6,339), and when indemnity is included the total system cost excess of planned vaginal birth reaches {pound}1,032-{pound}3,082 per birth. How this study might affect research, practice or policyA formal comparative-risk consent process at booking, equivalent to that currently required for planned caesarean section under RCOG Consent Advice No. 14, should be considered standard for all women; NICE should update its economic analysis of mode of delivery to incorporate litigation costs; and NHS tariff methodology should be reviewed to ensure indemnity is allocated in proportion to the pathway-level mechanisms that generate it.

Objective To examine the effects of combined oral contraceptive (OC) use on clinical markers of ovarian reserve by comparing Anti-Muellerian Hormone (AMH), antral follicle count (AFC), and ovarian volume (OV) before and after starting or stopping OC. Methods This analysis is based on data from a prospective cohort study conducted at the University Hospital Tubingen, Germany, as part of the IRTG-2804 project. A total of 54 healthy women were included and categorized into three groups based on their OC use status: OC starters (n = 12), stoppers (n = 16), and long-term OC-users (n = 26). Each participant underwent a transvaginal ultrasound (including AFC and OV) and serum sampling (including AMH) at two time points (S1 and S2), three to six months apart. OC starters were assessed first during the early follicular phase (day 1-7) and then during active OC intake (day 8-21), while stoppers were assessed in the reverse order. Long-term users were assessed twice during active OC intake. Results OC stoppers showed significant within-group increases in all ovarian reserve markers, including AMH ({Delta} = 2.57 ng/mL, p < .001), AFC ({Delta} = 3.88, p = .004), and OV, which almost doubled (1.94-fold increase; 95% CI [1.35, 2.80], p < .001). In contrast, OC starters exhibited a significant decline in AMH ({Delta} = -1.25 ng/mL, p = .013), but no changes in AFC or OV. No significant longitudinal changes were observed among long-term OC users. Conclusion AMH levels decrease after starting OC use whereas AFC and OV are not affected. In contrast, AMH, AFC, and OV recover within three to six months after stopping OC, suggesting a reversible suppression of ovarian reserve markers during OC use. These findings are clinically relevant for fertility counseling and for the interpretation of ovarian reserve markers in women using hormonal contraception.

Background: Intrauterine contraceptives (IUCs) are effective, but effects on genital inflammation among women living with HIV (WLHIV) by antiretroviral therapy (ART) use are unclear. We evaluated the longitudinal effects of copper IUC (C IUC) and the levonorgestrel intrauterine system (LNG IUS) on cervicovaginal cytokine profiles in a secondary analysis of a randomized trial (NCT01721798, 2013 to 2016). Methods: Cervicovaginal secretions were collected from 100 WLHIV (non ART users; ART users) randomized 1:1 to C IUC or LNG IUS. Twenty eight cytokines were measured prior to insertion and 3 and 6 months post insertion. Cytokine concentrations at each follow up visit were compared with baseline, using participant fixed effects models stratified by ART status. Results: At enrolment, non ART users had higher average concentrations of most cytokines (21/28) than women using ART. Among non-ART users, IUC use was not associated with cytokine increases; only MCP1 increased significantly at 3 months among C IUC users (log10 geometric mean ratio 0.77, 95%CI 0.38 to 1.17), while none increased with LNG IUS use. Among ART users, C IUC insertion resulted in broad and sustained cytokine increases at both 3 (16/28) and 6 months (15/28). At month 3, the largest increases in log10 geometric mean were observed for IL6 (1.04, 0.72 to 1.36), RANTES (0.97, 0.54 to 1.40), MCP1 (0.71, 0.46 to 0.96), MIP1; (0.66, 0.37 to 0.94), and GCSF (0.63, 0.36 to 0.89), which was maintained until month 6. Cytokine changes following LNG IUS insertion were minimal (IL5, month 3). Conclusions: Among ART users, C IUC is associated with increases in cervicovaginal cytokines, across functional classes. This supports LNG IUS as a less inflammatory option for WLHIV to minimize genital immune activation.

