Recently, large-scale population analytics have allowed for the exploration of birth month/season hypotheses among large cohorts of people. One study used 1.7 million patients from Columbia University in New York City (NYC) to confirm associations between neurological conditions, respiratory condition and reproductive conditions with birth month. [ 7 ]  In addition, they uncovered an association between cardiovascular diseases and birth month. [ 7 ]  This was subsequently confirmed in a separate study, also using data from NYC. [ 8 ]  Researchers also explored mechanisms correlated with birth season in a large population study including data from 10.5 million patients, from three countries (US, South Korea, and Taiwan) and six study sites. [ 9 ]  They found correlations between relative age and school cutoff periods. And that first trimester exposure to fine air particulates increased the risk of atrial fibrillation later in life. [ 9 ]


There is evidence that suggests that children born earlier in an academic year  gain an advantage over  their later-born classmates:


Birth rates of people who later die by suicide show disproportionate excess for April, May and June compared with the other months. Overall, the risk of suicide increases by 17% for people born in the spring–early summer compared with those born in the autumn–early winter; this risk increase was larger for women (29.6%) than for men (13.7%). [ 11 ]


Research works in Sweden show that those who preferred suicide by hanging rather than poisoning or petrol gases were significantly more likely to be born during February–April. Maximum of the month-of-birth curve for preferring hanging was for March–April and the minimum was for September–October. [ 12 ]


However, other studies have shown that there is no effect of season of birth on psychological disorders, such as depression and anxiety.  [ 13 ]


Late termination of pregnancy , also referred to politically as  third trimester abortion , [ 2 ]  describes the termination of  pregnancy  by inducing  labor  during a late stage of  gestation . [ 3 ]  In this context,  late  is not precisely defined, and different medical publications use varying  gestational age  thresholds. [ 3 ]  As of 2015,  in the United States , more than 90% of abortions occur before the 13th week, 1.3% take place after the 21st week, [ 4 ]  and less than 1% occur after 24 weeks. [ 5 ] [ 6 ]


Reasons for late terminations of pregnancy include circumstances where a pregnant woman's health is at risk or when  birth defects , such as lethal  fetal abnormalities , have been detected. [ 7 ] [ 8 ]


In the United States, the  mortality rate  for legal abortions overall is less than 1 in 100,000 procedures performed. The rate of mortality and  morbidity  increases with the gestational age of the fetus, so patients who have decided to have an abortion are strongly encouraged to get it early. [ 9 ]  Still, later abortion is not associated with any greater net negative physical or mental health outcomes (including mortality) than full-term pregnancy and childbirth in the United States. [ 10 ] [ 8 ] [ 11 ]


Late termination of pregnancy is more controversial than abortion in general. All countries in Europe only permit abortion later in pregnancy (after 10-14 weeks in most countries, 18 weeks in  Sweden  and  Iceland , and 24 weeks in  the Netherlands  and  Great Britain ) if specific circumstances are present, generally when the pregnancy represents a serious danger to the life, or to the physical or mental health of the woman, or when a serious malformation or anomaly of the  fetus  is diagnosed. [ 12 ]


A late termination of pregnancy often refers to an induced ending of pregnancy after the  20th week  of  gestation , i.e. after a  fetal age  (time since conception) of about 18 weeks. The exact point when an abortion is considered late-term, however, is not clearly defined.  In three articles published in 1998 in the same issue of the  Journal of the American Medical Association  (JAMA), two chose the 20th week of gestation and one chose the 28th week of gestation as the point where an abortion procedure would be considered late-term. [ 13 ] [ 14 ] [ 15 ]


In the United States, the point at which an abortion becomes late-term is often related to  fetal viability  (ability of the  fetus  to survive outside the  uterus ). Thus, late-term abortions are sometimes referred to as post-viability abortions. [ 16 ]


There is no sharp limit of development, age, or weight at which a fetus becomes viable. [ 17 ]  A 2015 study found that even with active treatment, no infants born at less than 22 weeks survived, but an infant born at 21 weeks and one day in April of 2021 did survive his premature birth. [ 18 ]  At 23 weeks survival without severe impairment is less than 2%, and at 25 weeks, up to 30% might survive without severe impairment. [ 19 ] [ 20 ]  According to studies between 2003 and 2005, [ 21 ] [ 22 ] [ 23 ]  20 to 35 percent of babies born at 24  weeks of gestation  survived, while 50 to 70 percent of babies born at 25 weeks, and more than 90 percent born at 26 to 27 weeks, survived. [ 20 ]  Because the chance of survival is variable based on interventions available and the weight and sex of the fetus, there is no consensus on viability. The American College of Obstetricians and Gynecologists reports that 23% of abortion providers offer abortions at 20 weeks of gestation and later, most often using a method called  dilation and evacuation  (D&E). [ 24 ]


Reasons for late terminations of pregnancy include when a pregnant woman's health is at risk or when  lethal fetal abnormalities  have been detected. [ 7 ] [ 8 ]


A 2013 study found, after excluding abortion "on grounds of fetal anomaly or life endangerment", that women seeking late abortions "fit at least one of five profiles: They were raising children alone, were depressed or using illicit substances, were in conflict with a male partner or experiencing domestic violence, had trouble deciding and then had access problems, or were young and nulliparous". The study concluded that "bans on abortion after 20 weeks will disproportionately affect young women and women with limited financial resources". [ 36 ]


The NHS records the reasons given for abortions at all stages of development. In 2015, 2,877 abortions were performed at 20 weeks or above, and only 230 of these at or beyond 24 weeks gestation. Of all abortions at 20 weeks or above, 23 (0.8%) were performed to save the life of the pregnant woman, 1,801 (63%) were performed for mental or physical health reasons, and 1046 (36%) were performed because of fetal abnormalities. [ 37 ]


As of 1998, among the 152 most populous countries, 54 either banned abortion entirely or permitted it only to save the life of the pregnant woman. [ 38 ]


On the other hand, as of 1998, 49 of the 152 most populous countries allowed abortion without restriction as to reason, but 44 of these required specific justification after a particular  gestational age : [ 38 ]


Dutch Criminal Code defines the "viability" of a fetus to 24 weeks, [ 39 ]  but doctors  de facto  limit on-request abortions to 22 weeks as a margin of error. [ citation needed ]


As of 2011 among those countries that allowed abortion without restriction as to reason, the gestational limits for such abortions on request were: 37 countries set a gestational limit of 12 weeks, 7 countries of 14 weeks, 4 did not set limits, 3 at viability, 3 at 10 weeks, one at 90 days, one at 8 weeks, one at 18 weeks, and one at 24 weeks. In addition,  abortion in Australia , and, to a certain extent,  abortion in the United States , is regulated at state/territory level, and laws vary by region. [ 40 ]


In these countries, abortions after the general gestational age limit are allowed only under restricted circumstances, which include, depending on country, risk to the woman's life, physical or mental health, fetal malformation, cases where the pregnancy was the result of  rape , or poor socio-economic conditions. For instance, in Italy, abortion is allowed on request up until 90 days, after which it is allowed only if the pregnancy or childbirth pose a threat to the woman's life, a risk to physical health of the woman, a risk to mental health of the woman; if there is a risk of fetal malformation; or if the pregnancy is the result of rape or other sexual crime. [ 41 ]  Denmark provides a wider range of reasons, including social and economic ones, which can be invoked by a woman who seeks an abortion after 12 weeks. [ 42 ]


Abortions at such stages must in general be approved by a doctor or a special committee, unlike early abortions which are performed on demand. The ease with which the doctor or the committee allows a late term abortion varies significantly by country, and is often influenced by the social and religious views prevalent in that region. [ citation needed ]


Some countries, like Canada, China (mainland only) and  Vietnam  have no legal limit on when an abortion can be performed. [ 38 ]


The  United States Supreme Court  decisions on abortion, including  Roe v. Wade ,  allow states to impose more restrictions on post-viability abortions than during the earlier stages of pregnancy.


As of December 2014, forty-three states had bans on late-term abortions that were not  facially  unconstitutional under  Roe v. Wade  or  enjoined  by court order. [ 43 ]  In addition, the Supreme Court in the case of  Gonzales v. Carhart  ruled that Congress may ban certain late-term abortion techniques, "both previability and postviability", [ 44 ]  as it had done in banning  intact dilation and extraction  with the  Partial-Birth Abortion Ban Act of 2003 . [ 45 ]


The Supreme Court has held that bans must include exceptions for threats to the woman's life, physical health, and mental health, but four states allow late-term abortions only when the woman's life is at risk; four allow them when the woman's life or physical health is at risk, but use a definition of health that abortion-rights organizations believe is impermissibly narrow. [ 43 ]   Note that just because a portion of a state's law is found to be unconstitutional does not mean that the entire law will be deemed unconstitutional: "[I]nvalidating the statute entirely is not always necessary or justified, for lower courts may be able to render narrower declaratory and injunctive relief," meaning the court could declare that only those parts of the law that are violative of the Constitution are invalid (declaratory relief), or that the court can prohibit the state from enforcing those portions of the law (injunctive relief). [ 46 ]


Eighteen states prohibit abortion after a certain number of weeks' gestation (usually 22 weeks from the last menstrual period). [ 43 ]   The U.S. Supreme Court held in  Webster v. Reproductive Health Services  that a statute may create "a presumption of viability" after a certain number of weeks, in which case the physician must be given an opportunity to rebut the presumption by performing tests. [ 47 ]  Because this provision is not explicitly written into these state laws, as it was in the Missouri law examined in  Webster , abortion-rights organizations believe that such a state law is unconstitutional, but only "to the extent that it prohibits pre-viability abortions". [ 48 ]


Ten states (although Florida's enforcement of such laws are under  permanent injunction ) require a second physician's approval before a late-term abortion can be performed. [ 43 ]   The U.S. Supreme Court struck down a requirement of "confirmation by two other physicians" (rather than one other physician) because "acquiescence by co-practitioners has no rational connection with a patient's needs and unduly infringes on the physician's right to practice". [ 49 ]  Abortion-rights organizations, such as the  Guttmacher Institute , posit that some of these state laws are unconstitutional, based on these and other Supreme Court rulings, at least to the extent that these state laws require approval of a second or third physician. [ 43 ]


Thirteen states have laws that require a second physician to be present during late-term abortion procedures in order to treat a fetus if born alive. [ 43 ]  The Court has held that a doctor's right to practice is not infringed by requiring a second physician to be present at abortions performed after viability in order to assist in the case of a living fetus. [ 50 ]  It is not common for live infants to be born after an abortion at any stage in pregnancy. [ 51 ]


