Lactococcus lactis strain producing TSLP (LL-TSLP) and investigated the effect of its administration on dextran sulfate sodium (DSS)-induced colitis model in mice.Thymic stromal lymphopoietin (TSLP) is a cytokine known to mature dendritics cells, lower pro-inflammatory IL-12 secretion, induce differentiation of anti-inflammatory FoxP3+ regulatory T cells (Treg). Moreover, Crohn’s disease patients have shown a reduction of intestinal TSLP expression. To understand the role of TSLP in inflammation, we constructed LL-TSLP secrete an active molecule which lowers secretion of IL-12 by dendritic cells. Treatment with LL-TSLP, increases the amount of TGF-β secreted by T cells in Mesenteric Lymph Node in healthy mice. In acute DSS-induced colitis, LL-TSLP delayed the Disease Activity Index and lowered histological score and colonic INF-γ production. In a DSS-recovery model, LL-TSLP induced a better protective effect if the strain was administered at the beginning of the colitis. At Day 4 of colitis we observed an induction of Treg by LL-TSLP.TSLP showed an anti-inflammatory protective role in DSS-induced colitis. We have demonstrated that a short and early administration of LL-TSLP is more efficient than a long lasting treatment. TSLP was first discovered in a thymic stromal cell line . It is mIBD which gathers Crohn’s disease (CD) and Ulcerative Colitis (UC) affects 1.4 million Americans and the prevalence rate is 396 per 100,000 individuals worldwide . IncidenOne of the ways explored to help in alleviating symptoms of the disease is the delivery of anti-inflammatory molecules by recombinant lactic acid bacteria (LAB). Recently, it has been shown that mice treated with LAB expressing the protease inhibitor Elafin were protected against gut inflammation . LAB havLactococcus lactis expressing TSLP (LL-TSLP) in order to study the effect of a local gut mucosal administration of TSLP on DSS-induced inflammation. LL-TSLP constructs demonstrated anti-inflammatory properties in vitro and protected mice from DSS-induced colitis after oral administration as shown by reduced weight loss, lower disease activity and microscopic score. Moreover mice were protected even if they were fed with LL-TSLP only during the four first days of the colitis. Additionally we showed that part of this protective effect was due to a higher recruitment of Treg.In this study we decided to construct L. lactis secreting TSLP (LL-TSLP). To this end, we cloned the tslp gene in the plasmid pLB333 carrying the SICE system, composed of the promoter of the stress-induced GroESL operon, the signal peptide of the well secreted L. lactis Exp4 protein and a terminator  of healthy animals received LL-WT, or LL-TSLP by oral route. Weight and DAI were daily monitored and scored. We did not observe differences in these scores, showing no changes in the physiology of mice (data not shown). After 14 days of treatment, mesenteric lymph nodes (MLN) were removed and cells were activated with anti-CD3 and anti-CD-28 antibodies. We detected a significantly (P < 0.05) higher secretion of TGF-β when mice received LL-TSLP compare to mice orally dosed with LL-WT  gene was deleted. Taylor et al. demonstrated that TSLPR−/− mice were more sensitive to DSS-induced colitis compared to the WT animals . TSLPR−/L. lactis strain producing TSLP, LL-TSLP. After 2 weeks of LL-TSLP oral administration in healthy mice we observed an increase of TGF-β production by anti-CD3/anti-CD28 stimulated cells from mesenteric lymph nodes. In an acute DSS-induced inflammation model, we showed that after 7 days of DSS, the DAI of mice treated with LL-TSLP tends to be lower during the 7 days of inflammation, despite absence of changes in weight loss. We observed a significant reduction of this score at D4, demonstrating the capacity of LL-TSLP to delay clinical signs at the beginning of colitis, especially feces softening and bleeding. Furthermore we showed that colonic tissue integrity measured by histological scores is less compromised within TSLP treated mice. Oral administration of LL-TSLP reduced the secretion of the pro-inflammatory cytokine, IFN-γ, showing that LAB-secreted TSLP protects the intestinal epithelium from damages induced by chemical treatment and modulates inflammation.In order to further understand the potential protective effect of TSLP on inflammation, we have developed