Spectroscopic analysis of embryo culture media for predicting reproductive potential in patients undergoing in vitro fertilization.
Turkish journal of obstetrics and gynecology
OBJECTIVE:To predict the reproductive potential of embryos via Raman spectroscopy evaluation of the spent culture media as well as with a conventional morphologic evaluation. MATERIALS AND METHODS:Women of reproductive age (n=31) who were treated for unexplained infertility and scheduled for single embryo transfer were invited to participate in this prospective study. After the embryos were removed from the culture, the spent culture media were stored at -80 °C after snap-freezing in liquid nitrogen. RESULTS:Fifteen patients were clinically pregnant, and 16 patients were clinically non-pregnant. Clinical pregnancy was predicted using Raman spectroscopy in 93% (14/15) of clinically pregnant patients, and in 62.5% (10 out of 16) of clinically non-pregnant patients. The sensitivity of the Raman spectroscopic analysis was 93% and the specificity was 62.5%. CONCLUSION:Metabolomic evaluation of spent embryo culture media is an emerging technique with promising objective results. However, there is clearly room for improvement.
10.4274/tjod.92604
Raman spectroscopy reveals the lipid phase transition in preimplantation mouse embryos during freezing.
Okotrub K A,Amstislavsky S Y,Surovtsev N V
Archives of biochemistry and biophysics
Although lipid phase transition is believed to be among the major damaging factors in oocytes and preimplantation embryos cryopreservation, lack of the appropriate experimental methods limits investigation of this phenomenon. Herein, we demonstrate the capabilities of Raman spectroscopy to detect the lipid phase transition within the freezing preimplantation mouse embryos. We exploit the sensibility of antisymmetric CH Raman peak to the phase state of lipids. It is shown that during the freezing of the mouse embryos the lipid phase transition occurs at the temperatures between -7 and 0 °C. Similar temperature dependences of CH mode intensities are found for lipids in the preimplantation embryos and a 1-palmitoyl-2-oleoyl-sn-glycero-3-phosphocholine, implying the similarity in the occupation rules of conformational states. Raman spectroscopy is considered as a method of choice to study the lipid phase transition during preimplantation mammalian embryos freezing and cryopreservation.
10.1016/j.abb.2017.10.001
Non-destructive monitoring of mouse embryo development and its qualitative evaluation at the molecular level using Raman spectroscopy.
Ishigaki Mika,Hashimoto Kosuke,Sato Hidetoshi,Ozaki Yukihiro
Scientific reports
Current research focuses on embryonic development and quality not only by considering fundamental biology, but also by aiming to improve assisted reproduction technologies, such as in vitro fertilization. In this study, we explored the development of mouse embryo and its quality based on molecular information, obtained nondestructively using Raman spectroscopy. The detailed analysis of Raman spectra measured in situ during embryonic development revealed a temporary increase in protein content after fertilization. Proteins with a β-sheet structure-present in the early stages of embryonic development-are derived from maternal oocytes, while α-helical proteins are additionally generated by switching on a gene after fertilization. The transition from maternal to embryonic control during development can be non-destructively profiled, thus facilitating the in situ assessment of structural changes and component variation in proteins generated by metabolic activity. Furthermore, it was indicated that embryos with low-grade morphology had high concentrations of lipids and hydroxyapatite. This technique could be used for embryo quality testing in the future.
10.1038/srep43942
Non-invasive Metabolomic Profiling of Embryo Culture Medium Using Raman Spectroscopy With Deep Learning Model Predicts the Blastocyst Development Potential of Embryos.
Frontiers in physiology
This study aimed to establish a non-invasive predicting model via Raman spectroscopy for evaluating the blastocyst development potential of day 3 high-quality cleavage stage embryos. Raman spectroscopy was used to detect the metabolic spectrum of spent day 3 (D3) embryo culture medium, and a classification model based on deep learning was established to differentiate between embryos that could develop into blastocysts (blastula) and that could not (non-blastula). The full-spectrum data for 80 blastula and 48 non-blastula samples with known blastocyst development potential from 34 patients were collected for this study. The accuracy of the predicting method was 73.53% and the main different Raman shifts between blastula and non-blastula groups were 863.5, 959.5, 1,008, 1,104, 1,200, 1,360, 1,408, and 1,632 cm from 80 blastula and 48 non-blastula samples by the linear discriminant method. This study demonstrated that the developing potential of D3 cleavage stage embryos to the blastocyst stage could be predicted with spent D3 embryo culture medium using Raman spectroscopy with deep learning classification models, and the overall accuracy reached at 73.53%. In the Raman spectroscopy, ribose vibration specific to RNA were found, indicating that the difference between the blastula and non-blastula samples could be due to materials that have similar structure with RNA. This result could be used as a guide for biomarker development of embryo quality assessment in the future.