In 2019, a US Senate Bill entitled the "Born-Alive Abortion Survivors Protection Act" raised the issue of live birth after abortion. [ 52 ] [ 53 ]  The bill would mandate that medical providers resuscitate neonates delivered showing signs of life during an abortion process. [ 52 ] [ 53 ]  During the debate around this issue, US Republicans alleged that medical providers "execute" live-born babies. Existing US laws would punish execution as homicide. Furthermore, US abortion experts refute the claim that a "born-alive" fetus is a common event and oppose enactment of laws that would mandate resuscitation against the wishes of the parents. [ 53 ] [ 54 ]


1.3% of abortions occur after 21 weeks of pregnancy in the US. Although it is very uncommon, women undergoing surgical abortion after this gestational age sometimes give birth to a fetus that may survive briefly. [ 55 ] [ 56 ] [ 57 ]  The periviable period is considered to be between 20 and 25 weeks gestation. [ 58 ]   Long-term survival  is possible after 22 weeks. [ 59 ]  However, odds of long-term survival between 22 and 23 weeks are 2–3 percent and odds of survival between 23 and 24 weeks are 20 percent. [ 60 ]  "Intact survival", which means survival of a neonate without subsequent damage to organs such as the brain or bowel is 1% at 22 weeks and 13% at 23 weeks. [ 60 ]  Survival odds increase with increasing gestational age. [ 60 ]


If medical staff observe signs of life, they may be required to provide care: emergency medical care if the child has a good chance of survival and palliative care if not. [ 61 ] [ 62 ] [ 63 ]   Induced fetal demise  before termination of pregnancy after 20–21 weeks gestation is recommended by some sources to avoid this and to comply with the US  Partial Birth Abortion Ban . [ 64 ] [ 65 ] [ 66 ] [ 67 ] [ 68 ]  Induced fetal demise does not improve the safety of an abortion procedure and may incur risks to the health of the woman having the abortion. [ 65 ]


There are at least four medical procedures associated with late-term abortions:


This article provides an  overview of human  sterilization  by country . While many countries permit voluntary sterilization for  contraceptive  purposes, some permit it only for medical or  eugenic  purposes. Additional restrictions may include  minimum age ,  parental  or  spousal consent . [ 1 ]


Male expendability , the  relative expendability argument , or the  expendable male hypothesis , is the idea that the lives of male humans are of less concern to a  population  than those of female humans because they are less necessary for population replacement. Since the 1970s, anthropologists have used the concept of male expendibility to study such things as  polygyny ,  matrilinearity , and  division of labor by gender role .


The concept comes from the idea that, from a  reproductivity  standpoint, one male may be able to impregnate or otherwise father offspring with many females. In humans, this would mean that a population with many reproducing women and few reproducing men would be able to grow more easily than a population with many reproducing men and few reproducing women.


According to Carol Mukhopadhyay and Patricia Higgins, the concept of male expendability was first described by fellow anthropologist  Ernestine Friedl  in 1975, [ 1 ]  though she gave it no particular name.   Friedl noted that most hunter-gatherer and horticultural groups that she had studied for her book,  Women and Men: An Anthropologist's View , gave the tasks of hunting and warfare to men, employing women very sparingly or not at all.  She hypothesized that this could be because hunting and warfare required the men to be away at home for long, unpredictable periods, which was not  compatible with the care of young children  in which many women were heavily occupied and could be because fewer men would be needed to replenish the population, given that women in horticultural societies were limited to about one child every three years. [ 2 ]


The idea of male expendability in  humans  stems from the assumption that the  biological  differences in the roles of the sexes in procreation translate into societal differences in the level of bodily risk considered appropriate for men and women. In  human reproduction , it requires far less time and energy for a man to produce  sperm  and  semen  and complete  sexual intercourse  than for a woman to complete  pregnancy  and childbirth. Male expendability takes the idea that one or a few men could therefore father children with many women such that a given population could still grow if it had many child-bearing women and only a few men but not the other way around. [ 3 ] [ 4 ]  Anthropologist Ernestine Friedl specifically cited the slow average reproductive rates of women in extant hunter-gatherer and horticultural societies of the 1970s (one child in three years) as a reason why this might be important. [ 2 ]


Anthropologists note that "most societies in the ethnographic record" allow polygyny, in which a man may have more than one female partner but a woman may not or at least is not encouraged to have more than one male partner.  In the male expendability model, it therefore makes sense for societies to assign the most dangerous jobs to men rather than to women. [ 5 ]   Anthropologists have used the idea of male expendability to study such subjects as  polygyny ,  matrilineality , [ 6 ] [ 7 ]  and  division of labor by gender . [ 5 ]


Dundes, Streiff, and Streiff link the concept to a male fear of being obsolete in reproduction with inspiration from feminist philosopher  Sara Ruddick . [ 8 ]


The  patriarchal  cognitive frame assigns the role of  sex object  to women and assigns to men the role of  violence object , with male expendability being corollary to the sexual objectification of women. [ 9 ] : 59   This form of male expendability includes the social expectation that men will step in to defend others from danger, work the most dangerous jobs, and risk death or serious injury by doing so. [ 10 ]


Ivana Milojević argues that while  patriarchy  assigns the role of  sex object  to women, it assigns to men the role of  violence object , with male expendability being corollary to the sexual objectification of women. [ 9 ]  Social psychologist  Roy Baumeister  argues that it is common within cultures that the most dangerous jobs are male dominated; job-related deaths are higher in those occupations. Men make up the great majority of construction workers, truck drivers, police, fire fighters, and armed service members. [ 11 ] [ 12 ]  Baumeister also notes that some genetic studies indicate that, in prehistoric times, more men than women lived and died without ever reproducing. "It would be shocking if these vastly different reproductive odds for men and women failed to produce some personality differences," he said in one speech. Baumeister concludes in his book, "Most cultures see individual men as more expendable than individual women." [ 13 ] [ 14 ] [ 15 ]


Anarcho-capitalist  economist  Walter Block  argues in  The Case for Discrimination  that male expendability is the result of women being the bottleneck of reproductive capacity in a population. [ 16 ]


Norwegian sociologist and scholar of  men's studies   Øystein Gullvåg Holter  argues that the male-led  Russian government 's belief in male expendability contributed to their delay in seeking international help during the  Kursk  submarine disaster , in which an all-male crew of 118 personnel was lost. He states, "If 118 women had been killed, alarm bells regarding discrimination against women would probably have gone off around the world." He states that able-bodied males were viewed as a more legitimate target during wars in  Bosnia ,  Kosovo ,  Timor ,  Rwanda , and  Chechnya . [ 17 ]


Miscarriage and grief   are both an event and subsequent process of grieving that develops in response to a  miscarriage . [ 1 ]  Almost all those experiencing a miscarriage experience  grief . [ 2 ] [ 3 ]  This event is often considered to be identical to the  death of a child  and has been described as traumatic. [ 4 ] [ 5 ] [ 6 ]   "Devastation" is another descriptor of miscarriage. [ 7 ]  Grief is a profound, intensely personal sadness stemming from irreplaceable loss, often associated with sorrow, heartache, anguish, and heartbreak. [ 8 ]  Sadness is an emotion along with grief, on the other hand, is a response to the loss of the bond or  affection  was formed and is a process rather than one single emotional response. Grief is not equivalent to depression. [ 9 ]  Grief also has physical,  cognitive , behavioral, social, cultural, and philosophical dimensions. [ 10 ]  Bereavement and  mourning  refer to the ongoing state of loss, and grief is the reaction to that loss. [ 1 ] [ 11 ] [ 12 ]   Emotional responses may be  bitterness ,  anxiety ,  anger ,  surprise ,  fear , and  disgust  and  blaming  others; these responses may persist for months. [ 13 ] [ 14 ] [ 15 ] [ 16 ] [ 17 ]   Self-esteem can be diminished as another response to miscarriage. [ 13 ]  Not only does miscarriage tend to be a traumatic event, women describe their treatment afterwards to be worse than the miscarriage itself. [ 18 ]


A miscarriage can often be "heart-breaking". [ 19 ]  A miscarriage can affect the women, husband, partner, siblings, grandparents, the whole family system and friends. [ 20 ]  Almost all those experiencing a miscarriage go through a  grieving  process. [ 1 ] [ 2 ] [ 3 ] [ 13 ]  Serious emotional impact is usually experienced immediately after the miscarriage. [ 1 ]  Some may go through the same loss when an  ectopic pregnancy  is terminated. [ 10 ] [ 21 ]  In some, the realization of the loss can take weeks. Providing  family support  to those experiencing the loss can be challenging because some find comfort in talking about the miscarriage while others may find the event painful to discuss. The father of the baby can have the same sense of loss. Expressing feelings of grief and loss can sometimes be harder for men. Some women are able to begin planning their next pregnancy after a few weeks of having the miscarriage. For others, planning another pregnancy can be difficult. [ 22 ] [ 23 ]  Organizations exist that provide information and counselling to help those who have had a miscarriage. [ 22 ] [ 24 ] [ 25 ]  Some women have a higher risk of developing prolonged grief and complicated grief than others. [ 26 ]  A factor that can affect grief for men is finding help in an environment that is traditionally women-focused for maternity care and support. [ 27 ]


Miscarriage has an emotional effect and can also lead to psychological disorders. One discorder that can develop is primary maternal preoccupation. This is defined as a " ...'special psychiatric condition' in which the pregnant woman identifies with her baby, highlights the crisis a woman faces when the baby with whom she is preoccupied and identified dies..." [ 11 ]  Grieving manifests itself differently for each woman after miscarriage. It may often go unrecognized. [ 11 ]  The grief that follows a miscarriage resembles, but is not the same as, the grief experienced after the loss of a family member. [ 28 ]  Disbelief, depression, anger, and yearning, are described as being a part of the normal grieving process. [ 29 ] [ 30 ] [ 9 ]  These reactions remain from three to nine months after the loss. Forty-one percent of parents experience a normal, expected decline in grief in the first two years while 59% were delayed in the resolution of their grief. [ 29 ]


Grieving can create feelings of  loneliness . [ 31 ]
This grieving has been called a type of   psychological trauma . [ 11 ] [ 5 ]  Other serious consequences can develop including depression,  anxiety disorder ,  post-traumatic stress disorder , and  somatoform disorder . These responses all are associated with grieving after a miscarriage. [ 32 ]  Some women are able to complete the grieving process a few weeks after the miscarriage and start anticipating their next pregnancy. Planning another pregnancy is traumatic for others. The impact of a miscarriage can be "crippling" psychologically. [ 13 ]  Anger can be directed toward those who have had successful  pregnancies and children. [ 5 ] [ 10 ]   A woman can grieve the "loss of a future child" and question her own role as a mother. [ 5 ]  They may blame themselves or their partner for the miscarriage. [ 1 ] [ 31 ] [ 16 ] [ 33 ]


Unsuccessful attempts to become pregnant through  in vitro fertilization  (IVF) can also elicit a similar grief response in women. [ 16 ]  Those experiencing a late miscarriage may have more significant distress compared to those who have experienced a miscarriage in the first trimester. [ 32 ]  Even depression can occur. [ 11 ]


"Women today...are aught in a unique historical moment: technology encourages them to form emotional attachments to their pregnancies, but society has not developed traditions to cushion the shock when those attachments are shattered." [ 34 ]


Descriptions of the miscarriage are expressed in non-clinical terms by those who have experienced the event.