Study question: Does twin status and zygosity (monozygotic vs. dizygotic; same-sex vs. opposite-sex) predict fertility outcomes and intergenerational reproductive patterns compared with singletons? Summary answer: Among females, dizygotic twins had modestly higher completed fertility than singletons and monozygotic twins and were more likely to have a twin birth. Fertility did not differ meaningfully among males. These differences were restricted to the twin generation and did not persist in the next generation, indicating sex-specific and generation-specific effects rather than intergenerational transmission. What is known already: Dizygotic twinning is associated with heritable hyperovulation and higher natural fertility but less is known about whether being a twin or zygosity influences reproductive outcomes across generations. Study design, size, duration: A population-based longitudinal cohort study using part of the Finnish Twin Cohort and national population registers. Participants included monozygotic (MZ; N = 4,068), same-sex dizygotic (SSDZ; N = 8,890), opposite-sex dizygotic (OSDZ; N = 8,474) twins, and singleton controls (N = 1,193,404) born between 1945-1957 (total N =1,254,103; 49.1% female), their mothers, their children, and their grandchildren. Participants/materials, setting, methods: Fertility outcomes (number of biological children, age at first birth, childlessness, multiple births) were derived from Finnish population registers. Analyses followed a preregistered plan (https://osf.io/qbwv3) Main results and the role of chance: Differences in fertility between singletons and twins were modest and varied by sex and zygosity. Differences were observed generally in the mothers of twins and female twins themselves, with limited differences in the offspring of twins as compared to the offspring of singletons. Twins were slightly older at first birth, had fewer total biological offspring, but were more likely to have a twin birth. Dizygotic twins in particular differed from monozygotic twins and singletons. Limitations, reasons for caution: Findings are limited to individuals born in mid-20th-century Finland and thus generalizability to recent populations or non-Nordic contexts may be restricted. Further, analyses are observational, and causal inference is limited due to alternative motivation behind fertility rates like social or cultural reasons. Wider implications of the findings: These findings suggest that zygosity and sex interact to shape reproductive outcomes, offering insight into genetic and environmental contributions to fertility. They highlight the value of large twin cohorts for studying intergenerational reproductive trends and the representativeness of twins in population-based fertility research.

Background A mode of birth decision aid (DA) can provide information and support discussions about the potential risks and benefits (outcomes) associated with planning a vaginal or caesarean birth. Evidence shows that DAs can enhance patient knowledge, reduce decisional conflict, minimise inconsistencies in decision-making support, especially in maternity settings, and promote informed decision making. Despite these benefits, DAs specific to mode of birth are currently lacking in routine antenatal care. This paper outlines the process we followed to reach consensus on which outcomes of planned mode of birth should be included in a mode of birth DA. Methods Outcome identification and selection occurred in three phases. Phase 1 involved compiling a long list of outcomes from systematic reviews, the NICE Caesarean Birth Guidance and qualitative interviews with stakeholders. In Phase 2, this list was refined via a 2 round Delphi survey to prioritise outcomes considered important. An outcome reached consensus if [&ge;]70% of all participants, or 70% of women/partners rated it as critically important (7-9), and <15% rated it as not important (1-3). Phase 3 involved two stakeholder consensus meetings to finalise the outcome list. Results Seventy-one outcomes were identified. Following two Delphi rounds and consensus meetings, 54 outcomes were rated as critically important. Seventeen outcomes were consistently rated as not critical across both the survey and consensus phases, meaning that [&ge;]70% of participants in each phase did not consider them essential for informing women during pregnancy. Of these, 8 were retained due to NICE recommendations and ultimately, 9 outcomes were excluded. The final list included 44 maternal and 18 child outcomes. Maternal outcomes related to assistance with birth, complications at the time of birth, issues during recovery, pelvic floor, psychological issues, sexual function, and future pregnancy. Child outcomes related to morbidity and death, disease, obesity, issues with cognitive development and physical development. Conclusions Sixty-two priority outcomes were identified for inclusion in a planned mode of birth DA.

ObjectiveMenopause is a significant physiological transition with implications for health outcomes (e.g., cardiometabolic), yet gaps remain in understanding the menopause transition, including how menopause timing and type influence health outcomes. Large-scale cohort studies in midlife (age[~]40-60) females, including the All of Us Research Program (AoURP), provide opportunities to study menopause across diverse populations and data modalities. We characterized menopause-related data in AoURP, focusing on age distributions and concordance between EHR diagnosis codes and self-reported survey responses. MethodsWe analyzed menopause-related survey, EHR diagnostic code, and genomic data among [~]396,000 participants in AoURP with female sex. We summarized menopause data across modalities, overlap between survey, EHR, and genomic data, and age distributions overall and across sociodemographic characteristics. ResultsAmong [~]396,000 females, surveys captured [~]193,000 menopause observations, nearly seven times more than structured EHR diagnoses ([~]28,000), suggesting under-ascertainement in EHR data. Nearly all females ([~]99%) with an EHR menopause diagnosis also reported menopause in the survey. Approximately 22,000 participants had intersected EHR, survey, and genomic menopause-related data. Survey-based age patterns matched expectations, with participants <40 years predominantly reporting pre-menopausal status and those >60 years predominantly reporting post-menopausal status. A small subset (N{approx}1,700; 4%) (age>70 years) reported no menopause, suggesting response or recall bias. EHR menopause codes were concentrated after age>45 years, with a notable spike at age 65. Modest differences in survey-based menopause age distributions were observed by sociodemographic characteristics (e.g., race, ancestry). ConclusionsThese findings inform sampling strategies, power calculations, phenotype definition, and study design for menopause research using AoURP.