Journal articles on the topic 'Fertility, Human – Australia'

IntroductionIn Australia, societal and individual preferences for funding fertility treatment remain largely unknown. This has resulted in a lack of evidence about willingness to pay (WTP) for fertility treatment by either the general population (the funders) or infertile individuals (who directly benefit). Using a stated preference discrete choice experiment (SPDCE) approach has been suggested as a more appropriate method to inform economic evaluations of fertility treatment. We outline the protocol for an ongoing study which aims to assess fertility treatment preferences of both the general population and infertile individuals, and indirectly estimate their WTP for fertility treatment.Methods and analysisTwo separate but related SPDCEs will be conducted for two population samples—the general population and infertile individuals—to elicit preferences for fertility treatment to indirectly estimate WTP. We describe the qualitative work to be undertaken to design the SPDCEs. We will use D-efficient fractional experimental designs informed by prior coefficients from the pilot surveys. The mode of administration for the SPDCE is also discussed. The final results will be analysed using mixed logit or latent class model.Ethics and disseminationThis study is being funded by the Australian National Health and Medical Research Council (NHMRC) project grant AP1104543 and has been approved by the University of New South Wales Human Research Ethics Committee (HEC 17255) and a fertility clinic’s ethics committee. Findings of the study will be disseminated in peer-reviewed journals and presented at various conferences. A lay summary of the results will be made publicly available on the University of New South Wales National Perinatal Epidemiology and Statistics Unit website. Our results will contribute to the development of an evidence-based policy framework for the provision of cost-effective and patient-centred fertility treatment in Australia.

IntroductionAs cancer treatments may impact on fertility, a high priority for young patients with breast cancer is access to evidence-based, personalised information for them and their healthcare providers to guide treatment and fertility-related decisions prior to cancer treatment. Current tools to predict fertility outcomes after breast cancer treatments are imprecise and do not offer individualised prediction. To address the gap, we are developing a novel personalised infertility risk prediction tool (FoRECAsT) for premenopausal patients with breast cancer that considers current reproductive status, planned chemotherapy and adjuvant endocrine therapy to determine likely post-treatment infertility. The aim of this study is to explore the feasibility of implementing this FoRECAsT tool into clinical practice by exploring the barriers and facilitators of its use among patients and healthcare providers.Methods and analysisA cross-sectional exploratory study is being conducted using semistructured in-depth telephone interviews with 15–20 participants each from the following groups: (1) premenopausal patients with breast cancer younger than 40, diagnosed within last 5 years, (2) breast surgeons, (3) breast medical oncologists, (4) breast care nurses (5) fertility specialists and (6) fertility preservation nurses. Patients with breast cancer are being recruited from the joint Breast Service of three affiliated institutions of Victorian Comprehensive Cancer Centre in Melbourne, Australia—Peter MacCallum Cancer Centre, Royal Melbourne Hospital and Royal Women’s Hospital, and clinicians are being recruited from across Australia. Interviews are being audio recorded, transcribed verbatim and imported into qualitative data analysis software to facilitate data management and analyses.Ethics and disseminationThe study protocol has been approved by Melbourne Health Human Research Ethics Committee, Australia (HREC number: 2017.163). Confidentiality and privacy are maintained at every stage of the study. Findings will be disseminated through peer-reviewed scholarly and scientific journals, national and international conference presentations, social media, broadcast media, print media, internet and various community/stakeholder engagement activities.

The world’s population, currently just over 6 billion, is projected to increase to 9–10 billion by the year 2050. Most of this growth will occur in the developing countries of Asia, where there is an enormous unmet demand for contraception, while an increasing number of developed countries will have declining populations. The human immunodeficiency virus (HIV) pandemic will target developing countries, with India destined to become its new epicenter. By 2050, there may be 1 billion HIV-infected people in the world. The significant protective effect of male circumcision may spare Islamic countries, such as Pakistan, Bangladesh, Iran and Indonesia, from the worst effects of the pandemic. Australia will be increasingly threatened by the high rates of population growth of her Asian neighbours. This, coupled with political instability and sea-level rises as a consequence of global warming, will turn the present trickle of refugees from a variety of Asian countries seeking safe haven on our sparsely populated northern coastline into a veritable flood. There will come a time when we have neither the manpower, nor the means, nor even the moral right to intercept, detain or repatriate the thousands who will come in peace, in search of a better life. However, if Australia is to stabilize its future population at around 23 million, which seems highly desirable on ecological grounds, then the net immigration rate must be limited to approximately 50000 people per year. Because the final point of departure for all these refugees is Indonesia, it is essential that Australia maintains good relations with Indonesia, so that together we can attempt to manage the refugee problem. However, Indonesia’s own population is destined to increase by 100 million in the next 50 years, which will only exacerbate the situation. Australia would be well advised to make a major increase in its paltry financial assistance to Indonesia’s excellent family planning programmes, which are currently starved of funds. Helping Indonesia to contain its population growth is Australia’s best long-term investment for its own future.

IntroductionFor couples undergoing assisted reproduction, a plethora of adjuncts are available; these are known as ‘add-ons’. Most add-ons are not supported by good quality randomised trial evidence of efficacy, with some proven to be ineffective. However, estimates suggest that over 70% of fertility clinics provide at least one add-on, often at extra cost to the patient. This study has three aims. First, to undertake a survey of in vitro fertilisation (IVF) clinics in the UK to ascertain which add-ons are being offered and at what cost. Second, to undertake qualitative semi-structured interviews of patients, clinicians and embryologists, to explore their opinions and beliefs surrounding add-ons. Third, to review the interpretation of the Human Fertilisation and Embryology Authority traffic light system, to better understand the information required by IVF patients, clinicians and embryologists when making decisions about add-ons.Methods and analysisAll UK IVF clinics will be contacted by email and invited to complete an online survey. The survey will ask them which add-ons they offer, at what cost per cycle and how information is shared with patients. Semi-structured interviews will be conducted in the UK and Australia with three groups of participants: (i) fertility patients; (ii) clinicians and (iii) embryologists. Participants for the interviews will be recruited via social media channels, website adverts, email and snowball sampling. Up to 20 participants will be recruited for each group in each country. Following an online consent process, interviews will be conducted via video-conferencing software, transcribed verbatim and data subjected to inductive thematic analysis.Ethics and disseminationEthical approval has been granted by the Universities of Sheffield, Bath Spa and Melbourne. Findings will be published in a peer-reviewed journal and disseminated to regulatory bodies in the UK and Australia. A lay summary of findings will be shared via Fertility Network, UK.

IntroductionPolycystic ovary syndrome (PCOS) is a common endocrine disorder in women of reproductive age and the leading cause of anovulatory infertility. Women with PCOS have a 15-fold higher prevalence of infertility, compared with women without PCOS, independent of body mass index (BMI). A healthy lifestyle is recommended to improve overall health and fertility in PCOS but there is limited evidence on the isolated effects of exercise, especially for reproductive outcomes. Previous findings indicate superior metabolic health benefits after vigorous compared with moderate-intensity exercise. Our primary aim is to determine the effect of high-intensity interval training (HIT) on menstrual frequency, as a proxy of reproductive function, in women with PCOS.Methods and analysisThe study is a two-centre, randomised, controlled trial with three parallel groups. Women (n=64) from Trondheim (Norway) and Melbourne (Australia) with PCOS according to the Rotterdam criteria will be randomly allocated (1:1:1) to high-volume HIT, low-volume HIT or a control group with no exercise after stratifying for BMI < or ≥ 27 kg/m2and study centre. Measurements for study end points will be undertaken at baseline, after a 16 week exercise intervention and at 12 months following baseline assessments. The primary outcome measure is menstruation frequency, measured as the number of self-reported menstrual bleedings divided by the number of expected menstrual bleedings during a 12-month period. Secondary outcome measurements include markers of cardiovascular, metabolic and reproductive health, as well as quality of life and adherence to and enjoyment of exercise.Ethics and disseminationThe Regional Committee Medical Research Ethics, Norway, and The Australian Catholic University Human Research Ethics Committee, Australia, have approved the trial protocol. This trial will provide new insight regarding the impact of exercise on fertility in PCOS. We expect this trial to contribute to new therapeutic exercise strategies as part of clinical care for women with PCOS.Trial registration numberClinical trial govNCT02419482.

IntroductionAchieving parenthood is challenging in individuals receiving renal replacement therapy (RRT; dialysis or kidney transplantation) for end-stage kidney disease. Decision-making regarding parenthood in RRT recipients should be underpinned by robust data, yet there is limited data on parental factors that drive adverse health outcomes. Therefore, we aim to investigate the perinatal risks and outcomes in parents receiving RRT.Methods and analysisThis is a multijurisdictional probabilistic data linkage study of perinatal, hospital, birth, death and renal registers from 1991 to 2013 from New South Wales, Western Australia, South Australia and the Australian Capital Territory. This study includes all babies born ≥20 weeks’ gestation or 400 g birth weight captured through mandated data collection in the perinatal data sets. Through linkage with the Australian and New Zealand Dialysis and Transplant (ANZDATA) registry, babies exposed to RRT (and their parents) will be compared with babies who have not been exposed to RRT (and their parents) to determine obstetric and fetal outcomes, birth rates and fertility rates. One of the novel aspects of this study is the method that will be used to link fathers receiving RRT to the mothers and their babies within the perinatal data sets, using the birth register, enabling the identification of family units. The linked data set will be used to validate the parenthood events directly reported to ANZDATA.Ethics and disseminationEthics approval was obtained from Human Research Ethics Committees (HREC) and Aboriginal HREC in each jurisdiction. Findings of this study will be disseminated at scientific conferences and in peer-reviewed journals in tabular and aggregated forms. De-identified data will be presented and individual patients will not be identified. We will aim to present findings to relevant stakeholders (eg, patients, clinicians and policymakers) to maximise translational impact of research findings.

Background Disease surveillance and response are critical components of epidemic preparedness. The disease response, in most cases, is a set of reactive measures that follow the outcomes of the disease surveillance. Hence, timely surveillance is a prerequisite for an effective response. Methodology/principal findings We apply epidemiological soundness criteria in combination with the Latent Influence Point Process and time-to-event models to construct a disease spread network. The network implicitly quantifies the fertility (whether a case leads to secondary cases) and reproduction (number of secondary cases per infectious case) of the cases as well as the size and generations (of the infection chain) of the outbreaks. We test our approach by applying it to historic dengue case data from Australia. Using the data, we empirically confirm that high morbidity relates positively with delay in disease response. Moreover, we identify what constitutes timely surveillance by applying various thresholds of disease response delay to the network and report their impact on case fertility, reproduction, number of generations and ultimately, outbreak size. We observe that enforcing a response delay threshold of 5 days leads to a large average reduction across all parameters (occurrence 87%, reproduction 83%, outbreak size 80% and outbreak generations 47%), whereas extending the threshold to 10 days, in comparison, significantly limits the effectiveness of the response actions. Lastly, we identify the components of the disease surveillance system that can be calibrated to achieve the identified thresholds. Conclusion We identify practically achievable, timely surveillance thresholds (on temporal scale) that lead to an effective response and identify how they can be satisfied. Our approach can be utilized to provide guidelines on spatially and demographically targeted resource allocation for public awareness campaigns as well as to improve diagnostic abilities and turn-around times for the doctors and laboratories involved.

Cross-border surrogacy is a global industry that offers intended parents options for family formation by providing foreign surrogate mothers remuneration, directly or via an intermediary, in excess of their actual out-of-pocket expenses. It is a multi-million-dollar business with no international regulation.1 In most countries, limited domestic regulation or oversight is in place. Many countries − such as Australia, the United Kingdom, New Zealand, Canada, Hong Kong and South Africa − only permit altruistic surrogacy, while Germany and France ban surrogacy entirely.2 Fully legalized commercial surrogacy is the model followed in some states in the United States of America (USA), as well as Georgia and Ukraine.3 This unregulated cross-border market has produced a lucrative business, with surrogacy arrangements growing by nearly 1,000 per cent between 2006 and 2010.4 The for-profit surrogacy sector has expanded and fertility not-for-profit organizations have also entered the market.5

More than twenty exotic vertebrate species are now listed as pests in Australia. Collectively, these pests have a huge economic and environmental impact and pose a major threat to Australia’s ecosystems and unique biodiversity. Management of such pests on a continental scale is a major challenge. Recent advances in biotechnology suggest alternatives to the lethal diseases normally sought for use as biological control agents. One proposal, being investigated in the Pest Animal Control Cooperative Research Centre, Canberra, is the use of biotechnology to develop a new generation of agents that act through controlling reproduction to prevent the build up of pest populations. The core concept is fertility control through immunocontraceptive vaccines delivered by viruses that specifically infect the target pest population. Proof of this exciting concept has been obtained for the mouse and, very recently, the rabbit, and a candidate vaccine vector identified for the fox, portending better control of a trio of Australia’s most pervasive pests. Other advances in biotechnology suggest ways to negate the build up of both innate and acquired immune resistance in target pest populations that normally act to limit the efficacy and effective life of biocontrol agents in the field. Prospects for extending the use of virally vectored vaccines to the field management of wildlife diseases are also identified. Targets for such vaccines include a growing suite of emerging diseases, hosted by Australia’s wildlife, which pose a threat to human and livestock health. Numerous technical challenges remain to be addressed before any of these new agents are ready for use in the field. However, the major risk to their development is now no longer viewed as being technical, but the failure to gain public acceptance for their use in the field. This already significant risk is exasperated by the present heightened level of public concern about all introductions of genetically modified organisms.

AbstractUse of the herbicide atrazine (ATR) is banned in the European Union; yet, it is still widely used in the USA and Australia. ATR is known to alter testosterone and oestrogen production and thus reproductive characteristics in numerous species. In this proof of concept study, we examined the effect of ATR exposure, at a supra-environmental dose (5 mg/kg bw/day), beginning on E9.5 in utero, prior to sexual differentiation of the reproductive tissues, until 26 weeks of age, on the development of the mouse penis. Notably, this is the first study to specifically investigate whether ATR can affect penis characteristics. We show that ATR exposure, beginning in utero, causes a shortening (demasculinisation) of penis structures and increases the incidence of hypospadias in mice. These data indicate the need for further studies of ATR on human reproductive development and fertility, especially considering its continued and widespread use.

Selenium is an essential micronutrient for humans and animals, required to increase immunity, protect cells from free radical damage and inflammation, and support a healthy metabolism. The typical manifestations of selenium deficiency in humans are loss of appetite, fatigue after even mild exercise, cardiac arrhythmia and palpitations, cardiac insufficiency, cardiomegaly, and congestive heart failure, swelling in the joints of arms and legs in children aged 5–13 years resulting in structural shortening of the fingers and long bones resulting in growth retardation and stunting. Clinical signs of selenium deficiency in cattle include mastitis, perinatal death and abortions, suboptimal fertility in adult cattle and suboptimal milk production, acute nutritional muscular dystrophy in young calves, sudden collapse or death of calves within 2–3 days of birth, stiff-legged gait, weakness and inability to stand or walk in young calves.Being a micronutrient for humans and animals, the margin between deficiency and toxicity of selenium are small and selenium supplementation has to be carefully planned. Agronomic biofortification by fertilizing crops on selenium deficient soils is the safest way and has been successfully tried in China and Finland. It is now practised in Australia and several other countries. However, the research work on selenium in soils, plants, animals and humans is of recent origin in India and needs utmost attention and priority considering its importance in the food chain.

Reproductive sciences have made major contributions to human health, livestock production and environmental management in the past and will continue to do so in future. In collaboration with other disciplines, reproductive scientists can provide scientifically valid information that will allow the rational development of policies on topics such as declining fertility in men and women, livestock breeding efficiencies, climate change, pest animal control, wildlife management and environmental influences. It is imperative that the reproductive sciences are recognised by the community and policy makers as important contributors to future health and welfare of animals, humans and the planet if these potential benefits are to be captured and utilised. Reproductive Health Australia (RHA) was launched recently to advocate for reproductive biology as a national health, economic and social priority. This short review provides a snapshot of why it is imperative that reproductive science receives the recognition that is due to it and provides examples of how it can contribute to the future of the planet.

Objective: The role of human papillomavirus (HPV) in cervical cancer and developments in medical technology to prevent cervical cancer has changed information needs for women participating in cervical screening. Design: Qualitative face-to-face interviews were conducted with 19 women diagnosed with HPV infection on their Pap smear following routine cervical screening. Setting: Family planning clinics, general practice and specialist gynaecologist practices in Sydney and the surrounding area, Australia. Main outcome measures: Women's information needs, preferences and experiences of HPV diagnosis. Results: Women wanted further information on different HPV viral types, transmission, implications for sexual partners, prevalence, latency and regression of HPV, their management options and the implications of infection for cancer risk and fertility. Uncertainty about the key aspects of HPV, the style in which the clinician communicated the result and the mode of delivering the result (letter, telephone or consultation) influenced women's psychological response to the diagnosis of HPV. The delivery of results by letter alone was linked to considerable anxiety among the women interviewed. Women's experience of searching the Internet for further information about HPV was reported as difficult, anxiety provoking and contributing to the stigma of the infection because information was often located in the context of other sexually transmitted infections, with multiple sexual partners highlighted as a risk factor for infection. Conclusion: Women participating in cervical screening need high-quality information about HPV and its role in cervical cancer prior to screening rather than afterwards, when they face an abnormal result. The clinician potentially plays an important role in moderating the effects of diagnosis through the manner and mode in which an HPV diagnosis is delivered. Revision of cervical screening policy and practice in light of the changes in the understanding of HPV is recommended.

Abstract STUDY QUESTION What is the impact of the poly(ADP-ribose) polymerase (PARP) inhibitor, olaparib, alone or in combination with chemotherapy on the ovary in mice? SUMMARY ANSWER Olaparib treatment, when administered alone, depletes primordial follicle oocytes, but olaparib does not exacerbate chemotherapy-mediated ovarian follicle loss in mice. WHAT IS KNOWN ALREADY The ovary contains a finite number of oocytes stored within primordial follicles, which give rise to all mature ovulatory oocytes. Unfortunately, they are highly sensitive to exogenous DNA damaging insults, such as cytotoxic cancer treatments. Members of the PARP family of enzymes are central to the repair of single-strand DNA breaks. PARP inhibitors have shown promising clinical efficacy in reducing tumour burden, by blocking DNA repair capacity. Olaparib is a PARP1/2 inhibitor recently FDA-approved for treatment of BRCA1 and BRCA2 mutation carriers with metastatic breast cancer. It is currently being investigated as an adjunct to standard treatment at an earlier stage, potentially curable, BRCA1- and BRCA2-associated breast cancer which affects reproductive age women. Despite this, there is no preclinical or clinical information regarding the potential impacts of olaparib on the ovary or on female fertility. Unfortunately, it may be many years before clinical data on fertility outcomes for women treated with PARP inhibitors becomes available, highlighting the importance of rigorous preclinical research using animal models to establish the potential for new cancer therapies to affect the ovary in humans. We aimed to comprehensively determine the impact of olaparib alone, or following chemotherapy, on the ovary in mice. STUDY DESIGN, SIZE, DURATION On Day 0, mice (n = 5/treatment group) were administered a single intraperitoneal dose of cyclophosphamide (75 mg/kg/body weight), doxorubicin (10 mg/kg), carboplatin (80 mg/kg), paclitaxel (7.5 mg/kg) or vehicle control. From Days 1 to 28, mice were administered subcutaneous olaparib (50 mg/kg) or vehicle control. This regimen is proven to reduce tumour burden in preclinical mouse studies and is also physiologically relevant for women. PARTICIPANTS/MATERIALS, SETTING, METHODS Adult female wild-type C57BL6/J mice at peak fertility (8 weeks) were administered a single intraperitoneal dose of chemotherapy, or vehicle, then either subcutaneous olaparib or vehicle for 28 days. Vaginal smears were performed on each animal for 14 consecutive days from Days 15 to 28 to monitor oestrous cycling. At 24 h after final treatment, ovaries were harvested for follicle enumeration and immunohistochemical analysis of primordial follicle remnants (FOXL2 expressing granulosa cells), DNA damage (γH2AX) and analysis of apoptosis by TUNEL assay. Serum was collected to measure circulating anti-Müllerian hormone (AMH) concentrations by ELISA. MAIN RESULTS AND THE ROLE OF CHANCE Olaparib significantly depleted primordial follicles by 36% compared to the control (P &lt; 0.05) but had no impact on other follicle classes, serum AMH, corpora lutea number (indicative of ovulation) or oestrous cycling. Primordial follicle remnants were rarely detected in control ovaries but were significantly elevated in ovaries from mice treated with olaparib alone (P &lt; 0.05). Similarly, DNA damage denoted by γH2AX foci was completely undetectable in primordial follicles of control animals but was observed in ∼10% of surviving primordial follicle oocytes in mice treated with olaparib alone. These observations suggest that functional PARPs are essential for primordial follicle oocyte maintenance and survival. Olaparib did not exacerbate chemotherapy-mediated follicle depletion in the wild-type mouse ovary. LARGE SCALE DATA N/A. LIMITATIONS, REASONS FOR CAUTION This study was performed in mice, so the findings may not translate to women and further studies utilizing human ovarian tissue and sera samples should be performed in the future. Only one long-term time point was analysed, therefore olaparib-mediated follicle damage should be assessed at more immediate time points in the future to support our mechanistic findings. WIDER IMPLICATIONS OF THE FINDINGS Olaparib dramatically depleted primordial follicles and this could be attributed to loss of intrinsic PARP-mediated DNA repair mechanisms. Importantly, diminished ovarian reserve can result in premature ovarian insufficiency and infertility. Notably, the extent of follicle depletion might be enhanced in BRCA1 and BRCA2 mutation carriers, and this is the subject of current investigations. Together, our data suggest that fertility preservation options should be considered for young women prior to olaparib treatment, and that human studies of this issue should be prioritized. STUDY FUNDING/COMPETING INTEREST(S) This work was made possible through Victorian State Government Operational Infrastructure Support and Australian Government NHMRC IRIISS. This work was supported by funding from the National Health and Medical Research Council (NHMRC); (K.J.H. #1050130) (A.L.W. #1120300). K.A.P. is a National Breast Cancer Foundation Fellow (Australia—PRAC-17-004). K.A.P. is the Breast Cancer Trials (Australia) Study Chair for the OlympiA clinical trial sponsored by AstraZeneca, the manufacturer of olaparib. All other authors declare no competing financial or other interests.