10.3389/fphys.2021.777259
Raman spectroscopic imaging of the whole Ciona intestinalis embryo during development.
PloS one
Intracellular composition and the distribution of bio-molecules play central roles in the specification of cell fates and morphogenesis during embryogenesis. Consequently, investigation of changes in the expression and distribution of bio-molecules, especially mRNAs and proteins, is an important challenge in developmental biology. Raman spectroscopic imaging, a non-invasive and label-free technique, allows simultaneous imaging of the intracellular composition and distribution of multiple bio-molecules. In this study, we explored the application of Raman spectroscopic imaging in the whole Ciona intestinalis embryo during development. Analysis of Raman spectra scattered from C. intestinalis embryos revealed a number of localized patterns of high Raman intensity within the embryo. Based on the observed distribution of bio-molecules, we succeeded in identifying the location and structure of differentiated muscle and endoderm within the whole embryo, up to the tailbud stage, in a label-free manner. Furthermore, during cell differentiation, we detected significant differences in cell state between muscle/endoderm daughter cells and daughter cells with other fates that had divided from the same mother cells; this was achieved by focusing on the Raman intensity of single Raman bands at 1002 or 1526 cm(-1), respectively. This study reports the first application of Raman spectroscopic imaging to the study of identifying and characterizing differentiating tissues in a whole chordate embryo. Our results suggest that Raman spectroscopic imaging is a feasible label-free technique for investigating the developmental process of the whole embryo of C. intestinalis.
10.1371/journal.pone.0071739
Raman spectrum: A potential biomarker for embryo assessment during fertilization.
Ding Jiayi,Xu Tian,Tan Xiaofang,Jin Hua,Shao Jun,Li Haibo
Experimental and therapeutic medicine
The aim of the study was to investigate whether Raman spectrum is consistent with the morphological scoring of the embryo of day 3 during fertilization (IVF). The spent culture media of embryo of day 3 from 10 patients were collected and analyzed. The samples were analyzed using Raman spectroscopy and graded according to the standard embryo scoring system simultaneously. Data showed that the Raman spectra obtained from the droplet of media were useful, as they can act as the characteristic signature for protein and amino acids. The Raman biospectroscopy-based metabonomics profiling of spent media was consistent with the result of conventional morphological evaluation. In conclusion, this technology offers great potential for the development of tools allowing rapid non-invasive assessment of the quality of embryo of day 3 during IVF.
10.3892/etm.2017.4160
Raman profiling of embryo culture medium to identify aneuploid and euploid embryos.
Liang Bo,Gao Yuan,Xu Jiabao,Song Yizhi,Xuan Liming,Shi Ting,Wang Ning,Hou Zhaoxu,Zhao Yi-Lei,Huang Wei E,Chen Zi-Jiang
Fertility and sterility
OBJECTIVE:To develop and validate Raman metabolic footprint analysis to determine chromosome euploidy and aneuploidy in embryos fertilized in vitro. DESIGN:Retrospective study. SETTING:Academic hospital. PATIENT(S):Unselected assisted reproductive technology population. INTERVENTION(S):To establish the analysis protocol, spent embryo culture medium samples with known genetic outcomes from 87 human embryos were collected and measured with the use of Raman spectroscopy. Individual Raman spectra were analyzed to find biologic components contributing to either euploidy or aneuploidy. To validate the protocol via machine-learning algorithms, additional 1,107 Raman spectra from 123 embryo culture media (61 euploidy and 62 aneuploidy) were analyzed. MAIN OUTCOME MEASURE(S):Raman-based footprint profiling of spent culture media and preimplantation genetic testing for aneuploidy (PGT-A). RESULT(S):Mean-centered Raman spectra and principal component analysis showed differences in the footprints of euploid and aneuploid embryos growing in culture medium. Significant differences in Raman bands associated with small RNAs and lipids were also observed. Stacking classification based on k-nearest-neighbor, random forests, and extreme-gradient-boosting algorithms achieved an overall accuracy of 95.9% in correctly assigning either euploidy or aneuploidy based on Raman spectra, which was validated by PGT-A sequencing results. CONCLUSION(S):This study suggests that chromosomal abnormalities in embryos should lead to changes of metabolic footprints in embryo growth medium that can be detected by Raman spectroscopy. The ploidy status of embryos was analyzed by means of Raman-based footprint profiling of spent culture media and was consistent with PGT-A testing performed by next-generation sequencing.
