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Angiosperms are the cornerstone of most terrestrial ecosystems and human livelihoods(1,2). A robust understanding of angiosperm evolution is required to explain their rise to ecological dominance. So far, the angiosperm tree of life has been determined primarily by means of analyses of the plastid genome(3,4). Many studies have drawn on this foundational work, such as classification and first insights into angiosperm diversification since their Mesozoic origins(5-7). However, the limited and biased sampling of both taxa and genomes undermines confidence in the tree and its implications. Here, we build the tree of life for almost 8,000 (about 60%) angiosperm genera using a standardized set of 353 nuclear genes(8). This 15-fold increase in genus-level sampling relative to comparable nuclear studies(9) provides a critical test of earlier results and brings notable change to key groups, especially in rosids, while substantiating many previously predicted relationships. Scaling this tree to time using 200 fossils, we discovered that early angiosperm evolution was characterized by high gene tree conflict and explosive diversification, giving rise to more than 80% of extant angiosperm orders. Steady diversification ensued through the remaining Mesozoic Era until rates resurged in the Cenozoic Era, concurrent with decreasing global temperatures and tightly linked with gene tree conflict. Taken together, our extensive sampling combined with advanced phylogenomic methods shows the deep history and full complexity in the evolution of a megadiverse clade.

ObjectiveTo assess attitudes and factors that influence public opinion in the general US population toward insurance coverage and provision of infertility care to lower income patients.DesignCross-sectional survey.SettingOnline.PatientsA nationally representative sample of US residents.InterventionsQuestionnaire with multiple choice and open response questions.Main outcome measuresPublic attitudes toward in vitro fertilization and infertility care coverage for lower income patients.ResultsA total of 1,027 (90.2%) participants completed the survey, among whom 620 (60.4%) had private insurance, 275 (26.8%) had Medicare/Medicaid, and 56 (5.5%) were uninsured. The majority (916, 89.2%) did not consider infertility a disease. Over half of the respondents (568, 55.3%) supported private insurance coverage of infertility services, including for in vitro fertilization. Most respondents, 735 (71.6%) believed that the prevalence and psychosocial impact of infertility were equal among the lower and higher income people. The majority of respondents with an opinion (512, 67.6%) believed that doctors should provide infertility treatments regardless of the income level of the patients. Of supporters, 40.1% believed in the right to have a family regardless of income, and 38.2% believed that doctors had a social responsibility to provide infertility services. After adjusting for covariates, age <45 years, noncollege graduates, desiring more children, believing that infertility was a disease, and residence in the Northeast region remained significant predictors for support of private insurance coverage.ConclusionsPublic perception of infertility as a disease is one of the strongest predictors of support for insurance coverage for infertility services, underscoring the need for enhanced advocacy and education in the general public.

ObjectiveTo assess attitudes and factors that influence public opinion in the general US population toward insurance coverage and provision of infertility care to lower income patients.DesignCross-sectional survey.SettingOnline.PatientsA nationally representative sample of US residents.InterventionsQuestionnaire with multiple choice and open response questions.Main outcome measuresPublic attitudes toward in vitro fertilization and infertility care coverage for lower income patients.ResultsA total of 1,027 (90.2%) participants completed the survey, among whom 620 (60.4%) had private insurance, 275 (26.8%) had Medicare/Medicaid, and 56 (5.5%) were uninsured. The majority (916, 89.2%) did not consider infertility a disease. Over half of the respondents (568, 55.3%) supported private insurance coverage of infertility services, including for in vitro fertilization. Most respondents, 735 (71.6%) believed that the prevalence and psychosocial impact of infertility were equal among the lower and higher income people. The majority of respondents with an opinion (512, 67.6%) believed that doctors should provide infertility treatments regardless of the income level of the patients. Of supporters, 40.1% believed in the right to have a family regardless of income, and 38.2% believed that doctors had a social responsibility to provide infertility services. After adjusting for covariates, age <45 years, noncollege graduates, desiring more children, believing that infertility was a disease, and residence in the Northeast region remained significant predictors for support of private insurance coverage.ConclusionsPublic perception of infertility as a disease is one of the strongest predictors of support for insurance coverage for infertility services, underscoring the need for enhanced advocacy and education in the general public.

PurposeToday, male and female adult and pediatric cancer patients, individuals transitioning between gender identities, and other individuals facing health extending but fertility limiting treatments can look forward to a fertile future. This is, in part, due to the work of members associated with the Oncofertility Consortium.MethodsThe Oncofertility Consortium is an international, interdisciplinary initiative originally designed to explore the urgent unmet need associated with the reproductive future of cancer survivors. As the strategies for fertility management were invented, developed or applied, the individuals for who the program offered hope, similarly expanded. As a community of practice, Consortium participants share information in an open and rapid manner to addresses the complex health care and quality-of-life issues of cancer, transgender and other patients. To ensure that the organization remains contemporary to the needs of the community, the field designed a fully inclusive mechanism for strategic planning and here present the findings of this process.ResultsThis interprofessional network of medical specialists, scientists, and scholars in the law, medical ethics, religious studies and other disciplines associated with human interventions, explore the relationships between health, disease, survivorship, treatment, gender and reproductive longevity.ConclusionThe goals are to continually integrate the best science in the service of the needs of patients and build a community of care that is ready for the challenges of the field in the future.