a strategy for TSLP delivery to the gut mucosal level by oral administration of LAB producing soluble functional TSLP. LAB have been used since many years now as vector for protein or DNA delivery at the mucosal level . We consTo assess the effect of LL-TSLP during the recovery phase, we performed an acute colitis model followed by 5 days of remission. TSLP was delivered by LL-TSLP all along the experiment (inflammation + recovery phase). We did not show any differences in weight loss and histological scores after 5 days of water but we confirmed the decrease of DAI in the early phase of inflammation. The recovery phase is a complex process and addition of TSLP seems not to be sufficient to accelerate the decrease of markers of inflammation or intestinal epithelium repair.Next, we hypothesized that early treatment with LL-TSLP could be sufficient to decrease inflammation markers. A group of mice received LL-TSLP during 7 days before and 4 days after the induction of colitis followed by LL-WT until the end of the experiment. TSLP delivery in the lumen at early phase, until D4, diminished the weight loss and significantly increased the weight gain at D8, D9, D11 and D12 compare to the LL-WT. Moreover it delayed and decreased the DAI (significantly at D5 and D6) and reduced the histological score. Therefore we conclude that, short and early TSLP treatment allowed a better protection against colitis than a longer treatment as demonstrated by a lower severity as well as a delay in the disease.To decipher by which mechanisms addition of TSLP leads to the colon protection in the early phase of the inflammation, we sacrificed the mice at D4. At this time we observed a higher percentage of CD4+CD25+Foxp3+ cells in mice treated with LL-TSLP, suggesting a role of Treg cells in the delay of the outbreak of the disease. In human, TSLP-matured DC are able to induce the expansion and the differentiation of CD4+CD25+Foxp3+ cells , 15. HowWe hypothesized that addition of TSLP to the lumen allows an enhancement of gut homeostasis by a rise of the number of Treg cells which leads to a delay of the disease. Release of TSLP could act directly as described by Spadoni et al. on Treg differentiation or indirectly. Indeed, TSLP is able to reinforce tight-junctions of lung epithelial cells by increasing several claudins and the occludin . In thisFinally, TSLP expression is reduced in colonic tissue of Crohn’s disease patients  and can Thymic stromal lymphopoietin showed an anti-inflammatory protective role in DSS-induced colitis. We have demonstrated that a short and early administration of LL-TSLP is more efficient than a long lasting treatment. We hypothesized that TSLP induced TGF-β secretion which thus will increase the Treg population.Lactococcus lactis MG1363 containing pNis-empty plasmid (LL-WT) and L. lactis MG1363 containing pGroESL-TSLP plasmid (LL-TSLP) were grown in M17 medium (Difco) supplemented with 1 % glucose and chloramphenicol (10 µg/mL) at 30 °C without agitation. pSEC plasmid and pGroESL are both derivative of the broad-host range plasmid pWV01 [id pWV01 .tslp gene was synthesized by Geneart (Invitrogen). After digestion by BamHI/SpeI, the fragment containing the gene of interest was integrated into a BamHI/SpeI digested pGroESL plasmid  from SICE system [L. lactis MG1363 at 2.4 kV, 200 Ω, 25 µF. Transformants were selected at 30 °C on M17 agar containing 1 % glucose and chloramphenicol (10 µg/mL). pGroESL-TSLP plasmids were extracted from recombinant transformants and verified by sequencing.Plasmid containing a murine E system . ConstruL. lactis strain was diluted in growth medium to a 0.1 OD600nm and incubate at 30 °C without agitation until a 0.4–0.6 OD600nm. Then different stresses were added as following: To induce a salt stress, different volumes of NaCl 5M solution were added into culture to obtain 1, 5 and 3 % NaCl final concentration and incubate at 30 °C without agitation. To provoke a heat-shock, bacterial cultures were centrifuged at room temperature at 4700 rpm during 15 min. Pellets were resuspended with pre-warmed culture medium at 30, 37 and 40 °C and incubate at these different temperatures without agitation. Four hours after stress, 1 mL of bacterial cultures was harvested and centrifuged at 4 °C at 10,000 rpm during 10 min. The 2 µm filtered supernatants were conserved at −20 °C for