Miscarriage has been found to be a traumatic event and a major loss for women. [ 18 ]  Pregnancy loss, including induced abortion is a risk factor for mental illness. The impact of miscarriage can be underestimated. [ 37 ] [ 6 ]  The trauma can be compounded if the miscarriage was accompanied by visible and relatively large amounts of blood loss. [ 38 ]
 Bipolar disorders  are associated with miscarriage. Depression and bipolar disorder becomes evident after a miscarriage in 43% of women. Some women are more likely to experience complicated and prolonged grief than others. [ 29 ]


Women experiencing miscarriage are at risk for grief reactions, anxiety or depression. [ 1 ]   Obsessiveness regarding the miscarriage can develop. [ medical citation needed ] [ 38 ]   Primary maternal preoccupation is also considered a consequence of miscarriage. This condition can occur if a woman who develops a close bond "with her baby" experiences the loss of the pregnancy. [ 11 ] [ medical citation needed ]


Different grieving "styles" can exist and vary between individuals. There can be a complete avoidance of dealing with the memories of the miscarriage and there can be an "obsessive" concentration on an event in the miscarriage. This is in contrast with the expected ability to "reminisce about the loss of a loved one". [ 38 ]   Complicated grief  differs from the more common form of grief that occurs after a miscarriage. The grieving process associated with other events such as the loss of a spouse or parent is expected to decline in predictable and steady rate. This not true for those experiencing grief after a miscarriage because only 41% follow the expected decline in grief while most, 59% do not fit this pattern. [ 29 ]


Instrumental grief can be active and/or problem-focused. Examples include working on house-related projects, creative tasks, and more. Men experiencing the loss of a baby may go through this type of grieving. [ 27 ]


Miscarriage is associated with  posttraumatic stress disorder . [ 6 ] [ 39 ] [ 29 ] [ 40 ]
Risks for developing PTSD after miscarriage are: emotional pain, expressions of emotion, and low levels of  social support. [ 39 ]  Even if relatively low levels of stress occur after the miscarriage, symptoms of PTSD including flashbacks, intrusive thoughts, dissociation and hyperarousal can later develop. [ 38 ]  The effects of stress can complicate miscarriage. [ 18 ] [ 15 ]  Miscarriage is a stressful event and because stress is a risk factor for subsequent miscarriage, its presence can become part of cycle that continues. [ 18 ]  Lower stress levels are associated with more favorable outcomes in future pregnancies while higher stress levels increase the risk. [ 41 ]


Physical recovery from miscarriage can have an effect on emotional disturbances. The body has to recover from the sudden pregnancy loss. In some instances  fatigue  is present.  Insomnia  can be a problem. [ 13 ] [ 14 ] [ 10 ]  The miscarriage is very upsetting to the family and can generate very strong emotions. Some women may feel that the miscarriage occurred because they somehow had caused it. Others may blame the father or partner for the miscarriage. [ 13 ] [ 42 ]  Coping with a miscarriage can very greatly between women and families. [ 1 ] [ 14 ]  Some find it difficult to talk about the miscarriage. [ 14 ] [ 13 ]  The narratives of women tend to coincide with quantified and measurable effects. [ 11 ]  Some women engage in activities that are believed to aid in recovery such as therapy, religion and art. [ 36 ]
Counseling can be offered but effective interventions to assist in recovery have been difficult to identify due to the reports of efficacy [ 43 ]  and ineffective counseling. Comparisons are hard to make. [ 1 ] [ 13 ] [ 32 ]  Despite the lack of studies that describe effective interventions for those with grief after a miscarriage, some clinicians still offer counselling and follow-up to help women recover and adapt to the loss. [ 44 ]


Recommendations to help recover from the event include:


Generally, the impact of experiencing miscarriage is underestimated. [ 6 ] [ 37 ]  Other methods used to promote recovery are relaxation techniques, guided imagery, and "thought-stopping". Even Gestalt role-playing has been used. Some women can "emotionally relocate the child", redefine a relationship "with the missing child", and engage in "continuing the bond" to incorporate the loss into their life experiences. [ 38 ]


Women who have miscarried report that they were dissatisfied with the care they received from physicians and nurses. [ 12 ]  One observer highlights the insensitivity of some health care providers when they approach the grieving mother "...by playing down her emotion as somehow an irrational response..." [ 33 ] [ 42 ]  Clinicians may not recognize the psychological impact of the miscarriage and can "expect parents to move on with their lives." [ 33 ]


Since the experiences of women can vary so widely, sensitive nursing care afterward is appropriate. [ 46 ]


One emotional response to miscarriage is the strong apprehension that can develop anticipating a subsequent pregnancy. [ 1 ] [ 13 ] [ 14 ]  Procreation abilities may also be questioned by the woman. [ 13 ] [ 5 ]  Significant distress can develop in the other children in the family when they think a sibling has died. They may regard this as a baby they did not get to meet. They can also experience grief and guilt find it difficult to express these emotions to their parents. The siblings may feel a need to act as if everything is the same and that they are unaffected in an attempt to protect their parents from their own feelings. Children can also need help, understanding and the ability to make sense of the event. [ 47 ]  Some things that can help children process grief include allowing them to express themselves or ask questions, becoming involved in the memory process, and more. [ 48 ]


Rituals that recognize the loss can be important in coping. [ 49 ]  Family and friends often conduct a memorial or burial service. [ 1 ] [ 22 ]  Hospitals also can provide support and help memorialize the event. Depending on locale others desire to have a private ceremony. [ 22 ]  The religious faith of the woman and family impacts the grief process. [ 50 ]  Conversely, the lack of recognition that the miscarriage has occurred by family and friends can be troubling and add to the trauma of the event. [ 51 ]


Grieving after the loss of a child through miscarriage in other cultures can vary from western culture. [ 52 ] [ 53 ]   An individual's culture plays a large role in determining an inappropriate pattern of grief, and it is appropriate to take into account cultural norms before reaching a complicated grief diagnosis. [ 54 ]  There are cultural differences in emotional levels, how these are expressed and how long they are expressed. External symptoms of grief differ in non-Western cultures, presenting increased somatization. [ 55 ]  Narratives by Swedish women include their own perception of losing a child. Investigations describe their grief over their miscarriage: "When miscarriage occurs it is not a gore, an embryo, or a fetus they lose, it is their child. They feel that they are the cause of the miscarriage through something they have done, eaten, or thought. They feel  abandonment  and they grieve for their profound loss; they are actually in bereavement." [ 56 ]  Native American women have cut their long hair following the death of a family member. [ 57 ]  The narratives of women tend to coincide with quantified and measurable effects. [ 11 ]  In women who are induced to have an abortion, an identical grieving process can occur. [ 51 ]  The emotional responses to a spontaneous abortion (miscarriage) and an elective abortion are sometimes identical. [ 1 ]  Spanish women experience grief in much the same way in the rest of Western culture. [ 58 ]  Some women find online forums helpful. [ 45 ]


Ovulation  is an important part of the  menstrual cycle  in female  vertebrates  where the  egg cells  are released from the  ovaries  as part of the  ovarian cycle . In female humans ovulation typically occurs near the midpoint in the menstrual cycle and after the  follicular phase . Ovulation is stimulated by an increase in  luteinizing hormone  (LH). The  ovarian follicles  rupture and release the secondary  oocyte  ovarian cells. [ 1 ]


After ovulation, during the  luteal phase , the egg will be available to be  fertilized  by  sperm . If it is not, it will break down in less than a day. Meanwhile, the  uterine  lining ( endometrium ) continues to thicken to be able to receive a  fertilized egg . If no  conception  occurs, the uterine lining will eventually break down and be shed from the body via the  vagina  during  menstruation . [ 2 ]


Some people choose to track ovulation in order to improve or aid becoming pregnant by timing intercourse with the their ovulation. [ 3 ]  The signs of ovulation may include  cervical mucus  changes, mild  cramping  in the abdominal area, and a small rise in  basal body temperature . Medication is also sometimes required by those experiencing infertility to induce ovulation. [ 3 ]


Ovulation occurs about midway through the  menstrual cycle , after the  follicular phase . The days in which a woman is most fertile can be calculated based on the date of the last menstrual period and the length of a typical menstrual cycle. [ 4 ]  The few days surrounding ovulation (from approximately days 10 to 18 of a 28-day cycle), constitute the most fertile phase. [ 5 ] [ 6 ] [ 7 ] [ 8 ]  The time from the beginning of the  last menstrual period  (LMP) until ovulation is, on average, 14.6 days, but with substantial variation among females and between cycles in any single female, with an overall 95%  prediction interval  of 8.2 to 20.5 days. [ 9 ]


The process of ovulation is controlled by the  hypothalamus  of the brain and through the release of hormones secreted in the  anterior lobe  of the  pituitary gland ,  luteinizing hormone  (LH) and  follicle-stimulating hormone  (FSH). [ 10 ]  In the  preovulatory  phase of the  menstrual cycle , the ovarian follicle will undergo a series of transformations called cumulus expansion, which is stimulated by FSH. After this is done, a hole called the  stigma  will form in the  follicle , and the secondary oocyte will leave the follicle through this hole. Ovulation is triggered by a spike in the  amount of FSH and LH released from the pituitary gland. During the  luteal (post-ovulatory) phase , the secondary oocyte will travel through the  fallopian tubes  toward the  uterus . If  fertilized  by a  sperm , the fertilized secondary oocyte or ovum may  implant  there 6–12 days later. [ 11 ]


The  follicular phase  (or proliferative phase) is the phase of the menstrual cycle during which the  ovarian follicles  mature. The follicular phase lasts from the beginning of  menstruation  to the start of ovulation. [ 12 ] [ 13 ]


For ovulation to be successful, the ovum must be supported by the  corona radiata  and  cumulus oophorous   granulosa cells . [ 14 ]  The latter undergo a period of proliferation and mucification known as cumulus expansion. Mucification is the secretion of a  hyaluronic acid -rich cocktail that disperses and gathers the cumulus cell network in a sticky matrix around the ovum. This network stays with the ovum after ovulation and has been shown to be necessary for fertilization. [ 15 ] [ 16 ]


Estrogen  levels peak towards the end of the follicular phase, around 12 and 24 hours. This, by positive feedback, causes a surge in levels of  luteinizing hormone  (LH) and  follicle-stimulating hormone  (FSH). This lasts from 24 to 36 hours, and results in the rupture of the ovarian follicles, causing the oocyte to be released from the ovary. [ 17 ]