AbstractThe incidence of dizygotic (Dz) twinning can be used as an index of natural human fertility. A retrospective study was done at The Royal Women's Hospital, Australia, to see whether the dizygotic to monozygotic (Mz) twinning ratio from one hospital can accurately reflect the national incidence of Dz twinning. The yearly twinning incidence from 1947–1997 was expressed as a Dz:Mz ratio, standardised for maternal age and plotted against previously published national statistics. The proportion of mothers born in Asia (of both singleton and multiples) between 1983–1997 was analysed to see whether different racial mixes might influence twinning trends. There were 5275 twins born of known sex and maternal age between 1947–1997. The agestandardised Dz:Mz ratio increased non-significantly from 1.39 in 1947 to 2.29 in 1953 (P = 0.08), underwent a significant decline to 0.73 in 1977, then remained stable until 1997 (P > 0.05). The same trends were also apparent when the data was pooled into 2-year groups with the increase from 1947/48–1953/54 becoming highly significant (P < 0.009). These trends observed in the hospital-based data were in close agreement with those found in the national statistics, with the exception of a rise in 1977–1982 only reflected in the Australia-wide data. In 1993, 2.6% of mothers were born in Asian countries; by 1997, this had risen to 10.6%. We found that the Dz:Mz ratio from one hospital closely reflects national twinning trends. Prospective studies must account for race, and would need around 200–300 twin pairs per year to minimise fluctuations of the ratio. Twin Research (2000) 3, 12–16.

Subterranean clover (Trifolium subterraneum L.) is the most widely sown annual pasture legume species in southern Australia, valued in the livestock and grains industries as a source of high-quality forage and for its ability to fix atmospheric nitrogen. From its initial accidental introduction into Australia in the 19th Century and subsequent commercialisation in the early 1900s, 45 cultivars have been registered in Australia. These consist of 32 cultivars of ssp. subterraneum, eight of ssp. yanninicum, and five of ssp. brachycalycinum and range in flowering time from 77 to 163 days from sowing, enabling the species to be grown in a diversity of rainfall environments, soil types, and farming systems. Eleven of these cultivars are introductions from the Mediterranean region, 15 are naturalised strains collected in Australia, 18 are the products of crossbreeding, and one is derived from mutagenesis. Cultivars developed in Italy have been commercialised for the local market, whereas other cultivars developed in Spain, Portugal, and France have not had commercial seed production. Important traits exploited include: (i) selection for low levels of the oestrogenic isoflavone formononetin, which causes reduced ewe fertility; (ii) increased levels of dormancy imposed by seed-coat impermeability (hard seeds) for cultivars aimed at crop rotations or unreliable rainfall environments; (iii) strong burr-burial ability to maximise seed production; (iv) resistance to important disease pathogens for cultivars aimed at medium- and high-rainfall environments, particularly to Kabatiella caulivora and root rot pathogens; (v) resistance to pests, particularly redlegged earth mites; and (vi) selection for unique leaf markings and other morphological traits (where possible) to aid cultivar identification. Cultivar development has been aided by a large genetic resource of ~10 000 accessions, assembled from its centre of origin in the Mediterranean Basin, West Asia, and the Atlantic coast of Western Europe, in addition to naturalised strains collected in Australia. The development of a core collection of 97 accessions, representing almost 80% of the genetic diversity of the species, and a genetic map, provides a platform for development of future cultivars with new traits to benefit the livestock and grains industries. New traits being examined include increased phosphorous-use efficiency and reduced methane emissions from grazing ruminant livestock. Economic analyses indicate that future trait development should focus on traits contributing to increased persistence and autumn–winter productivity, while other potential traits include increased nutritive value (particularly of senesced material), increased N2 fixation ability, and tolerance to cheap herbicides. Beneficial compounds for animal and human health may also be present within the species for exploitation.

International civil society has played a key role in shaping the international consensus which has facilitated the normative expansion of international law to accommodate abuses experienced by women. We examine this process of ‘feminisation’ with reference to the extent to which international law has accommodated women's lived experiences of violence and their struggle to secure the means to control their own fertility through access to reproductive health services, including abortion. While the movement to recognise violence against women as a human rights issue has garnered substantial support, the efforts of women's groups to advance consensus around reproductive rights, and particularly the right of safe access to abortion, have been highly contested. Conservative religious actors have mobilised to obstruct consensus at the international level and taken direct action at the local level to impede access to abortions. This direct action will be examined through a case study drawing on empirical research conducted in Australia. We will examine the activities of anti-abortion protest groups, their impact on the rights of others and the effectiveness of legislation put in place to restrict these activities within the radius of designated geographic zones. The consistency of these legislative regimes with international norms is evaluated within the framework of feminisation of international law.

Abstract STUDY QUESTION Do all regions of the paternal genome within the gamete display equivalent vulnerability to oxidative DNA damage? SUMMARY ANSWER Oxidative DNA damage is not randomly distributed in mature human spermatozoa but is instead targeted, with particular chromosomes being especially vulnerable to oxidative stress. WHAT IS KNOWN ALREADY Oxidative DNA damage is frequently encountered in the spermatozoa of male infertility patients. Such lesions can influence the incidence of de novo mutations in children, yet it remains to be established whether all regions of the sperm genome display equivalent susceptibility to attack by reactive oxygen species. STUDY DESIGN, SIZE, DURATION Human spermatozoa obtained from normozoospermic males (n = 8) were split into equivalent samples and subjected to either hydrogen peroxide (H2O2) treatment or vehicle controls before extraction of oxidized DNA using a modified DNA immunoprecipitation (MoDIP) protocol. Specific regions of the genome susceptible to oxidative damage were identified by next-generation sequencing and validated in the spermatozoa of normozoospermic males (n = 18) and in patients undergoing infertility evaluation (n = 14). PARTICIPANTS/MATERIALS, SETTING, METHODS Human spermatozoa were obtained from normozoospermic males and divided into two identical samples prior to being incubated with either H2O2 (5 mm, 1 h) to elicit oxidative stress or an equal volume of vehicle (untreated controls). Alternatively, spermatozoa were obtained from fertility patients assessed as having high basal levels of oxidative stress within their spermatozoa. All semen samples were subjected to MoDIP to selectively isolate oxidized DNA, prior to sequencing of the resultant DNA fragments using a next-generation whole-genomic sequencing platform. Bioinformatic analysis was then employed to identify genomic regions vulnerable to oxidative damage, several of which were selected for real-time quantitative PCR (qPCR) validation. MAIN RESULTS AND THE ROLE OF CHANCE Approximately 9000 genomic regions, 150–1000 bp in size, were identified as highly vulnerable to oxidative damage in human spermatozoa. Specific chromosomes showed differential susceptibility to damage, with chromosome 15 being particularly sensitive to oxidative attack while the sex chromosomes were protected. Susceptible regions generally lay outside protamine- and histone-packaged domains. Furthermore, we confirmed that these susceptible genomic sites experienced a dramatic (2–15-fold) increase in their burden of oxidative DNA damage in patients undergoing infertility evaluation compared to normal healthy donors. LIMITATIONS, REASONS FOR CAUTION The limited number of samples analysed in this study warrants external validation, as do the implications of our findings. Selection of male fertility patients was based on high basal levels of oxidative stress within their spermatozoa as opposed to specific sub-classes of male factor infertility. WIDER IMPLICATIONS OF THE FINDINGS The identification of genomic regions susceptible to oxidation in the male germ line will be of value in focusing future analyses into the mutational load carried by children in response to paternal factors such as age, the treatment of male infertility using ART and paternal exposure to environmental toxicants. STUDY FUNDING/COMPETING INTEREST(S) Project support was provided by the University of Newcastle’s (UoN) Priority Research Centre for Reproductive Science. M.J.X. was a recipient of a UoN International Postgraduate Research Scholarship. B.N. is the recipient of a National Health and Medical Research Council of Australia Senior Research Fellowship. Authors declare no conflict of interest.

New Zealand and Australia generate large quantities of agricultural, industrial, and municipal wastes. As authorities move to protect the environment by regulating waste disposal practices, environmentally sound methods of waste disposal are being sought. In particular, land application of wastes as a means of disposal, nutrient re-cycling, and water conservation is becoming increasingly popular. This paper provides an overview of the types, quantities, and characteristics of wastes generated in New Zealand and Australia, and highlights the problems with current waste disposal practices, including landfilling, incineration, and discharging into waters. This is followed by a detailed review of the beneficial effects and adverse impacts of land application of wastes on plant production and soil and environmental quality, and possible hazards to human health. The management of waste application on land is a challenging task and requires rigorous scientific input. Sludges and euents contain significant concentrations of plant nutrients, particularly nitrogen, phosphorus, and organic matter. Their application on land has been shown, in many cases, to result in significant increases in plant yields and improvements in soil physical conditions and chemical fertility. The constraints with some wastes, particularly those of industrial and municipal origin, are that they contain undesirable constituents, e.g. heavy metals, toxic organics, pathogens, and salts, or have extremely high or low pH. High concentrations of nitrate and phosphate derived from wastes are also of concern for ground and surface water contamination. The processes that control the fate of wastes in the soil are complex and many of them are poorly understood, e.g. rate of release of nutrients and other chemicals; leaching of nutrients, metals, and organics through macropores and as suspended solids; emission of greenhouse gases; impact of solvents, surfactants, and sludge organic matter on the sorption, degradation, and leaching of hydrophobic organics; and the long-term bioavailability and fate of metals and organics fixed by soil organic matter. More research is urgently required to develop a sound understanding of waste characteristics and the processes affecting their fate in the soil in order to ensure that land application of wastes is safe.

Nature conservation practice is increasingly required to stand within a context of multiple use as land and its resources come under greater pressure of use by people. Although biodiversity conservation is now universally adopted as the banner under which international and national conservation programmes march, it is not clear that it has widespread support based on an understanding of all its ramifications. Conversely land users in Australia and in tropical countries do indicate an understanding and acceptance of conservation objectives which focus on the processes which support ecosystem productivity. A focus on conservation of the ecological processes which perpetuate vegetation as habitat, water and the fertility of soil, may better integrate nature conservation into other land uses. This essay explores some of these questions in relation to two wetland areas in Indonesia. The Pantai Timur Mangrove Nature Reserve in Jambi Province, Sumatra is valuable for the conservation of certain migratory birds; however, it is so dynamic that species diversity is not significant. Despite this, ecological functions which have created the ecosystem may be critical to the continued productivity of the land and the quality of life of the people who live in it. In contrast the coastal wetland forests of Bunaken National Park are remarkably stable and while they are critical to ecological regulation of the quality and productivity of that environment, they also offer very special biodiversity values. The implications of these examples are examined in relation to conservation practice and to ecologically sustainable management. Design is proposed as a means through which local communities might take some control of land management in order to retain, restore or create landscapes which have sustainable, rich and productive natural and human attributes.

Abstract STUDY QUESTION How is endometrial epithelial receptivity, particularly adhesiveness, regulated at the luminal epithelial surface for embryo implantation in the human? SUMMARY ANSWER Podocalyxin (PCX), a transmembrane protein, was identified as a key negative regulator of endometrial epithelial receptivity; specific downregulation of PCX in the luminal epithelium in the mid-secretory phase, likely mediated by progesterone, may act as a critical step in converting endometrial surface from a non-receptive to an implantation-permitting state. WHAT IS KNOWN ALREADY The human endometrium must undergo major molecular and cellular changes to transform from a non-receptive to a receptive state to accommodate embryo implantation. However, the fundamental mechanisms governing receptivity, particularly at the luminal surface where the embryo first interacts with, are not well understood. A widely held view is that upregulation of adhesion-promoting molecules is important, but the details are not well characterized. STUDY DESIGN, SIZE, DURATION This study first aimed to identify novel adhesion-related membrane proteins with potential roles in receptivity in primary human endometrial epithelial cells (HEECs). Further experiments were then conducted to determine candidates’ in vivo expression pattern in the human endometrium across the menstrual cycle, regulation by progesterone using cell culture, and functional importance in receptivity using in vitro human embryo attachment and invasion models. PARTICIPANTS/MATERIALS, SETTING, METHODS Primary HEECs (n = 9) were isolated from the proliferative phase endometrial tissue, combined into three pools, subjected to plasma membrane protein enrichment by ultracentrifugation followed by proteomics analysis, which led to the discovery of PCX as a novel candidate of interest. Immunohistochemical analysis determined the in vivo expression pattern and cellular localization of PCX in the human endometrium across the menstrual cycle (n = 23). To investigate whether PCX is regulated by progesterone, the master driver of endometrial differentiation, primary HEECs were treated in culture with estradiol and progesterone and analyzed by RT-PCR (n = 5) and western blot (n = 4). To demonstrate that PCX acts as a negative regulator of receptivity, PCX was overexpressed in Ishikawa cells (a receptive line) and the impact on receptivity was determined using in vitro attachment (n = 3–5) and invasion models (n = 4–6), in which an Ishikawa monolayer mimicked the endometrial surface and primary human trophoblast spheroids mimicked embryos. Mann–Whitney U-test and ANOVA analyses established statistical significance at *P ≤ 0.05 and **P ≤ 0.01. MAIN RESULTS AND THE ROLE OF CHANCE PCX was expressed on the apical surface of all epithelial and endothelial cells in the non-receptive endometrium, but selectively downregulated in the luminal epithelium from the mid-secretory phase coinciding with the establishment of receptivity. Progesterone was confirmed to be able to suppress PCX in primary HEECs, suggesting this hormone likely mediates the downregulation of luminal PCX in vivo for receptivity. Overexpression of PCX in Ishikawa monolayer inhibited not only the attachment but also the penetration of human embryo surrogates, demonstrating that PCX acts as an important negative regulator of epithelial receptivity for implantation. LIMITATIONS, REASONS FOR CAUTION Primary HEECs isolated from the human endometrial tissue contained a mixture of luminal and glandular epithelial cells, as further purification into subtypes was not possible due to the lack of specific markers. Future study would need to investigate how progesterone differentially regulates PCX in endometrial epithelial subtypes. In addition, this study used primary human trophoblast spheroids as human embryo mimics and Ishikawa as endometrial epithelial cells in functional models, future studies with human blastocysts and primary epithelial cells would further validate the findings. WIDER IMPLICATIONS OF THE FINDINGS The findings of this study add important new knowledge to the understanding of human endometrial remodeling for receptivity. The identification of PCX as a negative regulator of epithelial receptivity and the knowledge that its specific downregulation in the luminal epithelium coincides with receptivity development may provide new avenues to assess endometrial receptivity and individualize endometrial preparation protocols in assisted reproductive technology (ART). The study also discovered PCX as progesterone target in HEECs, identifying a potentially useful functional biomarker to monitor progesterone action, such as in the optimization of progesterone type/dose/route of administration for luteal support. STUDY FUNDING/COMPETING INTEREST(S) Study funding was obtained from ESHRE, Monash IVF and NHMRC. LR reports potential conflict of interests (received grants from Ferring Australia; personal fees from Monash IVF Group and Ferring Australia; and non-financial support from Merck Serono, MSD, and Guerbet outside the submitted work. LR is also a minority shareholder and the Group Medical Director for Monash IVF Group, a provider of fertility preservation services). The remaining authors have no potential conflict of interest to declare. TRIAL REGISTRATION NUMBER NA.

Abstract STUDY QUESTION Is WNT signalling functional in normal and/or neoplastic human male germ cells? SUMMARY ANSWER Regulated WNT signalling component synthesis in human testes indicates that WNT pathway function changes during normal spermatogenesis and is active in testicular germ cell tumours (TGCTs), and that WNT pathway blockade may restrict seminoma growth and migration. WHAT IS KNOWN ALREADY Regulated WNT signalling governs many developmental processes, including those affecting male fertility during early germ cell development at embryonic and adult (spermatogonial) ages in mice. In addition, although many cancers arise from WNT signalling alterations, the functional relevance and WNT pathway components in TGCT, including germ cell neoplasia in situ (GCNIS), are unknown. STUDY DESIGN, SIZE, DURATION The cellular distribution of transcripts and proteins in WNT signalling pathways was assessed in fixed human testis sections with normal spermatogenesis, GCNIS and seminoma (2–16 individuals per condition). Short-term (1–7 h) ligand activation and long-term (1–5 days) functional outcomes were examined using the well-characterised seminoma cell line, TCam-2. Pathway inhibition used siRNA or chemical exposures over 5 days to assess survival and migration. PARTICIPANTS/MATERIALS, SETTING, METHODS The cellular localisation of WNT signalling components was determined using in situ hybridisation and immunohistochemistry on Bouin’s- and formalin-fixed human testis sections with complete spermatogenesis or germ cell neoplasia, and was also assessed in TCam-2 cells. Pathway function tests included exposure of TCam-2 cells to ligands, small molecules and siRNAs. Outcomes were measured by monitoring beta-catenin (CTNNB1) intracellular localisation, cell counting and gap closure measurements. MAIN RESULTS AND THE ROLE OF CHANCE Detection of nuclear-localised beta-catenin (CTNNB1), and key WNT signalling components (including WNT3A, AXIN2, TCF7L1 and TCF7L2) indicate dynamic and cell-specific pathway activity in the adult human testis. Their presence in germ cell neoplasia and functional analyses in TCam-2 cells indicate roles for active canonical WNT signalling in TGCT relating to viability and migration. All data were analysed to determine statistical significance. LARGE SCALE DATA No large-scale datasets were generated in this study. LIMITATIONS, REASONS FOR CAUTION As TGCTs are rare and morphologically heterogeneous, functional studies in primary cancer cells were not performed. Functional analysis was performed with the only well-characterised, widely accepted seminoma-derived cell line. WIDER IMPLICATIONS OF THE FINDINGS This study demonstrated the potential sites and involvement of the WNT pathway in human spermatogenesis, revealing similarities with murine testis that suggest the potential for functional conservation during normal spermatogenesis. Evidence that inhibition of canonical WNT signalling leads to loss of viability and migratory activity in seminoma cells suggests that potential treatments using small molecule or siRNA inhibitors may be suitable for patients with metastatic TGCTs. STUDY FUNDING AND COMPETING INTEREST(S) This study was funded by National Health and Medical Research Council of Australia (Project ID 1011340 to K.L.L. and H.E.A., and Fellowship ID 1079646 to K.L.L.) and supported by the Victorian Government’s Operational Infrastructure Support Program. None of the authors have any competing interests.