cytokine quantification by ELISA (R&D systems).Overnight cultures of TSLP-secreting 2-humidified incubator. Fifteen mL of medium were added at day 3 and completely changed at day 5; cells were harvest at day 7. BMDCs were then plated at 5 × 105 cells/well (96 wells/plate) and cultured in RPMI 1640 supplemented with 10 % decomplemented FBS and penicillin/streptomycin at 37 °C in a 10 % CO2-humidified incubator.Bone marrow cells from BALB/c mice were harvested aseptically and plated into a petri dish in RPMI 1640 (Life Technologies) supplemented with 10 % decomplemented fetal bovine serum (FBS), penicillin/streptomycin, β-mercaptoethanol 5 mM and 20 ng/mL GMCSF (peprotech) and cultured at 37 °C in a 10 % COL. lactis harboring a plasmid encoding for a non-relevant protein, the nuclease Nuc) was used and equivalent protein amount corresponding to concentrations used with concentrated TSLP was added. Twenty-four hours after stimulation, cells supernatants were harvested for IL-12 quantification by ELISA (mabTech).BMDCs were stimulated in presence (5 ng/mL) or absence of LPS and with recombinant TSLP (Biolegend or from LL-TSLP concentrated supernatants) at 10 ng/mL. A negative control of the culture medium (filtered supernatant of 9 ~ 5 × 109 Colony Forming Units of LL-WT or LL-TSLP. At D0 colitis was induced by adding 2.5 % (w/v) of Dextran Sulfate Sodium Salt (DSS) at a molecular weight of 36,000–50,000 (MPBio) to the drinking water for 4 days (DSS short) or 7 days (DSS acute and DSS recovery). The mice were sacrificed either at D4 (DSS short), D7 (DSS acute) or D12 (DSS recovery) after the DSS induction. For DSS recovery, DSS colitis induction was followed by 5 days of recovery with normal drinking water. As a control DSS mice have been fed during 12 days without DSS induction.After acclimatization during at least 7 days, 6 weeks old C57BL/6 mice were fed daily during the whole experiment with PBS or with 10Mice were monitored daily for weight loss, stool consistency, and fecal occult blood . Disease Activity Index (DAI) has been calculated according to the protocol established by Cooper et al. .Mice have been sacrificed by cervical dislocation and mesenteric lymphatic node (MLN) as well as colon have been harvested for colon washes, protein extraction and histological assessment.The colon was removed and washed with 1 mL of PBS supplemented with anti-protease to obtain the colon wash.g. Supernatant was stored at −20 °C before further analysis.Then the colon was opened and 1 cm was removed. The slice was grinded in 1 mL of PBS supplemented with anti-protease using a GentleMacs (Miltenyi) then centrifuged 2 min at 50006 cells/mL. Cell solutions were added to 24 well plates (Costar) pre-incubated 4 h with anti-CD3 and anti-CD28 antibodies, 4 µg/mL of each antibody (eBioscience) in PBS with 0.5 % FCS. Plates were incubated 48 h at 37 °C 5 % of CO2 and cytokine levels were assessed in supernatant.MLN isolated from mice were mashed and filtered . Lymphocytes in filtrate were count by flow cytometry (Accuri C6) and resuspended in culture medium  with 100 Unit of Streptomicin Penicilin, PAA Laboratories and 10 % Fetal Calf Serum (FCS) (Lonza) at 25 × 10Total amount of proteins from the different samples was determined using Bradford assay (Sigma-Aldrich) and the cytokine concentration  by ELISA (Mabtech). The concentration of each cytokine is normalized on the total proteins amount of each samples.For histological assessment, a colon sample was fixed in 4 % paraformaldehyde acid (sigma) and embedded in paraffin. Four micrometer sections were stained with hematoxylin/eosin and examined blindly .6 cells have been taken from mashed MLN filtrates. Treg cells have been stained for CD4, CD32 and FoxP3 using a mouse regulatory T cell Staining Kit 1 (eBioscience). Cell samples have been run through flow cytometry (BD Accuri) and double positive cells for CD32 and FoxP3 among CD4 positive cells have been counted.10®. Results represent mean ± SEM. Statistical significance was determined by the Mann–Withney test for charts and by 2-way Anova with Bonferroni post-test for curves *P < 0.05, **P < 0.01, **P < 0.001.All statistics and graphics have been performed on Prism-GraphPadAll animal assays were performed following the European Guidelines for the Care and Use of Laboratory Animals. Authorization number: 02550.01.