Through a signal transduction cascade initiated by LH, which activates the pro-inflammatory genes through cAMP secondary messenger,  proteolytic enzymes  are secreted by the follicle that degrade the follicular tissue at the site of the blister, forming a hole called the  stigma . The  secondary oocyte  leaves the ruptured  follicle and moves out into the  peritoneal cavity  through the stigma, where it is caught by the  fimbriae  at the end of the  fallopian tube . After entering the fallopian tube, the oocyte is pushed along by  cilia , beginning its journey toward the  uterus . [ 10 ]


By this time, the oocyte has completed  meiosis I , yielding two cells: the larger  secondary oocyte  that contains all of the cytoplasmic material and a smaller, inactive first polar body.  Meiosis II  follows at once but will be arrested in the  metaphase  and will so remain until fertilization. The  spindle apparatus  of the second meiotic division appears at the time of ovulation. If no fertilization occurs, the oocyte will degenerate between 12 and 24 hours after ovulation. [ 18 ]  Approximately 1–2% of ovulations release more than one oocyte. This tendency increases with maternal age. Fertilization of two different oocytes by two different spermatozoa results in fraternal twins. [ 10 ]


The precise moment of ovulation was captured on film for the first time in 2008, coincidentally, during a routine hysterectomy procedure. According to the attending gynecologist, the ovum's emergence and subsequent release from the ovarian follicle occurred within a 15-minute timeframe.  [ 19 ]


The follicle proper has met  the end of its lifespan. Without the oocyte, the follicle folds inward on  itself, transforming into the  corpus luteum  (pl. corpora lutea), a  steroidogenic cluster of cells that produces  estrogen  and  progesterone . These hormones induce the  endometrial glands to begin production of the  proliferative endometrium  and later  into  secretory endometrium , the site of embryonic growth if implantation occurs. The action of progesterone increases  basal body temperature  by one-quarter to one-half degree Celsius (one-half to one degree Fahrenheit).  The corpus luteum continues this  paracrine   action for the remainder of the menstrual cycle, maintaining the endometrium, before disintegrating into scar tissue during menses. [ 20 ]


The start of ovulation may be detected by signs that are not readily discernible other than to the ovulating female herself, thus humans are said to have a  concealed ovulation . [ 21 ]  In many animal species there are distinctive signals indicating the period when the female is fertile. Several explanations have been proposed to explain concealed ovulation in humans.


Females near ovulation experience changes in the  cervical mucus , and in  basal body temperature . Furthermore, many females experience secondary fertility signs including  Mittelschmerz  (pain associated with ovulation) and a heightened sense of  smell , and can sense the precise moment of ovulation. [ 22 ] [ 23 ]  However, midcycle pain may also not be due to Mittelschmerz, but due to other factors such as cysts, endometriosis, sexually transmitted infections, or an ectopic pregnancy. [ 24 ]  Other possible signs of ovulation include tender breasts, bloating, and cramps, although these symptoms are not a guarantee that ovulation is taking place. [ 25 ] [ 26 ]


Many females experience heightened sexual desire in the several days immediately before ovulation. [ 27 ]  One study concluded that females subtly improve their facial  attractiveness during ovulation. [ 28 ]


Symptoms related to the onset of ovulation, the moment of ovulation and the body's process of beginning and ending the menstrual cycle vary in intensity with each female but are fundamentally the same. The charting of such symptoms — primarily basal body temperature, mittelschmerz and cervical position — is referred to as the sympto-thermal method of fertility awareness, which allow auto-diagnosis by a female of her state of ovulation. Once training has been given by a suitable authority, fertility charts can be completed on a cycle-by-cycle basis to show ovulation. This gives the possibility of using the data to predict fertility for natural contraception and pregnancy planning.


Urine levels of the  hormone  pregnanediol 3-glucuronide of over 5 μg/mL has been used to confirm ovulation. This test has a 100% specificity over 107 women. [ 30 ]


Disorders of ovulation, also known as  ovulatory disorders  are classified as  menstrual disorders  and include oligoovulation (infrequent or irregular ovulation) and anovulation (absence of ovulation): [ 31 ]


The  World Health Organization  (WHO) has developed the following classification of ovulatory disorders: [ 32 ]


Menstrual disorders  can often indicate ovulatory disorder. [ 34 ]


Ovulation  induction is a promising  assisted reproductive technology  for patients with conditions such as  polycystic ovary syndrome  (PCOS)  and  oligomenorrhea . It is also used in  in vitro fertilization  to make the follicles mature before  egg retrieval . Usually,  ovarian stimulation  is used in conjunction with  ovulation induction  to stimulate the formation of multiple oocytes. [ 35 ]  Some sources [ 35 ]  include ovulation induction in the definition of  ovarian stimulation .


A low dose of  human chorionic gonadotropin  (HCG) may be injected after completed ovarian stimulation. Ovulation will occur between 24 and 36 hours after the HCG injection. [ 35 ]


By contrast,  induced ovulation  in some animal species occurs naturally, ovulation can be stimulated by coitus. [ 36 ]


Combined hormonal contraceptives  inhibit  follicular development  and prevent ovulation as a primary mechanism of action. [ 37 ]  The  ovulation-inhibiting dose  (OID) of an  estrogen  or  progestogen  refers to the dose required to consistently inhibit ovulation in women. [ 38 ]  Ovulation inhibition is an  antigonadotropic  effect and is mediated by inhibition of the secretion of the  gonadotropins , LH and FSH, from the pituitary gland.


In  assisted reproductive technology  including  in vitro fertilization , cycles where a  transvaginal oocyte retrieval  is planned generally necessitates ovulation suppression, because it is not practically feasible to collect oocytes after ovulation. For this purpose, ovulation can be suppressed by either a  GnRH agonist  or a  GnRH antagonist , with different protocols depending on which substance is used.


Most women who are able to conceive are fertile for an estimated five days before ovulation and one day after ovulation. [ 39 ]  There is some evidence that for couples who have been trying to conceive a child for less than 12 months, and the female is under 40 years old, practicing timed intercourse (timing intercourse with ovulation using urine tests that predict ovulation) may help improve the rate of pregnancy and live births. [ 39 ]  The role that stress plays in ovulation, fertility, and understanding the biological basis for stress-induced anovulation and the role of cortisol is not entirely clear. [ 40 ]


Polycystic ovary syndrome , or  polycystic ovarian syndrome  ( PCOS ), is the most common  endocrine  disorder in women of reproductive age. [ 14 ]  The syndrome is named after  cysts  which form on the  ovaries  of some women with this condition, though this is not a universal symptom, and not the underlying cause of the disorder. [ 15 ] [ 16 ]


The primary characteristics of PCOS include  hyperandrogenism ,  anovulation ,  insulin resistance , and  neuroendocrine  disruption. [ 17 ]  Women may also experience  irregular menstrual periods ,  heavy periods ,  excess hair ,  acne , pelvic pain,  difficulty getting pregnant , and patches of  darker skin . [ 3 ] [ 18 ]


A review of international evidence found that the prevalence of PCOS could be as high as 26% among some populations, though ranges between 4% and 18% are reported for general populations. [ 19 ] [ 20 ] [ 21 ]  According to the  World Health Organization  (WHO), PCOS affects over 8-13% of reproductive-aged women. [ 22 ]


The exact cause of PCOS remains uncertain, and treatment involves management of symptoms using medication. [ 20 ]


Two definitions are commonly used:


Signs and symptoms of PCOS include  irregular or no menstrual periods ,  heavy periods ,  excess body and facial hair ,  acne , pelvic pain,  difficulty getting pregnant , and  patches of thick, darker, velvety skin , [ 3 ]  ovarian cysts, enlarged ovaries, excess  androgens , and weight gain. [ 29 ] [ 30 ]


Associated conditions include  type 2 diabetes ,  obesity ,  obstructive sleep apnea ,  heart disease ,  mood disorders , and  endometrial cancer . [ 4 ]


Common signs and symptoms of PCOS include the following:


Women with PCOS tend to have central obesity, but studies are conflicting as to whether visceral and subcutaneous abdominal fat is increased, unchanged, or decreased in women with PCOS relative to non-PCOS women with the same  body mass index . [ 39 ]  In any case, androgens, such as  testosterone ,  androstanolone  (dihydrotestosterone), and  nandrolone decanoate  have been found to increase visceral fat deposition in both female animals and women. [ 40 ]


Although 80% of PCOS presents in women with obesity, 20% of women diagnosed with the disease are non-obese or "lean" women. [ 41 ]  However, obese women that have PCOS have a higher risk of adverse outcomes, such as  hypertension ,  insulin resistance ,  metabolic syndrome , and  endometrial hyperplasia . [ 42 ]


Even though most women with PCOS are overweight or obese, it is important to acknowledge that non-overweight women can also be diagnosed with PCOS. Up to 30% of women diagnosed with PCOS maintain a normal weight before and after diagnosis. "Lean" women still face the various symptoms of PCOS with the added challenges of having their symptoms properly addressed and recognized. Lean women often go undiagnosed for years, and usually are diagnosed after struggles to conceive. [ 43 ]  Lean women are likely to have a missed diagnosis of diabetes and cardiovascular disease. These women also have an increased risk of developing insulin resistance, despite not being overweight. Lean women are often taken less seriously with their diagnosis of PCOS, and also face challenges finding appropriate treatment options. This is because most treatment options are limited to approaches of losing weight and healthy dieting. [ 44 ]


Testosterone  levels are usually elevated in women with PCOS. [ 45 ] [ 46 ]  In a 2020  systematic review  and  meta-analysis  of sexual dysfunction related to PCOS which included 5,366 women with PCOS from 21 studies, testosterone levels were analyzed and were found to be 2.34 nmol/L (67 ng/dL) in women with PCOS and 1.57 nmol/L (45 ng/dL) in women without PCOS. [ 46 ]  In a 1995 study of 1,741 women with PCOS, mean testosterone levels were 2.6 (1.1–4.8) nmol/L (75 (32–140) ng/dL). [ 47 ]  In a 1998 study which reviewed many studies and subjected them to meta-analysis, testosterone levels in women with PCOS were 62 to 71 ng/dL (2.2–2.5 nmol/L) and testosterone levels in women without PCOS were about 32 ng/dL (1.1 nmol/L). [ 48 ]  In a 2010 study of 596 women with PCOS which used  liquid chromatography–mass spectrometry  (LC–MS) to quantify testosterone, median levels of testosterone were 41 and 47 ng/dL (with 25th–75th percentiles of 34–65 ng/dL and 27–58 ng/dL and ranges of 12–184 ng/dL and 1–205 ng/dL) via two different labs. [ 49 ]  If testosterone levels are above 100 to 200 ng/dL, per different sources, other possible causes of  hyperandrogenism , such as  congenital adrenal hyperplasia  or an  androgen -secreting  tumor , may be present and should be excluded. [ 47 ] [ 50 ] [ 45 ]


