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Reproductive Health Matters

An international journal on sexual and reproductive health and rights

ISSN: 0968-8080 (Print) 1460-9576 (Online) Journal homepage:


To cite this article: (2009) Research, Reproductive Health Matters, 17:33, 214-222, DOI: 10.1016/


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Abortion and mental health: evidence from the United States

The US Task Force on Mental Health and Abor- tion was charged with examining and summaris- ing current scientific research addressing mental health factors associated with abortion, includ- ing psychological responses. They evaluated all empirical studies (n=50) published in English after 1989 that compared the mental health of women who had had an induced abortion to the mental health of comparison groups of women or that examined factors that predict mental health among women who had had an elective abor- tion in the US (n=23). Methodological problems were common.

The best evidence indicated that among adult women with an unplanned pregnancy the rela- tive risk of mental health problems was no greater if they had a single elective first-trimester abortion than if they delivered that pregnancy. Evidence on the relative mental health risks associated with multiple abortions was more equivocal. Posi- tive associations may be linked to co-occurring risks that predispose a woman to both multiple unwanted pregnancies and mental health prob- lems. Based on few studies, terminating a wanted pregnancy late in pregnancy due to fetal abnor- mality appeared to be associated with negative psychological reactions equivalent to those expe- rienced by women who miscarry a wanted preg- nancy or experience a stillbirth or newborn death, but less than those who deliver a child with life- threatening abnormalities. The differing pat- terns observed among women who terminate an unplanned versus a planned pregnancy highlight the importance of taking pregnancy intendedness and wantedness into account when seeking to understand psychological reactions. Some women experience sadness, grief and feelings of loss following termination of a pregnancy, and some experience clinically significant disorders, includ- ing depression and anxiety. However, there was no evidence that an association between abortion history and mental health was caused by the

abortion per se, as opposed to other factors. Sev- eral factors are predictive of negative psycho- logical responses following first trimester abortion in the US, many of which also predict negative psychological reactions to other types of stress- ful life events, including childbirth, and hence are not uniquely predictive of psychological responses following abortion. Prior mental health emerged as the strongest predictor of post-abortion mental health.1

1. Major B, Appelbaum M, Beckman L, et al. Report of the American Psychological Association (APA) Task Force on mental health and abortion (executive summary). American Psychological Association 2008. At: <


Sexual relations and the need for information among young people: Colombia

A survey of the sexual behaviour of 3,000 young people aged 12–20 in Bogota, Colombia, found that they are making autonomous decisions regarding their sexual lives. The main reasons for their first sexual relations were“love” (40.7%) and “desire” (30.1%). Few mentioned “boy/

girlfriend's pressure” (1.4%), or “friend's pres- sure” (0.8%). 61.7% had their first sexual rela- tions with their girl/boy friend and 20.5% with a friend. 76% of young men and 66% of young women had already had sexual relations. The ideal starting age according to the majority was between 15 and 18. A minority (7.5% of young men and 4.5% of young women) considered the ideal age was between 10 and 14, a belief that could signal an increased number of pregnan- cies at these ages. Reasons for not yet starting their sex lives included“prefer to become adult first” (27%), “not ready for sexual relations”

(22.5%), and “do not want to risk pregnancy”

(23% of men and 19% of women). Religious or cul- tural codes did not play an important role– just


3.8% stated as their principal reason that their values and beliefs did not allow them to. However, young people were confused about the function of contraception, with 66.5% answering yes as to whether a contraceptive method can prevent a sexual transmitted disease. Only 35% knew what sexual and reproductive rights were, and less than 11% expressed interest in such rights.

HIV/AIDS, sexually transmitted infections and pregnancy were the topics of most interest for them. The findings highlight the need to dissemi- nate clearer messages about contraception, sexual and reproductive rights, affection and sexual diversity, all of which were of little interest to the young people surveyed.1

1. Castellanos A. Survey studies sexual health of Bogota's young people. RH Reality Check, 11 February 2009.

Young Iranians delaying marriage

A survey by the national youth organisation of Iran found that more than one in four men aged

19–29 had had sex before marriage, and 13% of these cases resulted in unwanted pregnancies that led to abortion. Sex outside marriage and abortion are outlawed under Iran's Islamic legal system, and despite the government's goal of promoting marriage, the average marriage age has risen to 40 for men and 35 for women. The organisation who disclosed the statistics later tried to dismiss the findings as based on an unrepresentative sample. According to the orga- nisation, Iran has 15 million single young people, seven million of whom are past the govern- ment's recommended marriage age of 29. The trend is producing the “unpleasant and dan- gerous social side effects” of premarital sex.