Pichia pastoris is a methylotrophic species of yeast, which means that it can grow on methanol as its sole carbon and energy source [Pichia expression system has several advantages: short length of the oligosaccharide chains added to proteins, correct folding and very high cell densities [P. pastoris vectors are designed for homologous integration into either AOX I locus, one of the two homologous AOX I genes present in this species or his4 locus. Gene insertion events at the AOX I (GS115) loci arise from a single crossover events between the loci and any of the three AOX I regions in the vector, the AOX I promoter, the AOX I transcription termination region (TT), or sequences even further downstream of AOX I (3′ AOX I) [y source . The Picensities . P. pastof AOX I ′ AOX I [of AOX I ′ AOX I [P pastoris GS115 (phenotype His+/Muts) with pPG Vector (pPIC9/ glucoamylase cDNA of Aspegillus awamori) integrad in the AOX locus were transformad with pPAmy vector (pPIC9 vector/α-amylase gene of Bacillus licheniformis), both previouly contructed in our laboratory. The pPAmy was linearizad by digesting with SacI enzyme to HIS4 locus integration. Transformation was carried out by electroporation of freshly prepared competent cells. The electroporated cells were recoved in 1 M sorbitol and spread onto MM agar plates containg starch 1 % (p/v) to identify positive clones. Transformants with larger halos and clear were considered as positive recombinant strains expressing tow enzymes in comparition the control strain (Strain previously constructed). Positive strains were then inoculated in 50 ml BMGY at 28 C for 48 h in shaking flasks. The cells were harvested by centrifugation and then grown in 25-ml BMMY with methanol induction  at 28 C for 120 h. The supernatants were collected by centrifugation and subjected to enzyme activity assay by Fuwa and DNS methods. Extracellular culture supernatant samples were used to proteins detection by SDS-PAGE 10%.Recombinants clones A total of 744 transformants were screened on MM plates. Eight positive transformants with the highest halos amylase activities were analyzed by SDS-PAGE. The gel electrophoresis revealed expression two protein. One protein band with molecular weight of 116 kDa and another with 58 kDa, correponding to glucoamylase and α-amylase respectively. When we compared the protein pattern of secreted enzymes is agree with protein pattern observed in control supernadant, previously studed in our laboratory. However, in preliminary analyse, none enzymatic activety was detectad in enzymatc assay by Fuwa and DNS methods. However, new transformations and integrations strategies has been performing by study group.


The unfolded protein response (UPR) is an ancient stress response that enables a cell to manage the energetic stress that accompanies protein folding. There has been a significant recent increase in our understanding of the UPR, how it integrates physiological processes within cells, and how this integration can affect cancer cells and cell fate decisions. Recent publications have highlighted the role of UPR signaling components on mediating various cell survival pathways, cellular metabolism and bioenergenics, and autophagy. We address the role of UPR on mediating endocrine therapy resistance and estrogen receptor-positive breast cancer cell survival. HSPA5; GRP78), activates the UPR as a consequence of its release from the three UPR signaling controllers, PKR-like endoplasmic reticulum kinase , activating transcription factor 6 (ATF6), and inositol-requiring enzyme 1 . Under most normal conditions, PERK, ATF6, and IRE1 are held inactive in the endoplasmic reticulum membrane when bound to GRP78. Activated PERK phosphorylates eIF2α, resulting in the inhibition of cap-dependent protein translation and the induction of activating transcription factor 4 (ATF4) transcription. Increased ATF4 levels stimulate the activity of the pro-apoptotic DNA-damage inducible transcription factor 3 . When released from GRP78, ATF6 translocates to the Golgi complex where it is cleaved by site1/site2 proteases to form a highly active transcription factor. ATF6 induces the transcription of various other protein chaperones, including GRP78. Release of IRE1 from GRP78 enables IRE1 to oligermize and autophosphorylate. This activation of IRE1 enables its unconventional cytoplasmic splicing of X-box binding protein 1 (XBP1); the endonuclease activity of IRE1 removes a 26-base pair intron in XBP1 to produce its transcriptionally active form  is an endoplasmic reticulum stress pathway, activated when unfolded or misfolded proteins accumulate within the endoplasmic reticulum lumen. Inappropriately folded proteins can amass when large amounts of proteins are being synthesized and/or when cellular energy availability is not sufficient to correctly fold the proteins being trafficked into the endoplasmic reticulum , 2. A siESR1; ERα). These cancers are often treated with ERα targeted therapies, such as receptor antagonists (antiestrogens) including tamoxifen (TAM) or fulvestrant (ICI), or aromatase inhibitors like