Warning signs may include a change in appearance. But there are also manifestations of mental health problems, such as anxiety, depression, and eating disorders. [ 29 ] [ medical citation needed ]


A diagnosis of PCOS suggests an increased risk of the following:


The risk of  ovarian cancer  and  breast cancer  is not significantly increased overall. [ 51 ]


PCOS is a  heterogeneous disorder  of uncertain cause. [ 64 ] [ 65 ]  There is some evidence that it is a  genetic disease . Such evidence includes the familial clustering of cases, greater  concordance  in  monozygotic  compared with  dizygotic  twins and heritability of endocrine and metabolic features of PCOS. [ 7 ] [ 64 ] [ 65 ]  There is some evidence that exposure to higher than typical levels of  androgens  and the  anti-Müllerian hormone  (AMH)  in utero  increases the risk of developing PCOS in later life. [ 66 ]


It may be caused by a combination of genetic and environmental factors. [ 6 ] [ 7 ] [ 67 ]  Risk factors include  obesity , a lack of physical exercise, and a family history of someone with the condition. [ 8 ]  Diagnosis is based on two of the following three findings:  anovulation , high androgen levels, and  ovarian cysts . [ 4 ]  Cysts may be detectable by  ultrasound . [ 9 ]  Other conditions that produce similar symptoms include  adrenal hyperplasia ,  hypothyroidism , and  high blood levels of prolactin . [ 9 ]


The genetic component appears to be inherited in an  autosomal dominant  fashion with high  genetic penetrance  but variable  expressivity  in females; this means that each child has a 50% chance of inheriting the predisposing genetic variant(s) from a parent, and, if a daughter receives the variant(s), the daughter will have the disease to some extent. [ 65 ] [ 68 ] [ 69 ] [ 70 ]  The genetic variant(s) can be inherited from either the father or the mother, and can be passed along to both sons (who may be asymptomatic carriers or may have symptoms such as early  baldness  and/or excessive hair) and daughters, who will show signs of PCOS. [ 68 ] [ 70 ]  The  phenotype  appears to manifest itself at least partially via heightened androgen levels secreted by  ovarian follicle theca  cells from women with the allele. [ 69 ]  The exact gene affected has not yet been identified. [ 7 ] [ 65 ] [ 71 ]  In rare instances, single-gene mutations can give rise to the phenotype of the syndrome. [ 72 ]  Current understanding of the pathogenesis of the syndrome suggests, however, that it is a complex multigenic disorder. [ 73 ]


Due to the scarcity of large-scale screening studies, the prevalence of endometrial abnormalities in PCOS remains unknown, though women with the condition may be at increased risk for endometrial hyperplasia and carcinoma as well as menstrual dysfunction and infertility. [ citation needed ]


The severity of PCOS symptoms appears to be largely determined by factors such as obesity. [ 7 ] [ 24 ] [ 74 ]  PCOS has some aspects of a  metabolic disorder , since its symptoms are partly reversible. Even though considered as a  gynecological  problem, PCOS consists of 28 clinical symptoms. [ 75 ]


Even though the name suggests that the ovaries are central to disease pathology, cysts are a symptom instead of the cause of the disease. Some symptoms of PCOS will persist even if both ovaries are removed; the disease can appear even if cysts are absent. Since its first description by Stein and Leventhal in 1935, the criteria of diagnosis, symptoms, and causative factors have been subject to debate. Gynecologists often see it as a gynecological problem, with the ovaries being the primary organ affected. However, recent insights show a multisystem disorder, with the primary problem lies in hormonal regulation in the  hypothalamus , with the involvement of many organs. The term PCOS is used due to the fact that there is a wide spectrum of symptoms possible. It is common to have polycystic ovaries without having PCOS; approximately 20% of European women  have polycystic ovaries, but most of those women do not have PCOS. [ 15 ]


PCOS may be related to or worsened by exposures [ clarification needed ]  during the  prenatal period , [ 76 ] [ 77 ] [ 78 ]   epigenetic  factors, environmental impacts (especially industrial endocrine disruptors, such as  bisphenol A  and certain drugs) [ 79 ] [ 80 ] [ 81 ]  and the increasing rates of obesity. [ 80 ]


Endocrine disruptors  are defined as chemicals that can interfere with the  endocrine system  by mimicking hormones such as  estrogen . According to the  NIH (National Institute of Health) , examples of endocrine disruptors can include  dioxins  and  triclosan . Endocrine disruptors can cause adverse health impacts in animals. [ 82 ]  Additional research is needed to assess the role that endocrine disruptors may play in disrupting reproductive health in women and possibly triggering or exacerbating PCOS and its related symptoms. [ 83 ]


Polycystic ovaries develop when the ovaries are stimulated to produce excessive amounts of androgenic hormones, in particular testosterone, by either one or a combination of the following (almost certainly combined with genetic susceptibility): [ 69 ]


A majority of women with PCOS have  insulin resistance  and/or are  obese , which is a strong risk factor for insulin resistance, although insulin resistance is a common finding among women with PCOS in normal-weight women as well. [ 10 ] [ 24 ] [ 33 ]  Elevated insulin levels contribute to or cause the abnormalities seen in the  hypothalamic–pituitary–ovarian axis  that lead to PCOS. Hyperinsulinemia increases  GnRH  pulse frequency, [ 84 ]  which in turn results in an increase in the LH/FSH ratio [ 84 ] [ 85 ]  increased ovarian androgen production; decreased follicular maturation; and decreased  SHBG  binding. [ 84 ]  Furthermore, excessive insulin increases the activity of  17α-hydroxylase , which catalyzes the conversion of  progesterone  to  androstenedione , which is in turn converted to testosterone. The combined effects of  hyperinsulinemia  contribute to an increased risk of PCOS. [ 84 ]


Adipose (fat) tissue  possesses  aromatase , an enzyme that converts androstenedione to  estrone  and testosterone to  estradiol . The excess of adipose tissue in obese women creates the paradox of having both excess androgens (which are responsible for hirsutism and  virilization ) and excess estrogens (which inhibit FSH via  negative feedback ). [ 86 ]


The syndrome acquired its most widely used name due to the common sign on ultrasound examination of multiple (poly) ovarian  cysts . These "cysts" are in fact immature  ovarian follicles . The follicles have developed from primordial follicles, but this development has stopped ("arrested") at an early stage, due to the disturbed ovarian function. The follicles may be oriented along the ovarian periphery, appearing as a 'string of pearls' on ultrasound examination. [ 87 ]


PCOS may be associated with  chronic inflammation , [ 88 ]  with several investigators correlating inflammatory mediators with anovulation and other PCOS symptoms. [ 89 ] [ 90 ]  Similarly, there seems to be a relation between PCOS and an increased level of  oxidative stress . [ 91 ]


Not every person with PCOS has polycystic ovaries (PCO), nor does everyone with  ovarian cysts  have PCOS; although a  pelvic ultrasound  is a major diagnostic tool, it is not the only one. [ 92 ]  The diagnosis is fairly straightforward using the Rotterdam criteria, even when the syndrome is associated with a wide range of symptoms. [ 93 ]


Other causes of irregular or absent menstruation and hirsutism, such as  hypothyroidism ,  congenital adrenal hyperplasia  (21-hydroxylase deficiency) (which may cause excessive body hair, deep tone voice and others symptoms similar to  hyperandrogenism ),  Cushing's syndrome ,  hyperprolactinemia  (leading to  anovulation ), androgen-secreting neoplasms, and other pituitary or adrenal disorders, should be investigated. [ 24 ] [ 26 ] [ 94 ]


Some other blood tests are suggestive but not diagnostic. The ratio of LH ( luteinizing hormone ) to FSH ( follicle-stimulating hormone ), when measured in  international units , is elevated in women with PCOS. Common  cut-offs  to designate abnormally high LH/FSH ratios are 2:1 [ 101 ]  or 3:1 [ 94 ]  as tested on day 3 of the menstrual cycle. The pattern is not very sensitive; a ratio of 2:1 or higher was present in less than 50% of women with PCOS in one study. [ 101 ]  There are often low levels of  sex hormone-binding globulin , [ 94 ]  in particular among obese or overweight women. [ 102 ]
 Anti-Müllerian hormone  (AMH) is increased in PCOS, and may become part of its diagnostic criteria. [ 103 ] [ 104 ] [ 105 ]


PCOS has no cure. [ 5 ]  Treatment may involve lifestyle changes such as weight loss and exercise. [ 10 ] [ 11 ]  Recent research suggests that daily exercise including both aerobic and strength activities can improve hormone imbalances. [ 108 ]


Birth control pills  may help with improving the regularity of periods, excess hair growth, and acne. [ 12 ]  Combined oral contraceptives are especially effective, and used as the first-line of treatment to reduce acne and hirsutism, and regulate menstrual cycle. This is especially the case in adolescents. [ 108 ]


Metformin ,  GLP-1 , and  anti-androgens  may also help. [ 12 ]  Other typical acne treatments and hair removal techniques may be used. [ 12 ]  Efforts to improve fertility include weight loss,  metformin , and  ovulation induction  using  clomiphene  or  letrozole . [ 109 ]   In vitro fertilization  is used by some in whom other measures are not effective. [ 109 ]


Certain cosmetic procedures may also help alleviate symptoms in some cases. For example, the use of laser hair removal, electrolysis, or general waxing, plucking and shaving are all effective methods for reducing hirsutism. [ 37 ]
The primary treatments for PCOS include lifestyle changes and use of medications. [ 110 ]


Goals of treatment may be considered under these categories: [ citation needed ]


In each of these areas, there is considerable debate as to the optimal treatment. One of the major factors underlying the debate is the lack of large-scale clinical trials comparing different treatments.  Smaller trials  tend to be  less reliable  and hence may produce conflicting results. General interventions that help to reduce weight or insulin resistance can be beneficial for all these aims, because they address what is believed to be the underlying cause. [ 111 ]  As PCOS appears to cause significant emotional distress, appropriate support may also be useful. [ 112 ]


Where PCOS is associated with being overweight or obesity, successful weight loss is the most effective method of restoring normal ovulation/menstruation. The  American Association of Clinical Endocrinologists  guidelines recommend a goal of achieving 10–15% weight loss or more, which improves  insulin resistance  and all [ clarification needed ]   hormonal disorders . [ 113 ]  Still, many women find it very difficult to achieve and sustain significant weight loss. Insulin resistance itself can cause increased food cravings and lower energy levels, which can make it difficult to lose weight on a regular weight-loss diet. A  scientific review  in 2013 found similar improvements in weight, body composition and  pregnancy rate , menstrual regularity, ovulation, hyperandrogenism, insulin resistance, lipids, and quality of life to occur with weight loss, independent of diet composition. [ 114 ]  Still, a  low GI diet , in which a significant portion of total carbohydrates is obtained from fruit, vegetables, and whole-grain sources, has resulted in greater menstrual regularity than a  macronutrient -matched healthy diet. [ 114 ]