The government introduced a £720 million fund to provide marriage loans, and there are plans to establish marriage bureaux to help people find partners. Many blame economic circum- stances for their failure to marry, but the trend may also be due to the availability of premarital sex and feminism among educated women, who no longer want to accept masculine domination through marriage.1

Saiza, Cordoba, Colombia, 2006


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1. Tait R. Premarital sex on rise as Iranians delay marriage, survey finds. Guardian (UK), 29 December 2008.

Intimate partner violence among couples in 10 DHS countries

This report analyses data from demographic and health surveys in Bangladesh, Bolivia, Dominican Republic, Haiti, Kenya, Malawi, Moldova, Rwanda, Zambia, and Zimbabwe, focusing on married or cohabiting women aged 20–44. The report pro- vides prevalence estimates for intimate partner violence; characteristics of women, their part- ners, relationships, households and communi- ties, to evaluate which women are most at risk;

and health outcomes in women potentially related to intimate partner violence. Intimate partner vio- lence is common; it is most common in Bangladesh (75%), Bolivia (52%), Zambia (45%), and least common in the Dominican Republic (15%) and Haiti (12%). One third of Bangladeshi women experienced spousal violence in the year preced- ing the survey, compared to 10% in the Domin- ican Republic. Women who saw their fathers beat their mothers were more likely themselves to be abused in all six countries where this was mea- sured. In half the countries, women who believed that wife beating was justified were more likely to report violence. Women's education was a pro- tective factor in Bangladesh, Bolivia, Kenya and Zimbabwe. Partner characteristics were not con- sistently associated with women's experience of vio- lence, although men's alcohol use was statistically significant for all eight countries where data were available. The consequences of spousal violence can be severe. In eight countries, abused women were more likely to have an unintended pregnancy, and in six countries they were more likely to report a history of abortion, miscarriage or stillbirth.1

1. Hindin MJ, Kishor S, Ansara DL. Intimate partner violence among couples in 10 DHS countries:

predictors and health outcomes. DHS Analytical Studies No.18. Calverton MD: Macro International Inc; 2008.

Violence against pregnant women:

Nigeria and New Zealand

As recognition grows of the prevalence of vio- lence against women, there is increasing interest

in the relationship between violence, pregnancy and pregnancy outcomes. Three studies show that intimate partner violence is far from rare against pregnant women, one of which shows a correlation with abortion and miscarriage. In Abeokuta, Nigeria, among 534 pregnant women attending health facilities, prevalence of violence within the 12 months prior to pregnancy was 14%. Polygamous union, low level of education in both woman and partner and consumption of alcohol by partners were significant (p<0.05) risk factors. Verbal abuse was the most common (66%); other types of abuse included flogging (11%), slaps (9.5%), threats of violence (6.8%) and forced sexual intercourse (2.7%). Most per- petrators were husbands (66%) and parents (16%).

Some 2.3% of pregnant women had experienced violence during their current pregnancy. Unplanned pregnancy (25%) was not significantly associated with violence. There were similarities in the forms of violence experienced before and during preg- nancy and the perpetrators.1

Among a population-based sample of 2,391 New Zealand women who had ever been preg- nant, aged 18–64 years, in two regions (urban and rural), almost one in three reported having had at least one miscarriage, and one in ten reported terminating a pregnancy. Controlling for potential confounders, women who had ever expe- rienced intimate partner violence were 1.4 times as likely to have had a miscarriage compared with women who had never experienced IPV (p<0.01), and were 2.5 times as likely to have had an induced abortion (p<0.0001).2

In Karachi, Pakistan, of 500 women who delivered a live singleton baby in four tertiary care hospitals, 44% reported abuse during the pregnancy, of whom 43% reported emotional abuse and 12.6% reported physical abuse. Fac- tors independently associated with abuse during pregnancy were number of living children, inter- familial conflicts, husband's exposure to mater- nal abuse, and husband's use of tobacco. Women who had adequate social support were less likely to be abused by their husbands.3