ObjectiveTo examine the factors associated with increased deoxyribonucleic acid fragmentation index (DFI), evaluate the pregnancy outcomes of men with increased DFI, and compare three independent DFI assays.DesignSecondary analysis.SettingNine US-based fertility centers.PatientsInfertile men (N = 147) with sperm concentration ≤15 × 106/mL, motility ≤40%, or normal morphology ≤4% were enrolled. The female partners were ovulatory, ≤40 years old, and had documented tubal patency.InterventionsAt a baseline visit, the men provided a semen sample. The couples attempted conception without assistance for 3 months and with ovarian stimulation and intrauterine insemination in the subsequent 3 months.Main outcome measuresThe DFI was analyzed using the sperm chromatin structure assay (SCSA) with increased DFI defined as >30%. The predictors of increased DFI were determined by a multivariable linear regression model. The pregnancy outcomes were compared using the χ2 test. The independent DFI assays (SCSA, deoxynucleotidyl transferase-mediated dUTP nick end labeling, and Comet) were compared with Pearson and Spearman correlations.ResultsThe 19% of men with increased DFI were older (36.0 vs. 33.0 years) and had lower total sperm motility (38.2% ± 20.5% vs. 45.2% ± 15.6%). Increased male age was found to be a significant predictor of DFI (0.75, 95% confidence interval [0.06, 1.45]). Increased DFI was not associated with conception or live birth. There was a modest correlation of the deoxynucleotidyl transferase-mediated dUTP nick end labeling assay with the SCSA (r = 0.34) and Comet assay (r = 0.19).ConclusionsOlder age was associated with increased DFI among infertile men. The DFI assays were only weakly correlated, indicating a standard definition of DFI is needed to truly interrogate how sperm deoxyribonucleic acid fragmentation impacts male fertility.

Today, male and female adult and pediatric cancer patients, individuals transitioning between gender identities, and other individuals facing health extending but fertility limiting treatments can look forward to a fertile future. This is, in part, due to the work of members associated with the Oncofertility Consortium. The Oncofertility Consortium is an international, interdisciplinary initiative originally designed to explore the urgent unmet need associated with the reproductive future of cancer survivors. As the strategies for fertility management were invented, developed or applied, the individuals for who the program offered hope, similarly expanded. As a community of practice, Consortium participants share information in an open and rapid manner to addresses the complex health care and quality-of-life issues of cancer, transgender and other patients. To ensure that the organization remains contemporary to the needs of the community, the field designed a fully inclusive mechanism for strategic planning and here present the findings of this process. This interprofessional network of medical specialists, scientists, and scholars in the law, medical ethics, religious studies and other disciplines associated with human interventions, explore the relationships between health, disease, survivorship, treatment, gender and reproductive longevity. The goals are to continually integrate the best science in the service of the needs of patients and build a community of care that is ready for the challenges of the field in the future.

PurposeToday, male and female adult and pediatric cancer patients, individuals transitioning between gender identities, and other individuals facing health extending but fertility limiting treatments can look forward to a fertile future. This is, in part, due to the work of members associated with the Oncofertility Consortium.MethodsThe Oncofertility Consortium is an international, interdisciplinary initiative originally designed to explore the urgent unmet need associated with the reproductive future of cancer survivors. As the strategies for fertility management were invented, developed or applied, the individuals for who the program offered hope, similarly expanded. As a community of practice, Consortium participants share information in an open and rapid manner to addresses the complex health care and quality-of-life issues of cancer, transgender and other patients. To ensure that the organization remains contemporary to the needs of the community, the field designed a fully inclusive mechanism for strategic planning and here present the findings of this process.ResultsThis interprofessional network of medical specialists, scientists, and scholars in the law, medical ethics, religious studies and other disciplines associated with human interventions, explore the relationships between health, disease, survivorship, treatment, gender and reproductive longevity.ConclusionThe goals are to continually integrate the best science in the service of the needs of patients and build a community of care that is ready for the challenges of the field in the future.

BackgroundFew studies have examined health literacy and fertility knowledge among women from low income, socio-culturally diverse communities presenting for fertility care in the United States. Our study sought to examine demographic predictors of fertility-related knowledge among infertile women from low and high-resource communities in two major metropolitan centers in the United States.MethodsFertility Knowledge Assessments were administered to women presenting for fertility care at county medical centers serving low-resource, largely immigrant patients and to women from largely affluent populations presenting to comprehensive fertility centers in two cities. The influence of demographic predictors on fertility knowledge was examined through regression analysis.ResultsA total of 143 women were included in our analysis. In the county hospital/low resource clinic (LR, n = 70), the mean age was 32.8 ± 6.1 years vs 35.0 ± 5.0 years in the fee-for-service/high resource clinic (HR, n = 73). Among the LR patients, 74% were immigrants, 71% had an annual income <$25,000 and 52% had completed high school. Among HR patients, 36% were immigrants, 60% had an annual income >$100,000, and 95% had some college or above. On average, women from HR settings scored 3.0 points higher on the Fertility Knowledge Assessment than their LR counterparts (p < 0.001). Upon multivariate analysis, education level remained the sole independent factor associated with fertility knowledge assessment score (p < 0.001). Stratifying by resource level revealed that income was highly associated with fertility knowledge (p < 0.01) among high resource individuals even when adjusting for education level.ConclusionsWomen from low resource, largely immigrant communities, seeking fertility care have greater disparities in fertility knowledge and lower health literacy compared to women from high resource clinical settings. Further studies are needed to understand these barri