Reducing intake of food groups that cause inflammation, such as dairy, sugars and simple carbohydrates, can be beneficial. [ 37 ]


A  mediterranean diet  is often very effective due to its anti-inflammatory and anti-oxidative properties. [ 108 ]


Vitamin D deficiency  may play some role in the development of the  metabolic syndrome , and treatment of any such deficiency is indicated. [ 115 ] [ 116 ]  However, a systematic review of 2015 found no evidence that vitamin D supplementation reduced or mitigated metabolic and hormonal dysregulations in PCOS. [ 117 ]  As of 2012, interventions using  dietary supplements  to correct metabolic deficiencies in people with PCOS had been tested in small, uncontrolled and nonrandomized clinical trials; the resulting data are insufficient to recommend their use. [ 118 ]


Medications for PCOS include  oral contraceptives  and  metformin . The oral contraceptives increase  sex hormone binding globulin  production, which increases binding of free testosterone. This reduces the symptoms of  hirsutism  caused by high testosterone and regulates return to normal  menstrual periods . [ 115 ]   Anti-androgens  such as  finasteride ,  flutamide ,  spironolactone , and  bicalutamide  do not show advantages over oral contraceptives, but could be an option for people who do not tolerate them. [ 119 ]   Finasteride  is the only oral medication for the treatment of  androgenic alopecia , that is  FDA  approved. [ 37 ]


Metformin is a medication commonly used in  type 2 diabetes mellitus  to reduce insulin resistance, and is used  off label  (in the UK, US, AU and EU) to treat insulin resistance seen in PCOS. In many cases, metformin also supports ovarian function and return to normal ovulation. [ 115 ] [ 120 ]  A newer insulin resistance medication class, the  thiazolidinediones  (glitazones), have shown equivalent efficacy to metformin, but metformin has a more favorable side effect profile. [ 121 ] [ 122 ]  The United Kingdom's  National Institute for Health and Clinical Excellence  recommended in 2004 that women with PCOS and a  body mass index  above 25 be given metformin when other therapy has failed to produce results. [ 123 ] [ 124 ]  Metformin may not be effective in every type of PCOS, and therefore there is some disagreement about whether it should be used as a general first line therapy. [ 125 ]  In addition to this, metformin is associated with several unpleasant side effects: including abdominal pain, metallic taste in the mouth, diarrhoea and vomiting. [ 126 ]  Metformin is thought to be safe to use during pregnancy ( pregnancy category  B in the US). [ 127 ]  A review in 2014 concluded that the use of metformin does not increase the risk of major  birth defects  in women treated with metformin during the first trimester. [ 128 ]  Liraglutide may reduce weight and waist circumference in people with PCOS more than other medications. [ 129 ]  The use of  statins  in the management of underlying metabolic syndrome remains unclear. [ 110 ]


It can be difficult to become pregnant with PCOS because it causes irregular  ovulation . Medications to induce fertility when trying to conceive include the ovulation inducer  clomiphene  or pulsatile  leuprorelin .  Evidence from randomised controlled trials suggests that in terms of live birth, metformin may be better than placebo, and metform plus clomiphene may be better than clomiphene alone, but that in both cases women may be more likely to experience gastrointestinal side effects with metformin. [ 130 ]


Some individuals with PCOS may have difficulty getting pregnant since their body does not produce the hormones necessary for regular ovulation. [ 131 ]  PCOS might also increase the risk of miscarriage or premature delivery. However, it is possible to have a normal pregnancy. [ citation needed ]


For women that do,  anovulation  or infrequent ovulation is a common cause and PCOS is the main cause of anovulatory infertility. [ 132 ]  Other factors include changed levels of  gonadotropins ,  hyperandrogenemia , and  hyperinsulinemia . [ 133 ]  Like women without PCOS, women with PCOS that are ovulating may be infertile due to other causes, such as tubal blockages due to a history of sexually transmitted diseases. [ 134 ]


For overweight anovulatory women with PCOS,  weight loss  and diet adjustments, especially to reduce the intake of simple carbohydrates, are associated with resumption of natural ovulation. [ 135 ]  Digital health interventions have been shown to be particularly effective in providing combined therapy to manage PCOS through both lifestyle changes and medication. [ 136 ]


Femara  is an alternative medicine that raises FSH levels and promote the development of the follicle. [ 37 ]


For those women that, after weight loss, are still anovulatory, or for anovulatory lean women,  ovulation induction  using the medications  letrozole  or  clomiphene citrate  are the principal treatments used to promote ovulation. [ 137 ] [ 138 ] [ 139 ]  Clomiphene can cause mood swings and abdominal cramping for some. [ 37 ]


Previously, the anti-diabetes medication  metformin  was recommended treatment for anovulation, but it appears less effective than letrozole or clomiphene. [ 140 ] [ 141 ]


For women not responsive to letrozole or clomiphene and diet and lifestyle modification, there are options available including  assisted reproductive technology  procedures such as  controlled ovarian hyperstimulation  with  follicle-stimulating hormone  (FSH) injections followed by  in vitro fertilisation  (IVF). [ 142 ]


Though surgery is not commonly performed, the polycystic ovaries can be treated with a laparoscopic procedure called " ovarian drilling " (puncture of 4–10 small follicles with electrocautery, laser, or biopsy needles), [ 143 ]  which often results in either resumption of spontaneous ovulations [ 115 ]  or ovulations after adjuvant treatment with clomiphene or FSH. [ 144 ]  (Ovarian wedge resection is no longer used as much due to complications such as  adhesions  and the presence of frequently effective medications.) There are, however, concerns about the long-term effects of ovarian drilling on ovarian function. [ 115 ]


In a small UK randomized trial,  bariatric surgery  led to more spontaneous ovulations than behavioral interventions combined with medical therapy in adult women with PCOS, raising the prospect that surgery could enhance prospects of spontaneous fertility. [ 145 ]


Women with PCOS are far more likely to have depression than women without. Symptoms of depression might be heightened by certain physiological manifestations of this disease such as hirsutism or obesity that can lead to low self-esteem or poor body image. [ 35 ]   Researchers suggest that there be mental health screenings performed in tandem with PCOS assessment in order to identify these complications early and treat them accordingly. [ 146 ]


PCOS is associated with other mental health related conditions besides depression such as  anxiety ,  bipolar disorder , and  obsessive–compulsive disorder . [ 35 ]  Additionally, it has been found to significantly increase risk of eating disorders. [ 146 ]   Screening for these mental health conditions will also be helpful in treatment of PCOS.


Lifestyle changes for people with PCOS have been proven to be difficult due to lack of intrinsic motivation, altered risk perception or other PCOS-related barriers. However, self management techniques and behavior change can be taught in a multidisciplinary approach with the goal of supporting women with PCOS in managing their symptoms. [ 147 ]


When appropriate (e.g., in women of child-bearing age who require contraception), a standard contraceptive pill is frequently effective in reducing hirsutism. [ 115 ]  Progestogens such as norgestrel and levonorgestrel should be avoided due to their androgenic effects. [ 115 ]  Metformin combined with an oral contraceptive may be more effective than either metformin or the oral contraceptive on its own. [ 148 ]


In the case of taking medication for acne, Kelly Morrow-Baez PHD, in her exposition titled  Thriving with PCOS,  informs that it "takes time for medications to adjust hormone levels, and once those hormone levels are adjusted, it takes more time still for pores to be unclogged of overproduced oil and for any bacterial infections under the skin to clear up before you will see discernible results." (p. 138)  [ 37 ]


Other medications with anti-androgen effects include  flutamide , [ 149 ]  and  spironolactone , [ 115 ]  which can improve hirsutism. Metformin can reduce hirsutism, perhaps by reducing insulin resistance, and is often used if there are other features such as insulin resistance, diabetes, or obesity that are likely to respond to metformin.  Eflornithine  (Vaniqa) is a medication that is applied to the skin in cream form, and acts directly on the hair follicles to inhibit hair growth. It is usually applied to the face. [ 115 ]   5-alpha reductase inhibitors  (such as  finasteride  and  dutasteride ) may also be used; [ 150 ]  they work by blocking the conversion of  testosterone  to  dihydrotestosterone  (the latter of which is responsible for most hair growth alterations and  androgenic acne ).


Although these agents have shown significant efficacy in clinical trials (for oral contraceptives, in 60–100% of individuals [ 115 ] ), the reduction in hair growth may not be enough to eliminate the social embarrassment of hirsutism or the inconvenience of plucking or shaving. Individuals vary in their response to different therapies. It is usually worth trying other medications if one does not work, but medications do not work well for all individuals. [ 151 ]


If fertility is not the primary aim, then  menstruation  can usually be regulated with a contraceptive pill. [ 115 ]  The purpose of regulating menstruation, in essence, is for the patient's convenience, and perhaps  their sense of well-being; there is no medical requirement for regular periods, as long as they occur sufficiently often. [ 152 ]


If a regular menstrual cycle is not desired, then therapy for an irregular cycle is not necessarily required. Most experts say that, if a menstrual bleed occurs at least every three months, then the endometrium (womb lining) is being shed sufficiently often to prevent an increased risk of endometrial abnormalities or cancer. [ 153 ]  If menstruation occurs less often or not at all, some form of progestogen replacement is recommended. [ 150 ]


A 2017 review concluded that while both myo-inositol and D-chiro-inositols may regulate menstrual cycles and improve ovulation, there is a lack of evidence regarding effects on the probability of pregnancy. [ 154 ] [ 155 ]  A 2012 and 2017 review have found  myo-inositol  supplementation appears to be effective in improving several of the hormonal disturbances of PCOS. [ 156 ] [ 157 ]  Myo-inositol reduces the amount of gonadotropins and the length of controlled ovarian hyperstimulation in women undergoing in vitro fertilization. [ 158 ]  A 2011 review found not enough evidence to conclude any beneficial effect from  D-chiro-inositol . [ 159 ]  There is insufficient evidence to support the use of  acupuncture , current studies are inconclusive and there's a need for additional  randomized controlled trials . [ 160 ] [ 161 ]


PCOS is the most common  endocrine disorder  among women between the ages of 18 and 44. [ 24 ]  It affects approximately 2% to 20% of this age group depending on how it is defined. [ 8 ] [ 13 ]  When someone is infertile due to lack of ovulation, PCOS is the most common cause and could guide to patients' diagnosis. [ 4 ]  The earliest known description of what is now recognized as PCOS dates from 1721 in Italy. [ 162 ]


The prevalence of PCOS depends on the choice of diagnostic criteria. The  World Health Organization  estimates that it affects 116 million women worldwide as of 2010 (3.4% of women). [ 163 ]  Another estimate indicates that 7% of women of reproductive age are affected. [ 164 ]  Another study using the Rotterdam criteria found that about 18% of women had PCOS, and that 70% of them were previously undiagnosed. [ 24 ]  Prevalence also varies across countries due to lack of large-scale scientific studies; India, for example, has a purported rate of 1 in 5 women having PCOS. [ 165 ]