Abstract STUDY QUESTION What was the utilization, effectiveness and safety of practices in ART globally in 2012 and what global trends could be observed? SUMMARY ANSWER The total number of ART cycles increased by almost 20% since 2011 and the main trends were an increase in frozen embryo transfers (FET), oocyte donation, preimplantation genetic testing and single embryo transfers (SET), whereas pregnancy and delivery rates (PR, DR) remained stable, and multiple deliveries decreased. WHAT IS KNOWN ALREADY ART is widely practiced throughout the world, but continues to be characterized by significant disparities in utilization, availability, practice, effectiveness and safety. The International Committee for Monitoring Assisted Reproductive Technologies (ICMART) annual world report provides a major tool for tracking trends in ART treatment for over 25 years and gives important data to ART professionals, public health authorities, patients and the general public. STUDY DESIGN, SIZE, DURATION A retrospective, cross-sectional survey on the utilization, effectiveness and safety of ART procedures performed globally during 2012 was carried out. PARTICIPANTS/MATERIALS, SETTING, METHODS Sixty-nine countries and 2600 ART clinics submitted data on ART cycles performed during the year 2012, and their pregnancy outcome, through national and regional ART registries. ART cycles and outcomes are described at country, regional and global levels. Aggregate country data were processed and analyzed based on methods developed by ICMART. MAIN RESULTS AND ROLE OF CHANCE A total of 1 149 817 ART cycles were reported for the treatment year 2012. After imputing data for missing values and non-reporting clinics in reporting countries, 1 948 898 cycles (an increase of 18.6% from 2011) resulted in &gt;465 286 babies (+17.9%) in reporting countries. China did not report and is not included in this estimate. The best estimate of global utilization including China is ∼2.8 million cycles and 0.9 million babies. From 2011 to 2012, the number of reported aspirations and FET cycles increased by 6.9% and 16.0%, respectively. The proportion of women aged 40 years or older undergoing non-donor ART increased from 24.0% in 2011 to 25.2% in 2012. ICSI, as a percentage of non-donor aspiration cycles, increased from 66.5% in 2011 to 68.9% in 2012. The IVF/ICSI combined delivery rates per fresh aspiration and FET cycles were 19.8% and 22.1%, respectively. In fresh non-donor cycles, SET increased from 31.4% in 2011 to 33.7% in 2012, while the average number of transferred embryos decreased from 1.91 to 1.88, respectively—but with wide country variation. The rates of twin deliveries following fresh non-donor transfers decreased from 19.6% in 2011 to 18.0% in 2012, and the triplet rate decreased from 0.9% to 0.8%. In FET non-donor cycles, SET was 54.8%, with an average of 1.54 embryos transferred and twin and triplet rates of 11.1% and 0.4%, respectively. The cumulative DR per aspiration increased from 28.0% in 2011 to 28.9% in 2012. The overall perinatal mortality rate per 1000 births was 21.4 following fresh IVF/ICSI and 15.9 per 1000 following FET. LIMITATIONS, REASONS FOR CAUTION The data presented depend on the quality and completeness of data submitted by individual countries to ICMART directly or through regional registries. This report covers approximately two-thirds of` world ART activity, with a major missing country, China. Continued efforts to improve the quality and consistency of reporting ART data by registries are still needed, including the use of internationally agreed standard definitions (International Glossary of Infertility and Fertility Care). WIDER IMPLICATIONS OF THE FINDINGS The ICMART world reports provide the most comprehensive global statistical census and review of ART utilization, effectiveness, safety and quality. While ART treatment continues to increase globally, the wide disparities in access to treatment, procedures performed and embryo transfer practices warrant attention by clinicians and policy makers. With the increasing practice of SET and of freeze all and resulting increased proportion of FET cycles, it is clear that PR and DR per aspiration in fresh cycles do not give an overall accurate estimation of ART efficiency. It is time to use cumulative live birth rate per aspiration, combining the outcomes of FET cycles with the associated fresh cycle from which the embryos were obtained, and to obtain global consensus on this approach. STUDY FUNDING/COMPETING INTEREST(S) The authors declare no conflict of interest and no specific support from any organizations in relation to this manuscript. ICMART gratefully acknowledges financial support from the following organizations: American Society for Reproductive Medicine; European Society for Human Reproduction and Embryology; Fertility Society of Australia; Japan Society for Reproductive Medicine; Japan Society of Fertilization and Implantation; Red Latinoamericana de Reproduccion Asistida; Society for Assisted Reproductive Technology; Ferring Pharmaceuticals and Abbott (both providing ICMART unrestricted grants unrelated to world reports). TRIAL REGISTRATION NUMBER NA.

Background and objectives: To explore the ethical and legal complexities arising from the controversial issue of surrogacy, particularly in terms of how they affect fundamental rights of children and parents. Surrogacy is a form of medically-assisted procreation (MAP) in which a woman “lends” her uterus to carry out a pregnancy on behalf of a third party. There are pathological conditions, such as uterine agenesis or hysterectomy outcomes, that may prevent prospective mothers from becoming pregnant or carry a pregnancy to term; such patients may consider finding a surrogate mother. Many issues relating to surrogacy remain unresolved, with significant disagreements and controversy within the scientific community and public opinion. There are several factors called into play and multiple parties and stakeholders whose objectives and interests need to somehow be reconciled. First and foremost, the authors contend, it is essential to prioritize and uphold the rights of children born through surrogacy and heterologous MAP. Materials and methods: To draw a parallel between Italy and the rest of the world, the legislation in force in twelve European countries was analyzed, eleven of which are part of the European Union (France, Germany, Italy, Spain, Greece, Netherlands, Belgium, Denmark, Lithuania, Czech Republic and Portugal) and three non-members of the same (United Kingdom, Ukraine and Russia), as well as that of twelve non-European countries considered exemplary (United States, Canada, Australia, India, China, Thailand, Israel, Nigeria and South Africa); in particular, legislative sources and legal databases were drawn upon, in order to draw a comparison with the Italian legislation currently in force and map out the evolution of the Italian case law on the basis of the judgments issued by Italian courts, including the Constitutional and Supreme Courts and the European Court of Human Rights (ECHR); search engines such as PubMed and Google Scholar were also used, by entering the keywords “surrogacy” and “surrogate motherhood”, to find scientific articles concerning assisted reproduction techniques with a close focus on surrogacy. Results: SM is a prohibited and sanctioned practice in Italy; on the other hand, it is allowed in other countries of the world, which leads Italian couples, or couples from other countries where it is banned, to often contact foreign centers in order to undertake a MAP pathway which includes surrogacy; in addition, challenges may arise from the legal status of children born through surrogacy abroad: to date, in most countries, there is no specific legislation aimed at regulating their legal registration and parental status. Conclusion: With reference to the Italian context, despite the scientific and legal evolution on the subject, a legislative intervention aimed at filling the regulatory gaps in terms of heterologous MAP and surrogacy has not yet come to fruition. Considering the possibility of “fertility tourism”, i.e., traveling to countries where the practice is legal, as indeed already happens in a relatively significant number of cases, the current legislation, although integrated by the legal interpretation, does not appear to be effective in avoiding the phenomenon of procreative tourism. Moreover, to overcome some contradictions currently present between law 40 and law 194, it would be appropriate to outline an organic and exhaustive framework of rules, which should take into account the multiplicity of interests at stake, in keeping with a fair and sustainable balance when regulating such practices.

Background and objectives: To explore the ethical and legal complexities arising from the controversial issue of surrogacy, particularly in terms of how they affect fundamental rights of children and parents. Surrogacy is a form of medically-assisted procreation (MAP) in which a woman “lends” her uterus to carry out a pregnancy on behalf of a third party. There are pathological conditions, such as uterine agenesis or hysterectomy outcomes, that may prevent prospective mothers from becoming pregnant or carry a pregnancy to term; such patients may consider finding a surrogate mother. Many issues relating to surrogacy remain unresolved, with significant disagreements and controversy within the scientific community and public opinion. There are several factors called into play and multiple parties and stakeholders whose objectives and interests need to somehow be reconciled. First and foremost, the authors contend, it is essential to prioritize and uphold the rights of children born through surrogacy and heterologous MAP. Materials and methods: To draw a parallel between Italy and the rest of the world, the legislation in force in twelve European countries was analyzed, eleven of which are part of the European Union (France, Germany, Italy, Spain, Greece, Netherlands, Belgium, Denmark, Lithuania, Czech Republic and Portugal) and three non-members of the same (United Kingdom, Ukraine and Russia), as well as that of twelve non-European countries considered exemplary (United States, Canada, Australia, India, China, Thailand, Israel, Nigeria and South Africa); in particular, legislative sources and legal databases were drawn upon, in order to draw a comparison with the Italian legislation currently in force and map out the evolution of the Italian case law on the basis of the judgments issued by Italian courts, including the Constitutional and Supreme Courts and the European Court of Human Rights (ECHR); search engines such as PubMed and Google Scholar were also used, by entering the keywords “surrogacy” and “surrogate motherhood”, to find scientific articles concerning assisted reproduction techniques with a close focus on surrogacy. Results: SM is a prohibited and sanctioned practice in Italy; on the other hand, it is allowed in other countries of the world, which leads Italian couples, or couples from other countries where it is banned, to often contact foreign centers in order to undertake a MAP pathway which includes surrogacy; in addition, challenges may arise from the legal status of children born through surrogacy abroad: to date, in most countries, there is no specific legislation aimed at regulating their legal registration and parental status. Conclusion: With reference to the Italian context, despite the scientific and legal evolution on the subject, a legislative intervention aimed at filling the regulatory gaps in terms of heterologous MAP and surrogacy has not yet come to fruition. Considering the possibility of “fertility tourism”, i.e., traveling to countries where the practice is legal, as indeed already happens in a relatively significant number of cases, the current legislation, although integrated by the legal interpretation, does not appear to be effective in avoiding the phenomenon of procreative tourism. Moreover, to overcome some contradictions currently present between law 40 and law 194, it would be appropriate to outline an organic and exhaustive framework of rules, which should take into account the multiplicity of interests at stake, in keeping with a fair and sustainable balance when regulating such practices.

Abstract STUDY QUESTION Can Chlamydia be found in the testes of infertile men? SUMMARY ANSWER Chlamydia can be found in 16.7% of fresh testicular biopsies and 45.3% of fixed testicular biopsies taken from a selection of infertile men. WHAT IS KNOWN ALREADY Male chlamydial infection has been understudied despite male and female infections occurring at similar rates. This is particularly true of asymptomatic infections, which occur in 50% of cases. Chlamydial infection has also been associated with increased sperm DNA damage and reduced male fertility. STUDY DESIGN, SIZE, DURATION We collected diagnostic (fixed, n = 100) and therapeutic (fresh, n = 18) human testicular biopsies during sperm recovery procedures from moderately to severely infertile men in a cross-sectional approach to sampling. PARTICIPANTS/MATERIALS, SETTING, METHODS The diagnostic and therapeutic biopsies were tested for Chlamydia-specific DNA and protein, using real-time PCR and immunohistochemical approaches, respectively. Serum samples matched to the fresh biopsies were also assayed for the presence of Chlamydia-specific antibodies using immunoblotting techniques. MAIN RESULTS AND THE ROLE OF CHANCE Chlamydial major outer membrane protein was detected in fixed biopsies at a rate of 45.3%. This was confirmed by detection of chlamydial DNA and TC0500 protein (replication marker). C. trachomatis DNA was detected in fresh biopsies at a rate of 16.7%, and the sera from each of these three positive patients contained C. trachomatis-specific antibodies. Overall, C. trachomatis-specific antibodies were detected in 72.2% of the serum samples from the patients providing fresh biopsies, although none of the patients were symptomatic nor had they reported a previous sexually transmitted infection diagnosis including Chlamydia. LIMITATIONS, REASONS FOR CAUTION No reproductively healthy male testicular biopsies were tested for the presence of Chlamydia DNA or proteins or Chlamydia-specific antibodies due to the unavailability of these samples. WIDER IMPLICATIONS FOR THE FINDINGS Application of Chlamydia-specific PCR and immunohistochemistry in this human male infertility context of testicular biopsies reveals evidence of a high prevalence of previously unrecognised infection, which may potentially have a pathogenic role in spermatogenic failure. STUDY FUNDING/COMPETING INTEREST(S) Funding for this project was provided by the Australian NHMRC under project grant number APP1062198. We also acknowledge assistance from the Monash IVF Group and Queensland Fertility Group in the collection of fresh biopsies, and the Monash Health and co-author McLachlan (declared equity interest) in retrieval and sectioning of fixed biopsies. E.M. declares an equity interest in the study due to financing of fixed biopsy sectioning. All other authors declare no conflicts of interest. TRIAL REGISTRATION NUMBER N/A

Background Acquisition of high quality sperm is key to the artificial propagation of eels in captivity, but fertility drugs are expensive and repeated handling is stressful to the fish. An interrupted treatment regime (an initial hormone injection to stimulate spermatogenesis, followed several weeks later by weekly booster injections to induce sperm maturation) for acquisition of sperm in captive male eels has promise for high sperm quality on the one hand, and animal welfare benefits on the other. To further develop this approach for shortfinned eel, Anguilla australis, we evaluated the efficacy of (i) different initial doses of human chorionic gonadotropin (hCG) and (ii) route of administration. Methods Male eels were artificially induced to mature with a single injection of 0, 250, 500 or 1,000 IU/fish of hCG, administered either intramuscularly (IM) or intraperitoneally (IP). Sperm maturation was induced with 150 IU hCG/fish from week 5 onwards and sperm collected for evaluation of quality by computer-assisted sperm analysis. Results Control males did not mature and hence, sperm could not be retrieved and analysed, but all other treatments were effective in inducing testicular maturation. Milt volume tended to be higher for fish injected IM compared to those injected IP, whereas hCG dose had no effect. Conversely, the concentration of spermatozoa tended to be higher for several sperm collection time points in IP-injected than in IM-injected fish. Sperm quality, represented by percent motility, percent progressive motility and curvilinear velocity, was equal in fish given an initial dose of 250 IU hCG to those given higher initial doses of hCG. Conclusions We recommend that an initial dose of 250 IU hCG/fish be administered to induce spermatogenesis in male A. australis, and, after a period of 4–5 weeks, weekly booster injections of ∼150 IU hCG/fish be administered in the day prior to sperm collection; both routes of administration (IM or IP) are equally effective. We contend that an interrupted treatment regime has notable benefits for induced maturation in male anguillids, as it reduces fish handling and manipulation and reduces the resources required to produce high quality sperm.

Management of free-ranging horses (Equus ferus caballus) is a complex socio-ecological issue in Australia (AU), New Zealand (NZ), and the United States (US). In these countries, horses are the results of colonial introductions and occupy very harsh rangeland environments exerting a grazing disturbance that has generated ecological concerns. Although many social and ecological concerns are similar, each country also has nuances. In 2018, we conducted a field-based comparison of AU, NZ, and US using an inductive approach to identify similarities, differences, and emerging themes through conversations with &gt;100 individuals from New South Wales Australia, the North Island of New Zealand, and the western US. Additional data sources included field observations and archival documents. Consistent emergent themes identified included: strong public emotion, politicization of management, population growth concerns, negative ecological impact concerns, agreement that horses should be treated humanely, disagreement as to what practices were the most humane, interest and scepticism about fertility control, the need for transparency, compromise to accommodating horses and acknowledgement of social values, and recognition that collaboration is the only means to achieve both healthy rangelands and healthy horses. Unique themes identified included: NZ empowering advocate groups to become part of the solution, conflict between horses and livestock is a mostly US conflict, equids originated in the US, concern about the sustainability of adoption programs, different expectations/options for management on private lands, cultural history such as brumby running in AU, permanent branding of horses in the US, litigation as a uniquely US strategy (although a judgement on recent AU litigation is pending), government data accepted to guide removals in NZ but not always in AU or US, and complex heterogeneous land surface ownership patterns makes management difficult in the US. The difficulty of horse management in these countries is attributed to social intricacies rather than biological/ecological gaps of knowledge.

Abstract STUDY QUESTION Is there an association between prenatal exposure to stressful life events and age at menarche, and does childhood BMI mediate this association? SUMMARY ANSWER Girls exposed to prenatal stress had a slightly earlier age at menarche, but this association did not show a dose-response effect and was not mediated by childhood offspring BMI. WHAT IS ALREADY KNOWN Prenatal stress may impact on reproductive function in females including age at menarche, but human data are very limited. High childhood BMI is known to be associated with earlier age at menarche. Only one small study has measured the association between maternal stress and age at menarche and reported that childhood BMI mediated the association between maternal stress and earlier age at menarche. However, neither maternal stress nor age at menarche was prospectively recorded and the study was limited to 31 mother–daughter pairs. STUDY DESIGN, SIZE, DURATION The Raine Study is a large prospective population-based pregnancy cohort study (n = 1414 mother–daughter pairs) continuously followed from prenatal life through to adolescence. In the present study, we examined the association between exposure to maternal stressful life events during early, late and total gestation and age at menarche in offspring using 753 mother–daughter pairs with complete case information. PARTICIPANTS/MATERIALS, SETTING, METHODS Mothers prospectively reported stressful life events during pregnancy at 18 and 34 weeks using a standardized 10-point questionnaire. Exact date of menarche was assessed using a purpose-designed questionnaire at 8, 10, 14 and 17 years of age. Complete information on exposure, outcome and confounding variables was obtained from 753 mothers–daughter pairs. Multivariate linear regression complete case analysis was used to examine associations between maternal stressful life event exposure and age at menarche. Potential selection bias was evaluated using multiple imputations (50 datasets). The mediating effects of offspring childhood BMI (ages 5, 8, or 10 years) on these associations were measured in separate sub-analyses. MAIN RESULTS AND ROLE OF CHANCE Most (580/753, 77%) daughters were exposed to at least one prenatal stressful life event. Exposure to maternal stressful life events during the entire pregnancy was associated with a non-linear earlier age at menarche. Exposure to one event and two or more psychological stressful events was associated with a 3.5 and 1.7-month earlier onset of puberty, respectively when compared to the reference group with no exposure maternal stressful life events. The estimates from multiple imputation with 50 datasets were comparable with complete case analysis confirming the existence of an underlying effect. No separate significant effects were observed for exposure during early or late gestation. The association between prenatal stressful events and age at menarche was not mediated by childhood BMI in the offspring. LIMITATIONS, REASONS FOR CAUTION Stressful life events may have affected pregnant women in different ways and self-perceived maternal stress severity may have provided a more precise estimate of gestational psychological stress. The observed non-linear U-shape of the association between maternal psychological stress and age at menarche did not reflect a dose-response. This suggests that the first exposure to prenatal stress exerts a greater effect on fetal reproductive development. A potential mechanism is via dramatic initial activation of the hypothalamic–pituitary–adrenal (HPA) axis following the first stressful life event which is greater than that observed following subsequent exposure to two or more maternal stressful life events. Whilst we adjusted for a priori chosen confounders, we cannot exclude residual confounding or confounding by factors we did not include. Maternal age at menarche was not available so the effects of familial history/genetics could not be assessed. There was a large loss due to the number of girls with no information on date of menarche and missing confounder information implying risk of selection bias and multiple imputation analyses did not fully exclude this risk (similar direction but slightly weaker estimate magnitude). WIDER IMPLICATIONS OF THE FINDINGS Menarche is a sentinel reproductive event and earlier age at menarche carries implications for psychological, social and reproductive health and for long-term risk of common non-communicable diseases. Understanding the factors regulating age at menarche has extensive health implications. This is the first population-based cohort study in humans to demonstrate that prenatal psychological stress might directly modify age at menarche. STUDY FUNDING/COMPETING INTEREST(S) Dr. Bräuner and Trine Koch’s salaries were supported by Doctor Sofus Carl Emil Friis and spouse Olga Doris Friis foundation, The Danish Cancer Society (Kræftens Bekæmpelse, RP15468, R204-A12636, Denmark) and The Danish Health Foundation (Helsefonden, F-22181-23, Denmark). Martha Hickey was funded by NHMRC Practitioner Fellowships. The funding bodies played no role in the design, collection, analysis, or interpretation of data; in the writing of the manuscript; or in the decision to submit the manuscript for publication. Dr. Hart has received personal fees in his function as the Medical Director of Fertility Specialists of Western Australia and received educational sponsorship grants from MSD, Merck-Serono and from Ferring Pharmaceuticals. Dr Hart has also received personal fees from Shareholders in Western IVF outside the submitted work. TRIAL REGISTRATION NUMBER NA.

Soil is one of the principal substrates of human life and can serve as a reservoir of water and nutrients. Humic substances, indicators of soil fertility, are dominant in soil organic matter. However, soil degradation has been occurring all over the world, usually by soil salinization. Sustainable soil productivity has become an urgent problem to be solved. In this study, fluorescence excitation-emission matrices integrated with parallel factor analysis (PARAFAC) and canonical correlation analysis (CCA) were applied to characterize the components of fulvic acid (FA) and humic acid (HA) substances extracted from soils from the Liaohe River Delta, China. Along the saline gradient, soil samples with four disparate depths were gathered from four aboriginal halophyte communities, i.e., the Suaeda salsa Community (SSC), Chenopodium album Community (CAC), Phragmites australis Community (PAC), and Artemisia selengensis Community (ASC). Six components (C1 to C6) were identified in the FA and HA substances. The FA dominant fractions accounted for an average of 45.81% of the samples, whereas the HA dominant fractions accounted for an average of 42.72%. Mature levels of the HA fractions were higher than those of the FA fractions, so was the condensation degree, microbial activity, and humification degree of the FA fractions. C1 was associated with the ultraviolet FA, C2 was referred to as visible FA, C3 and C4 were relative to ultraviolet HA, C5 represented microbial humic-like substances (MH), and C6 referred to visible HA. C1, C2, C5 and C6 were latent factors of the FA fractions, determined using the CCA method and could possibly be used to differentiate among the SSC, CAC, PAC and ASC samples. C3, C4, C6 and C5 were latent factors of the HA fractions, which might be able to distinguish the ASC samples from the SSC, CAC and PAC samples. Fluorescence spectroscopy combined with the PARAFAC and CCA is a practical technique that is applied to assess the humic substance content of salinized soils.