1. Fawole AO, Hunyinbo KI, Fawole OI. Prevalence of violence against pregnant women in Abeokuta, Nigeria. Australian and New Zealand Journal of Obstetrics and Gynaecology 2008;48(4):


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2. Fanslow J, Silva M, Whitehead A. Pregnancy outcomes and intimate partner violence in New Zealand. Australian and New Zealand Journal of Obstetrics and Gynaecology 2008;


3. Farid M, Saleem S, Karim MS, et al. Spousal abuse during pregnancy in Karachi, Pakistan. International Journal of Gynecology and Obstetrics 2008;101:


Determining the optimal screening interval with cervical cytology and HPV testing in Europe

Cytology screening has reduced the incidence of cervical cancer in countries with organised screening. To design cost-effective screening strategies combining human papillomavirus (HPV) testing with cervical cytology, the optimal screening interval must be determined. This study obtained large-scale data on the long- term predictive value of cytology and HPV testing for the development of cervical intra- epithelial neoplasia grade 3 (CIN3+). Data from seven primary HPV screening studies in six European countries were pooled, giving infor- mation on 24,295 women attending cervical screening who had had at least one cervical smear or HPV test during follow-up.

The cumulative incidence rate of CIN3+ after six years was considerably lower among women negative for HPV at baseline (0.27%, 95% CI, 0.12%–0.45%) than among women with nega- tive results on cytology (0.97%, 0.53%–1.34%).

By comparison, the cumulative incidence rate for women with negative cytology results at the most commonly recommended screening interval in Europe− three years − was 0.51% (0.23%–

0.77%). The cumulative incidence rate among women with negative cytology results who were positive for HPV increased continuously over time, reaching 10% at six years, whereas the rate among women with positive cytology results who were negative for HPV remained below 3%. There was a uniformly low rate of CIN3+ among women with negative results on both cytology and HPV tests. The authors con- clude that a consistently low six-year cumu- lative incidence rate of CIN3+ among women negative for HPV suggests that cervical screen- ing strategies in which women are screened for HPV every six years are safe and effective.1

1. Dillner J, Rebolj M, Birembaut P, et al. Long term predictive values of cytology and human papillomavirus testing in cervical cancer screening:

joint European cohort study. BMJ 2008;377:a1754.

Why STIs are increasing in Japan

Sexually transmitted infections (STIs) increased rapidly in Japan during the 1990s. To determine the epidemiological characteristics of STI patients, male cases (n=765) from 21 clinics across Japan and controls from the general population (n=1,167), aged 18 to 59 years, were compared using two datasets of nationwide sexual behaviour sur- veys conducted in 1999. Male STI patients were more likely to be under 40, unmarried and at least college/university educated, more likely to have had multiple partnerships in the pre- vious year, unprotected vaginal sex with regular partners, unprotected vaginal and/or oral sex with casual partners, and unprotected vaginal and oral sex with paid partners in the previous year.1 A high proportion of the men had had sex with women sex workers: 62% of cases and 10.5% of controls had paid for sex with women in the last year, of whom 47% of cases and 24% of controls who had paid for vaginal sex had not used a condom. For oral sex, 78%

of cases who had paid for sex had not used a condom. To improve STI control in Japan uni- versal condom use for oral and vaginal sex with sex workers should be encouraged. When sex work was legalised in some Australian states, the STI rate fell and condom use became uni- versal. Sex work in Japan is illegal, constrain- ing efforts to improve occupational health and safety of sex workers and their clients. Infor- mation on STIs is also limited, as they are not notifiable in Japan. Surveillance is a critical and inexpensive component of any public health intervention and its introduction may be easier than legalising the sex industry.2

1. Homma T, Ono-Kihara M, Zamani S, et al.

Demographic and behavioural characteristics of male sexually transmitted disease patients in Japan: a nationwide case-control study. Sexually Transmitted Diseases 2008;35(12):990–96.

2. Fairley CK, Onodera S. Opportunities for the prevention of sexually transmitted infections in Japan [Editorial].

Sexually Transmitted Diseases 2008;35(12):997–98.