BackgroundFew studies have examined health literacy and fertility knowledge among women from low income, socio-culturally diverse communities presenting for fertility care in the United States. Our study sought to examine demographic predictors of fertility-related knowledge among infertile women from low and high-resource communities in two major metropolitan centers in the United States.MethodsFertility Knowledge Assessments were administered to women presenting for fertility care at county medical centers serving low-resource, largely immigrant patients and to women from largely affluent populations presenting to comprehensive fertility centers in two cities. The influence of demographic predictors on fertility knowledge was examined through regression analysis.ResultsA total of 143 women were included in our analysis. In the county hospital/low resource clinic (LR, n = 70), the mean age was 32.8 ± 6.1 years vs 35.0 ± 5.0 years in the fee-for-service/high resource clinic (HR, n = 73). Among the LR patients, 74% were immigrants, 71% had an annual income <$25,000 and 52% had completed high school. Among HR patients, 36% were immigrants, 60% had an annual income >$100,000, and 95% had some college or above. On average, women from HR settings scored 3.0 points higher on the Fertility Knowledge Assessment than their LR counterparts (p < 0.001). Upon multivariate analysis, education level remained the sole independent factor associated with fertility knowledge assessment score (p < 0.001). Stratifying by resource level revealed that income was highly associated with fertility knowledge (p < 0.01) among high resource individuals even when adjusting for education level.ConclusionsWomen from low resource, largely immigrant communities, seeking fertility care have greater disparities in fertility knowledge and lower health literacy compared to women from high resource clinical settings. Further studies are needed to understand these barri

Once unimaginable, fertility management is now a nationally established part of cancer care in institutions, from academic centers to community hospitals to private practices. Over the last two decades, advances in medicine and reproductive science have made it possible for men, women and children to be connected with an oncofertility specialist or offered fertility preservation soon after a cancer diagnosis. The Oncofertility Consortium's National Physicians Cooperative is a large-scale effort to engage physicians across disciplines - oncology, urology, obstetrics and gynecology, reproductive endocrinology, and behavioral health - in clinical and research activities to enable significant progress in providing fertility preservation options to children and adults. Here, we review the structure and function of the National Physicians Cooperative and identify next steps.

Extracellular microRNAs (miRNAs) and other small RNAs are implicated in cellular communication and may be useful as disease biomarkers. We systematically compared small RNAs in 12 human biofluid types using RNA sequencing (RNA-seq). miRNAs and tRNA-derived RNAs (tDRs) accounted for the majority of mapped reads in all biofluids, but the ratio of miRNA to tDR reads varied from 72 in plasma to 0.004 in bile. miRNA levels were highly correlated across all biofluids, but levels of some miRNAs differed markedly between biofluids. tDR populations differed extensively between biofluids. Y RNA fragments were seen in all biofluids and accounted for >10% of reads in blood plasma, serum, and cerebrospinal fluid (CSF). Reads mapping exclusively to Piwi-interacting RNAs (piRNAs) were very rare, except in seminal plasma. These results demonstrate extensive differences in small RNAs between human biofluids and provide a useful resource for investigating extracellular RNA biology and developing biomarkers.

Extracellular microRNAs (miRNAs) and other small RNAs are implicated in cellular communication and may be useful as disease biomarkers. We systematically compared small RNAs in 12 human biofluid types using RNA sequencing (RNA-seq). miRNAs and tRNA-derived RNAs (tDRs) accounted for the majority of mapped reads in all biofluids, but the ratio of miRNA to tDR reads varied from 72 in plasma to 0.004 in bile. miRNA levels were highly correlated across all biofluids, but levels of some miRNAs differed markedly between biofluids. tDR populations differed extensively between biofluids. Y RNA fragments were seen in all biofluids and accounted for >10% of reads in blood plasma, serum, and cerebrospinal fluid (CSF). Reads mapping exclusively to Piwi-interacting RNAs (piRNAs) were very rare, except in seminal plasma. These results demonstrate extensive differences in small RNAs between human biofluids and provide a useful resource for investigating extracellular RNA biology and developing biomarkers.

Once unimaginable, fertility management is now a nationally established part of cancer care in institutions, from academic centers to community hospitals to private practices. Over the last two decades, advances in medicine and reproductive science have made it possible for men, women and children to be connected with an oncofertility specialist or offered fertility preservation soon after a cancer diagnosis. The Oncofertility Consortium's National Physicians Cooperative is a large-scale effort to engage physicians across disciplines - oncology, urology, obstetrics and gynecology, reproductive endocrinology, and behavioral health - in clinical and research activities to enable significant progress in providing fertility preservation options to children and adults. Here, we review the structure and function of the National Physicians Cooperative and identify next steps.

Prepubertal boys treated with high-dose chemotherapy do not have an established means of fertility preservation because no established in vitro technique exists to expand and mature purified spermatogonial stem cells (SSCs) to functional sperm in humans. In this study, we define and characterize the unique testicular cellular niche required for SSC expansion using testicular tissues from men with normal spermatogenesis. Highly purified SSCs and testicular somatic cells were isolated by fluorescence-activated cell sorting using SSEA-4 and THY1 as markers of SSCs and somatic cells. Cells were cultured on various established niches to assess their role in SSC expansion in a defined somatic cellular niche. Of all the niches examined, cells in the SSEA-4 population exclusively bound to adult testicular stromal cells, established colonies, and expanded. Further characterization of these testicular stromal cells revealed distinct mesenchymal markers and the ability to undergo differentiation along the mesenchymal lineage, supporting a testicular multipotent stromal cell origin. In vitro human SSC expansion requires a unique niche provided exclusively by testicular multipotent stromal cells with mesenchymal properties. These findings provide an important foundation for developing methods of inducing SSC growth and maturation in prepubertal testicular tissue, essential to enabling fertility preservation for these boys.