10.1016/j.fertnstert.2018.11.036
Raman spectroscopy of follicular fluid and plasma with machine-learning algorithms for polycystic ovary syndrome screening.
Zhang Xinyi,Liang Bo,Zhang Jun,Hao Xinyao,Xu Xiaoyan,Chang Hsun-Ming,Leung Peter C K,Tan Jichun
Molecular and cellular endocrinology
Polycystic ovary syndrome (PCOS) is the main cause of anovulatory infertility and affects women throughout their lives. The specific diagnostic method is still under investigation. In the present study, we aimed to identify the metabolic tracks of the follicular fluid and plasma samples from women with PCOS by performing Raman spectroscopy with principal component analysis and spectral classification models. Follicular fluid and plasma samples obtained from 50 healthy (non-PCOS) and 50 PCOS women were collected and measured by Raman spectroscopy. Multivariate statistical methods and different machine-learning algorithms based on the Raman spectra were established to analyze the results. The principal component analysis of the Raman spectra showed differences in the follicular fluid between the non-PCOS and PCOS groups. The stacking classification models based on the k-nearest-neighbor, random forests and extreme gradient boosting algorithms yielded a higher accuracy of 89.32% by using follicular fluid than the accuracy of 74.78% obtained with plasma samples in classifying the spectra from the two groups. In this regard, PCOS may lead to the changes of metabolic profiles that can be detected by Raman spectroscopy. As a novel, rapid and affordable method, Raman spectroscopy combined with advanced machine-learning algorithms have potential to analyze and characterize patients with PCOS.
10.1016/j.mce.2020.111139
Raman Spectrum of Follicular Fluid: A Potential Biomarker for Oocyte Developmental Competence in Polycystic Ovary Syndrome.
Huang Xin,Hong Ling,Wu Yuanyuan,Chen Miaoxin,Kong Pengcheng,Ruan Jingling,Teng Xiaoming,Wei Zhiyun
Frontiers in cell and developmental biology
Polycystic ovary syndrome (PCOS) is a common endocrine and metabolic disorder in reproductive women where abnormal folliculogenesis is considered as a common characteristic. Our aim is to evaluate the potential of follicular fluid (FF) Raman spectra to predict embryo development and pregnancy outcome, so as to prioritize the best promising embryo for implantation, reducing both physiological and economical burdens of PCOS patients. In addition, the altered metabolic profiles will be identified to explore the aetiology and pathobiology of PCOS. In this study, follicular fluid samples obtained from 150 PCOS and 150 non-PCOS women were measured with Raman spectroscopy. Individual Raman spectrum was analyzed to find biologic components contributing to the occurrence of PCOS. More importantly, the Raman spectra of follicular fluid from the 150 PCOS patients were analyzed machine-learning algorithms to evaluate their predictive value for oocyte development potential and clinical pregnancy. Mean-centered Raman spectra and principal component analysis (PCA) showed global differences in the footprints of follicular fluid between PCOS and non-PCOS women. Two Raman zones (993-1,165 cm and 1,439-1,678 cm) were identified for describing the largest variances between the two groups, with the former higher and the latter lower in PCOS FF. The tentative assignments of corresponding Raman bands included phenylalanine and -carotene. Moreover, it was found that FF, in which oocytes would develop into high-quality blastocysts and obtain high clinical pregnancy rate, were detected with lower quantification of the integration at 993-1,165 cm and higher quantification of the integration at 1,439-1,678 cm in PCOS. In addition, based on Raman spectra of PCOS FF, the machine-learning algorithms via the fully connected artificial neural network (ANN) achieved the overall accuracies of 90 and 74% in correctly assigning oocyte developmental potential and clinical pregnancy, respectively. The study suggests that the PCOS displays unique metabolic profiles in follicular fluid which could be detected by Raman spectroscopy. Specific bands in Raman spectra have the biomarker potential to predict the embryo development and pregnancy outcome for PCOS patients. Importantly, these data may provide some valuable biochemical information and metabolic signatures that will help us to understand the abnormal follicular development in PCOS.