The mature mammalian oocyte is the central link between generations. It is not only responsible for the transfer of the female genome between generations, but also largely determines embryo and early fetal developmental potential. For any female, oocytes are in limited supply and are easily damaged, such that the availability of high quality or developmentally competent oocytes is a fundamental rate-limiting factor in female fertility. This is particularly relevant in Australian society today with the steadily rising age to first conception which adversely affects oocyte quality and female fertility. Yet despite years of research and clinical IVF we still have a poor understanding of the molecular and cellular processes that control oocyte quality. It is clear that oocytes acquire developmental competence in the ovarian follicle. The acquisition of competence necessitates communication between the oocyte and maternal systems, a process which endows developmental potential as the oocyte grows and matures inside the follicle. At the cellular level this is achieved by bi-directional communication between oocytes and their companion somatic cells [1]. Over the past 10 years my laboratory has focused heavily on the nature of these oocyte-somatic communication axes and their impact on oocyte quality. Over this period, our work and that of others has shaped a new paradigm in ovarian biology, which is that the oocyte is not passive in the follicle, but rather that it actively directs the differentiation of its neighbouring somatic cells into cumulus cells through the secretion of GDF9 and BMP15 growth factors [2]. In doing so, oocytes dictate the function of their neighboring cumulus cells, directing them to perform functions needed for the appropriate growth and development of the oocyte. For example, cumulus cells supply oocytes with an array of nutrients, substrates and regulatory molecules such as cAMP, many directly through gap-junctions. These communication axes establish and maintain an elaborate and intricate local oocyte-cumulus auto regulatory loop that is required to enable post-fertilisation development. A clear clinical application of this new knowledge is in Artificial Reproductive Technologies, in particular oocyte in vitro maturation (IVM) [3]. IVM biotechnologies have the capacity to capture the vast supply of oocytes in the mammalian ovary and generate mature oocytes in vitro. Generating offspring using IVM is already a clinically and commercially viable biotechnology in livestock breeding programs, particularly in cattle. IVM is a particularly attractive technology for the treatment of human infertility, as it removes the need for expensive and potentially harmful ovarian hyperstimulation protocols used in clinical IVF. However, widespread application of IVM in humans requires an increase in efficiency and further examination of safety of the technology. Recent work from my laboratory has increased IVM success rates in animals by using GDF9 and BMP15 in IVM [2, 3] and by developing a new system of “Induced-IVM” that more closely resembles the mechanisms of oocyte maturation in vivo. Most recently, the latter approach has led to substantial increases in embryo yield and pregnancy outcomes to levels equivalent to hormone-stimulated IVF [4]. The next challenge is to adapt these new approaches to clinical/field conditions to provide new opportunities for infertile women and for the development of a wide range of reproductive biotechnologies.

Abstract STUDY QUESTION Can an artificial intelligence (AI)-based model predict human embryo viability using images captured by optical light microscopy? SUMMARY ANSWER We have combined computer vision image processing methods and deep learning techniques to create the non-invasive Life Whisperer AI model for robust prediction of embryo viability, as measured by clinical pregnancy outcome, using single static images of Day 5 blastocysts obtained from standard optical light microscope systems. WHAT IS KNOWN ALREADY Embryo selection following IVF is a critical factor in determining the success of ensuing pregnancy. Traditional morphokinetic grading by trained embryologists can be subjective and variable, and other complementary techniques, such as time-lapse imaging, require costly equipment and have not reliably demonstrated predictive ability for the endpoint of clinical pregnancy. AI methods are being investigated as a promising means for improving embryo selection and predicting implantation and pregnancy outcomes. STUDY DESIGN, SIZE, DURATION These studies involved analysis of retrospectively collected data including standard optical light microscope images and clinical outcomes of 8886 embryos from 11 different IVF clinics, across three different countries, between 2011 and 2018. PARTICIPANTS/MATERIALS, SETTING, METHODS The AI-based model was trained using static two-dimensional optical light microscope images with known clinical pregnancy outcome as measured by fetal heartbeat to provide a confidence score for prediction of pregnancy. Predictive accuracy was determined by evaluating sensitivity, specificity and overall weighted accuracy, and was visualized using histograms of the distributions of predictions. Comparison to embryologists’ predictive accuracy was performed using a binary classification approach and a 5-band ranking comparison. MAIN RESULTS AND THE ROLE OF CHANCE The Life Whisperer AI model showed a sensitivity of 70.1% for viable embryos while maintaining a specificity of 60.5% for non-viable embryos across three independent blind test sets from different clinics. The weighted overall accuracy in each blind test set was &gt;63%, with a combined accuracy of 64.3% across both viable and non-viable embryos, demonstrating model robustness and generalizability beyond the result expected from chance. Distributions of predictions showed clear separation of correctly and incorrectly classified embryos. Binary comparison of viable/non-viable embryo classification demonstrated an improvement of 24.7% over embryologists’ accuracy (P = 0.047, n = 2, Student’s t test), and 5-band ranking comparison demonstrated an improvement of 42.0% over embryologists (P = 0.028, n = 2, Student’s t test). LIMITATIONS, REASONS FOR CAUTION The AI model developed here is limited to analysis of Day 5 embryos; therefore, further evaluation or modification of the model is needed to incorporate information from different time points. The endpoint described is clinical pregnancy as measured by fetal heartbeat, and this does not indicate the probability of live birth. The current investigation was performed with retrospectively collected data, and hence it will be of importance to collect data prospectively to assess real-world use of the AI model. WIDER IMPLICATIONS OF THE FINDINGS These studies demonstrated an improved predictive ability for evaluation of embryo viability when compared with embryologists’ traditional morphokinetic grading methods. The superior accuracy of the Life Whisperer AI model could lead to improved pregnancy success rates in IVF when used in a clinical setting. It could also potentially assist in standardization of embryo selection methods across multiple clinical environments, while eliminating the need for complex time-lapse imaging equipment. Finally, the cloud-based software application used to apply the Life Whisperer AI model in clinical practice makes it broadly applicable and globally scalable to IVF clinics worldwide. STUDY FUNDING/COMPETING INTEREST(S) Life Whisperer Diagnostics, Pty Ltd is a wholly owned subsidiary of the parent company, Presagen Pty Ltd. Funding for the study was provided by Presagen with grant funding received from the South Australian Government: Research, Commercialisation and Startup Fund (RCSF). ‘In kind’ support and embryology expertise to guide algorithm development were provided by Ovation Fertility. J.M.M.H., D.P. and M.P. are co-owners of Life Whisperer and Presagen. Presagen has filed a provisional patent for the technology described in this manuscript (52985P pending). A.P.M. owns stock in Life Whisperer, and S.M.D., A.J., T.N. and A.P.M. are employees of Life Whisperer.

Abstract STUDY QUESTION Does NLRP3 (NOD-, LRR- and pyrin domain-containing protein 3) inflammasome activation within decidualized endometrial stromal cells accompany menstruation and is this reflected systemically? SUMMARY ANSWER Components of the NLRP3 inflammasome immunolocalize to decidualized endometrial stromal cells immediately prior to menstruation, and are activated in an in vitro model of menstruation, as evidenced by downstream interleukin (IL)-1beta and IL-18 release, this being reflected systemically in vivo. WHAT IS KNOWN ALREADY Menstruation is a highly inflammatory event associated with activation of NFκB (nuclear factor kappa-light-chain-enhancer of activated B cells), local release of chemokines and cytokines and inflammatory leukocyte influx. Systemically, chemokines and cytokines fluctuate across the menstrual cycle. STUDY DESIGN, SIZE, DURATION This study examined the NLRP3 inflammasome and activation of downstream IL-1beta and IL-18 in endometrial tissues from women of known fertility (≥1 previous parous pregnancy) across the menstrual cycle (n ≥ 8 per cycle phase), serum from women during the proliferative, secretory and menstrual phases (≥9 per cycle phase) of the cycle and menstrual fluid collected on Day 2 of menses (n = 18). Endometrial stromal cells isolated from endometrial tissue biopsies (n = 10 in total) were used for an in vitro model of pre-menstrual hormone withdrawal. PARTICIPANTS/MATERIALS, SETTING, METHODS Expression and localization of components of the NLRP3 inflammasome (NLRP3 & apoptosis-associated speck–caspase recruit domain [ASC]) in endometrial tissues was performed by immunohistochemistry. Unbiased digital quantification of immunohistochemical staining allowed determination of different patterns of expression across the menstrual cycle. Serum from women across the menstrual cycle was examined for IL-1beta and IL-18 concentrations by ELISA. An in vitro model of hormone withdrawal from estrogen/progestin decidualized endometrial stromal cells was used to more carefully examine activation of the NLRP3 inflammasome. Endometrial stromal cells isolated from endometrial tissue biopsies (n = 10) were treated with estrogen/medroxyprogesterone acetate for 12 days to induce decidualization (assessed by release of prolactin) followed by withdrawal of steroid hormone support. Activation of NLRP3, & ASC in these cells was examined on Days 0–3 after hormone withdrawal by Western immunoblotting. Release of IL-1beta and IL-18 examined during decidualization and across the same time course of hormone withdrawal by ELISA. Specific involvement of NLRP3 inflammasome activation in IL-1beta and IL-18 release after hormone withdrawal was investigated via application of the NLRP3 inflammasome inhibitor MCC950 at the time of hormone withdrawal. MAIN RESULTS AND THE ROLE OF CHANCE Critical components of the NLRP3 inflammasome (NLRP3, ASC) were increased in menstrual phase endometrial tissues versus early secretory phase tissues (P &lt; 0.05, n/s, respectively). NLRP3 and ASC were also elevated in the proliferative versus secretory phase of the cycle (P &lt; 0.01, n/s, respectively) with ASC also significantly increased in the late-secretory versus early-secretory phase (P &lt; 0.05). The pattern of activation was reflected in systemic levels of the inflammasome mediators, with IL-1beta and IL-18 elevated in peripheral blood serum during menstruation (Day 2 of menses) versus secretory phase (P = 0.026, P = 0.0042, respectively) and significantly elevated in menstrual fluid (Day 2 of menses) versus systemic levels across all cycle phases, suggesting that local inflammasome activation within the endometrium during menses is reflected by systemic inflammation. NLRP3 and ASC localized to decidualized cells adjacent to the spiral arterioles in the late secretory phase of the menstrual cycle, where the menstrual cascade is thought to be initiated, and to endometrial leukocytes during the menstrual phase. NLRP3 also localized to glandular epithelial cells during the late-secretory/menstrual phases. Localization of both NLRP3 and ASC switched from predominant epithelial localization during the early-secretory phase to stromal localization during the late-secretory/menstrual phase. Using an in vitro model of hormone withdrawal from decidualized human endometrial stromal cells, we demonstrated progressive activation of NLRP3 and ASC after hormone withdrawal increasing from Day 0 of withdrawal/Day 12 of decidualization to Day 3 of withdrawal. Downstream release of IL-1beta and IL-18 from decidualized stromal cells after hormone withdrawal followed the same pattern with the role of NLRP3 inflammasome activation confirmed via the inhibition of IL-1beta and IL-18 release upon application of MCC950. LARGE SCALE DATA N/A. LIMITATIONS, REASONS FOR CAUTION This study uses descriptive and semi-quantitative measures of NLRP3 inflammasome activation within endometrial tissues. Further, the in vitro model of pre-menstrual hormone withdrawal may not accurately recapitulate the in vivo environment as only one cell type is present and medroxyprogesterone acetate replaced natural progesterone due to its longer stability. WIDER IMPLICATIONS OF THE FINDINGS We provide novel evidence that the NLRP3 inflammasome is activated within decidualized endometrial stromal cells immediately prior to menses and that local activation of the inflammasome within the endometrium appears to be reflected systemically in by activation of downstream IL-1beta and IL-18. Given the prevalence of menstrual disorders associated with inflammation including dysmenorrhoea and aspects of pre-menstrual syndrome, the inflammasome could be a novel target for ameliorating such burdens. STUDY FUNDING/COMPETING INTEREST(S) The authors have no competing interests. J.E. was supported by a Fielding Foundation fellowship, NHMRC project grants (#1139489 and #1141946) and The Hudson Institute of Medical Research. L.A.S. was supported by The Hudson Institute of Medical Research and J.H. by an Australian Government Research Training Program Scholarship. We acknowledge the Victorian Government’s Operating Infrastructure funding to the Hudson Institute. TRIAL REGISTRATION NUMBER N/A

Conventional agriculture is implemented across approximately 75 per cent of the world’s agricultural land and has been linked to climate change and biodiversity loss. In contrast, regenerative agriculture focuses on practices that build soil fertility and improve ecosystem functioning to mitigate climate change and increase biodiversity. This review assesses how the regenerative practice of crop diversification influences soil fertility and crop productivity, pest control, water quality and climate-change mitigation. I take an Ecosystem Services Approach to assessing crop diversification, which is a form of natural resource management that considers the relationship between human and environmental needs. These ecosystem services are analysed within the Australian context to determine both current issues and potential opportunities in Australian agriculture. This review reveals that current methods of agriculture in Australia could be improved, and crop diversification offers a key opportunity for helping Australia ensure food security under future climate change. Further research on interspecies interactions is required to help classify the specific crops that provide beneficial ecosystem services in Australia.

Abstract Study question How diverse is the board-level executive leadership of the leading fertility and reproductive health societies in Europe, Australia and North America? Summary answer There is good gender diversity among the reproductive health societies included in the study, with limited ethnic diversity. What is known already Reproductive health societies promote understanding and interest in reproductive biology and medicine. They are leading authorities, providing guidelines, opinions, and direction to practitioners, policy makers and the public. Membership on these societies’ board is a marker of influence and prestige. Many societies have clear Equality and Diversity Statement on their website, suggesting that they value representation of members from whom they obtain fees. This study presents a quantification of the executive leadership demographic diversity of major fertility and reproductive health societies in Europe, Australia and North America to evaluate diversity in governance. Study design, size, duration We conducted a review of the websites of ten leading fertility and reproductive health societies in the Europe, Australia and North America to quantity gender and ethnic diversity. Data analysis was conducted on the information obtained in January 2022. We included the executive leadership team /governing board members but excluded subgroup leaders or special interest group coordinators. Participants/materials, setting, methods Organisations reviewed include: American College of Obstetricians and Gynaecologists(ACOG), American Society for Reproductive Medicine(ASRM), British Fertility Society(BFS), Canadian Fertility and Andrology Society(CFAS), European Society of Human Reproduction and Embryology(ESHRE), The Fertility Society of Australia and New Zealand(FSA), International Federation of Obstetrics and Gynaecology(FIGO), The Royal Australian and New Zealand College of Obstetricians and Gynaecologists(RANZCOG), Royal College of Obstetricians and Gynaecologists (RCOG), and The Society of Obstetricians and Gynaecologists of Canada(SOGC). Main results and the role of chance Proportion for each demographic group at the time of the study are summarised below; where n = total number of board members; Gender: W= women, M= Men; ethnicity: Wh = White, B = Black and A = Asian. In total, the number of board level/executive leadership members, responsible for governance in the societies reviewed were 112. Gender diversity was 41% Men, 59% Women, while ethnic diversity was 82% White, 3% Black and 15% Asian. It is encouraging to see the gender parity in the executive leadership of the organisations review, there remains an important need to improve ethnic diversity in order to better represent the membership and wider community they serve. This has implications for role-modelling, equity, minimising the negative impact of groupthink and reaching/giving underrepresented group a voice. Limitations, reasons for caution Results presented are based on a snapshot at the time of review. Organisations periodically change leadership. Additionally, gender identification is based on self-identification in individual’s profile biography. Wider implications of the findings As reproductive health organisations continue make extensive contributions to the field, it is important for their leadership to represent the diversity of members and wider population they serve. There remains a need to move beyond diversity and equality statement to actively deploy policies and processes to improve and monitor representation. Trial registration number not applicable

Male fertility has been deteriorating worldwide for considerable time, with the greatest deterioration recorded mainly in the United States, Europe countries, and Australia. That is, especially in countries where an abundance of chemicals called endocrine disruptors has repeatedly been reported, both in the environment and in human matrices. Human exposure to persistent and non-persistent chemicals is ubiquitous and associated with endocrine-disrupting effects. This group of endocrine disrupting chemicals (EDC) can act as agonists or antagonists of hormone receptors and can thus significantly affect a number of physiological processes. It can even negatively affect human reproduction with an impact on the development of gonads and gametogenesis, fertilization, and the subsequent development of embryos. The negative effects of endocrine disruptors on sperm gametogenesis and male fertility in general have been investigated and repeatedly demonstrated in experimental and epidemiological studies. Male reproduction is affected by endocrine disruptors via their effect on testicular development, impact on estrogen and androgen receptors, potential epigenetic effect, production of reactive oxygen species or direct effect on spermatozoa and other cells of testicular tissue. Emerging scientific evidence suggests that the increasing incidence of male infertility is associated with the exposure to persistent and non-persistent endocrine-disrupting chemicals such as bisphenols and perfluoroalkyl chemicals (PFAS). These chemicals may impact men’s fertility through various mechanisms. This study provides an overview of the mechanisms of action common to persistent (PFAS) and nonpersistent (bisphenols) EDC on male fertility.

Transported through colonial technologies such as Wardian cases and imperial ships, or simply popped in envelopes and sent via the postal service, the reproductive bodies of plants have been extracted, commodified, reproduced, and proliferated to satisfy human needs and desires. The ongoing and historical movement of plants and their reproductive capacity—known now through the disembodied clinical term germplasm—for economic, social, political, and agricultural purposes provides a lens through which global fertility chains can be studied. I study one such fertility chain: the movement of seeds of plants into frozen vaults known as “seed banks.” While colonial plant movements are associated with exploitative control, newer plant extractions for seed banking are shielded from rebuke because they embody the unquestionably positive valence of “biodiversity conservation.” The view from Australia captures the awkwardness of seed banking as a reproductive technology because the ongoing tensions between Indigenous struggles and settler-colonial nation building, and the urgency around climate change, are far from resolved. The politics of the Anthropocene are particularly poignant in Australia because anthropogenic destruction looks very different when viewed from the perspective of either Indigenous people or settlers.

Abstract STUDY QUESTION Do mitochondria-targeted therapies reverse ageing- and oxidative stress-induced spindle defects in oocytes from mice and humans? SUMMARY ANSWER Exposure to MitoQ or BGP-15 during IVM protected against spindle and chromosomal defects in mouse oocytes exposed to oxidative stress or derived from reproductively aged mice whilst MitoQ promoted nuclear maturation and protected against chromosomal misalignments in human oocytes. WHAT IS KNOWN ALREADY Spindle and chromosomal abnormalities in oocytes are more prevalent with maternal aging, increasing the risk of aneuploidy, miscarriage and genetic disorders such as Down’s syndrome. The origin of compromised oocyte function may be founded in mitochondrial dysfunction and increased reactive oxygen species (ROS). STUDY DESIGN, SIZE, DURATION Oocytes from young and old mice were treated with MitoQ and/or BGP-15 during IVM. To directly induce mitochondrial dysfunction, oocytes were treated with H2O2, and then treated the MitoQ and/or BGP-15. Immature human oocytes were cultured with or without MitoQ. Each experiment was repeated at least three times, and data were analyzed by unpaired-sample t-test or chi-square test. PARTICIPANTS/MATERIALS, SETTING, METHODS Immature germinal vesicle (GV) stage oocytes from 1-, 12- and 18-month-old mice were obtained from preovulatory ovarian follicles. Oocytes were treated with MitoQ and/or BGP-15 during IVM. GV-stage human oocytes were cultured with or without MitoQ. Mitochondrial membrane potential and mitochondrial ROS were measured by live-cell imaging. Meiotic spindle and chromosome alignments were visualized by immunofluorescent labeling of fixed oocytes and the 3-dimensional images were analyzed by Imaris. MAIN RESULTS AND THE ROLE OF CHANCE MitoQ or BGP-15 during IVM protects against spindle and chromosomal defects in oocytes exposed to oxidative stress and in oocytes from aged mice (P &lt; 0.001). In human oocytes, the presence of MitoQ during IVM promoted nuclear maturation and had a similar positive effect in protecting against chromosomal misalignments (P &lt; 0.001). LIMITATIONS, REASONS FOR CAUTION Our study identifies two excellent candidates that may help to improve fertility in older women. However, these potential therapies must be tested for efficacy in clinical IVM systems, and undergo thorough examination of resultant offspring in preclinical models before utilization. WIDER IMPLICATIONS OF THE FINDINGS Our results using in-vitro systems for oocyte maturation in both mouse and human provide proof of principle that mitochondrially targeted molecules such as MitoQ and BGP-15 may represent a novel therapeutic approach against maternal aging-related spindle and chromosomal abnormalities. STUDY FUNDING/COMPETING INTEREST(S) The project was financially supported by the National Health and Medical Research Council and Australian Research Council, Australia. U.A.-Z. was supported by the Iraqi Higher Education and Scientific Research Ministry PhD scholarship and O.C. was supported by TUBITAK-1059B191601275. M.P.M. consults for MitoQ Inc. and holds patents in mitochondria-targeted therapies. R.L.R. is an inventor on patents relating to the use of BGP-15 to improve gamete quality. TRIAL REGISTRATION NUMBER N/A

Abstract STUDY QUESTION What is the recommended assessment and management of infertile women with polycystic ovary syndrome (PCOS), based on the best available evidence, clinical expertize and consumer preference? SUMMARY ANSWER International evidence-based guidelines, including 44 recommendations and practice points, addressed prioritized questions to promote consistent, evidence-based care and improve the experience and health outcomes of infertile women with PCOS. WHAT IS KNOWN ALREADY Previous guidelines on PCOS lacked rigorous evidence-based processes, failed to engage consumer and multidisciplinary perspectives or were outdated. The assessment and management of infertile women with PCOS are inconsistent. The needs of women with PCOS are not being adequately met and evidence practice gaps persist. PARTICIPANTS/MATERIALS, SETTING, METHODS Governance included a six continent international advisory and a project board, a multidisciplinary international guideline development group (GDG), consumer and translation committees. Extensive health professional and consumer engagement informed the guideline scope and priorities. The engaged international society-nominated panel included endocrinology, gynaecology, reproductive endocrinology, obstetrics, public health and other experts, alongside consumers, project management, evidence synthesis and translation experts. Thirty-seven societies and organizations covering 71 countries engaged in the process. Extensive online communication and two face-to-face meetings over 15 months addressed 19 prioritized clinical questions involving nine evidence-based reviews and 10 narrative reviews. Evidence-based recommendations (EBRs) were formulated prior to consensus voting within the guideline panel. STUDY DESIGN, SIZE, DURATION International evidence-based guideline development engaged professional societies and consumer organizations with multidisciplinary experts and women with PCOS directly involved at all stages. A (AGREE) II-compliant processes were followed, with extensive evidence synthesis. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was applied across evidence quality, desirable and undesirable consequences, feasibility, acceptability, cost, implementation and ultimately recommendation strength. The guideline was peer-reviewed by special interest groups across our partner and collaborating societies and consumer organizations, was independently assessed against AGREE II criteria and underwent methodological review. This guideline was approved by all members of the GDG and has been approved by the NHMRC. MAIN RESULTS AND THE ROLE OF CHANCE The quality of evidence (QOE) for the EBRs in the assessment and management of infertility in PCOS included very low (n = 1), low (n = 9) and moderate (n = 4) quality with no EBRs based on high-quality evidence. The guideline provides 14 EBRs, 10 clinical consensus recommendations (CCRs) and 20 clinical practice points on the assessment and management of infertility in PCOS. Key changes in this guideline include emphasizing evidence-based fertility therapy, including cheaper and safer fertility management. LIMITATIONS, REASONS FOR CAUTION Overall evidence is generally of low to moderate quality, requiring significantly greater research in this neglected, yet common condition. Regional health systems vary and a process for adaptation of this guideline is provided. WIDER IMPLICATIONS OF THE FINDINGS The international guideline for the assessment and management of infertility in PCOS provides clinicians with clear advice on best practice based on the best available evidence, expert multidisciplinary input and consumer preferences. Research recommendations have been generated and a comprehensive multifaceted dissemination and translation program supports the guideline with an integrated evaluation program. STUDY FUNDING/COMPETING INTEREST(S) The guideline was primarily funded by the Australian National Health and Medical Research Council of Australia (NHMRC) supported by a partnership with ESHRE and the American Society for Reproductive Medicine (ASRM). GDG members did not receive payment. Travel expenses were covered by the sponsoring organizations. Disclosures of conflicts of interest were declared at the outset and updated throughout the guideline process, aligned with NHMRC guideline processes. Dr Costello has declared shares in Virtus Health and past sponsorship from Merck Serono for conference presentations. Prof. Norman has declared a minor shareholder interest in the IVF unit Fertility SA, travel support from Merck and grants from Ferring. Prof. Norman also has scientific advisory board duties for Ferring. The remaining authors have no conflicts of interest to declare. This article was not externally peer-reviewed by Human Reproduction Open.