IntroductionThe prevalence and associations of sexual bother in male medical students has not been extensively studied.AimsThe aim of this study is to analyze predictors of sexual bother in a survey of male North American medical students.MethodsStudents enrolled in allopathic and osteopathic medical schools in North America between February 2008 and July 2008 were invited to participate in an internet-based survey of sexuality and sexual function.Main outcome measuresThe principle outcome measure was a single-item question inquiring about global satisfaction with sexual function. The survey also consisted of a questionnaire that included ethnodemographic factors, student status, sexual history, and a validated scale for the assessment of depression. Respondents completed the International Index of Erectile Function, the premature ejaculation diagnostic tool, and the Self-Esteem and Relationship Quality survey (SEAR). Descriptive statistics, analysis of variance, and multivariable logistic regression were utilized to analyze responses.ResultsThere were 480 male subjects (mean age 26.3 years) with data sufficient for analysis. Forty-three (9%) reported sexual bother. Sexual bother was significantly more common in men with erectile dysfunction (ED), high risk of premature ejaculation (HRPE), depressive symptoms, and lower sexual frequency. However, after multivariate analysis including SEAR scores, ED, and HRPE were no longer independently predictive of sexual bother. Higher scores for all domains of the SEAR were associated with lower odds of sexual bother.ConclusionsED and HRPE are associated with sexual bother in this young and presumably healthy population. However, after controlling for relationship factors neither ED nor HRPE independently predicted sexual bother. It is plausible to hypothesize that sexual dysfunction from organic causes is rare in this population and is seldom encountered outside of relationship perturbations. Attention to relationship and psyc

IntroductionThe role of sexuality as an association of medical student well-being has not been extensively studied.AimWe explored the relationship between depressive symptoms, sexuality, and sexual dysfunction in male North American medical students.Main outcome measureNorth American medical students were invited to participate in an Internet-based survey. The Center for Epidemiological Studies Depression Scale (CES-D) was utilized to screen for depressive symptoms.MethodsSubjects completed an ethnodemographic survey, a sexuality survey, and instruments for the quantification of anxiety, sexuality, and psychosocial function. Descriptive statistics, odds ratios (ORs), and logistic regression were used to analyze our data.ResultsThere were 844 male subjects with complete data on the CES-D and the Spielberger State-Trait Anxiety Index. Depressive symptoms (CES-D ≥ 16) were present in 37% of respondents and were more common in subjects with greater levels of anxiety. Subjects who were in sexual relationships and/or had frequent sexual activity were less likely to be depressed compared to other subjects. Erectile dysfunction (ED) was associated with significantly greater likelihood of depressive symptoms (OR 2.90 and 9.27 for depressive symptoms in men with mild or moderate/severe ED relative to men without ED, P < 0.01). After adjusting for ethnodemographic and sexual history factors, ED remained significantly positively associated with depressive symptoms (OR 2.87 and 6.59 for depressive symptoms in men with mild or moderate/severe ED relative to men without ED after adjustment, P ≤ 0.01). Inclusion of data related to psychosocial/relationship factors in the multivariate model eliminated the significant association between ED and depressive symptoms (OR 1.59 and 2.29 for depressive symptoms in men with mild or moderate/severe ED relative to men without ED after adjustment with the Self-Esteem and Relationship quality instrument, P > 0.05), suggesting that psychos

Background:Infertility is a prevalent disease of reproductive health that exerts an impact on an estimated 80 million people worldwide. For many, involuntary childlessness becomes a central and preoccupying issue in their lives, the impact of which is exacerbated by lack of access to basic care and treatment. These effects maybe further magnified among immigrant communities, a growing but highly marginalized population that has been shown in other areas of reproductive health to experience worse health outcomes and delays in access to care. To date, few studies have examined the unique medical and sociocultural considerations of infertility among immigrant populations in the United States. Methods:Our study is a cross-sectional analysis of women presenting for infertility evaluation at a county hospital serving a low resource, socioculturally diverse largely immigrant communities in comparison to infertile women from a largely affluent population presenting to a high resource, comprehensive fertility center. We employed surveys to evaluate demographics and socioeconomic parameters as well as abstracted data from medical records to obtain infertility diagnoses. Multivariate regression analysis was applied to examine impact of sociocultural factors as predictors of duration of untreated infertility disease burden experienced by patients. Results:Eighty-seven women were included in our analysis. In the county hospital/low resource clinic (LR), the mean age was 32.9 ± 4.9 vs 36.4 ± 6.3 years in the fee-for-service/high resource clinic (HR). The mean reported duration of infertility in LR and HR patients was 3.4 ± 3.0 vs 2.3 ± 1.5 years. 70% of LR patients were monolingual non-English speakers vs 5.4% of HR patients. 59% of LR patients reported an annual household income of less than $25,000 and 70% did not have a college degree. 81.1% of HR patients reported an income of higher than $100,000, and 81.1% had completed college or graduate school. The most common

Unlike other human biological fluids, semen contains multiple types of amyloid fibrils in the absence of disease. These fibrils enhance HIV infection by promoting viral fusion to cellular targets, but their natural function remained unknown. The similarities shared between HIV fusion to host cell and sperm fusion to oocyte led us to examine whether these fibrils promote fertilization. Surprisingly, the fibrils inhibited fertilization by immobilizing sperm. Interestingly, however, this immobilization facilitated uptake and clearance of sperm by macrophages, which are known to infiltrate the female reproductive tract (FRT) following semen exposure. In the presence of semen fibrils, damaged and apoptotic sperm were more rapidly phagocytosed than healthy ones, suggesting that deposition of semen fibrils in the lower FRT facilitates clearance of poor-quality sperm. Our findings suggest that amyloid fibrils in semen may play a role in reproduction by participating in sperm selection and facilitating the rapid removal of sperm antigens.