10.3389/fcell.2021.777224
Non-invasive oocyte quality assessment.
Sciorio Romualdo,Miranian Daniel,Smith Gary D
Biology of reproduction
Oocyte quality is perhaps the most important limiting factor in female fertility; however, the current methods of determining oocyte competence are only marginally capable of predicting a successful pregnancy. We aim to review the predictive value of non-invasive techniques for the assessment of human oocytes and their related cells and biofluids that pertain to their developmental competence. Investigation of the proteome, transcriptome, and hormonal makeup of follicular fluid, as well as cumulus-oocyte complexes are currently underway; however, prospective randomized non-selection-controlled trials of the future are needed before determining their prognostic value. The biological significance of polar body morphology and genetics are still unknown and the subject of debate. The predictive utility of zygotic viscoelasticity for embryo development has been demonstrated, but similar studies performed on oocytes have yet to be conducted. Metabolic profiling of culture media using human oocytes are also limited and may require integration of automated, high-throughput targeted metabolomic assessments in real time with microfluidic platforms. Light exposure to oocytes can be detrimental to subsequent development and utilization of time-lapse imaging and morphometrics of oocytes is wanting. Polarized light, Raman microspectroscopy, and coherent anti-Stokes Raman scattering are a few novel imaging tools that may play a more important role in future oocyte assessment. Ultimately, the integration of chemistry, genomics, microfluidics, microscopy, physics, and other biomedical engineering technologies into the basic studies of oocyte biology, and in testing and perfecting practical solutions of oocyte evaluation, are the future for non-invasive assessment of oocytes.
10.1093/biolre/ioac009
The association between occupational factors, depression, and health-related quality of life in military women in the Republic of Korea: a cross-sectional study.
Health and quality of life outcomes
BACKGROUND:Health-related quality of life (HRQOL) is an important concept to consider both individuals' ability to manage their daily lives and health status across the lifespan. Despite this variable's importance, there is a lack of clarification on the factors associated with HRQOL, especially for military women. The aim of this study was to examine factors associated with HRQOL of military women in the Republic of Korea (ROK) Army. METHODS:This cross-sectional study included 196 participants who were currently within their 5-year service period. HRQOL was measured by the Korean version of the Short-Form 36 Health Survey Questionnaire version 2.0 (SF-36v2), and depression was assessed using the Korean version of the Patient Health Questionnaire-9 (PHQ-9). Differences in HRQOL according to general and occupational factors were analyzed using the independent t-test and analysis of variance (ANOVA). Multiple linear regression analysis was performed to identify factors associated with the HRQOL of women serving as military junior officers. RESULTS:The mean score for the physical component summary (PCS) of SF-36v2 was 56.0 ± 5.8, and that for the mental component summary (MCS) of SF-36v2 was 47.2 ± 10.0. For depression, the mean score was 5.4 ± 5.2, whereas 19.4% of the participants scored more than 10 out of 27 points, which means moderate to severe. No variables showed statistically significant relationships with the PCS. However, military women showed a lower score for MCS when they were officers (adjusted β = - 3.52; 95% CI = - 5.47, - 1.58), had higher perceived stress (adjusted β = - 0.62, 95% CI = - 0.83, - 0.41), and a higher score for depression (adjusted β = - 0.86, 95% CI = - 1.10, - 0.63). CONCLUSIONS:Although depression levels were not severe, it was a significant factor of HRQOL. Stress and depression were found to be significant factors associated with the MCS in military women. Therefore, to improve their HRQOL, the ROK Army should provide early screening, intervention, and management program for high-risk military women. In addition, an appropriate organizational atmosphere within the military must be created to promote such programs.
10.1186/s12955-021-01846-1
Preconception Health Risk Factors in Women with and without a History of Military Service.