Traditionally, the country way of life, the country worldview -- the country culture -- has been understood differently to the city way of life. Notions of rural have been represented in terms such as 'Eden', 'Arcadia', 'Golden Age', and associated with beauty, fertility, moral uprightness and authenticity. In contrast, notions of urban have been characterised by pollution, sterility, degeneration and artificiality. In Australia, the culture of the first white settlers developed out of this tradition, but with its own distinctive characteristics. The harshness and indomitability of the landscape became the means by which unique character, unifying myths of belonging and societal significance were constructed and asserted. In contrast to the communities of the country's original inhabitants, which were perceived as passive, unproductive and disconnected, the new culture was characterised by notions of 'land', 'masculinity', 'white', 'productive', 'homogenous' and 'nationalistic' (Moore 54; Turner 6; Ward; White 16ff.). Defining the country worldview in contemporary Australia, however, is problematic. Question marks hang over the continued significance, even existence, of a specifically country culture. Post-war Australia has witnessed enormous economic and social changes, wrought by improved transport and communication networks, a shrinking rural population, and the decreasing importance of the agricultural industries. The steady decline in grass roots support for the National Party of Australia, traditional defender of the country way of life, suggests that the voting population no longer views the upholding of specifically pro-country policies as necessary to the well-being of the nation. Australia is now recognised as the most urbanised, sub-urbanised and multi-cultural of the western industrialised nations. Globalisation of the mass communications media has blurred the boundaries between rural, urban, state and national. Consequently, many argue that the differences between the country and city are now insignificant (for example, Aitkin 34-41). Yet notions of country that are distinct, even definitive, continue to be represented in various urban-based communications industries, cultural policies, and the discourses of environmental politics and nationalism. Examples include John Laws's very popular Across Australia radio talk-back programme which celebrates the outback, the farmer and 'battler', and the 'True Blue' music of country artist John Williamson; the push by the Green movement to separate and protect wilderness areas of 'natural' bushland from the corrupting influences of human cultivation; and the continued significance of the 'bush' and 'bushman' in divers constructions of national cultural identity. Share and Lawrence argue that such representations are a state of mind rather than a state of being, "in the imagination of the cosmopolis" only (Share & Lawrence 101). Imagined or otherwise, however, the evidence suggests that they are representations which are nevertheless there -- albeit constructed in varying ways, with varying emphases, and in a variety of settings. Tamworth: Country at Heart Jacka argues that it is the 'local', constructed by a specific set of forces and circumstances and operating within a particular time frame and place, that provides the best or most 'authentic' means of analysing notions of the 'country' (qtd. in Share & Lawrence 102). Tamworth, situated in North Western New South Wales, approximately four hundred kilometres from Sydney, is one such 'authentic' locality. The city of Tamworth and its surrounding hinterland is populated by some 55,000 people. Timber and farmland constitute 95% of its land use. Agricultural production generates the bulk of its net income. The Tamworth electoral district has been designated 'country' by the State Electoral Office. Promotional billboards erected by the Tamworth City Council and situated on all major highways into the city describe Tamworth as 'the heart of country'. Tamworth is renowned as 'the Country Music Capital of Australasia' and celebrates 'country' values annually through a highly successful Country Music Festival. Clearly, notions of country are significant in the shaping of how Tamworth is perceived as a community locally and nationally. These notions are an important component of the process of meaning generation, circulation and exchange inTamworth -- indeed, they are an important component of the essential fabric that constitutes the Tamworth culture. Analysis The Tamworth worldview was studied through an analysis of the coverage of the local NSW state election campaigns of 1995 and 1999 by Tamworth's only regional daily newspaper, the Northern Daily Leader. Regional daily newspapers are a useful means of analysing the major preoccupations of a culture. They contribute significantly to the construction and representation of the communities they serve: they are moulded by the specific needs of their communities; they are prominent influences of the norms, values and processes of these communities; they are the product of a community that is connected by common and local interests and knowledge, written with and by the people of this community (Mules et al. 242). The coverage of the 1995 and 1999 election campaigns represented a discrete sample of texts with a common focus. An important aspect of this focus was Mr Tony Windsor, Independent State Member for Tamworth. Windsor's Independent status was significant to the study. Firstly, it suggests that he was elected to office on his own merits or on the merits of his policies, as against any particular party affiliation. Papadakis and Bean argue that a vote for an Independent most often represents a protest vote against the dominant players in the political system rather than any systemic approval of the policy positions or other qualities of the recipient (109). This may well have been the case for Windsor's initial victory in 1991. However, in the 1995 election he won an unprecedented 83% of the primary vote, representing voters from right across the political spectrum. He further increased his majority in the 1999 election. Windsor's extraordinary popularity suggests that his appeal cut across the political boundaries into the social and cultural realms. As such, Windsor embodies a singular means of analysing the socio-politico-cultural preoccupations of those he represents. The study tracked story frequency and space, and analysed pictorial, headline and lead texts in terms of story focus, personal and thematic associations, and candidate agency. It was found that the Leader markedly privileged Windsor over his opponents in regards to story frequency and space. The pictorial and key word analyses identified Windsor's public persona as more active and more person-oriented than those of his opponents, and as associated more often with exterior settings, particularly those in or connected with 'bush' locations. This stood in contrast to the representations of his major ALP opponents. In both elections they were female, associated more with interior settings, and represented as speaking more than doing, passive more than active, and concerned more with their emotions and states of being than was Windsor. Overall, the Leader's representation of Windsor was found to comprise the six notions noted above as being characteristic of the traditional country worldview. Windsor's connections with and concerns for the land and country issues were significant. The construction of male and female gender roles was masculinist in nature. The absence of any signifiers associated with notions of 'Aboriginality', 'ethnicity', even 'diversity', indicated the existence of naturalised discourses of 'white' and 'homogeneity'. Notions of productivity were evident through Windsor's preoccupation with the business and industry. Nationalism was implied through Windsor's association with characteristics that epitomise traditional understandings of what it is to be an Australian. Two additional characteristics were also identified. The first of these was named 'Independent', as indicated through the significance placed upon Windsor's politically Independent status. It was defined by the traditional understandings of the country worldview and ideas of integrity, 'a fair go' for the country, and of giving power back to the people. In contrast, the major political parties, ALP and National Party, were associated with the city, corruption, interference, lack of democracy, the undermining of country values by city values, and a subordination of the country to the city. The second characteristic was named 'community'. It was indicated through ideas of belonging and like-mindedness, andWindsor's representation as friendly, person-oriented and concerned with the active provision of services for the people. Implications The Tamworth culture is characterised by the notions of 'land', 'masculinity', 'white', 'productive', 'homogenous', 'nationalistic', 'Independent' and 'community'. This very characterisation, however, is one that gives rise to a number of questions. What drove the Leader to construct and represent the Tamworth culture in this way? How did and does this particular characterisation serve the needs of the Tamworth people? How and why are these needs different to the needs of city people -- or even people in other rural communities? Perhaps the best answer lies with the demonstrated longevity of the essential nature of the Tamworth worldview. Traditional notions of country have remained distinctive, even definitive, despite Australia's urbanisation, suburbanisation, multiculturalism; despite the enormous economic and social changes that have been wrought by globalisation; despite the consequent blurring of boundaries between rural, urban, state and national. This traditional nature, it seems, is resistant to change. Yet there is also evidence that a blurring of boundaries, even change, has occurred in Tamworth. Examples include the fact that the combined income generated by secondary and tertiary industries in the Tamworth district is now greater than that generated by agriculture; Windsor, with whom the Leader so closely associates the land and other notions traditionally associated with the country, also holds a university degree in economics; the annual Country Music Festival is celebrated largely from within the confines of the city of Tamworth itself; Tamworth City Council and Country Music Festival both have sites on the World Wide Web, thereby connecting them with the very globalisation that the Leader would have them resisting. Although this may suggest that the country has actually appropriated, even assimilated many of the notions that are most often associated with change in today's society, it also seems that this assimilation is one that is on the country's terms only. Notions of the city are subordinated to notions of the country. Change is appropriated, but in a way that maintains the status quo -- that perpetuates the essential country worldview, both locally and nationally. Such evidence of change may also suggest that the Leader's representation of Windsor, of Tamworth, is perhaps a state of mind rather than a state of being. It is a representation that taps into the imagination of the people rather than their everyday existence. In so doing, it worked to position over 85% of the population into voting a particular way in the 1995 and 1999 NSW State elections. It may also work to draw the many people from around Australia who bring their tourist dollars into Tamworth each year to celebrate country values through the Country Music Festival. The Tamworth culture may well uphold a construction of Australian identity that is outside the direct experience of those who live on the coastal fringes, yet it provides an attractive, even desirable holiday destination for many. Perhaps this is because people, country and city alike, continue to see the country as a place that offers them a simple solution to tensions and conflicts that are otherwise unresolvable. Change produces anxiety -- especially a postmodern change in which all semblances of certainty have been removed. On the other hand, the study suggests that the country worldview represents that which does not change. Its definitive nature stands in contrast and provides an alternative to the relativism of the city. Notions of country represent a surety in a world that is otherwise uncertain. References Aitkin, D. "Countrymindedness: The Spread of an Idea." Australian Cultural History 4 (1985): 34-41. Moore, A. "The Old Guard and 'Countrymindedness' during the Great Depression." Journal of Australian Studies 27 (1990): 54. Mules, W., T. Shirato, and B. Wigman. "Rural Identity within the Symbolic Order: Media Representations of the Drought." Communication and Culture in Rural Areas. Ed. P. Share. Wagga Wagga: Charles Sturt UP, 1995. 242. 6. Papadakis, E., and C. Bean. "Independents and the Minor Parties: The Electoral System." Australian Journal of Political Science 30 (1995): 109. Share, P., G. Lawrence. "Fear and Loathing in Wagga Wagga: Cultural Representations of the Rural and Possible Policy Implications." Communication and Culture in Rural Areas. Ed. P. Share. Wagga Wagga: Charles Sturt UP, 1995. Turner, G. Making It National. Sydney: Allen & Unwin, 1994. Ward, R. The Australian Legend. Melbourne: Oxford UP, 1958. White, R. Inventing Australia. Sydney:Allen & Unwin, 1981. 16ff. Citation reference for this article MLA style: Catherine Richardson. "The Politics of a Country Culture: State of Mind or State of Being?" M/C: A Journal of Media and Culture 3.2 (2000). [your date of access] <http://www.api-network.com/mc/0005/country.php>. Chicago style: Catherine Richardson, "The Politics of a Country Culture: State of Mind or State of Being?," M/C: A Journal of Media and Culture 3, no. 2 (2000), <http://www.api-network.com/mc/0005/country.php> ([your date of access]). APA style: Catherine Richardson. (2000) The politics of a country culture: state of mind or state of being?. M/C: A Journal of Media and Culture 3(2). <http://www.api-network.com/mc/0005/country.php> ([your date of access]).