BackgroundInfertility is a prevalent disease of reproductive health that exerts an impact on an estimated 80 million people worldwide. For many, involuntary childlessness becomes a central and preoccupying issue in their lives, the impact of which is exacerbated by lack of access to basic care and treatment. These effects maybe further magnified among immigrant communities, a growing but highly marginalized population that has been shown in other areas of reproductive health to experience worse health outcomes and delays in access to care. To date, few studies have examined the unique medical and sociocultural considerations of infertility among immigrant populations in the United States.MethodsOur study is a cross-sectional analysis of women presenting for infertility evaluation at a county hospital serving a low resource, socioculturally diverse largely immigrant communities in comparison to infertile women from a largely affluent population presenting to a high resource, comprehensive fertility center. We employed surveys to evaluate demographics and socioeconomic parameters as well as abstracted data from medical records to obtain infertility diagnoses. Multivariate regression analysis was applied to examine impact of sociocultural factors as predictors of duration of untreated infertility disease burden experienced by patients.ResultsEighty-seven women were included in our analysis. In the county hospital/low resource clinic (LR), the mean age was 32.9 ± 4.9 vs 36.4 ± 6.3 years in the fee-for-service/high resource clinic (HR). The mean reported duration of infertility in LR and HR patients was 3.4 ± 3.0 vs 2.3 ± 1.5 years. 70% of LR patients were monolingual non-English speakers vs 5.4% of HR patients. 59% of LR patients reported an annual household income of less than $25,000 and 70% did not have a college degree. 81.1% of HR patients reported an income of higher than $100,000, and 81.1% had completed college or graduate school. The most common infer

Unlike other human biological fluids, semen contains multiple types of amyloid fibrils in the absence of disease. These fibrils enhance HIV infection by promoting viral fusion to cellular targets, but their natural function remained unknown. The similarities shared between HIV fusion to host cell and sperm fusion to oocyte led us to examine whether these fibrils promote fertilization. Surprisingly, the fibrils inhibited fertilization by immobilizing sperm. Interestingly, however, this immobilization facilitated uptake and clearance of sperm by macrophages, which are known to infiltrate the female reproductive tract (FRT) following semen exposure. In the presence of semen fibrils, damaged and apoptotic sperm were more rapidly phagocytosed than healthy ones, suggesting that deposition of semen fibrils in the lower FRT facilitates clearance of poor-quality sperm. Our findings suggest that amyloid fibrils in semen may play a role in reproduction by participating in sperm selection and facilitating the rapid removal of sperm antigens.

IntroductionInfertility affects approximately 6.7 million women in the United States. Couples with infertility have significantly more anxiety, depression, and stress. This is compounded by the fact that almost 40% of couples undergoing assisted reproduction technology still cannot conceive, which can have an ongoing effect on quality of life, marital adjustment, and sexual impact.AimTo assess the sexual impact of infertility in women undergoing fertility treatment.MethodsThis study is a cross-sectional analysis of women in infertile couples seeking treatment at academic or private infertility clinics. Basic demographic information was collected. Respondents were surveyed regarding sexual impact and perception of their infertility etiology. Multivariate regression analyses were used to identify factors independently associated with increased sexual impact.Main outcome measureSexual impact of perceived fertility diagnosis.ResultsIn total, 809 women met the inclusion criteria, of whom 437 (54%) agreed to participate and 382 completed the sexual impact items. Most of the infertility was female factor only (58.8%), whereas 30.4% of infertility was a combination of male and female factors, 7.3% was male factor only, and 3.5% was unexplained infertility. In bivariate and multivariate analyses, women who perceived they had female factor only infertility reported greater sexual impact compared with woman with male factor infertility (P = .01). Respondents who were younger than 40 years experienced a significantly higher sexual impact than respondents older than 40 years (P < .01). When stratified by primary and secondary infertility, respondents with primary infertility overall reported higher sexual impact scores.ConclusionIn women seeking fertility treatment, younger age and female factor infertility were associated with increased sexual impact and thus these women are potentially at higher risk of sexual dysfunction. Providers should consider the role young

IntroductionInfertility affects approximately 6.7 million women in the United States. Couples with infertility have significantly more anxiety, depression, and stress. This is compounded by the fact that almost 40% of couples undergoing assisted reproduction technology still cannot conceive, which can have an ongoing effect on quality of life, marital adjustment, and sexual impact.AimTo assess the sexual impact of infertility in women undergoing fertility treatment.MethodsThis study is a cross-sectional analysis of women in infertile couples seeking treatment at academic or private infertility clinics. Basic demographic information was collected. Respondents were surveyed regarding sexual impact and perception of their infertility etiology. Multivariate regression analyses were used to identify factors independently associated with increased sexual impact.Main outcome measureSexual impact of perceived fertility diagnosis.ResultsIn total, 809 women met the inclusion criteria, of whom 437 (54%) agreed to participate and 382 completed the sexual impact items. Most of the infertility was female factor only (58.8%), whereas 30.4% of infertility was a combination of male and female factors, 7.3% was male factor only, and 3.5% was unexplained infertility. In bivariate and multivariate analyses, women who perceived they had female factor only infertility reported greater sexual impact compared with woman with male factor infertility (P = .01). Respondents who were younger than 40 years experienced a significantly higher sexual impact than respondents older than 40 years (P < .01). When stratified by primary and secondary infertility, respondents with primary infertility overall reported higher sexual impact scores.ConclusionIn women seeking fertility treatment, younger age and female factor infertility were associated with increased sexual impact and thus these women are potentially at higher risk of sexual dysfunction. Providers should consider the role young