McCabe Jennifer E,Katon Jodie G,Ma Erica,Fortney John C,Grote Nancy K,Zephyrin Laurie C,Callegari Lisa S
Women's health issues : official publication of the Jacobs Institute of Women's Health
INTRODUCTION:Given the increasing number of women service members and veterans of childbearing age, it is important to understand the preconception risks in this potentially vulnerable population. This study compared the prevalence of modifiable preconception risk factors among women with and without a history of service. METHODS:Analyses included data from the 2013 and 2014 Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System. Preconception risk factors included health behaviors, chronic conditions, and mental health among women of childbearing age. Multivariate logistic regressions were used to compare the adjusted prevalence of each outcome among women with and without a history of service. Interaction terms assessed variation by age and history of service. RESULTS:Compared with women without a history of service, women with a history of service reported higher prevalence of insufficient sleep (49.6% vs. 36.3%; p < .001) and diagnosed depression (26.5% vs. 21.6%; p < .01). Women with a history of service were overall less likely to have obesity (19.8% vs. 26.5%; p < .001). Age-stratified results suggested that, compared with women without a history of service, women with a history of service were more likely to smoke in the 25 to 34 age group and reported comparable levels of obesity in the 35 to 44 age group. CONCLUSIONS:Women with a history of service demonstrated a preconception health profile that differs from women without a history of service. It is critical that providers are aware of their patients' military status and potential associated risks.
10.1016/j.whi.2018.08.002
Self-reported health behaviors, including sleep, correlate with doctor-informed medical conditions: data from the 2011 Health Related Behaviors Survey of U.S. Active Duty Military Personnel.
BMC public health
BACKGROUND:Health behaviors and cardiometabolic disease risk factors may differ between military and civilian populations; therefore, in U.S. active duty military personnel, we assessed relationships between demographic characteristics, self-reported health behaviors, and doctor-informed medical conditions. METHODS:Data were self-reported by 27,034 active duty military and Coast Guard personnel who responded to the 2011 Department of Defense Health Related Behaviors Survey. Multivariate linear and logistic regressions were used to estimate cross-sectional associations between (1) demographic characteristics (age, sex, service branch, marital status, children, race/ethnicity, pay grade) and self-reported behaviors (exercise, diet, smoking, alcohol, sleep); (2) demographic characteristics and doctor-informed medical conditions (hypertension, hypercholesterolemia, low high density lipoprotein (HDL) cholesterol, hyperglycemia) and overweight/obesity; and (3) behaviors and doctor-informed medical conditions. RESULTS:Among respondents (age 29.9 ± 0.1 years, 14.7% female), females reported higher intake than men of fruit, vegetables, and dairy; those with higher education reported higher intakes of whole grains; those currently married and/or residing with children reported higher intake of starches. Older age and female sex were associated with higher odds (ORs 1.25 to 12.54 versus the youngest age group) of overweight/obesity. Older age and female sex were also associated with lower odds (ORs 0.29 to 0.65 versus male sex) of doctor-informed medical conditions, except for blood glucose, for which females had higher odds. Those currently married had higher odds of high cholesterol and overweight/obesity, and separated/divorced/widowed respondents had higher odds of high blood pressure and high cholesterol. Short sleep duration (< 5 versus 7-8 h/night) was associated with higher odds (ORs 1.36to 2.22) of any given doctor-informed medical condition. Strength training was associated with lower probability of high cholesterol, high triglycerides, and low HDL, and higher probability of overweight/obesity. Dietary factors were variably associated with doctor-informed medical conditions and overweight/obesity. CONCLUSIONS:This study observed pronounced associations between health behaviors-especially sleep-and medical conditions, thus adding to evidence that sleep is a critical, potentially modifiable behavior within this population. When possible, adequate sleep should continue to be promoted as an important part of overall health and wellness throughout the military community.
10.1186/s12889-018-5781-2
A comparison of alcohol use and related problems among women and men in the military.
Brown Janice M,Bray Robert M,Hartzell Michael C
Military medicine
Using data from the 2002 Department of Defense Survey of Health Related Behaviors, we examined levels of drinking and alcohol-related problems (dependence symptoms, driving after drinking, productivity loss, serious consequences) for enlisted men and women and male and female officers. Findings showed that men were more likely than women to be heavy or binge drinkers and to experience alcohol-related problems. Similarly, enlisted men and women were more likely than male and female officers to be heavy or binge drinkers. Driving after drinking was more common among men than women and more common among officers than enlisted personnel. Officers had lower rates of dependence symptoms and other serious consequences than enlisted personnel. Despite men's heavier drinking, women showed equal or higher rates of dependence symptoms and productivity loss and appeared to be at risk for alcohol problems at lower levels of consumption.