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Promising news on microbicides

The US National Institutes of Health has announced promising results of a multi-site clinical trial − known as HPTN 035− of two candidate vaginal microbicides, carried out in South Africa, Malawi, Zambia, Zimbabwe and the US. Women who were offered PRO2000 gel plus condoms had 30% fewer HIV infections than those offered only condoms or condoms plus a placebo gel. Reported adher- ence to the gel was high at 81%. In another analy- sis accounting for the time that women did not use the product because they were pregnant, PRO2000 was 36% more protective against HIV compared to the control arms. The other microbi- cide tested, BufferGel, did not reduce HIV risk.

This is the first time a vaginal gel has been shown to reduce infection and represents a“proof of con- cept”. Another effectiveness trial of PRO2000, conducted by the UK-funded Microbicide Deve- lopment Programme, is in its final stages in South Africa, Tanzania, Uganda and Zambia. This trial− known as MDP 301− has enrolled over 9,000 women, three times the number in HPTN 035. The next generation of microbicide trials will focus on candidates that incorporate the same antiretroviral drugs that have been successfully used for AIDS treatment. Already a trial evaluating a tenofovir- based microbicide is underway in South Africa.1

1. Global Campaign for Microbicides. HIV prevention advocates welcome promising news on

microbicides. Press release, 9 February 2009. At:


Pregnancy during breastfeeding in rural Egypt Prolonged breastfeeding is encouraged in Egypt, but does not reliably protect against pregnancy except during the first six post-partum months provided the mother is exclusively or almost exclu- sively breastfeeding and has amenorrhoea. These criteria are known as the lactational amenorrhoea method of contraception (LAM). Reluctance to use other methods of contraception during lactation may result in unplanned pregnancy if LAM crite- ria are not fulfilled. 2,617 parous women attend- ing a hospital in Egypt for antenatal care were interviewed about their beliefs, breastfeeding practices and current pregnancy. More than 95% of women breastfed the child before their current pregnancy and the occurrence of preg-

nancy during breastfeeding was common (25.3%

of the women). Conception occurred during the first six months post-partum in 4.4%, before resumption of menstruation in 15.1% and while exclusively or almost exclusively breastfeeding in 28.1%. Only 10 pregnancies (1.5%) occurred when all the prerequisites of LAM were present.

Unintended pregnancy is common among breast- feeding women: 29% of pregnancies conceived during breastfeeding were unintended, 10% of women had considered terminating their preg- nancy while 4.4% of them reported trying to do so. Many of these unintended pregnancies occurred while breastfeeding is being relied upon for contra- ception. LAM must be properly taught, and women should start using another form of contraception as soon as any of the prerequisites of LAMis absent.1

1. Shaaban OM, Glasier AF. Pregnancy during breastfeeding in rural Egypt. Contraception 2008;77:350–54.

Micronutrient supplementation in pregnancy in developing countries

The beneficial effects of vitamin A, iodine, folic acid and iron supplementation on the outcomes of pregnancy and the health of newborns have been well documented in most populations, and WHO advocates the routine use of iron–folic acid supplements in antenatal care. Lately, interest has focused on the effects of multiple micronutrient supplementation in areas where deficiencies of multiple micronutrients are prevalent. Researchers examined the effect of daily supplements of iron– folic acid (60mg of iron) or a combination of 15 multiple micronutrients (with 30mg of iron, as recommended by Unicef) on maternal anaemia, duration of gestation, birthweight, neonatal and perinatal mortality in rural China. The comparison arm consisted of women randomly allocated to receive folic acid supplements, the regime pro- moted by the Ministry of China. Participants were 5,828 pregnant women with 4,697 live births.

Iron–folic acid supplementation signifi- cantly reduced the risk of early preterm delivery (<34 weeks), and early neonatal mortality com- pared with folic acid alone (RR 0.50, 95% CI, 0.27–0.94). Although supplementation with multi- ple micronutrients significantly increased birth- weight compared with folic acid by 42g, this did not translate into a significant reduction in early

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neonatal mortality. Both micronutrients and iron– folic acid significantly increased gestational age at birth and maternal haemoglobin concentrations, compared with folic acid alone, but nearly half of the women taking micronutrients and iron–folic acid remained anaemic in the third trimester.

Future endeavours should focus on identifying more optimal micronutritional approaches.1,2

1. Zeng L, Cheng Y, Dang S, et al. Impact of micronutrient supplementation during pregnancy on birth weight, duration of gestation, and perinatal mortality in rural western China: double blind cluster randomised controlled trial. BMJ 2008;337:a2001.