Photo by Christian Bowen on Unsplash ABSTRACT Assisted Reproductive Technology can be a beneficial tool for couples unable to reproduce independently; however, it has historically discriminated against the LGBTQ+ community members. Given the evolution and acceptance of LGBTQ rights in recent years, discrimination and barriers to access reproductive technology and health care should be readdressed as they still exist within this community. INTRODUCTION In recent years, the LGBTQ+ community has made great strides toward attaining equal rights. This fight dates back to 1970 when Michael Baker and McConnell applied for a marriage license in Minnesota.[1] After the county courthouse denied the couple's request, they appealed to the Minnesota Supreme Court. Baker and McConnell’s dispute reached the US Supreme Court. Baker v. Nelson[2] was the first time a same-sex couple attempted to pursue marriage through higher courts in the US.[3] Because the couple lost the case, Baker changed his name to a gender-neutral one, and McConnell adopted Baker, allowing Baker and McConnell to have legal protections like the ability to receive certain inheritances. Baker and McConnell received a marriage license from an unsuspecting clerk from Blue Earth County, where they wed on September 3, 1971.[4] BACKGROUND The Supreme Court’s decision left individual state legislatures the option to accommodate same-sex couples’ rights constitutionally. As a result, some states banned same-sex marriage, while others offered alternative options such as domestic partnerships. With many obstacles, such as the Defense of Marriage Act (DOMA) and President Bush’s efforts to limit marriage to heterosexual people, Massachusetts became the first state to legalize gay marriage in 2003.[5] Other states slowly followed. Finally, in 2015 the US Supreme Court made same-sex marriage legal in all 50 states in Obergefell v. Hodges,[6] marking an important milestone for the LGBTQ+ community’s fight toward marriage equality. The Obergefell v. Hodges decision emphasized that members of the homosexual community are “not to be condemned to live in loneliness, excluded from one of civilization's oldest institutions,” thus granting them the right to “equal dignity in the eyes of the law.”[7] This paper argues that in the aftermath of the wide acceptance of LGBTQ rights, discrimination and barriers to access reproductive technology and health care persist nationally. Procreation also faces discrimination. Research supports that children’s overall psychological and physical welfare with same-sex parents does not differ compared to children with heterosexual parents.[8] Some others worry about the children’s developmental health and argue that same-sex male couples’ inability to breastfeed their children may be harmful; however, such parents can obtain breast milk via surrogate donation.[9] Further concerns regarding confusion in gender identity in children raised by same-sex parents are not supported by research in the field indicating that there are “no negative developmental or psychological outcomes for a child, nor does it result in differing gender identity, gender role behavior or sexual partner preference compared to opposite-sex parents.”[10] ANALYSIS l. Desire to Procreate The American perception toward same-sex unions has evolved “from pathology to deviant lifestyle to identity.”[11] In 2001, only 35 percent of Americans favored same‐sex marriage, while 62 percent favored it in 2017.[12] The “Gay marriage generation”[13] has a positive attitude toward same-sex unions, arising from the “interaction among activists, celebrities, political and religious leaders, and ordinary people, who together reconfigured Americans’ social imagination of homosexuality in a way that made gay marriage seem normal, logical, and good.”[14] Same-sex couples’ right to build a biological family and ability to do so using modern reproductive technology is unclear. The data generated by the LGBTQ Family Building Survey revealed “dramatic differences in expectations around family building between LGBTQ millennials (aged 18-35) and older generations of LGBTQ people,”[15] which may be in part attributable to recent federal rulings in favor of same-sex couples. Three important results from this survey are that 63 percent of LGBTQ millennials are considering expanding their families throughout parenthood, 48 percent of LGBTQ millennials are actively planning to grow their families, compared to 55 percent of non-LGBTQ millennials; and 63 percent of those LGBTQ people interested in building a family expect to use assisted reproductive technology (ART), foster care, or adoption to become parents.[16] There are 15.9 million Americans who identify as LGBTQ+ (6.1 million of whom are 18 to 35 years old); thus, an estimated “3.8 million LGBTQ+ millennials are considering expanding their families in the coming years, and 2.9 million are actively planning to do so.”[17] Yet access and affordability to ART, especially in vitro fertilization (IVF) and surrogacy for same-sex couples, has not been consistent at a national level. The two primary problems accessing ART for the LGBTQ community are the lack of federal law and cost. A federal law that guaranteed coverage would address both problems. ll. ART for Same-Sex Couples All same-sex male (SSM) couples and same-sex female (SSF) couples must involve third parties, including surrogates or egg or sperm donors.[18] ART involves the legal status of “up to two women (surrogate and egg donor),” the intended parents, and the child for SSM couples.[19] While sometimes necessary for heterosexual couples using ART, an egg or sperm from someone other than the intended parents or a surrogate will always be necessary for the LGBTQ people seeking ART. ART, in particular IVF, is essential for infertile couples unable to conceive on their own. Unlike other industrialized countries (such as Canada, the United Kingdom, Sweden, Germany, and Australia), the US does not heavily oversee this multibillion-dollar industry.[20] The American Society for Reproductive Medicine does provide lengthy guidelines to fertility clinics and sperm banks; however, state lawmakers have been less active as they seem to avoid the controversy surrounding controversial topics like embryo creation and abortion.[21] As a result, states “do not regulate how many children may be conceived from one donor, what types of medical information or updates must be supplied by donors, what genetic tests may be performed on embryos, how many fertilized eggs may be placed in a woman or how old a donor can be.”[22] lll. A Flawed Definition of Infertility The WHO defines the medical definition of infertility as “a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after twelve months or more of regular unprotected sexual intercourse.”[23] This antiquated definition must be updated to include social infertility to integrate same-sex couples’ rights.[24] In the US, single individuals and LGBTQ couples interested in building a family by biological means are considered “socially infertile.”[25] If insurance coverage is allotted only to those with physical infertility, then it is exclusive to the heterosexual community. Although some states, such as New York, discussed below, have directly addressed this inequality by extending the definition of infertility and coverage of infertility treatments to include all residents regardless of sexual orientation, this is not yet the norm everywhere else. The outdated definition of infertility is one of the main issues affecting same-sex couples’ access to ART, as medical insurance companies hold on to the formal definition of infertility to deny coverage. lV. Insurance Coverage for IVF Insurance coverage varies per state and relies on the flawed definition of infertility. As of August 2020, 19 states have passed laws requiring insurance coverage for infertility, 13 of which include IVF coverage, as seen in Figure 1. Also, most states do not offer IVF coverage to low-income people through Medicaid.[26] In states that mandate IVF insurance coverage, the utilization rate was “277% of the rate when there was no coverage,”[27] which supports the likelihood that in other states, the cost is a primary barrier to access. When insurance does not cover ART, ART is reserved for wealthy individuals. One cycle of ART could cost, on average, “between $10,000 and $15,000.”[28] In addition, multiple cycles are often required as one IVF cycle only has “about a 25% to 30%” live birth success rate.[29] Altogether, the total cost of successful childbirth was estimated from $44,000 to $211,940 in 1992.[30] On February 11, 2021, New York Governor Andrew M. Cuomo “directed the Department of Financial Services to ensure that insurers begin covering fertility services immediately for same-sex couples who wish to start a family.”[31] New York had recently passed an IVF insurance law that required “large group insurance policies and contracts that provide medical, major medical, or similar comprehensive-type coverage and are delivered or issued for delivery in New York to cover three cycles of IVF used in the treatment of infertility.”[32] But the law fell short for same-sex couples, which were still required to “pay 6 or 12 months of out-of-pocket expenses for fertility treatments such as testing and therapeutic donor insemination procedures before qualifying for coverage.”[33] Cuomo’s subsequent order made up for gaps in the law, which defined infertility as “the inability to conceive after a certain period of unprotected intercourse or donor insemination.”[34] Cuomo’s order and the law combine to make New York an example other states can follow to broaden access to ART. V. Surrogacy Access to surrogacy also presents its own set of problems, although not exclusive to the LGBTQ community. Among states, there are differences in how and when parental rights are established. States in dark green in Figure 2 allow pre-birth orders, while the states in light green allow post-birth parentage orders. Pre-birth orders “are obtained prior to the child’s birth, and they order that the intended parent(s) will be recognized as the child’s only legal parent(s) and will be placed on the child’s birth certificate,” while post-birth parentage orders have the same intent but are obtained after the child’s birth. [35] For instance, states can require genetic testing post-birth, possibly causing a delay in establishing parentage.[36] Although preventable through the execution of a health care power of attorney, a surrogate mother could be the legal, medical decision-maker for the baby before the intended parents are legally recognized. On February 15, 2021, gestational surrogacy – the most popular type of surrogacy in which the surrogate has no biological link to the baby – was legalized in New York,[37] but it remains illegal in some states such as Nebraska, Louisiana, and Michigan.[38] In addition, the costs of surrogacy are rising, and it can cost $100,000 in the US.[39] Medicaid does not cover surrogacy costs,[40] and some health insurance policies provide supplemental surrogacy insurance with premiums of approximately $10,000 and deductibles starting at $15,000.[41] Thus, “surrogacy is really only available to those gay and lesbian couples who are upper class,”[42] leaving non-affluent couples out of options to start a family through biological means. Vl. A Right to Equality and Procreation Some argue that same-sex couples should have the right to procreate (or reproductive rights). Based on arguments stemming from equal rights and non-discrimination, same-sex couples who need to use ART to procreate should have access to it. The need to merge social infertility into the currently incomplete definition of fertility could help same-sex couples achieve access through insurance coverage. The human right of equality and non-discrimination guarantees “equal and effective protection against discrimination on any ground.”[43] The United Nations later clarified that “sexual orientation is a concept which is undoubtedly covered” [44] by this protection. The right to procreate is not overtly mentioned in the US Constitution; however, the Equal Protection Clause states that “No State shall make or enforce any law which shall abridge the privileges or immunities of citizens of the United States… without due process of law.”[45] In fact, some states have abridged the reproductive privileges of some US citizens by upholding prohibitive and intricate mechanisms that deter same-sex couples from enjoying the privileges other citizens have. The Supreme Court acknowledged procreation as a “fundamental”[46] personal right, in Skinner v. Oklahoma, mandating that the reproductive rights of individuals be upheld as the right to procreate is “one of the basic civil rights of man”[47] because “procreation [is] fundamental to the very existence and survival of the race.”[48] In Eisenstadt v. Baird, the courts also supported that “the decision whether to bear or beget a child” fundamentally affects a person.[49] I argue that this protection extends to same-sex couples seeking to procreate. Finally, Obergefell v. Hodges held that the Due Process and Equal Protection clauses ensure same-sex couples the right to marriage, as marriage “safeguards children and families, draw[ing] meaning from related rights of childrearing, procreation, and education.”[50] By implicit or explicit means, these cases align with the freedom to procreate that should not be unequally applied to different social or economic groups. Yet, the cases do not apply to accessing expensive tools to procreate. As heterosexuals and the LGBTQ community face trouble accessing expensive ART for vastly different reasons, especially IVF and surrogacy, the equal rights or discrimination argument is not as helpful. For now, it is relevant to adoption cases where religious groups can discriminate.[51] The insurance coverage level may be the best approach. While the social norms adapt and become more inclusive, the elimination of the infertility requirement or changing the definition of infertility could work. Several arguments could address the insurance coverage deficit. Under one argument, a biological or physical inability to conceive exists in the homosexual couple trying to achieve a pregnancy. Depending on the wording or a social definition, a caselaw could be developed arguing the medical definition of infertility applies to the LGBTQ community as those trying to procreate are physically unable to conceive as a couple planning to become parents. One counterargument to that approach is that it can be offensive to label people infertile (or disabled) only because of their status as part of a homosexual couple.[52] CONCLUSION In the last 50 years, there has been a notable shift in the social acceptance of homosexuality.[53] Marriage equality has opened the door for further social and legal equality, as evidenced by the increased number of same-sex couples seeking parenthood “via co-parenting, fostering, adoption or surrogacy” – colloquially referred to as the ‘Gayby Boom’.[54] However, some prejudice and disdain toward LGBTQ+ parenting remain. Equitable access to ART for all people may be attainable as new technology drives costs down, legislators face societal pressure to require broader insurance coverage, and social norms become more inclusive. [1] Eckholm, E. (2015, May 17). The same-sex couple who got a marriage license in 1971. Retrieved April 08, 2021, from https://www.nytimes.com/2015/05/17/us/the-same-sex-couple-who-got-a-marriage-license-in-1971.html [2] Eckholm, E. [3] A brief history of civil rights in the United States: A timeline of the legalization of same-sex marriage in the U.S. (2021, January 27). Retrieved April 08, 2021, from https://guides.ll.georgetown.edu/c.php?g=592919&p=4182201 [4] Eckholm, E. [5] A brief history of civil rights in the United States: A timeline of the legalization of same-sex marriage in the U.S. (2021, January 27). Retrieved April 08, 2021, from https://guides.ll.georgetown.edu/c.php?g=592919&p=4182201 [6] A brief history of civil rights in the United States [7] A brief history of civil rights in the United States [8] Lee, J., & Bolzendahl, C. (2019). Acceptance and Rejection: Patterns of opinion on homosexuality in the United States and the world. Sociological Forum, 34(4), 1026-1031. doi:10.1111/socf.12562 [9] Lee, J., et al. [10] Lee, J., et al. [11] Lee, J., et al. [12] Lee, et al. [13] Lee, et al. [14] Lee, et al. [15] LGBTQ family building survey. (2020, July 02). Retrieved April 08, 2021, from https://www.familyequality.org/resources/lgbtq-family-building-survey/ [16] LGBTQ family building survey. (2020, July 02). Retrieved April 08, 2021, from https://www.familyequality.org/resources/lgbtq-family-building-survey/ [17] LGBTQ family building survey. (2020, July 02). Retrieved April 08, 2021, from https://www.familyequality.org/resources/lgbtq-family-building-survey/ [18] Mackenzie, S. C., Wickins-Drazilova, D., & Wickins, J. (2020). The ethics of fertility treatment for same-sex male couples: Considerations for a modern fertility clinic. European Journal of Obstetrics & Gynecology and Reproductive Biology, 244, 71-75. doi:10.1016/j.ejogrb.2019.11.011 [19] Mackenzie, et al. [20] Ollove, M. (2015, March 18). States not eager to regulate fertility industry. Retrieved April 08, 2021, from https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2015/3/18/states-not-eager-to-regulate-fertility-industry [21] Ollove, M. [22] Ollove, M. [23] World Health Organization. (2020, September 14). Infertility. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/infertility [24] Leondires, M. P. (2020, March 19). Fertility insurance Mandates & same-sex couples. Retrieved April 08, 2021, from https://www.gayparentstobe.com/gay-parenting-blog/fertility-insurance-mandates-same-sex-couples/ [25] Lo, W., & Campo-Engelstein, L. (2018). Expanding the Clinical Definition of Infertility to Include Socially Infertile Individuals and Couples. Reproductive Ethics II, 71–83. https://doi.org/10.1007/978-3-319-89429-4_6 [26] Mohapatra, S. (2015). Assisted Reproduction Inequality and Marriage Equality. Chicago-Kent Law Review, 92(1). Retrieved April 08, 2021, from https://scholarship.kentlaw.iit.edu/cgi/viewcontent.cgi?article=4146&context=cklawreview [27] Mohapatra, S. [28] Mohapatra, S. [29] Mohapatra, S. [30] Mohapatra, S. [31] Governor Cuomo announces new actions to expand access to FERTILITY coverage for same sex couples as part of 2021 Women's Agenda. (n.d.). [32] Health Insurers FAQs: IVF and Fertility Preservation Law Q&A Guidance. (n.d.). Retrieved April 08, 2021, from https://www.dfs.ny.gov/apps_and_licensing/health_insurers/ivf_fertility_preservation_law_qa_guidance [33] Governor Cuomo announces new actions to expand access to FERTILITY coverage for same sex couples as part of 2021 Women's Agenda. (n.d.). Retrieved April 08, 2021, from https://www.governor.ny.gov/news/governor-cuomo-announces-new-actions-expand-access-fertility-coverage-same-sex-couples-part#:~:text=February%2011%2C%202021-,Governor%20Cuomo%20Announces%20New%20Actions%20to%20Expand%20Access%20to%20Fertility,Part%20of%202021%20Women's%20Agenda&text=Cuomo%20today%20directed%20the%20Department,wish%20to%20start%20a%20family. [34] Leondires, M. P. [35] Assisted reproduction parentage proceedings information: Academy of Adoption and Assistive Reproduction Attorneys (AAAA). (2019, March 14). Retrieved April 08, 2021, from https://adoptionart.org/assisted-reproduction/parentage-proceedings/ [36] Assisted reproduction parentage proceedings information. [37] Governor Cuomo reminds surrogates and parents of their new Insurance rights and protections During Gestational Surrogacy. (n.d.). Retrieved April 08, 2021, from https://www.governor.ny.gov/news/governor-cuomo-reminds-surrogates-and-parents-their-new-insurance-rights-and-protections-during [38] U.S. Surrogacy Map: Surrogacy laws by state. (2020, December 23). Retrieved April 08, 2021, from https://www.creativefamilyconnections.com/us-surrogacy-law-map/ [39] Mohapatra, S. [40] Beitsch, R. (2017, June 29). As surrogacy surges, new parents seek legal protections. Retrieved April 08, 2021, from https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2017/06/29/as-surrogacy-surges-new-parents-seek-legal-protections#:~:text=Medicaid%20does%20not%20cover%20surrogacy,and%20intended%20parents%20at%20risk. [41] Where to find surrogacy insurance? (2017, November 02). Retrieved April 08, 2021, from https://surrogate.com/intended-parents/surrogacy-laws-and-legal-information/where-can-i-find-surrogacy-insurance/ [42] Mohapatra, S. [43] International covenant on civil and political rights. (n.d.). Retrieved April 08, 2021, from https://www.ohchr.org/en/professionalinterest/pages/ccpr.aspx [44] United Nations. (2003). Human rights in the administration of justice: a manual on human rights for judges, prosecutors and lawyers. [45] U.S. Const. amend. XIV, § 1. [46] Skinner v. Oklahoma, Https://caselaw.findlaw.com/us-supreme-court/316/535.html (June 1, 1942). [47] Skinner v. Oklahoma [48] Skinner v. Oklahoma [49] Eisenstadt v. Baird, Https://www.lexisnexis.com/community/casebrief/p/casebrief-eisenstadt-v-baird (March 22, 1972). [50] Obergefell v. Hodges [51] Higgins, T. (2021, June 17). Supreme Court sides with Catholic adoption agency that refuses to work with LGBT couples. CNBC. https://www.cnbc.com/2021/06/17/supreme-court-sides-with-catholic-adoption-agency-that-refuses-to-work-with-lgbt-couples.html. [52] Bowerman, M., May, A., & Rossman, S. (2017, April 24). Should the definition of infertility be more inclusive? USA Today. https://www.usatoday.com/story/news/nation-now/2017/04/22/same-sex-couples-covered-infertility-insurance/100644092/. [53] Mackenzie, et al. [54] Mackenzie, et al.

Introduction The decline of marriage in the West has been extensively researched over the last three decades (Carmichael and Whittaker; de Vaus; Coontz; Beck-Gernshein). Indeed, it was fears that the institution would be further eroded by the legalisation of same sex unions internationally that provided the impetus for the Australian government to amend the Marriage Act (1961). These amendments in 2004 sought to strengthen marriage by explicitly defining, for the first time, marriage as a legal partnership between one man and one woman. The subsequent heated debates over the discriminatory nature of this definition have been illuminating, particularly in the way they have highlighted the ongoing social significance of marriage, even at a time it is seen to be in decline. Demographic research about partnering practices (Carmichael and Whittaker; Simons; Parker; Penman) indicates that contemporary marriages are more temporary, fragile and uncertain than in previous generations. Modern marriages are now less about a permanent and “inescapable” union between a dominant man and a submissive female for the purposes of authorised sex, legal progeny and financial security, and more about a commitment between two social equals for the mutual exchange of affection and companionship (Croome). Less research is available, however, about how couples themselves reconcile the inherited constructions of romantic love as selfless and unending, with trends that clearly indicate that romantic love is not forever, ideal or exclusive. Civil marriage ceremonies provide one source of data about representations of love. Civil unions constituted almost 70 per cent of all marriages in Australia in 2010, according to the Australian Bureau of Statistics. The civil marriage ceremony has both a legal and symbolic role. It is a legal contract insofar as it prescribes a legal arrangement with certain rights and responsibilities between two consenting adults and outlines an expectation that marriage is voluntarily entered into for life. The ceremony is also a public ritual that requires couples to take what are usually private feelings for each other and turn them into a public performance as a way of legitimating their relationship. Consistent with the conventions of performance, couples generally customise the rest of the ceremony by telling the story of their courtship, and in so doing they often draw upon the language and imagery of the Western Romantic tradition to convey the personal meaning and social significance of their decision. This paper explores how couples construct the idea of love in their relationship, first by examining the western history of romantic love and then by looking at how this discourse is invoked by Australians in the course of developing civil marriage ceremonies in collaboration with the author. A History of Romantic Love There are many definitions of romantic love, but all share similar elements including an intense emotional and physical attraction, an idealisation of each other, and a desire for an enduring and unending commitment that can overcome all obstacles (Gottschall and Nordlund; Janowiak and Fischer). Romantic love has historically been associated with heightened passions and intense almost irrational or adolescent feelings. Charles Lindholm’s list of clichés that accompany the idea of romantic love include: “love is blind, love overwhelms, a life without love is not worth living, marriage should be for love alone and anything less is worthless and a sham” (5). These elements, which invoke love as sacred, unending and unique, perpetuate past cultural associations of the term. Romantic love was first documented in Ancient Rome where intense feelings were seen as highly suspect and a threat to the stability of the family, which was the primary economic, social and political unit. Roman historian Plutarch viewed romantic love based upon strong personal attraction as disruptive to the family, and he expressed a fear that romantic love would become the norm for Romans (Lantz 352). During the Middle Ages romantic love emerged as courtly love and, once again, the conventions that shaped its expression grew out of an effort to control excessive emotions and sublimate sexual desire, which were seen as threats to social stability. Courtly love, according to Marilyn Yalom, was seen as an “irresistible and inexhaustible passion; a fatal love that overcomes suffering and even death” (66). Feudal social structures had grounded marriage in property, while the Catholic Church had declared marriage a sacrament and a ceremony through which God’s grace could be obtained. In this context courtly love emerged as a way of dealing with the conflict between the individual and family choices over the martial partner. Courtly love is about a pure ideal of love in which the knight serves his unattainable lady, and, by carrying out feats in her honour, reaches spiritual perfection. The focus on the aesthetic ideal was a way to fulfil male and female emotional needs outside of marriage, while avoiding adultery. Romantic love re-appeared again in the mid-eighteenth century, but this time it was associated with marriage. Intellectuals and writers led the trend normalising romantic love in marriage as a reaction to the Enlightenment’s valorisation of reason, science and materialism over emotion. Romantics objected to the pragmatism and functionality induced by industrialisation, which they felt destroyed the idea of the mysterious and transcendental nature of love, which could operate as a form of secular salvation. Love could not be bought or sold, argued the Romantics, “it is mysterious, true and deep, spontaneous and compelling” (Lindholm 5). Romantic love also emerged as an expression of the personal autonomy and individualisation that accompanied the rise of industrial society. As Lanz suggests, romantic love was part of the critical reflexivity of the Enlightenment and a growing belief that individuals could find self actualisation through the expression and expansion of their “emotional and intellectual capacities in union with another” (354). Thus it was romantic love, which privileges the feelings and wishes of an individual in mate selection, that came to be seen as a bid for freedom by the offspring of the growing middle classes coerced into marriage for financial or property reasons. Throughout the 19th century romantic love was seen as a solution to the dehumanising forces of industrialisation and urbanisation. The growth of the competitive workplace—which required men to operate in a restrained and rational manner—saw an increase in the search for emotional support and intimacy within the domestic domain. It has been argued that “love was the central preoccupation of middle class men from the 1830s until the end of the 19th century” (Stearns and Knapp 771). However, the idealisation of the aesthetic and purity of love impacted marriage relations by casting the wife as pure and marital sex as a duty. As a result, husbands pursued sexual and romantic relationships outside marriage. It should be noted that even though love became cemented as the basis for marriage in the 19th century, romantic love was still viewed suspiciously by religious groups who saw strong affection between couples as an erosion of the fundamental role of the husband in disciplining his wife. During the late 19th and early 20th centuries romantic love was further impacted by urbanisation and migration, which undermined the emotional support provided by extended families. According to Stephanie Coontz, it was the growing independence and mobility of couples that saw romantic love in marriage consolidated as the place in which an individual’s emotional and social needs could be fully satisfied. Coontz says that the idea that women could only be fulfilled through marriage, and that men needed women to organise their social life, reached its heights in the 1950s (25-30). Changes occurred to the structure of marriage in the 1960s when control over fertility meant that sex was available outside of marriage. Education, equality and feminism also saw women reject marriage as their only option for fulfilment. Changes to Family Law Acts in western jurisdictions in the 1970s provided for no-fault divorce, and as divorce lost its stigma it became acceptable for women to leave failing marriages. These social shifts removed institutional controls on marriage and uncoupled the original sexual, emotional and financial benefits packaged into marriage. The resulting individualisation of personal lifestyle choices for men and women disrupted romantic conventions, and according to James Dowd romantic love came to be seen as an “investment” in the “future” that must be “approached carefully and rationally” (552). It therefore became increasingly difficult to sustain the idea of love as a powerful, mysterious and divine force beyond reason. Methodology In seeking to understand how contemporary partnering practices are reconstituting romantic love, I draw upon anecdotal data gathered over a nine-year period from my experiences as a marriage celebrant. In the course of personalising marriage ceremonies, I pose a series of questions designed to assist couples to explain the significance of their relationship. I generally ask brides and grooms why they love their fiancé, why they want to legalise their relationship, what they most treasure about their partner, and how their lives have been changed by their relationship. These questions help couples to reflexively interrogate their own relationship, and by talking about their commitment in concrete terms, they produce the images and descriptions that can be used to describe for guests the internal motivations and sentiments that have led to their decision to marry. I have had couples, when prompted to explain how they know the other person loves them say, in effect: “I know that he loves me because he brings me a cup of coffee every morning” or “I know that she loves me because she takes care of me so well.” These responses are grounded in a realism that helps to convey a sense of sincerity and authenticity about the relationship to the couple’s guests. This realism also helps to address the cynicism about the plausibility of enduring love. The brides and grooms in this sample of 300 couples were a socially, culturally and economically diverse group, and they provided a wide variety of responses ranging from deeply nuanced insights into the nature of their relationship, to admissions that their feelings were so private and deeply felt that words were insufficient to convey their significance. Reoccurring themes, however, emerged across the cases, and it is evident that even as marriage partnerships may be entered into for a variety of reasons, romantic love remains the mechanism by which couples talk of their feelings for each other. Australian Love and Marriage Australians' attitudes to romantic love and marriage have, understandably, been shaped by western understandings of romantic love. It is evident, however, that the demands of late modern capitalist society, with its increased literacy, economic independence and sexual equality between men and women, have produced marriage as a negotiable contract between social equals. For some, like Carol Pateman, this sense of equality within marriage may be illusory. Nonetheless, the drive for individual self-fulfilment by both the bride and groom produces a raft of challenges to traditional ideas of marriage as couples struggle to find a balance between independence and intimacy; between family and career; and between pursuing personal goals and the goals of their partners. This shift in the nature of marriage has implications for the “quest for undying romantic love,” which according to Anthony Giddens has been replaced by other forms of relationship, "each entered into for its own sake, for what can be derived by each person from a sustained association with another; and which is continued only in so far as it is thought by both parties to deliver enough satisfactions for each individual to stay within it” (qtd. in Lindholm 6). The impact of these social changes on the nature of romantic love in marriage is evident in how couples talk about their relationship in the course of preparing a ceremony. Many couples describe the person they are marrying as their best friend, and friendship is central to their commitment. This description supports research by V.K. Oppenheimer which indicates that many contemporary couples have a more “egalitarian collaborative approach to marriage” (qtd. in Carmichael and Whittaker 25). It is also standard for couples to note in ceremonies that they make each other happy and contented, with many commenting upon how their partners have helped to bring focus and perspective to their work-oriented lives. These comments tend to invoke marriage as a refuge from the isolation, competition, and dehumanising elements of workplaces. Since emotional support is central to the marriage contract, it is not surprising that care for each other is another reoccurring theme in ceremonies. Many brides and grooms not only explicitly say they are well taken care of by their partner, but also express admiration for their partner’s treatment of their families and friends. This behaviour appears to be seen as an indicator of the individual’s capacity for support and commitment to family values. Many couples admire partner’s kindness, generosity and level of personal self-sacrifice in maintaining the relationship. It is also not uncommon for brides and grooms to say they have been changed by their love: become kinder, more considerate and more tolerant. Honesty, communication skills and persistence are also attributes that are valued. Brides and grooms who have strong communication skills are also praised. This may refer to interpersonal competency and the willingness to acquire the skills necessary to negotiate the endless compromises in contemporary marriage now that individualisation has undermined established rules, rituals and roles. Persistence and the ability not to be discouraged by setbacks is also a reoccurring theme, and this connects with the idea that marriage is work. Many couples promise to grow together in their marriage and to both take responsibility for the health of their relationship. This promise implies awareness that marriage is not the fantasy of happily ever after produced in romantic popular culture, but rather an arrangement that requires hard work and conscious commitment, particularly in building a union amidst many competing options and distractions. Many couples talk about their relationship in terms of companionship and shared interests, values and goals. It is also not uncommon for couples to say that they admire their partner for supporting them to achieve their life goals or for exposing them to a wider array of lifestyle choices and options like travel or study. These examples of interdependence appear to make explicit that couples still see marriage as a vehicle for personal freedom and self-realisation. The death of love is also alluded to in marriage ceremonies. Couples talk of failed past relationships, but these are produced positively as a mechanism that enables the couple to know that they have now found an enduring relationship. It is also evident that for many couples the decision to marry is seen as the formalisation of a preexisting commitment rather than the gateway to a new life. This is consistent with figures that show that 72 per cent of Australian couples chose to cohabit before marriage (Simons 48), and that cohabitation has become the “normative pathway to marriage” (Penman 26). References to children also feature in marriage ceremonies, and for the couples I have worked with marriage is generally seen as the pre-requisite for children. Couples also often talk about “being ready” for marriage. This seems to refer to being financially prepared. Robyn Parker citing the research of K. Edin concludes that for many modern couples “rushing into marriage before being ‘set’ is irresponsible—marrying well (in the sense of being well prepared) is the way to avoid divorce” (qtd. in Parker 81). From this overview of reoccurring themes in the production of Australian ceremonies it is clear that romantic love continues to be associated with marriage. However, couples describe a more grounded and companionable attachment. These more practical and personalised sentiments serve to meet both the public expectation that romantic love is a precondition for marriage, while also avoiding the production of romantic love in the ceremony as an empty cliché. Grounded descriptions of love reveal that attraction does not have to be overwhelming and unconquerable. Indeed, couples who have lived together and are intimately acquainted with each other’s habits and disposition, appear to be most comfortable expressing their commitment to each other in more temperate, but no less deeply felt, terms. Conclusion This paper has considered how brides and grooms constitute romantic love within the shifting partnering practices of contemporary Australia. It is evident “in the midst of significant social and economic change and at a time when individual rights and freedom of choice are important cultural values” marriage remains socially significant (Simons 50). This significance is partially conveyed through the language of romantic love, which, while freighted with an array of cultural and historical associations, remains the lingua franca of marriage, perhaps because as Roberto Unger observes, romantic love is “the most influential mode of moral vision in our culture” (qtd. in Lindholm 5). It is thus possible to conclude, that while marriage may be declining and becoming more fragile and impermanent, the institution remains important to couples in contemporary Australia. Moreover, the language and imagery of romantic love, which publicly conveys this importance, remains the primary mode of expressing care, affection and hope for a partnership, even though the changed partnering practices of late modern capitalist society have exposed the utopian quality of romantic love and produced a cynicism about the viability of its longevity. It is evident in the marriage ceremonies prepared by the author that while the language of romantic love has come to signify a broader range of more practical associations consistent with the individualised nature of modern marriage and demystification of romantic love, it also remains the best way to express what Dowd and Pallotta describe as a fundamental human “yearning for communion with and acceptance by another human being” (571). References Beck, U., and E. Beck-Gernsheim, Individualisation: Institutionalised Individualism and Its Social and Political Consequences. London: Sage, 2002. Beigel, Hugo G. “Romantic Love.” American Sociological Review 16.3 (1951): 326–34. Carmichael, Gordon A, and Andrea Whittaker. “Forming Relationships in Australia: Qualitative Insights into a Process Important to Human Well Being.” Journal of Population Research 24.1 (2007): 23–49. Coontz, Stephanie. Marriage, A History: How Love Conquered Marriage. New York: Viking, 2005. Croome, Rodney. “Love and Commitment, To Equality.” The Drum Opinion, Australian Broadcasting Corporation (ABC) News. 8 June 2011. 14 Aug. 2012 < http://www.abc.net.au/unleashed/2749898.html >. de Vaus, D.L. Qu, and R. Weston. “Family Trends: Changing Patterns of Partnering.” Family Matters 64 (2003): 10–15. Dowd, James T, and Nicole R. Pallotta. “The End of Romance: The Demystification of Love in the Postmodern Age.” Sociological Perspectives 43.4 (2000): 549–80. Gottschall, Jonathan, and Marcus Nordlund. “Romantic Love: A Literary Universal?” Philosophy and Literature 30 (2006): 450–70. Jankowiak, William, and Ted Fischer, “A Cross-Cultural Perspective on Romantic Love,” Ethnology 31 (1992): 149–55. Lantz, Herman R. “Romantic Love in the Pre-Modern Period: A Sociological Commentary.” Journal of Social History 15.3 (1982): 349–70. Lindholm, Charles. “Romantic Love and Anthropology.” Etnofoor 19:1 Romantic Love (2006): 5–21. Parker, Robyn. “Perspectives on the Future of Marriage.” Australian Institute of Family Studies 72 Summer (2005): 78–82.Pateman, Carole. “Women and Consent.” Political Theory (1980): 149–68. Penman, Robyn. “Current Approaches to Marriage and Relationship Research in the United States and Australia.” Family Matters 70 Autumn (2005): 26–35. Simons, Michelle. “(Re)-forming Marriage in Australia?” Australian Institute of Family Matters 73 (2006): 46–51.Stearns, Peter N, and Mark Knapp. “Men and Romantic Love: Pinpointing a 20th-Century Change.” Journal of Social History 26.4 (1993): 769–95. Yalom, Marilyn. A History of the Wife. New York: Harper Collins, 2001.