UnlabelledSemen enhances HIV infection in vitro, but how long it retains this activity has not been carefully examined. Immediately postejaculation, semen exists as a semisolid coagulum, which then converts to a more liquid form in a process termed liquefaction. We demonstrate that early during liquefaction, semen exhibits maximal HIV-enhancing activity that gradually declines upon further incubation. The decline in HIV-enhancing activity parallels the degradation of peptide fragments derived from the semenogelins (SEMs), the major components of the coagulum that are cleaved in a site-specific and progressive manner upon initiation of liquefaction. Because amyloid fibrils generated from SEM fragments were recently demonstrated to enhance HIV infection, we set out to determine whether any of the liquefaction-generated SEM fragments associate with the presence of HIV-enhancing activity. We identify SEM1 from amino acids 86 to 107 [SEM1(86-107)] to be a short, cationic, amyloidogenic SEM peptide that is generated early in the process of liquefaction but that, conversely, is lost during prolonged liquefaction due to the activity of serine proteases. Synthetic SEM1(86-107) amyloids directly bind HIV-1 virions and are sufficient to enhance HIV infection of permissive cells. Furthermore, endogenous seminal levels of SEM1(86-107) correlate with donor-dependent variations in viral enhancement activity, and antibodies generated against SEM1(86-107) recognize endogenous amyloids in human semen. The amyloidogenic potential of SEM1(86-107) and its virus-enhancing properties are conserved among great apes, suggesting an evolutionarily conserved function. These studies identify SEM1(86-107) to be a key, HIV-enhancing amyloid species in human semen and underscore the dynamic nature of semen's HIV-enhancing activity.ImportanceSemen, the most common vehicle for HIV transmission, enhances HIV infection in vitro, but how long it retains this activity has not been investigated. Semen na

ObjectiveTo determine the time that infertile couples spend seeking and utilizing fertility care.DesignProspective cohort.SettingEight community and academic infertility practices.Patient(s)A total of 319 couples presenting for a fertility evaluation.Intervention(s)Face-to-face and telephone interviews and questionnaires.Main outcome measure(s)Participants recorded diaries of time spent on provider visits, travel, telephone, and miscellaneous activities. Participants also recorded time off from work due to the physical and mental stress related to fertility care. Linear regression was used to assess relationship between fertility characteristics and time spent pursuing care.Result(s)Diaries were completed by 319 subjects. Over an 18-month time period, the average time spent on fertility care was 125 hours, equating to 15.6 days, assuming an 8-hour workday. For couples utilizing cycle-based treatments (CBT), overall time spent pursuing care averaged 142 hours, versus 58 hours for couples using other therapies, with the majority of time spent on provider visits (73 hours). After multivariable adjustment for clinical and sociodemographic characteristics, possessing a college degree and intensity of fertility treatment were independently associated with increased time spent pursuing fertility care. Furthermore, couples that spent the most time on care were significantly more likely to experience fertility-related stress.Conclusion(s)Over the course of 18 months of observation, couples pursuing fertility treatment dedicated large amounts of time to attaining their family-building goals. This burden on couples adds to the already significant financial and emotional burdens of fertility treatment and provides new insight into the difficulties that these couples face.

The present study deals with the largely unknown Peperomia subgenus Tildenia. Chapter 1 focuses on the South American centre of Tildenia biodiversity. Initially a general rectified description of Peperomia subgenus Tildenia is presented based on the latest molecular analyses. Fourteen new species are described together with two formerly published varieties that are raised to species rank. Furthermore, for one name, basionym rejection and lectotypification are proposed. All valid species from the South American centre of diversity are treated in a phylogenetic framework. A comparable study of the North American centre of diversity is presented in Chapter 2 including a key to all Tildenia species from Mexico and Central America and the description of thirteen new species (one former variety). The new descriptions within this study doubles the species number of subgenus Tildenia. Chapter 3 is a biogeographical study comprising the whole distribution area revealing the place of origin and the age of Peperomia subgenus Tildenia. The appearance of the major lineages of the subgenus is examined against the background of orogeny and climate changes in the respective distribution areas, to retrace the evolutional driving forces of this plant group. In Chapter 4 Tildenia is used as a model group for the characterisation of a new nuclear single copy gene applicable for general use for phylogentic resoltution on species level and below.

The present study deals with the largely unknown Peperomia subgenus Tildenia. Chapter 1 focuses on the South American centre of Tildenia biodiversity. Initially a general rectified description of Peperomia subgenus Tildenia is presented based on the latest molecular analyses. Fourteen new species are described together with two formerly published varieties that are raised to species rank. Furthermore, for one name, basionym rejection and lectotypification are proposed. All valid species from the South American centre of diversity are treated in a phylogenetic framework. A comparable study of the North American centre of diversity is presented in Chapter 2 including a key to all Tildenia species from Mexico and Central America and the description of thirteen new species (one former variety). The new descriptions within this study doubles the species number of subgenus Tildenia. Chapter 3 is a biogeographical study comprising the whole distribution area revealing the place of origin and the age of Peperomia subgenus Tildenia. The appearance of the major lineages of the subgenus is examined against the background of orogeny and climate changes in the respective distribution areas, to retrace the evolutional driving forces of this plant group. In Chapter 4 Tildenia is used as a model group for the characterisation of a new nuclear single copy gene applicable for general use for phylogentic resoltution on species level and below.

The present study deals with the largely unknown Peperomia subgenus Tildenia. Chapter 1 focuses on the South American centre of Tildenia biodiversity. Initially a general rectified description of Peperomia subgenus Tildenia is presented based on the latest molecular analyses. Fourteen new species are described together with two formerly published varieties that are raised to species rank. Furthermore, for one name, basionym rejection and lectotypification are proposed. All valid species from the South American centre of diversity are treated in a phylogenetic framework. A comparable study of the North American centre of diversity is presented in Chapter 2 including a key to all Tildenia species from Mexico and Central America and the description of thirteen new species (one former variety). The new descriptions within this study doubles the species number of subgenus Tildenia. Chapter 3 is a biogeographical study comprising the whole distribution area revealing the place of origin and the age of Peperomia subgenus Tildenia. The appearance of the major lineages of the subgenus is examined against the background of orogeny and climate changes in the respective distribution areas, to retrace the evolutional driving forces of this plant group. In Chapter 4 Tildenia is used as a model group for the characterisation of a new nuclear single copy gene applicable for general use for phylogentic resoltution on species level and below.