anastrozole or letrozole that inhibit ligand (17β-estradiol) production. About half of all ERα positive tumors respond to one of these first-line endocrine therapies, while the remainder is de novo resistant  amplified, and triple negative] when compared with the normal surrounding breast tissue, indicating a critical role for GRP78 in driving breast tumorigenesis /BCL2, and (iii) IP3R/Ca2+. In Module-1, activated mammalian target of rapamycin (MTOR) can inhibit Unc-51 like autophagy activating kinase 1 (ULK1). ULK1 forms a complex with autophagy related gene 13 (ATG13) and RB1-inducible coil-coil 1  that initiates autophagosome formation (CaMKK2), promoting the ability of AMP-activated protein kinase  to inhibit the autophagic repression regulated by mTOR signaling. Concurrently, calcium release activates death associated protein kinase (DAPK) to activate BECN1. Also, calcium stimulates protein kinase C-θ  to promote the lipidation of microtubule associated protein 1 light chain 3  promoting autophagic activation (Autophagy is a cellular pathway of “self-eating” . Our groormation . In Moduormation . In the tivation . Therefoin vivo restored tamoxifen sensitivity to resistant tumors (PINK1) silencing restored antiestrogen sensitivity to resistant breast cancer cell lines  protein levels, a protein critical for the induction of mitophagy  c-Jun terminal kinase (JNK) stimulation , 41. WhiTSC2) or AMPK silencing, demonstrating that GRP78 modulates AMPK signaling to effect autophagosome formation  or the ligand (aromatase inhibitors) have been successful at treating this disease. Unfortunately, many of these tumors acquired resistance and recur as endocrine insensitive breast cancers. Therefore, understanding the ER signaling network and the permutations that derive from the antiestrogen resistance phenotype is critical to make progress in the treatment of advanced breast cancers. Many growth factor signaling pathways are implicated in the development of resistance including MAPK, phosphoinositol 3-kinase (PI3K), epidermal growth factor (EGF), and insulin-like growth factor (IGF) 1 receptor signaling . Also, vWhile estrogens primarily acting through ERα stimulate breast cancer cell survival and growth, ERα-targeted therapies such as tamoxifen or fulvestrant (ICI) stimulate pro-survival UPR and autophagy signaling . We prev2 to DAG conversion releasing cytoplasmic 1,4,5-triphosphate (IP3) through PLC-γ activation. IP3 stimulates the release of calcium from the endoplasmic reticulum and promotes UPR signaling and cellular proliferation , was recently shown to effect UPR signaling. ER-β inhibits the growth of breast cancer cells directly opposing the proliferative actions of ERα , GRP170 (HYOU1), GRP75 , and GRP58 (PDIA3)  . As with (PDIA3) , GRP58 i (PDIA3) . FurtherWe previously showed the novel regulation of GRP78 on regulating AMPK and mTOR signaling to control autophagy in breast cancer cells , 62. OthERα targeting therapies, such as tamoxifen and fulvestrant, stimulate UPR signaling resulting in breast cancer cell survival . AdditioThe predominant focus of many studies is on the molecular signaling in tumor epithelial cells. However, breast tumors contain many different cell types including endothelial cells, fibroblastic cells, macrophages, and T-cells that integrate to form a complex bio-infrastructure that generally supports neoplastic epithelial cell growth . UnderstSNAI1; snail). Snail binds to and inhibits e-cadherin, thereby promoting EMT. Inhibition of XBP1 inhibited snail, while concurrently increasing e-cadherin expression (Increased extracellular matrix (ECM) collagen deposition was associated with breast tumor progression and chemotherapy resistance , 84. Stupression . Overexppression . These dThe unfolded protein response signaling integrates many different cellular processes, including protein folding, rates of transcription and translation, protein degradation, autophagy, metabolism, and cell fate pathways. Breast cancer tumors have elevated UPR signaling components, including GRP78 and XBP1, which drive endocrine therapy resistance. Treatment of breast cancer cell lines and tumors with ERα targeting therapies results in the activation of pro-survival UPR signaling, suggesting an intrinsic resistance mechanism. Designing drugs, which may target pro-survival UPR components , while activating pro-apoptotic UPR signaling (CHOP) would be highly beneficial for the treatment of these cancers. Estrogen and ERα both serve as a central regulator of autophagy and UPR modulating these signaling pathways through different molecular mechanisms. Antiestrogen therapies result in the accumulation of dysfunctional ERα in the cytosol, leading to UPR activation, while endocrine therapies direct inhibition of ERα activity promotes autophagosome formation. Both the stimulation of autophagy and UPR by antiestrogens promote survival and resistance. Recently, some studies are investigating the role of UPR signaling in the tumor microenvironment. Of particular interest is the critical role of UPR signaling in immunity, highlighting the importance of syngeneic models in developing UPR-targeting therapeutic strategies. While targeting UPR may be beneficial to inhibit tumor epithelial cells, the effect on innate and adaptive immunity is less clear. Further studies are needed to clarify the role of UPR in T-cell signaling and macrophage cytolytic capacity. Other studies showed UPR signaling promotes changes within the tumor microenvironment that favors migration, metastasis, and invasiveness, clearly demonstrating why targeting UPR would be an effective therapeutic option for the treatment of breast cancer.RC and KC both wrote and edited the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