There are few studies that have investigated the racial differences in cardiometabolic factors in women with PCOS. There is also limited data on the racial differences in the risk of metabolic syndrome and cardiovascular disease in adolescents and young adults with PCOS. [ 166 ]  The first study to comprehensively examine racial differences discovered notable racial differences in risk factors for cardiovascular disease. African American women were found to be significantly more obese, with a significantly higher prevalence of metabolic syndrome compared to white adult women with PCOS. [ 167 ]  It is important for the further research of racial differences among women with PCOS, to ensure that every woman that is affected by PCOS has the available resources for management. [ 168 ] [ 169 ]


Ultrasonographic findings of polycystic ovaries are found in 8–25% of women non-affected by the syndrome. [ 170 ] [ 171 ] [ 172 ] [ 173 ]  14% women on oral contraceptives are found to have polycystic ovaries. [ 171 ]  Ovarian cysts are also a common side effect of levonorgestrel-releasing  intrauterine devices  (IUDs). [ 174 ]


There are few studies that have investigated the racial differences in cardiometabolic factors in women with PCOS. [ 175 ]


The condition was first described in 1935 by American gynecologists Irving F. Stein Sr. and Michael L. Leventhal, from whom its original name of  Stein–Leventhal syndrome  is taken. [ 92 ] [ 23 ]  Stein and Leventhal first described PCOS as an endocrine disorder in the United States, and since then, it has become recognized as one of the most common causes of oligo ovulatory infertility among women. [ 51 ]


The earliest published description of a person with what is now recognized as PCOS was in 1721 in Italy. [ 162 ]  Cyst-related changes to the ovaries were described in 1844. [ 162 ]


Other names for this syndrome include polycystic ovarian syndrome, polycystic ovary disease, functional ovarian hyperandrogenism, ovarian  hyperthecosis , sclerocystic ovary syndrome, and Stein–Leventhal syndrome. The  eponymous  last option is the original name; it is now used, if at all, only for the subset of women with all the symptoms of amenorrhea with infertility,  hirsutism , and enlarged polycystic ovaries. [ 92 ]


Most common names for this disease derive from a typical finding on medical images, called a polycystic ovary. A polycystic ovary has an abnormally large number of developing eggs visible near its surface, looking like many small  cysts . [ 92 ]


In 2005, 4 million cases of PCOS were reported in the US, costing $4.36 billion in healthcare costs. [ 176 ]  In 2016 out of the National Institute Health's research budget of $32.3 billion for that year, 0.1% was spent on PCOS research. [ 177 ]  Among women aged between 14 and 44, PCOS is conservatively estimated to cost $4.37 billion per year. [ 25 ]


As opposed to women in the general population, women with PCOS experience higher rates of depression and anxiety. International guidelines and Indian guidelines suggest psychosocial factors should be considered in women with PCOS, as well as screenings for depression and anxiety. [ 178 ]  Globally, this aspect has been increasingly focused on because it reflects the true impact of PCOS on the lives of patients. Research shows that PCOS adversely impacts a patient's quality of life. [ 178 ] [ 179 ]


A number of celebrities and public figures have spoken about their experiences with PCOS, including:


Reproductive loss , sometimes  reproductive disappointment  or  reproductive grief , describes a potential emotional response to unsuccessful attempts at human reproduction or family-building. These experienced losses may include involuntary  childlessness  generally,  pregnancy loss  from all causes (including ectopic pregnancy, spontaneous abortion, induced abortion, and traumatic injury),  perinatal death ,  stillbirth ,  infecundity  and  infertility  from all causes (including voluntary, coerced or accidental sterilization, and post-menopausal infertility), failed attempts to conceive, failed fertility treatments, failed gestational surrogacy procedures, and losses related to all dimensions of the adoption process. [ 1 ] [ 2 ] [ 3 ]  Responses to miscarriage, stillbirth,  selective reduction  and neonatal death are a subtype of reproductive loss called  perinatal bereavement . [ 4 ]


Reproductive loss is categorized as a  non-definite loss  that elicits as unique grief response and can be prone to social  grief disenfranchisement . [ 5 ]  Responses to reproductive loss may be gender-specific. [ 6 ]  However, per the  Journal of Social Philosophy , processing these experiences is complicated by the lack of "settled cultural—or philosophical—understanding of what exactly is bad or grief-worthy about the death of an embryo/fetus or the failure of a pregnancy to produce a surviving child." [ 7 ]  Perinatal losses have been described as uniquely ambiguous in that they are "loss of a future with a family member who has not yet been integrated into family life yet maintains a psychological presence within the family system." [ 8 ]  The ambiguity of the reproductive loss may be central to its experience of the bereaved;  Maureen Corrigan  called stillbirth a "nightmare that hasn't been quite categorized." [ 9 ]


Scholarship in the journal  Social Work  has argued that reproductive losses can be "significant life course events that may affect identity, social role, self-image, and conceptualization of a woman's reproductive history and human sexuality across the entire range of practice settings." [ 10 ]   L. Serene Jones  of  Yale Divinity School  found that both American mainline Protestant and feminist communities had little discourse on the concept of reproductive loss or grief. [ 6 ]


Late-term fetal demise has been found to be a risk factor for  post-traumatic stress disorder  in formerly pregnant women. [ 11 ]


Creative works about reproductive loss include the  Up  opening sequence , the film  Private Life , the painting  Henry Ford Hospital , the memoir  An Exact Replica of a Figment of My Imagination , and the strip " Loss " from the webcomic  Ctrl+Alt+Del .


This  psychology -related article is a  stub . You can help Wikipedia by  expanding it .


Reproductive surgery  is  surgery  in the field of  reproductive medicine . It can be used for contraception, e.g. in  vasectomy , wherein the  vasa deferentia  of a male are severed, but is also used plentifully in  assisted reproductive technology . Reproductive surgery is generally divided into three categories: surgery for infertility, in vitro fertilization, and fertility preservation. [ 1 ]


A reproductive surgeon is an  obstetrician-gynecologist  or  urologist  who specializes in reproductive surgery. [ 2 ]


Reproductive surgeries will be referred to based on biological sex, and terms such male and female will be used to denote to men and women respectively.


Reproductive surgery aims to address concerns spanning from male and female fertility to gender-affirming care. [ 3 ] [ 4 ]  Uses for reproductive surgery may encompass different abnormalities, dysfunctions, and areas of focus that are unable to be treated solely through medication or nonsurgical treatment. [ 4 ]  Screening measures may be completed to determine the necessity of surgery. For example, intrauterine pathology may be assessed by utilizing techniques such as  hysteroscopy  to identify complications for reproductive surgical interventions. [ 4 ]


Assisted reproductive technology  (ART) supports enhancement of fertility success through processes such as  in vitro fertilization  (IVF). [ 4 ]  Screening and reproductive surgery also have a role in identifying and addressing abnormalities, such as notable cysts, prior to initiating IVF. [ 4 ]  Surgical sperm retrieval is an alternative means of  semen collection , where other means are not possible in circumstances like  posthumous sperm retrieval  or male infertility. [ 5 ] [ 6 ]


These surgical techniques may also be utilized as a form of permanent contraception referred to as sterilization. [ 7 ]  A  vasectomy  or  tubal ligation  would be examples of this procedure for male and female individuals respectively. [ 8 ] [ 9 ]  Reproductive surgeons can potentially perform a reverse vasectomy to restore male reproductive function following the vasectomy. Individuals may choose to reverse the procedure due to pain experience after the surgery. [ 9 ]


People might find themselves wanting to preserve their fertility. Biological material such as sperm or  oocyte  are capable of being surgically collected and preserved cryogenically. [ 6 ]  Fertility preservation also provides individuals who are receiving gender-affirming surgeries the option of preserving  gametes  if having biological children is desired following the procedures and hormonal therapy. [ 6 ] [ 7 ]


Reproductive surgery is also considered for complications such as  endometriosis ,  polycystic ovary syndrome ,  ectopic pregnancy , and  vas deferens obstruction . [ 1 ]


Albeit an increase in overall use of  assisted reproductive technology  (ART), surgeries on the fallopian tubes and ovaries have decreased, leading to a rise in insecurity in the field of reproductive surgery. [ 10 ]  Reproductive surgery in women has largely been complementary to other ART methods such as medication, except for in tubal infertility, where surgery remains the main treatment. [ 11 ]  Although reproductive surgery has been most relevant for severe symptoms, there has been a strong interest in greater analysis surrounding this topic of research. [ 10 ]


Reproductive surgery first began with fertility sparing surgeries, such as  uterine myomectomy , and was transitioned later into the addition of surgeries for infertility and the advancement of success rates for fertility.  Hysterectomies  and myomectomies date back to ancient times, where fascination grew around fertility sparing surgeries, specifically for young women who were able to conceive but were considered to have suspected ailments. [ 10 ]  However, the lack of knowledge of medicine eventually led to mortality, thereby causing myomectomies to become more uncommon. Overtime, various advancements and extensive research allowed for the discovery of minimally invasive myomectomies, which became popular among women who were capable of bearing children. [ 10 ]


Laparoscopy  continues to be a common procedure approach as it is minimally invasive and is thought to be associated with a decrease in hospital stay and surgical complications. [ 10 ]  The development of newer technology and surgical techniques allowed for the increase in success rates for various other surgeries, such as  endometriosis  and  adenomyosis  surgeries or  adnexal  surgeries.