The present study deals with the largely unknown Peperomia subgenus Tildenia. Chapter 1 focuses on the South American centre of Tildenia biodiversity. Initially a general rectified description of Peperomia subgenus Tildenia is presented based on the latest molecular analyses. Fourteen new species are described together with two formerly published varieties that are raised to species rank. Furthermore, for one name, basionym rejection and lectotypification are proposed. All valid species from the South American centre of diversity are treated in a phylogenetic framework. A comparable study of the North American centre of diversity is presented in Chapter 2 including a key to all Tildenia species from Mexico and Central America and the description of thirteen new species (one former variety). The new descriptions within this study doubles the species number of subgenus Tildenia. Chapter 3 is a biogeographical study comprising the whole distribution area revealing the place of origin and the age of Peperomia subgenus Tildenia. The appearance of the major lineages of the subgenus is examined against the background of orogeny and climate changes in the respective distribution areas, to retrace the evolutional driving forces of this plant group. In Chapter 4 Tildenia is used as a model group for the characterisation of a new nuclear single copy gene applicable for general use for phylogentic resoltution on species level and below.

PurposeTo determine factors associated with students' comfort in addressing patients' sexuality in the clinical context.MethodThe authors invited students enrolled in MD-degree-granting and osteopathic medical schools in the United States and Canada to participate in an anonymous Internet survey between February and July 2008. The survey assessed ethnodemographic factors and sexual history. Respondents also completed the Center for Epidemiologic Studies Depression Scale. Male respondents completed the International Index of Erectile Function and the Premature Ejaculation Diagnostic Tool. Female respondents completed the Female Sexual Function Index and the Index of Sex Life. The authors used descriptive statistics, ANOVA, and multivariable logistic regression to analyze responses.ResultsThe authors' analyses included 2,261 completed survey responses: 910 from men, 1,343 from women, and 8 from individuals who self-identified as "other" gendered. Over 53% of respondents (n = 1,206) stated that they felt they had not received sufficient training in medical school to address sexual concerns clinically. Despite this, 81% of students (n = 1,827) reported feeling comfortable dealing with their patients' sexuality issues. Students with limited sexual experience, students at risk for sexual problems, and students who felt that they had not been trained adequately were less likely to report being comfortable talking to patients about sexual health issues.ConclusionsPerception of inadequate sexuality training in medical school and personal issues pertaining to sex may be associated with students' difficulty in addressing patients' sexuality. Adequate training is preeminently associated with feeling comfortable addressing patients' sexuality and should be a priority for medical education.

A fuzzy logic expert system has been developed that automatically allocates electronic attack (EA) resources in real-time. This expertise-based resource manager is made up of four trees: the isolated platform tree, the multiplatform tree, the fuzzy parameter selection tree, and the fuzzy strategy tree. The initial version of the algorithm was optimized using a genetic algorithm using fitness functions constructed based on expertise. A new approach is being explored that involves embedding the resource manager in an electronic game environment. The game allows a human expert to play against the resource manager in a simulated battle space with each of the defending platforms being exclusively directed by the fuzzy resource manager and the attacking platforms being controlled by the human expert or operating autonomously under their own logic. This approach automates the knowledge discovery problem. The theory of coevolutionary optimization is introduced, reoptimization criteria and stopping criteria are discussed, an algorithm for automatically constructing coevolutionary fitness functions is introduced, and examples are provided to show the effectiveness of coevolutionary optimization. A measure of effectiveness (MOE) for validation is discussed. Finally. the effectiveness of the resource manager and the optimization procedures is shown through a demanding example.

A fuzzy logic-based resource manager (RM) that will allocate electronic attack (EA) resources distributed across many platforms is under development. The platforms will consist of ships, helicopters, airplanes, land-based facilities, robotic devices, and, potentially, satellites. The RM will allow codification of military expertise in a simple mathematical formalism known as the fuzzy decision tree. The fuzzy decision tree will form what is known as a fuzzy linguistic description, i.e., a formal fuzzy if-then rule-based representation of the system. Since the decision tree is fuzzy, the uncertainty inherent in the root concepts propagates throughout the tree. The functional form of the fuzzy membership functions for the root concepts will be selected heuristically and will generally carry one or more free parameters. The free parameters in the root concepts will be determined by optimization both initially and later at noncritical times. A genetic algorithm will be used for optimization.

The United States military has been increasingly tasked to conduct MOOTW in regions controlled by warlords, individuals who have seized or maintained power through the use of military force. Examples from the recent past include Panama, Haiti, Somalia, Iraq and the Balkans. The US has achieved mixed results in these MOOTW missions. As we enter the 21st Century, it is quite likely that we will be called upon to conduct MOOTW in many other areas of the globe unknown to most Americans. To preclude a repeat of the October 1993 tragedy in which eighteen military personnel were killed in Somalia, US commanders must utilize operational art. Specifically, operational commanders must utilize the operational factors of time, force and space. Additionally, these commanders should apply the principles of war and reject MOOTW doctrine that constrains the effectiveness of US forces against warlords.