2. Hiremath G. Micronutrient supplementation in pregnancy in developing countries. BMJ 2008;337:a1942.

Medical abortion has no negative effects on future pregnancies

The long term safety of surgical abortion in the first trimester is well established. To determine whether medical abortion is equally safe, all women living in Denmark who had undergone an abortion for non-clinical reasons between 1999 and 2004 were identified, and information regarding their subsequent pregnancies was obtained from national registries dating back to 1973. Medication abortion, using mifepristone and misoprostol, became available in Denmark in 1997. Between 1999 and 2004, 30,349 women had had abortions of whom 16,883 had subse- quent pregnancies. Data on 11,814 pregnancies in women who had had a previous first trimes- ter medical abortion (2,710) or surgical abortion (9,104 women) showed after adjustment for potential confounders, that neither medical nor surgical abortion were associated with an increased risk of adverse birth outcomes, whether from ectopic pregnancy, spontaneous abortion, pre-term birth or low birthweight. Gestational age at medical abortion did not affect any of these outcomes.1

1. Virk J, Zhang J, Olsen J. Medical abortion and the risk of subsequent adverse pregnancy outcomes. New England Journal of Medicine 2007;357(7):648–53.

Ibuprofen versus paracetamol for pain relief during medical abortion

Pain is a common problem during medical abor- tion, which occurs with uterine contraction in response to misoprostol. To determine the effi- cacy of ibuprofen versus paracetamol in pain relief during medical abortion and to evaluate whether ibuprofen interferes with the action of misoprostol, a prospective double-blind con- trolled study was set up. 120 women underwent first-trimester termination of pregnancy. They received 600 mg mifepristone orally, followed by 400μg of oral misoprostol two days later.

They were randomised to receive ibuprofen or paracetamol when pain relief was necessary.

The majority of women (118 of 120) complained of abdominal pain after receiving misoprostol.

Pain was effectively managed with both drugs, but ibuprofen was found to be significantly more effective for pain relief compared with paraceta- mol (p<0.0001). There was no difference in the failure rate of medical abortion. Despite its anti- prostaglandin effects, ibuprofen appears to be more effective than paracetamol for pain reduc- tion during medical abortion and does not appear to interfere with the action of misoprostol.1

1. Livshits A, Machtinger R, David LB, et al. Ibuprofen and paracetomol for pain relief during medical abortion:

a double-blind randomised controlled study. Fertility and Sterility 2008 (20 March) E-pub ahead of print.

Oral vs. buccal route for misoprostol after mifepristone in first trimester medical abortion

After mifepristone was approved in the USA in 2000, vaginal use of misoprostol became a standard of care in early medical abortion.

However, alternative routes of misoprostol, specifically oral (immediately swallowing pills), buccal (holding pills in the cheek) and sublin- gual (holding pills under the tongue) are now of increasing interest to women. This study explored the use of oral and buccal misoprostol after mifepristone for terminating pregnancy up to 63 days gestation. 966 women seeking abortions at seven facilities in the USA were randomly assigned to 800 mcg oral or buccal misoprostol 24–36 hours after 200 mg mife- pristone, with follow-up 7–14 days later. Success rates in the oral and buccal groups were 91.3%

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(389/426) and 96.2% (405/421), respectively (p=0.003, RR 0.95). Ongoing pregnancy occurred in 3.5% of women who took oral misoprostol compared with 1.0% in the buccal group (p=

0.012, RR 3.71). Oral and buccal regimens per- formed similarly up to 49 days of pregnancy, but success with oral misoprostol decreased as pregnancy advanced. In pregnancies of 57–63 days, success with oral misoprostol fell to 85.1% and there were significantly more ongoing preg- nancies, whereas success remained high with buccal at 94.8% (p=0.015, RR 0.90). Adverse effects were similar, although fever and chills were reported approximately 10% more common with buccal use. Satisfaction and acceptability were high with both routes. Buccal misoprostol 800 mcg after mifepristone 200 mg is a good option for medical abortion up to 63 days of pregnancy. Oral misoprostol 800 mcg is also safe and effective up to 49 days, but success rates diminish after that.1

1. Winikoff B, Dzuba IG, Creinin MD, et al. Two distinct oral routes of misoprostol in mifepristone medical abortion: a randomized controlled trial. Obstetrics and Gynecology 2008;112(6):1303–10.