With respect to the future of reproductive surgeries, greater advancements of surgical techniques and equipment are growing in popularity to increase the potential of fertility success rates. For example, vaginal natural orifice transluminal endoscopic surgery (vNOTES) is a new innovative approach that has been used for  ovarian torsion , tubal  ectopic pregnancy , and ovarian  cystectomies . [ 10 ]  This surgical approach is minimally invasive and has emerged in an effort to reduce pain, risks, and potential for scarring. [ 12 ]  Another technique that has emerged is radiofrequency ablation (RFA) which has been used for  uterine fibroids . It works to necrotize fibroids through the use of laparoscopic and transcervical procedures with two devices, Acessa (Hologic) and Sonata (Gynesonics). However, these two medical devices come with the caveat that  fertility may not be preserved in those with uterine leiomyoma. [ 10 ]  Although not ideal for people who are able to and wanting to bear children, RFA still poses as an alternative successful technique to reducing the volume of fibroids. [ 13 ]


A new common interest in alliance with reproductive surgery is the use of regenerative medicine. Although it has not been studied in its entirety, the use of stem cells to restore damaged endometrium has shown promising improvements. [ 14 ] [ 15 ]  Regenerative medicine has been used for premature ovarian failure and will continue to be studied for in vitro fertilization (IVF). [ 10 ]  With the use of various stem cells, researchers hope to mitigate and treat any future signs of infertility with the use of two specific stem cells,  induced pluripotent stem cells  (iPSCs) and  mesenchymal stem cells  (MSC). [ 16 ]


The risks and complications of reproductive surgery depend on patient specific characteristics and the degree of the surgery itself; however, some common complications of general reproductive surgery are hemorrhage, visceral damage, infection, and blot clotting. [ 17 ]


In vasectomies, infection and hematomas are the most frequently reported complications of surgery, with the incidence rate of infection being 3-4% and the incidence rate of hematoma ranging around 0-29%. [ 18 ]  An important note to consider is the fact that the surgical technique of the vasectomy did have an impact on the incident rates of these complications.  No-scalpel vasectomy  (NSV) is widely recognized due to its low incident rate of complications. [ 18 ]  Another common complication of vasectomy is post-vasectomy pain syndrome (PVPS). PVPS involves chronic pain that may be persistent or intermittent in one or both of the testicles, and lasting longer than three months after the procedure. [ 19 ]  While the pathophysiology of PVPS is unknown, various causes include damage to structures of the testis, buildup of pressure from epididymal congestion, and compression of nerves in the testis. The pain in PVPS can manifest in various forms, such as pain and tenderness in the scrotum, pressure or pain after ejaculation, pain with sex, etc. [ 19 ]  Incidence rates of PVPS are around 1-14%. [ 18 ]


In hysterectomies, complications of the procedure include infection, gastrointestinal injury, and venous thromboembolic injury. Similar to vasectomies, one of the most common complications is infection, with the incidence rate being 10.5% for abdominal hysterectomy, 13% for vaginal hysterectomy, and 9% for laparoscopic hysterectomy. [ 20 ]


Today, one of the most effective forms of ART is  in vitro fertilization  (IVF). [ 21 ]  While it is very effective in those experiencing infertility, there are numerous risks of IVF, such as multiple births, premature delivery, and  ovarian hyper-stimulation syndrome . Ovarian hyper-stimulation syndrome is a condition that involves enlargement of the ovaries as the result of the injected fertility drugs causing increased capacity of the blood vessels to allow molecules to go in and out. [ 21 ] [ 22 ]  It can lead to abdominal pain, soreness, and nausea for those experiencing it. [ 22 ]  The symptoms and severity of ovarian hyper-stimulation syndrome can be classified amongst various grades. Grade 1 involves mild discomfort and abdominal distention, and as the grades increase, severity and symptoms also increase. Grade 4 and grade 5 encompass severe ovarian hyper-stimulation syndrome and involve changes in blood volume and viscosity due to the condition. [ 22 ]  Those who have a history of heightened response to gonadotropins, history of previous ovarial hyper-stimulation, and/or have a history of polycystic ovary syndrome (PCOS) are at increased risk of developing this complication. [ 22 ]


There are no existing medical guidelines that outline the absolute contraindications to reproductive surgery. However, there are relative contraindications recommended in the current literature. There are several circumstances under which having reproductive surgery is contraindicated. This is because surgery itself may cause extensive tissue damage to the person, the success of the procedure is limited (i.e. the condition is invasive or metastatic), or the surgery's potential risk outweighs the potential benefits. [ 17 ]  However, each person's situation is different and the possibility of reproductive surgery should be consulted with a healthcare professional.


Uterine atony  after fetal extraction, and pre-existing maternal bleeding disorders have been reported as accepted contraindications for cesarean myomectomies in women. [ 23 ] [ 24 ]  Contraindications to reproductive surgery used for tubal surgery and infertility include women ages 43 and older, tubal disease that surgery cannot treat (i.e., surgery cannot be safely performed without hurting the person or the patient has multiple medical conditions that reduces the chance of success),  bipolar disease , and abnormal semen analysis. [ 25 ]


Many studies examining surgery for  endometriosis  excluded women who previously received medical or surgical treatment for endometriosis. [ 26 ]  Women with a pre-operative diagnosis of a deep endometriosis of their bowel or bladder were also excluded from surgery. [ 27 ]


For male reproductive surgery for the treatment of  varicocele  by percutaneous embolization, current literature considers adolescents, allergies to  contrast , men with a bilateral grade 3 varicocele, and men with  primary infertility  as relative contraindications to surgery. [ 28 ]


Reproductive technology  encompasses all current and anticipated uses of technology in human and animal reproduction, including assisted reproductive technology (ART), [ 1 ]   contraception  and others. It is also termed Assisted Reproductive Technology, where it entails an array of appliances and procedures that enable the realization of safe, improved and healthier  reproduction . While this is not true of all people, for an  array  of married couples, the ability to have children is vital. But through the  technology , infertile couples have been provided with options that would allow them to conceive children. [ 2 ]


Assisted reproductive technology (ART) is the use of reproductive technology to treat low fertility or  infertility . Modern technology can provide infertile couples with assisted reproductive technologies. The natural method of reproduction has become only one of many new techniques used today. There are millions of couples that do not have the ability to reproduce on their own because of infertility and therefore, must resort to these new techniques. The main causes of infertility are that of  hormonal  malfunctions and anatomical abnormalities. [ 3 ]  ART is currently the only form of assistance for individuals who, for the time being, can only conceive through  surrogacy  methods). [ 4 ]  Examples of ART include  in vitro  fertilization (IVF)  and its possible expansions, including:


In 1981, after the birth of Elizabeth Carr, the first baby in the United States to be conceived through in vitro fertilization (IVF). Her birth gave hope to many couples struggling with infertility. Dr. Howard Jones brought together the leading practitioners of the five US-based IVF programs ( Norfolk , [ clarification needed ]   Vanderbilt ,  University of Texas at Houston , and the  University of Southern California ,  Yale)  to discuss the establishment of a national registry for in vitro fertilization attempts and outcomes. 2 years later, in 1985 the society for assisted reproductive technology (SART) was founded as a special interest entity within the American Fertility Society. [ 5 ]  SART has not only informed the evolution of infertility care but also improved success of antiretroviral therapy. [ 6 ]


Reproductive technology can inform  family planning  by providing individual prognoses regarding the likelihood of pregnancy. It facilitates the monitoring of  ovarian reserve ,  follicular  dynamics and associated  biomarkers  in females, [ 7 ]  as well as   semen analysis  in males. [ 8 ]


Contraception , also known as  birth control , is a form of reproductive technology that enables people to prevent  pregnancy . [ 9 ]  There are many forms of contraception, but the term covers any method or device which is intended to prevent pregnancy in a  sexually active  woman. Methods are intended to "prevent the  fertilization  of an egg or implantation of a  fertilized egg  in the  uterus ." [ 10 ]  Different forms of birth control have been around since ancient times, but widely available effective and safe methods only became available during the mid-1900s. [ 11 ]


The following reproductive techniques are not currently in routine clinical use; most are still undergoing development:


Research is currently investigating the possibility of same-sex procreation, which would produce offspring with equal genetic contributions from either two females or two males. [ 12 ]  This form of reproduction has become a possibility through the creation of either  female sperm  (containing the genetic material of a female) or  male eggs  (containing the genetic material of a male). Same-sex procreation would remove the need for lesbian and gay couples to rely on a third party donation of a sperm or an egg for reproduction. [ 13 ]
The first significant development occurred in 1991, in a patent application filed by U.Penn. scientists to fix male sperm by extracting some sperm, correcting a genetic defect in vitro, and injecting the sperm back into the male's testicles. [ 14 ]  While the vast majority of the patent application dealt with male sperm, one line suggested that the procedure would work with XX cells, i.e., cells from an adult woman to make female sperm.


In the two decades that followed, the idea of female sperm became more of a reality. In 1997, scientists partially confirmed such techniques by creating chicken female sperm in a similar manner. [ 15 ]  They did so by injecting blood stem cells from an adult female chicken into a male chicken's testicles. In 2004, other Japanese scientists created two female offspring by combining the eggs of two adult mice. [ 16 ] [ 17 ]


In 2008, research was done specifically for methods on creating human female sperm using artificial or natural  Y chromosomes  and testicular transplantation. [ 18 ]  A UK-based group predicted they would be able to create human female sperm within five years. So far no conclusive successes have been achieved. [ 3 ]


In 2018 Chinese research scientists produced 29 viable mice offspring from two mother mice by creating sperm-like structures from haploid  Embryonic stem cells  using  gene editing  to alter imprinted regions of DNA. They were unable to get viable offspring from two fathers. Experts noted that there was little chance of these techniques being applied to humans in the near future. [ 19 ] [ 20 ]


Recent technological advances in fertility treatments introduce ethical problems, such as the affordability of the various procedures. The exorbitant prices can limit who has access. [ 12 ]  The cost of performing ART per live birth varies among countries. [ 21 ]  The average cost per IVF cycle in the United States is USD 9,266. [ 22 ]  However, the cost per live birth for autologous ART treatment cycles in the United States, Canada, and the United Kingdom ranged from approximately USD 33,000 to 41,000 compared to USD 24,000 to 25,000 in Scandinavia, Japan, and Australia [ 23 ]


The funding structure for IVF/ART is highly variable among different nations. For example, no federal government reimbursement exists for IVF in the United States, although certain states have insurance mandates for ART [ 24 ]


Many issues of reproductive technology have given rise to  bioethical  issues, since technology often alters the assumptions that lie behind existing systems of sexual and reproductive  morality . Other ethical considerations arise with the application of ART to women of advanced maternal age, who have higher changes of medical complications (including  pre-eclampsia ), and possibly in the future its application to post- menopausal  women. [ 25 ] [ 26 ] [ 27 ]  Also, ethical issues of  human enhancement  arise when reproductive technology has evolved to be a potential technology for not only reproductively inhibited people but even for otherwise re-productively healthy people. [ 28 ]


Cryopreservation of Oocytes


Cryopreservation techniques have significantly evolved in recent decades, enabling the long-term storage of human oocytes and embryos for fertility preservation. The introduction of  vitrification , a rapid-freezing method that prevents the formation of ice crystals, has markedly improved post-thaw survival rates and oocyte viability. This method employs high concentrations of cryoprotectants to ensure cellular integrity while maintaining spindle structure and chromosomal alignment.


Ovarian Reserve Assessment


Accurate assessment of ovarian reserve has become a cornerstone of individualized reproductive treatment plans.  Anti-Müllerian hormone (AMH)  and  antral follicle count (AFC)  are the primary markers used to evaluate the remaining oocyte pool. AMH, secreted by granulosa cells of preantral and small antral follicles, offers a cycle-independent, minimally invasive method for predicting ovarian response in assisted reproductive technology (ART).


Ethical Considerations


The use of reproductive technologies, particularly for non-medical fertility preservation, has raised ethical questions. Critics argue that societal pressures may drive unnecessary interventions, while proponents highlight the empowerment of individuals in making reproductive choices. Balancing accessibility and ethical integrity remains a key challenge for the field.