Polyacrylamide is a polymer of controllable molecular weight formed by the polymerization of acrylamide monomers available in one of three forms: solid (powder or micro beads), aqueous solution, or inverse emulsions (in water droplets coated with surfactant and suspended in mineral oil). Residual acrylamide monomer is likely an impurity in most Polyacrylamide preparations, ranging from <1 ppm to 600 ppm. Higher levels of acrylamide monomers are present in the solid form compared to the other two forms. Polyacrylamide is reportedly used in 110 cosmetic formulations, at concentrations ranging from 0.05% to 2.8%. Residual levels of acrylamide in Poly acrylamide can range from < .01 % to 0.1 %, although representative levels were reported at 0.02% to 0.03%. Because of the large sizes of Polyacrylamide polymers, they do not penetrate the skin. Polyacrylamide itself is not significantly toxic. For example, an acute oral toxicity study of Polyacrylamide in rats reported that a single maximum oral dose of 4.0 g/kg body weight was tolerated. In subchronic oral toxicity studies, rats and dogs treated with Polyacrylamide at doses up to 464 mg/kg body weight showed no signs of toxicity. Several 2-year chronic oral toxicity studies in rats and dogs fed diets containing up to 5% Polyacrylamide had no significant adverse effects. Polyacrylamide was not an ocular irritant in animal tests. No compound-related lesions were noted in a three-generation reproductive study in which rats were fed 500 or 2000 ppm Polyacrylamide in their diet. Polyacrylamide was not carcinogenic in several chronic animal studies. Human cutaneous tolerance tests performed to evaluate the irritation of 5% (w/w) Polyacrylamide indicated that the compound was well tolerated. Acrylamide monomer residues do penetrate the skin. Acrylamide tested in a two-generation reproductive study at concentrations up to 5 mg/kg day x in drinking water, was associated with prenatal lethality at the highest dose, with evidence of parental toxicity. The no adverse effects level was close to the 0.5 mg/kg day x dose. Acrylamide tested in a National Toxicology Program (NTP) reproductive and neurotoxicity study at 3, 10, and 30 ppm produced no developmental or female reproductive toxicity. However, impaired fertility in males was observed, as well as minimal neurotoxic effects. Acrylamide neurotoxicity occurs in both the central and peripheral nervous systems, likely through microtubule disruption, which has been suggested as a possible mechanism for genotoxic effects of acrylamide in mammalian systems. Acrylamide was genotoxic in mammalian in vitro and in vivo assays. Acrylamide was a tumor initiator, but not an initiator/promoter, in two different mouse strains at a total dose of 300 mg/kg (6 doses over 2 weeks) resulting in increased lung adenomas and carcinomas without promotion. Acrylamide was tested in two chronic bioassays using rats. In one study, increased incidence of mammary gland tumors, glial cell tumors, thyroid gland follicular tumors, oral tissue tumors, uterine tumors and clitoral gland tumors were noted in female rats. In male rats, the number of tumors in the central nervous system (CNS), thyroid gland, and scrotum were increased with acrylamide exposure. In the second study, using higher doses and a larger number of female rats, glial cell tumors were not increased, nor was there an increase in mammary gland, oral tissue, clitoral gland, or uterine tumors. Tumors of the scrotum in male rats were confirmed, as were the thyroid gland follicular tumors in males and females. Taken together, there was a dose-dependent, but not statistically significant, increase in the number of astrocytomas. Different human lifetime cancer risk predictions have resulted, varying over three orders of magnitude from 2 × 10 3 to 1.9 × 120 6. In the European Union, acrylamide has been limited to 0.1 ppm for leave-on cosmetic products and 0.5 ppm for other cosmetic products. An Australian risk assessment suggested negligable health risks from acrylamide in cosmetics. The Cosmetic Ingredient Review (CIR) Expert Panel acknowledged that acrylamide is a demonstrated neurotoxin in humans and a carcinogen in animal tests, but that neurotoxic levels could not be attained by use of cosmetics. Although there are mechanisms of action of acrylamide that have been proposed for tumor types seen in rat studies that suggest they may be unique to the rat, the Panel was not convinced that these results could be disregarded as a species-specific finding with no relevance to human health and safety. Based on the genotoxicity and carcinogenicity data, the Panel does not believe that acrylamide is a genotoxic carcinogen in the usual manner and that several of the risk assessment approaches have overestimated the human cancer risk. The Panel did conclude, however, that it was appropriate to limit acrylamide levels to 5 ppm in cosmetic formulations.

Scenario: You are exhausted after a long day at work and collapse in front of the television for some mindless entertainment. One of your favourite comedy shows is on. You begin to relax. You laugh a couple of times. There's a commercial break. You watch the first ad for a hardware store, giving it only half your attention. And then there's another ad, something about a father and son in a car together and then ". WOOOMPH! A truck slams into the car. The message is "Speed kills!" Or there are people playing and sunbathing on a beach, happy holidays, and then vultures descend and surround them. The message is "Slip! Slop! Slap! Don't die in the sun this summer". Or someone is shown smoking a cigarette and the caption reads : "Give up now. You'll soon stop dying for a cigarette". This might be accompanied by scenes of a post-mortem, dissections of human lungs or brain. Context Threat appeals are used frequently in health and road safety promotion. Many use the threat of death as the consequence of undesirable behaviours, for example, "Quit smoking or you'll die' (Henley and Donovan). ("Non-death threats' appeal to other consequences such as "Quit smoking or your skin will age'.) There is an implicit notion of premature death threat, although this is rarely stated explicitly. When reminded of our risk of premature death, we are reminded by extension of the ultimate inevitability of our death. An understanding of the philosophy of existentialism can help us understand why consumers may, quite reasonably, tune out, or literally switch off health promotion messages that remind them of their own death. This paper explores the effect on consumers of these mass media invocations of the fear of death, or "death threats'. Verbatim comments are included from six focus groups conducted on fear and health promotion. Groups were delineated by age (16-20 years, 21-29 years and 30-49 years), gender, and socio-economic status (blue collar/white collar) (Henley). What is existential dread? Fear is one of the primary human emotions (along with anger, sadness, love, joy and surprise) and "dread' is one of the emotion names associated with fear (Shaver et al. 1067). We do not need to learn how to feel fear. We have to learn what to fear, however. Despite the joke about death and taxes, death is uniquely inevitable. (Some people do manage to avoid taxes!) In his definitive work, Denial of Death, Becker stated his belief that knowledge of our own death is the source of 'man's peculiar and greatest anxiety' (70); it's what makes us human. Existentialists think that knowing about the inevitability of our own death can be overwhelming, arousing the worst fear imaginable, "existential dread' (Bugental 287). Existential philosophers and psychologists believe that part of this anxiety stems from the existential dread of "not being'. Discussing Heidegger's analysis of the meaning of death in Being and Time, Barrett put it this way: The point is that I may die at any moment, and therefore death is my possibility now. It is like a precipice at my feet. It is also the most extreme and absolute of my possibilities: extreme, because it is the possibility of not being and hence cuts off all other possibilities; absolute, because man can surmount all other heartbreaks, even the deaths of those he loves, but his own death puts an end to him (201). The essence of existential philosophy is this idea that we are all deeply, terribly afraid of death. Fear of death can be seen even in very young children (Anthony, The child's; Anthony, The discovery; Nagy) who express considerable anxiety about death, but quickly learn from their parents and others how to deny it (Yalom). Existential psychologists have suggested that the fear of our own death is the cause of much of our psychopathology (Yalom). Existentialists believe that the most common response to existential anxiety is to deny it, creating in oneself a 'state of forgetfulness of being' as far as possible. Weisman described three levels of denial in terminally ill patients: "first-order denial' of the facts of illness; "second-order denial' of the implications of the illness; and "third-order denial' of death itself. He noted that often a patient moves from first and second order denial into "middle knowledge' (i.e., acceptance of near death), but then relapses. Weisman remarked that this relapse is often the signal that the terminal phase has begun. This aspect of denial is a complicated factor in the complex measurement of death anxiety. When people say they are not afraid of death, who can say whether they are denying fear or truly not afraid? In either case, health promotion appeals that threaten death may not be effective, either because the fear is denied or because there is no fear. In focus groups exploring people's concepts of death (Henley 111), few people acknowledged being afraid of their own death and many specifically stated that they were not afraid of their own death. One woman voiced the universal difficulty of truly conceiving what it might be like "not to be' (Kastenbaum and Aisenberg) when she said: 'death seems like such an unrealistic proposition'. People did acknowledge fears about death, such as dying painfully, so health promotion messages that threaten these other dimensions of death anxiety may be more effective. Health promotion practitioners frequently use these related death fears. The fear of causing death, for example, is used in road safety advertisements. However, this discussion on existential fear is limited to threat appeals of death per se. Death threats in health promotion Is arousing existential dread an effective way to market healthy behaviours? At first sight, it seems logical that the threat of death would be more persuasive than lesser threats and yet it may not be the most effective approach. There is some evidence that lesser threats may be more effective for some groups of adolescents and young adults for smoking (Donovan and Leivers), and for road safety behaviours (Donovan et al.). For example, for some 18 year old males, the threat of being caught drinking and driving, of losing their driving licence and, thus, their new-found independence may be a more effective deterrent than the threat of dying in a car accident (Donovan et al.). The humiliation of being arrested and charged for drink-driving may be the most powerful persuader for adults of all ages (Bevins). For men attending the Jerusalem Centre for Impotency and Fertility, impotence was reported a more persuasive threat than death: 78% of men who were told that smoking causes impotence quit smoking, compared to 40% who quit when told that smoking causes heart attacks ("No smoking tip"). One woman in a focus group said, 'you tend to think short-term, "can I afford a $100 fine?" rather than long-term, "this is my life." If I stop to think about it, obviously I'm more afraid of dying than $100 [fine], but that's not what I think about' (Henley 95). This makes sense in the context of forgetfulness, the denial of death. We don't want to be reminded of our death so we switch off the death message. Lesser threats may be more easily internalised. Does arousing existential dread do any harm? Perhaps. Job suggested that fear arousal is likely to be effective only for specific behaviours that successfully reduce the level of fear arousal and that high-fear messages may actually increase behaviours that people employ to reduce anxiety, such as smoking and alcohol consumption. People high in anxiety are hypothesised to be hypersensitive to threats and likely to employ a restricted range of self-soothing coping behaviours to reduce negative affect (Wickramasekera and Price). Death threat appeals such as "Quit smoking or you'll die' may arouse defensive, counter-productive responses, at least in some people, because it is impossible to identify any specific behaviour that could successfully reduce the particular, unique fear of death per se. Firestone identified a number of psychological defences against death anxiety, including self-nourishing and addictive habits, such as smoking and overeating. Ironically, these same behaviours are frequently the subject of health promotion campaigns. If such campaigns arouse death anxiety in an effort to curb defensive responses to death anxiety, there clearly could be an increase rather than a decrease in those defensive responses. Arousing death anxiety might contribute to fatalistic thinking. Job described some people's defenses against very high fear, for example, "...you've got to go sometime' or "...when your number's up, your number's up'. In focus groups, people commented, 'if an accident is going to happen, it's going to happen' and 'what's the point of giving up [unhealthy behaviours] if you get run over by a bus tomorrow?' (Henley 95, 108). Rippetoe and Rogers found that fatalistic thinking occurred when subjects did not believe that the recommended behaviour would avert the threat. That is, people may realise that quitting smoking could avert lung cancer and even some causes of premature death but that nothing can avert death itself. Fatalism may be one of the most maladaptive responses because the threat is acknowledged but rendered ineffective (Rippetoe and Rogers). Social marketers can make some of their persuasive communications more effective if they are more mindful of consumers' existential fears. A sensitivity to consumers' psychological defences against existential fear may result in more effective use of threat appeals in health promotion. Mindfulness Mindful that the title of this paper itself may arouse some existential dread, I end with a comment on the existentialist alternative to denial. Existentialists advocate a state of 'mindfulness of being' or 'ontological mode' (Heidegger, quoted in Yalom 31) in which "one remains mindful of being, not only mindful of the fragility of being but mindful, too ... of one's responsibility for one's own being." (Yalom 31). The existentialist strives to be as mindful, as present in the moment, and therefore as authentic as possible. This involves the acceptance of existential anxiety as an appropriate and reasonable response to the human condition (Bugental). Some focus group participants wanted to know in advance that they were going to die, 'so you can fit things in you'd want to do and say goodbye'. Others thought it was better not to know or 'you'd start having regrets'. One person pointed out that we do know in advance: 'you know you're going to die sometime!'. This last comment was followed by a sober, almost shocked silence suggesting that, even while we are freely discussing death on one level, the full meaning of death may still elude us. As consumers of health promotion messages, we are exposed to many reminders of our finite existence. If we sit mindlessly in front of the television receiving these messages, we may feel some unresolved discomfort. People talk about looking away, or switching channels when particularly shocking ads are shown. The existentialist alternative response would be to embrace these reminders and use them to sustain a state of mindfulness. With this state of mindfulness comes a heightened sense of responsibility for one's own being. It is in this ontological mode that we are most likely to adopt the healthy behaviours recommended in health promotion messages. By hearing the death threat openly, and acting to protect ourselves from at least those causes of premature death that may lie within our control, we may be able to discover a fuller experience of what it means to be alive. References Anthony, Sylvia. The Child's Discovery of Death. New York: Harcourt, Brace & World, 1940. Anthony, Sylvia. The Discovery of Death in Childhood and After. Harmondsworth, Middlesex: Penguin Education, 1973. Barrett, W. Irrational Man, A Study in Existential Philosophy. London: Heinemann, 1958. Becker, Ernest. The Denial of Death. New York: The Free Press, 1973. Bevins, John. "Using Advertising to Sell and Promote Health and Healthy Products". Paper presented at the ACHPER Health Products and Services Marketing Seminar. Kuring-gai College, Sydney, 1987. Bugental, J. F. T. The Search for Authenticity: An Existential-analytic Approach to Psychotherapy. New York: Holt, Rinehart and Winston, Inc., 1965. Donovan, Robert J., and Sue Leivers. Young Women and Smoking. Report to Commonwealth Department of Human Services and Health. Perth: Donovan Research, 1988. Donovan, Robert J., Nadine Henley, Geoffrey Jalleh, and Clive Slater. Road Safety Advertising: An Empirical Study and Literature Review. Canberra: Federal Office of Road Safety, 1995. Firestone, Robert W. "Psychological Defenses against Death Anxiety." Death Anxiety Handbook: Research, Instrumentation, and Application. Series in Death Education, Aging, and Health Care. Ed. Robert A. Neimeyer. Washington, DC: Taylor & Francis, 1994. 217-241. Henley, Nadine R. "Fear Arousal in Social Marketing: Death vs Non-death Threats." Doctoral Dissertation, University of Western Australia, Perth, 1997. Henley, Nadine and Robert J. Donovan. "Threat Appeals in Social Marketing: Death as a "Special Case'". International Journal of Nonprofit and Voluntary Sector Marketing, 4.4 (1999): 300-319. Job, R. F. Soames. "Effective and Ineffective Use of Fear in Health Promotion Campaigns." American Journal of Public Health, 78 (1988): 163-167. Kastenbaum, R., and R. Aisenberg. The Psychology of Death. London: Duckworth, 1974. Nagy, Maria H. "The Child's View of Death." The Meaning of Death. Ed. Herman Feifel. New York: McGraw-Hill Book Company, 1959. 79-98. "No Smoking Tip for Lovers". Daily Telegraph, (1994, September 24): p. 4. Rippetoe, P.A. and Rogers, R.W. "Effects of components of protection-motivation theory on adaptive and maladaptive coping with a health threat." Journal of Personality and Social Psychology, 52.3 (1987): 596-604. Shaver, P., J. Schwartz, D. Kirson, and C. O'Connor. "Emotion Knowledge: Further Exploration of a Prototype Approach." Journal of Personality and Social Psychology, 52.6 (1987): 1061-1086. Weisman, A.D. On dying and denying: A psychiatric study of terminality. New York: Behavioral Publications, 1972. Wickramasekera, Ian and Daniel C. Price. "Morbid Obesity, Absorption, Neuroticism, and the High Risk Model of Threat Perception." American Journal of Clinical Hypnosis, 39 (1997): 291-301. Yalom, I. D. Existential Psychotherapy. New York: Basic Books, 1980. Citation reference for this article MLA Style Henley, Nadine. "You will die! " M/C: A Journal of Media and Culture 5.1 (2002). [your date of access] < http://www.media-culture.org.au/0203/youwilldie.php>. Chicago Style Henley, Nadine, "You will die! " M/C: A Journal of Media and Culture 5, no. 1 (2002), < http://www.media-culture.org.au/0203/youwilldie.php> ([your date of access]). APA Style Henley, Nadine. (2002) You will die! . M/C: A Journal of Media and Culture 5(1). < http://www.media-culture.org.au/0203/youwilldie.php> ([your date of access]).