Interval between mifepristone and misoprostol for second trimester medical abortion The conventional timing of misoprostol admin- istration after mifepristone for second trimester medical abortion is 36–38 hours, but simulta- neous administration, which is more convenient, has not been studied. This randomised controlled trial of 142 women in Shanghai and Hong Kong is the first to compare the two intervals. Results show that the success rate of medical termination of pregnancy at 24 hours with 200 mg oral mife- pristone followed by vaginal misoprostol was significantly lower with the simultaneous regi- men (91.5%) compared with the 36–38 hour regimen (100%). The simultaneous use of mife- pristone and misoprostol was associated with a longer induction-to-abortion interval (median 10 hours compared to 4.9 hours) and a higher requirement of misoprostol. It was also asso- ciated with more side effects in terms of febrile episodes and chills and rigors. The increased side effects were probably due to the increased total amount of misoprostol required to induce abortion in the simultaneous administration group.

The effectiveness of the 36–38 hour regimen in

this study was similar to those previously pub- lished for this regimen, inferring external validity.

The study supports pre-treatment with mife- pristone 36–38 hours before misoprostol.1

1. Chai J, Tang OS, Hong QQ, et al. A randomised trial to compare two dosing intervals of misoprostol following mifepristone administration in second trimester medical abortion. Human Reproduction 2009;1(1):1–5.

Misoprostol alone for second trimester abortion: vaginal versus sublingual route When mifepristone is not available, abortion can be induced safely with misoprostol alone.

To identify an effective misoprostol-only regi- men for the termination of second trimester preg- nancy, 681 healthy pregnant women requesting medical abortion at 13–20 weeks gestation in 11 centres in Armenia, Georgia, Hungary, India, Slovenia, South Africa and Viet Nam were ran- domised to two treatment groups: 400 mcg of misoprostol sublingually or vaginally every three hours up to five doses, followed by sublingual administration of 400 mcg misoprostol every 3 hours up to five doses if abortion had not occurred after 24 hours. At 24 hours, the com- plete abortion rate was higher in the vaginal group: 85.9% vs. 79.8% in the sublingual group (95% CI, 0.5–11.8). Thus, equivalence could not be concluded, but the difference was driven by the nulliparous women, among whom vaginal administration was clearly superior to sublin- gual administration (87.3% versus 68.5%). No significant difference was observed between vagi- nal and sublingual treatments among parous women (84.7% versus 88.5%). The rates of side effects were similar in both groups except for fever, which was more common in the vaginal group. About 70% of women in both groups preferred sublingual administration. Repeat administration of misoprostol either vaginally or sublingually was effective and acceptable for second trimester abortion. Vaginal administra- tion was more effective than sublingual adminis- tration in the nulliparous women.1

1. von Hertzen H, Piaggio G, Wojdyla D, et al. Comparison of vaginal and sublingual misoprostol for second trimester abortion: randomized controlled equivalence trial. Human Reproduction 2009;24:106–12.

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Cumulative live birth rates after IVF Outcomes of in vitro fertilisation (IVF) treatment are traditionally reported as pregnancies per IVF cycle. However, a couple's primary concern is the chance of a live birth over an entire treat- ment course. This study estimated cumulative live birth rates among patients undergoing their first fresh-embryo, non-donor IVF cycle between 2000 and 2005 at one large centre. Couples were followed until either discontinuation of treat- ment or delivery of a live-born infant. Analyses were performed using both optimistic and con- servative methods. Optimistic methods assumed that patients who did not return for subsequent IVF cycles would have the same chance of a pregnancy resulting in a live birth as patients who continued treatment. Conservative methods assumed no live births among patients who did not return. Among 6,164 patients undergoing 14,248 cycles, the cumulative live birth rate after six cycles was 72% (95% CI, 70–74) with the optimistic analysis and 51% (95% CI, 49–52) with the conservative analysis. Among patients who were younger than 35 the corresponding rates after six cycles were 86% (95% CI, 83–88) and 65% (95% CI, 64–67). Among patients aged 40 or older, the corresponding rates were 42%

(95% CI, 37–47) and 23% (95% CI, 21–25). The cumulative live-birth rate decreased with increas- ing age (p<0.001). These results indicate that IVF may largely overcome infertility in younger women, but it does not reverse the age-associated decline in fertility.1

1. Malizia BA, Hacker MR, Penzias AS. Cumulative live-birth rates after in vitro fertilization [abstract].

New England Journal of Medicine 2009;360(3):236–43.