10.7205/milmed-d-09-00080
Pregnancy and Abortion: Experiences and Attitudes of Deployed U.S. Servicewomen.
Seymour Jane W,Fix Laura,Grossman Daniel,Grindlay Kate
Military medicine
INTRODUCTION:More U.S. servicewomen than civilian women experience unintended pregnancies, which can impact their health, well-being, and careers. Despite this, federal policy limits abortion access and coverage for military personnel to cases of rape, incest, and life endangerment. This study aimed to document servicewomen's experiences with unintended pregnancy and abortion during deployment, and their knowledge and opinions of military policies related to sexual activity, pregnancy, and abortion. MATERIAL AND METHODS:Between June 2016 and July 2017, we conducted a cross-sectional online survey among a convenience sample of current and former U.S. Military, National Guard, and Reserves members whose last deployment ended in 2010 or later. We asked open- and closed-ended questions about demographics, experiences with pregnancy and abortion during deployment, and knowledge and opinions of military policies related to sexual activity, pregnancy, and abortion. We ran descriptive statistics on closed-ended questions and inductively coded open-ended question responses. This study was approved by the Allendale Investigational Review Board. RESULTS:A total of 319 participants were included. The majority said that servicewomen are reprimanded for sexual activity and becoming pregnant during deployment in all or some circumstances. Among these respondents, one-third said that fear of reprimand for sexual activity affects deployed servicewomen's use of contraception. Twenty respondents became pregnant or discovered that they were pregnant during deployment; twelve were unable to access the pregnancy- and/or abortion-related services they wanted or needed. Among those whose last deployment ended in 2013 or later (n = 141), when federal policy expanded abortion coverage for servicemembers to include cases of rape and incest, the minority knew the correct coverage or provision policies for abortion in cases of rape and incest or life endangerment. The majority believed that the military should cover and provide abortion in cases of rape, incest, or life endangerment and for unwanted pregnancies. CONCLUSION:Among this convenience sample of current and former servicewomen with an overseas deployment that ended in 2010 or later, 6% became pregnant or discovered that they were pregnant during deployment, and most of these respondents reported being unable to access the pregnancy- and/or abortion-related services they wanted or needed. The majority reported lack of knowledge of military abortion policies and that servicewomen are reprimanded for pregnancy and/or sexual activity in some or all circumstances, with many noting this reprimand as a barrier to contraceptive use for some servicewomen. Predeployment health visits may be one intervention point for disseminating the military's abortion policies; commanding officers should also be well versed in these policies so that they are able to provide effective leadership to junior military members.
10.1093/milmed/usaa128
Deployment and Preterm Birth Among US Army Soldiers.
Shaw Jonathan G,Nelson D Alan,Shaw Kate A,Woolaway-Bickel Kelly,Phibbs Ciaran S,Kurina Lianne M
American journal of epidemiology
With increasing integration of women into combat roles in the US military, it is critical to determine whether deployment, which entails unique stressors and exposures, is associated with adverse reproductive outcomes. Few studies have examined whether deployment increases the risk of preterm birth; no studies (to our knowledge) have examined a recent cohort of servicewomen. We therefore used linked medical and administrative data from the Stanford Military Data Repository for all US Army soldiers with deliveries between 2011 and 2014 to estimate the associations of prior deployment, recency of deployment, and posttraumatic stress disorder with spontaneous preterm birth (SPB), adjusting for sociodemographic, military-service, and health-related factors. Of 12,877 deliveries, 6.1% were SPBs. The prevalence was doubled (11.7%) among soldiers who delivered within 6 months of their return from deployment. Multivariable discrete-time logistic regression models indicated that delivering within 6 months of return from deployment was strongly associated with SPB (adjusted odds ratio = 2.1, 95% confidence interval: 1.5, 2.9). Neither multiple past deployments nor posttraumatic stress disorder was significantly associated with SPB. Within this cohort, timing of pregnancy in relation to deployment was identified as a novel risk factor for SPB. Increased focus on servicewomen's pregnancy timing and predeployment access to reproductive counseling and effective contraception is warranted.
10.1093/aje/kwy003