This article investigates the prosthesis of identity through the process of branding. It examines cross-cultural manifestations of this phenomena from sixth millennium BCE Syria to twelfth century Japan and Britain. From the Neolithic Era, humanity has sort to extend their identities using pictorial signs that were characteristically simple. Designed to be distinctive and instantly recognisable, the totemic symbols served to signal the origin of the bearer. Subsequently, the development of branding coincided with periods of increased in mobility both in respect to geography and social strata. This includes fifth millennium Mesopotamia, nineteenth century Britain, and America during the 1920s.There are fewer articles of greater influence on contemporary culture than A Theory of Human Motivation written by Abraham Maslow in 1943. Nearly seventy-five years later, his theories about the societal need for “belongingness” and “esteem” remain a mainstay of advertising campaigns (Maslow). Although the principles are used to sell a broad range of products from shampoo to breakfast cereal they are epitomised by apparel. This is with refence to garments and accessories bearing corporation logos. Whereas other purchased items, imbued with abstract products, are intended for personal consumption the public display of these symbols may be interpreted as a form of signalling. The intention of the wearers is to literally seek the fulfilment of the aforementioned social needs. This article investigates the use of brands as prosthesis.Coats and Crests: Identity Garnered on Garments in the Middle Ages and the Muromachi PeriodA logo, at its most basic, is a pictorial sign. In his essay, The Visual Language, Ernest Gombrich described the principle as reducing images to “distinctive features” (Gombrich 46). They represent a “simplification of code,” the meaning of which we are conditioned to recognise (Gombrich 46). Logos may also be interpreted as a manifestation of totemism. According to anthropologist Claude Levi-Strauss, the principle exists in all civilisations and reflects an effort to evoke the power of nature (71-127). Totemism is also a method of population distribution (Levi-Strauss 166).This principle, in a form garnered on garments, is manifested in Mon Kiri. The practice of cutting out family crests evolved into a form of corporate branding in Japan during the Meiji Period (1868-1912) (Christensen 14). During the Muromachi period (1336-1573) the crests provided an integral means of identification on the battlefield (Christensen 13). The adorning of crests on armour was also exercised in Europe during the twelfth century, when the faces of knights were similarly obscured by helmets (Family Crests of Japan 8). Both Mon Kiri and “Coat[s] of Arms” utilised totemic symbols (Family Crests of Japan 8; Elven 14; Christensen 13). The mon for the imperial family (figs. 1 & 2) during the Muromachi Period featured chrysanthemum and paulownia flowers (Goin’ Japaneque). “Coat[s] of Arms” in Britain featured a menagerie of animals including lions (fig. 3), horses and eagles (Elven).The prothesis of identity through garnering symbols on the battlefield provided “safety” through demonstrating “belongingness”. This constituted a conflation of two separate “needs” in the “hierarchy of prepotency” propositioned by Maslow. Fig. 1. The mon symbolising the Imperial Family during the Muromachi Period featured chrysanthemum and paulownia. "Kamon (Japanese Family Crests): Ancient Key to Samurai Culture." Goin' Japaneque! 15 Nov. 2015. 27 July 2019 <http://goinjapanesque.com/05983/>.Fig. 2. An example of the crest being utilised on a garment can be found in this portrait of samurai Oda Nobunaga. "Japan's 12 Most Famous Samurai." All About Japan. 27 Aug. 2018. 27 July 2019 <https://allabout-japan.com/en/article/5818/>.Fig. 3. A detail from the “Index of Subjects of Crests.” Elven, John Peter. The Book of Family Crests: Comprising Nearly Every Family Bearing, Properly Blazoned and Explained, Accompanied by Upwards of Four Thousand Engravings. Henry Washbourne, 1847.The Pursuit of Prestige: Prosthetic Pedigree from the Late Georgian to the Victorian Eras In 1817, the seal engraver to Prince Regent, Alexander Deuchar, described the function of family crests in British Crests: Containing The Crest and Mottos of The Families of Great Britain and Ireland; Together with Those of The Principal Cities and Heraldic Terms as follows: The first approach to civilization is the distinction of ranks. So necessary is this to the welfare and existence of society, that, without it, anarchy and confusion must prevail… In an early stage, heraldic emblems were characteristic of the bearer… Certain ordinances were made, regulating the mode of bearing arms, and who were entitled to bear them. (i-v)The partitioning of social classes in Britain had deteriorated by the time this compendium was published, with displays of “conspicuous consumption” displacing “heraldic emblems” as a primary method of status signalling (Deuchar 2; Han et al. 18). A consumerism born of newfound affluence, and the desire to signify this wealth through luxury goods, was as integral to the Industrial Revolution as technological development. In Rebels against the Future, published in 1996, Kirkpatrick Sale described the phenomenon:A substantial part of the new population, though still a distinct minority, was made modestly affluent, in some places quite wealthy, by privatization of of the countryside and the industrialization of the cities, and by the sorts of commercial and other services that this called forth. The new money stimulated the consumer demand… that allowed a market economy of a scope not known before. (40)This also reflected improvements in the provision of “health, food [and] education” (Maslow; Snow 25-28). With their “physiological needs” accommodated, this ”substantial part” of the population were able to prioritised their “esteem needs” including the pursuit for prestige (Sale 40; Maslow).In Britain during the Middle Ages laws “specified in minute detail” what each class was permitted to wear (Han et al. 15). A groom, for example, was not able to wear clothing that exceeded two marks in value (Han et al. 15). In a distinct departure during the Industrial Era, it was common for the “middling and lower classes” to “ape” the “fashionable vices of their superiors” (Sale 41). Although mon-like labels that were “simplified so as to be conspicuous and instantly recognisable” emerged in Europe during the nineteenth century their application on garments remained discrete up until the early twentieth century (Christensen 13-14; Moore and Reid 24). During the 1920s, the French companies Hermes and Coco Chanel were amongst the clothing manufacturers to pioneer this principle (Chaney; Icon).During the 1860s, Lincolnshire-born Charles Frederick Worth affixed gold stamped labels to the insides of his garments (Polan et al. 9; Press). Operating from Paris, the innovation was consistent with the introduction of trademark laws in France in 1857 (Lopes et al.). He would become known as the “Father of Haute Couture”, creating dresses for royalty and celebrities including Empress Eugene from Constantinople, French actress Sarah Bernhardt and Australian Opera Singer Nellie Melba (Lopes et al.; Krick). The clothing labels proved and ineffective deterrent to counterfeit, and by the 1890s the House of Worth implemented other measures to authenticate their products (Press). The legitimisation of the origin of a product is, arguably, the primary function of branding. This principle is also applicable to subjects. The prothesis of brands, as totemic symbols, assisted consumers to relocate themselves within a new system of population distribution (Levi-Strauss 166). It was one born of commerce as opposed to heraldry.Selling of Self: Conferring Identity from the Neolithic to Modern ErasIn his 1817 compendium on family crests, Deuchar elaborated on heraldry by writing:Ignoble birth was considered as a stain almost indelible… Illustrious parentage, on the other hand, constituted the very basis of honour: it communicated peculiar rights and privileges, to which the meaner born man might not aspire. (v-vi)The Twinings Logo (fig. 4) has remained unchanged since the design was commissioned by the grandson of the company founder Richard Twining in 1787 (Twining). In addition to reflecting the heritage of the family-owned company, the brand indicated the origin of the tea. This became pertinent during the nineteenth century. Plantations began to operate from Assam to Ceylon (Jones 267-269). Amidst the rampant diversification of tea sources in the Victorian era, concerns about the “unhygienic practices” of Chinese producers were proliferated (Wengrow 11). Subsequently, the brand also offered consumers assurance in quality. Fig. 4. The Twinings Logo reproduced from "History of Twinings." Twinings. 24 July 2019 <https://www.twinings.co.uk/about-twinings/history-of-twinings>.The term ‘brand’, adapted from the Norse “brandr”, was introduced into the English language during the sixteenth century (Starcevic 179). At its most literal, it translates as to “burn down” (Starcevic 179). Using hot elements to singe markings onto animals been recorded as early as 2700 BCE in Egypt (Starcevic 182). However, archaeologists concur that the modern principle of branding predates this practice. The implementation of carved seals or stamps to make indelible impressions of handcrafted objects dates back to Prehistoric Mesopotamia (Starcevic 183; Wengrow 13). Similar traditions developed during the Bronze Age in both China and the Indus Valley (Starcevic 185). In all three civilisations branding facilitated both commerce and aspects of Totemism. In the sixth millennium BCE in “Prehistoric” Mesopotamia, referred to as the Halaf period, stone seals were carved to emulate organic form such as animal teeth (Wengrow 13-14). They were used to safeguard objects by “confer[ring] part of the bearer’s personality” (Wengrow 14). They were concurrently applied to secure the contents of vessels containing “exotic goods” used in transactions (Wengrow 15). Worn as amulets (figs. 5 & 6) the seals, and the symbols they produced, were a physical extension of their owners (Wengrow 14).Fig. 5. Recreation of stamp seal amulets from Neolithic Mesopotamia during the sixth millennium BCE. Wengrow, David. "Prehistories of Commodity Branding." Current Anthropology 49.1 (2008): 14.Fig. 6. “Lot 25Y: Rare Syrian Steatite Amulet – Fertility God 5000 BCE.” The Salesroom. 27 July 2019 <https://www.the-saleroom.com/en-gb/auction-catalogues/artemis-gallery-ancient-art/catalogue-id-srartem10006/lot-a850d229-a303-4bae-b68c-a6130005c48a>. Fig. 7. Recreation of stamp seal designs from Mesopotamia from the late fifth to fourth millennium BCE. Wengrow, David. "Prehistories of Commodity Branding." Current Anthropology 49. 1 (2008): 16.In the following millennia, the seals would increase exponentially in application and aesthetic complexity (fig. 7) to support the development of household cum cottage industries (Wengrow 15). In addition to handcrafts, sealed vessels would transport consumables such as wine, aromatic oils and animal fats (Wengrow 18). The illustrations on the seals included depictions of rituals undertaken by human figures and/or allegories using animals. It can be ascertained that the transition in the Victorian Era from heraldry to commerce, from family to corporation, had precedence. By extension, consumers were able to participate in this process of value attribution using brands as signifiers. The principle remained prevalent during the modern and post-modern eras and can be respectively interpreted using structuralist and post-structuralist theory.Totemism to Simulacrum: The Evolution of Advertising from the Modern to Post-Modern Eras In 2011, Lisa Chaney wrote of the inception of the Coco Chanel logo (fig. 8) in her biography Chanel: An Intimate Life: A crucial element in the signature design of the Chanel No.5 bottle is the small black ‘C’ within a black circle set as the seal at the neck. On the top of the lid are two more ‘C’s, intertwined back to back… from at least 1924, the No5 bottles sported the unmistakable logo… these two ‘C’s referred to Gabrielle, – in other words Coco Chanel herself, and would become the logo for the House of Chanel. Chaney continued by describing Chanel’s fascination of totemic symbols as expressed through her use of tarot cards. She also “surrounded herself with objects ripe with meaning” such as representations of wheat and lions in reference prosperity and to her zodiac symbol ‘Leo’ respectively. Fig. 8. No5 Chanel Perfume, released in 1924, featured a seal-like logo attached to the bottle neck. “No5.” Chanel. 25 July 2019 <https://www.chanel.com/us/fragrance/p/120450/n5-parfum-grand-extrait/>.Fig. 9. This illustration of the bottle by Georges Goursat was published in a women’s magazine circa 1920s. “1921 Chanel No5.” Inside Chanel. 26 July 2019 <http://inside.chanel.com/en/timeline/1921_no5>; “La 4éme Fête de l’Histoire Samedi 16 et dimache 17 juin.” Ville de Perigueux. Musée d’art et d’archéologie du Périgord. 28 Mar. 2018. 26 July 2019 <https://www.perigueux-maap.fr/category/archives/page/5/>. This product was considered the “financial basis” of the Chanel “empire” which emerged during the second and third decades of the twentieth century (Tikkanen). Chanel is credited for revolutionising Haute Couture by introducing chic modern designs that emphasised “simplicity and comfort.” This was as opposed to the corseted highly embellished fashion that characterised the Victorian Era (Tikkanen). The lavish designs released by the House of Worth were, in and of themselves, “conspicuous” displays of “consumption” (Veblen 17). In contrast, the prestige and status associated with the “poor girl” look introduced by Chanel was invested in the story of the designer (Tikkanen). A primary example is her marinière or sailor’s blouse with a Breton stripe that epitomised her ascension from café singer to couturier (Tikkanen; Burstein 8). This signifier might have gone unobserved by less discerning consumers of fashion if it were not for branding. Not unlike the Prehistoric Mesopotamians, this iteration of branding is a process which “confer[s]” the “personality” of the designer into the garment (Wengrow 13 -14). The wearer of the garment is, in turn, is imbued by extension. Advertisers in the post-structuralist era embraced Levi-Strauss’s structuralist anthropological theories (Williamson 50). This is with particular reference to “bricolage” or the “preconditioning” of totemic symbols (Williamson 173; Pool 50). Subsequently, advertising creatives cum “bricoleur” employed his principles to imbue the brands with symbolic power. This symbolic capital was, arguably, transferable to the product and, ultimately, to its consumer (Williamson 173).Post-structuralist and semiotician Jean Baudrillard “exhaustively” critiqued brands and the advertising, or simulacrum, that embellished them between the late 1960s and early 1980s (Wengrow 10-11). In Simulacra and Simulation he wrote,it is the reflection of a profound reality; it masks and denatures a profound reality; it masks the absence of a profound reality; it has no relation to any reality whatsoever: it is its own pure simulacrum. (6)The symbolic power of the Chanel brand resonates in the ‘profound reality’ of her story. It is efficiently ‘denatured’ through becoming simplified, conspicuous and instantly recognisable. It is, as a logo, physically juxtaposed as simulacra onto apparel. This simulacrum, in turn, effects the ‘profound reality’ of the consumer. In 1899, economist Thorstein Veblen wrote in The Theory of the Leisure Class:Conspicuous consumption of valuable goods it the means of reputability to the gentleman of leisure… costly entertainments, such as potlatch or the ball, are peculiarly adapted to serve this end… he consumes vicariously for his host at the same time that he is witness to the consumption… he is also made to witness his host’s facility in etiquette. (47)Therefore, according to Veblen, it was the witnessing of “wasteful” consumption that “confers status” as opposed the primary conspicuous act (Han et al. 18). Despite television being in its experimental infancy advertising was at “the height of its powers” during the 1920s (Clark et al. 18; Hill 30). Post-World War I consumers, in America, experienced an unaccustomed level of prosperity and were unsuspecting of the motives of the newly formed advertising agencies (Clark et al. 18). Subsequently, the ‘witnessing’ of consumption could be constructed across a plethora of media from the newly emerged commercial radio to billboards (Hill viii–25). The resulting ‘status’ was ‘conferred’ onto brand logos. Women’s magazines, with a legacy dating back to 1828, were a primary locus (Hill 10).Belonging in a Post-Structuralist WorldIt is significant to note that, in a post-structuralist world, consumers do not exclusively seek upward mobility in their selection of brands. The establishment of counter-culture icon Levi-Strauss and Co. was concurrent to the emergence of both The House of Worth and Coco Chanel. The Bavarian-born Levi Strauss commenced selling apparel in San Francisco in 1853 (Levi’s). Two decades later, in partnership with Nevada born tailor Jacob Davis, he patented the “riveted-for-strength” workwear using blue denim (Levi’s). Although the ontology of ‘jeans’ is contested, references to “Jene Fustyan” date back the sixteenth century (Snyder 139). It involved the combining cotton, wool and linen to create “vestments” for Geonese sailors (Snyder 138). The Two Horse Logo (fig. 10), depicting them unable to pull apart a pair of jeans to symbolise strength, has been in continuous use by Levi Strauss & Co. company since its design in 1886 (Levi’s). Fig. 10. The Two Horse Logo by Levi Strauss & Co. has been in continuous use since 1886. Staff Unzipped. "Two Horses. One Message." Heritage. Levi Strauss & Co. 1 July 2011. 25 July 2019 <https://www.levistrauss.com/2011/07/01/two-horses-many-versions-one-message/>.The “rugged wear” would become the favoured apparel amongst miners at American Gold Rush (Muthu 6). Subsequently, between the 1930s – 1960s Hollywood films cultivated jeans as a symbol of “defiance” from Stage Coach staring John Wayne in 1939 to Rebel without A Cause staring James Dean in 1955 (Muthu 6; Edgar). Consequently, during the 1960s college students protesting in America (fig. 11) against the draft chose the attire to symbolise their solidarity with the working class (Hedarty). Notwithstanding a 1990s fashion revision of denim into a diversity of garments ranging from jackets to skirts, jeans have remained a wardrobe mainstay for the past half century (Hedarty; Muthu 10). Fig. 11. Although the brand label is not visible, jeans as initially introduced to the American Goldfields in the nineteenth century by Levi Strauss & Co. were cultivated as a symbol of defiance from the 1930s – 1960s. It documents an anti-war protest that occurred at the Pentagon in 1967. Cox, Savannah. "The Anti-Vietnam War Movement." ATI. 14 Dec. 2016. 16 July 2019 <https://allthatsinteresting.com/vietnam-war-protests#7>.In 2003, the journal Science published an article “Does Rejection Hurt? An Fmri Study of Social Exclusion” (Eisenberger et al.). The cross-institutional study demonstrated that the neurological reaction to rejection is indistinguishable to physical pain. Whereas during the 1940s Maslow classified the desire for “belonging” as secondary to “physiological needs,” early twenty-first century psychologists would suggest “[social] acceptance is a mechanism for survival” (Weir 50). In Simulacra and Simulation, Jean Baudrillard wrote: Today abstraction is no longer that of the map, the double, the mirror or the concept. Simulation is no longer that of a territory, a referential being or a substance. It is the generation by models of a real without origin or reality: a hyperreal… (1)In the intervening thirty-eight years since this document was published the artifice of our interactions has increased exponentially. In order to locate ‘belongness’ in this hyperreality, the identities of the seekers require a level of encoding. Brands, as signifiers, provide a vehicle.Whereas in Prehistoric Mesopotamia carved seals, worn as amulets, were used to extend the identity of a person, in post-digital China WeChat QR codes (fig. 12), stored in mobile phones, are used to facilitate transactions from exchanging contact details to commerce. Like other totems, they provide access to information such as locations, preferences, beliefs, marital status and financial circumstances. These individualised brands are the most recent incarnation of a technology that has developed over the past eight thousand years. The intermediary iteration, emblems affixed to garments, has remained prevalent since the twelfth century. Their continued salience is due to their visibility and, subsequent, accessibility as signifiers. Fig. 12. It may be posited that Wechat QR codes are a form individualised branding. Like other totems, they store information pertaining to the owner’s location, beliefs, preferences, marital status and financial circumstances. “Join Wechat groups using QR code on 2019.” Techwebsites. 26 July 2019 <https://techwebsites.net/join-wechat-group-qr-code/>.Fig. 13. Brands function effectively as signifiers is due to the international distribution of multinational corporations. This is the shopfront of Chanel in Dubai, which offers customers apparel bearing consistent insignia as the Parisian outlet at on Rue Cambon. Customers of Chanel can signify to each other with the confidence that their products will be recognised. “Chanel.” The Dubai Mall. 26 July 2019 <https://thedubaimall.com/en/shop/chanel>.Navigating a post-structuralist world of increasing mobility necessitates a rudimental understanding of these symbols. Whereas in the nineteenth century status was conveyed through consumption and witnessing consumption, from the twentieth century onwards the garnering of brands made this transaction immediate (Veblen 47; Han et al. 18). The bricolage of the brands is constructed by bricoleurs working in any number of contemporary creative fields such as advertising, filmmaking or song writing. They provide a system by which individuals can convey and recognise identities at prima facie. They enable the prosthesis of identity.ReferencesBaudrillard, Jean. Simulacra and Simulation. Trans. Sheila Faria Glaser. United States: University of Michigan Press, 1994.Burstein, Jessica. Cold Modernism: Literature, Fashion, Art. United States: Pennsylvania State University Press, 2012.Chaney, Lisa. Chanel: An Intimate Life. United Kingdom: Penguin Books Limited, 2011.Christensen, J.A. Cut-Art: An Introduction to Chung-Hua and Kiri-E. New York: Watson-Guptill Publications, 1989. Clark, Eddie M., Timothy C. 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