Impact of obesity on female fertility and fertility treatment

The worldwide incidence of obesity continues to escalate, with consequences not only for general health but also reproductive health.

This review finds that there is a high preva- lence of obese women in the infertile population and numerous studies highlight a link between obesity and infertility. 30–50% of women with polycystic ovarian syndrome are overweight or obese, and obesity may play a specific pathologi- cal role in this syndrome. Obesity is also related to

menstrual irregularities: rates of amenorrhoea, oligomenorrhoea and menorrhagia are four times higher in obese women. Obesity contributes to anovulatory and ovulatory infertility via an imbal- ance between hormones such as oestrogen and androgens. Obese women have a reduced concep- tion rate and reduced response to fertility treat- ment. There is a lower chance of a live birth after in vitro fertilisation, and impaired response to ovarian stimulation. Obesity reduces the likelihood that a woman is accepted for assisted conception techniques, particularly where health care is pub- licly funded. Obesity increases miscarriage and contributes to maternal and perinatal complica- tions. The risk of perinatal death and congenital abnormalities double in obese mothers. Reduc- tion of obesity, particularly abdominal obesity, is associated with improvements in reproductive function, and treatment for obesity itself should be an initial aim in obese infertile women before embarking on ovulation-inducing drugs or other assisted conception techniques.1

1. Zain MM, Norman RJ. Impact of obesity on female fertility and fertility treatment. Women's Health 2008;4(2):183–94.

Sexual problems among women in the United States

The PRESIDE survey is a cross-sectional, population-based, nationally-representative survey of 31,581 adult women in the United States. Two validated questionnaires were used to capture respondents' self-evaluation of cur- rent sexual behaviours and problems, and any distress about their sex life during the 30 days before the survey. 43.1% of women reported a sexual problem of some kind. Low desire was most common (38.7%), followed by low arousal (26.1%) and difficulty reaching orgasm (20.5%).

22.2% of all women had sexually-related per- sonal distress, most commonly associated with low sexual desire (10%). Any distressing sexual problem (both sexual problem and sexually- related personal distress) occurred in 12% of respondents, and was more common in women aged 45–64 years than in younger or older women.

Correlates of distressing sexual problems included poor self-assessed health, low education level, depression, anxiety, thyroid conditions, and urinary

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incontinence. Lower levels of distress in elderly women, despite higher levels of sexual problems, may be due to the significance of other medical problems, changes in partner status and sexual function, or increased importance of other fac- tors in relationships of long duration.1

1. Shifren JL, Monz BU, Russo PA, et al. Sexual problems and distress in United States women:

prevalence and correlates. Obstetrics and Gynecology 2008;112(5):970–78.

The Hajnal line: dividing Europe by nuptiality behaviour

The Hajnal line links St Petersburg, Russia and Trieste, Italy (see Figure 1). (The dotted line is Hajnal's. The solid lines show areas of high nuptiality west of the Hajnal line.) The father of RHM's finance officer Paula, John Hajnal, who died in November 2008, showed with this line in 1965 that Europe is divided into two areas, characterised by different levels of nuptiality.

West of this line, the average age of women at first marriage was 24 or more and for men 26, spouses were relatively close in age, and 10%

or more of adults never married. East of the line, the mean age of both sexes at marriage was earlier, spousal age disparity was greater and marriage nearly universal. Subsequent research has amply confirmed Hajnal's continental divide.

The Western European pattern restricted fertility, especially when it was coupled with very low levels of childbirth out of wedlock. Birth control took place by delaying marriage more than sup- pressing fertility within it. The region's late mar-

riage pattern has received considerable attention, in part because it appears to be unique; it was not found in any other part of the world prior to the 20th century. Many historians have wondered whether this unique regime might explain, in part, why capitalism first took root in northwestern Europe, contributing to the region's relatively low mortality rates, and the precocious formation of a mobile class of landless wage-earners. Others have highlighted the significance of the late marriage pattern for gender relations, the relative strength of women's position within marriage, and the vitality of women's community networks.1

1. Hajnal J. European marriage pattern in historical perspective in D.V. Glass and D.E.C. Eversley, (eds.) Population in History, Arnold, Londres, 1965.

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