A recursive multisensor association algorithm has been developed based on fuzzy logic. It simultaneously determines fuzzy grades of membership and fuzzy cluster centers. It is capable of associating data from various sensor types and performing without operator intervention. It associates data from the same target for multiple sensor types. The algorithm also provides an estimate of the number of targets present, reduced noise estimates of the quantities being measured, and a measure of confidence to assign to the data association. The fuzzy logic formalism used offers the opportunity to incorporate additional information or heuristic rules easily. A comparison of the algorithm to a more conventional Bayesian association algorithm is provided. Also, procedures for defuzzification, i.e., mapping fuzzy results to hard results are discussed as well as the method of determining target validity. Various simulated real time data sets are analyzed and provide a basis for comparison of the fuzzy and Bayesian association algorithms.

A fuzzy clustering algorithm based on a least-square cost function is examined. Given inorganic sensor data, the algorithm can without operator intervention decompose the data into clusters associated with particular emitters. The algorithm determines a fuzzy cluster center that represents a reduced noise estimate of measured quantities. Also, the algorithm finds the grade of membership of each data point in each cluster. The grade of membership tells the degree to which each data point belongs to a cluster, and it can be used as a measure of confidence in the cluster assignment. A second component of the algorithm superclustering allows the number of targets present in the data to be determined without a priori information, also allowing a refinement of the fuzzy cluster centers and grades of membership. The combined fuzzy clustering and superclustering algorithm is applied to both simulated and electronic support measures (ESM) data.

A tracking algorithm that combines clustering and speed discrimination is examined. A performance matrix is defined, and for simulated data, the algorithm is shown to have a success rate as high as 92%, in terms of its ability to extract emitter tracks from data. Conditions under which the algorithm succeeds or fails are analyzed. The algorithm is applied to real inorganic sensor data for ships and aircraft, and the results are discussed.

Eight undergraduate pilot training students were trained to specified levels of performance in all major areas of basic pilot training using the Advanced Simulator for Undergraduate Pilot Training (ASUPT); half were trained using the platform motion system and half without. Subsequently, they completed basic pilot training (to Air Training Command (ATC) phase standards) in T-37 aircraft. Training hours required and check ride scores were compiled for each subject. Similar data were collected for a control group of eight subjects trained using the conventional ATC syllabus. Using data obtained from both groups, estimates of transfer of training percentages, and training effectiveness ratios were computed. Simulator trained students required fewer aircraft hours in all areas of basic UPT and achieved check ride scores equal to or better than the group. No significant or practical differences were documented between performances of the motion and no-motion trained groups for any category of maneuvers. This was a first effort to incorporate a full mission simulator into an operational pilot training program. Several problem areas were identified which must be solved before full success can be achieved. These same problems should be relevant to application of other full mission simulators in other training programs. In addition, some ASUPT deficiencies were identified.

This report provides a brief survey of literature on retention of motor, procedural and communication skills judged relevant to pilot training. Also included are data concerning more recent pilot recurrent training information available from the United States Air Force, the United States Army and the Federal Aviation Agency. Implications of these data for USAF continuation pilot training are discussed and an approach to obtaining more specific information is recommended. (Author)

A new ferrimagnetic single-crystal sphere orientation device has been developed for use with a variety of sphere sizes and compositions. Similar to other instruments which operate on a magnetic principle, this orienter provides (110) axes alignments. However, with one small electromagnet, it is considerably simpler than previously reported instruments of this type. From theoretical considerations, it is concluded that high alignment sensitivity will be obtained for polished spheres of low mass density, small radius, high magnetocrystalline anisotropy, and low coefficient of friction between sphere and support. It is also concluded that the sphere should be supported in cavities of conical geometry, with the cone angle as small as possible. The results of both x-ray analysis and microscope visual observation with a number of typical spheres indicate that the combination of accuracy and reliability of the instrument is superior to that of the other devices and suggests that the factors controlling the alignment sensitivity as derived from theory are at least qualitatively correct.

Systems analysis represents an approach to, or a way of looking at, complex problems of choice under uncertainty. It offers a means of discovering how to design or to make effective use over time of technologically complex structure in which the different componetns may have apparently conflicting objectives; that is, an approach to choosing a strategy that yields the best balance among risks, effectiveness, and costs. Its purpose is to place each element in its proper context so that in the end the system as a whole may achieve its aim with a minimal expenditure of resources. Thus systems analysis is a common sense approach to problems of decision.

Twenty-one Ss, selected from three Undergraduate Pilot Training classes, were given contact flight training in a T-4G/EPT simulator before going to T-37 aircraft for further training. Fourteen of these Ss were also given instrument training in the T-4G/EPT before completing such training in the aircraft. The remaining seven Ss received instrument training in the UPT T-4 instrument and procedures trainer. A specially designed syllabus was used which incorporated batch training, proficiency advancement, and other revised instructional strategies. Check pilot scores for each of the instructional phases were used in comparing performances of the experimental Ss with those of the conventionally trained students. Results indicate devices having the capabilities of the T-4G could be used to achieve an average saving per student of three aircraft hours in contact flight training and ten hours in instrument training. Results also indicate a savings of eight aircraft hours could be achieved in instrument training by using the specially devised syllabus of instruction with existing T-4 instrument trainers.

The report describes the A/F37A/T-4G (T-4G) simulator syllabus developed by the Flying Training IVISION OF THE Air Force Human Resources Laboratory, to demonstrate the effectiveness of a limited visual, limited motion flight simulator in T-37 undergraduate pilot training. This report describes the syllabus development procedures employed, clarifies the resulting syllabus content and format, and provides a guide for development of future special purpose syllabi. (Author)

The report provides a description of all steps required to develop daily performance record sheets (PRS); provides examples of PRSs which were used successfully; describes instructor training necessary to insure satisfactory results; and highlights restrictions or limitation to the use of this technique. (Author)