We examined the overall contributions of the poor and non-poor in fertility decline across the Asian countries. Further, we analyzed the direct and indirect factors that determine the reproductive behaviour of two distinct population sub-groups.Data from several new rounds of DHS surveys are available over the past few years. The DHS provides cross-nationally comparable and useful data on fertility, family planning, maternal and child health along with the other information. Six selected Asian countries namely: Bangladesh, India, Indonesia, Nepal, Philippines, and Vietnam are considered for the purpose of the study. Three rounds of DHS surveys for each country (except Vietnam) are considered in the present study.Economic status is measured by computing a “wealth index”, i.e. a composite indicator constructed by aggregating data on asset ownership and housing characteristics using principal components analysis (PCA). Computed household wealth index has been broken into three equal parts (33.3 percent each) and the lowest and the highest 33.3 percent is considered as poor and non-poor respectively. The Bongaarts model was employed to quantify the contribution of each of the proximate determinants of fertility among poor and non-poor women.Fertility reduction across all population subgroups is now an established fact despite the diversity in the level of socio-economic development in Asian countries. It is clear from the analysis that fertility has declined irrespective of economic status at varying degrees within and across the countries which can be attributed to the increasing level of contraceptive use especially among poor women. Over the period of time changing marriage pattern and induced abortion are playing an important role in reducing fertility among poor women.Fertility decline among majority of the poor women across the Asian countries is accompanied by high prevalence of contraceptive use followed by changing marriage pattern and induced abortion. Fertility decline is strongly associated with socio-economic development since changed or improved socio-economic conditions motivate individuals, couples and families to reduce fertility , 3, 4, 5Contrary to common wisdom, the worldwide fertility decline which occurred over the past forty years in developing countries was anticipated by demographers and population forecasters. What was not really anticipated was its magnitude. Since the transition from high to low fertility is now virtually universal, it is clear that its onset does not depend on the level of development and that the path it will follow is not necessarily determined by socio-economic factors such as levels of education, female employment, or urbanization , 1, 7. TA number of experiences confirm that the initial fertility reduction was instigated by educated and socio-economically affluent group of women , 9, 10. During the two decades, Asian fertility declined dramatically . Almost The recent decline in fertility in developing countries created interest among researchers, policy makers and academicians. This is because such a dramatic change in fertility has occurred without a substantial improvement in socio-economic status, health conditions and outlier factors thought to be needed to bring about a fertility decline. Some argue that the decline in the fertility level was achieved mainly because of a successful family planning programme . PopulatMarriage, the legal and cultural institution that sanctions childbearing, is one of the most important determinants of fertility. Age at first marriage has a major effect on childbearing because women who marry early have, on average, a longer period of exposure to the risk of becoming pregnant and a greater number of lifetime births. It is widely acknowledged that age at marriage has a significant influence on fertility, particularly in countries where childbearing occurs within marriage. Therefore, in societies where child bearing prior to marriage is not socially acceptable, postponement of marriage contributes significantly towards a reduction in the level of fertility by shortening the total reproductive span of women. This in turn reduces the number of children a woman is likely to have and has a negative impact on the population growth rate of a country. Age pattern of marriage was discovered as an important factor for reducing marital fertility rate due to late marriage and a higher proportion of celibacy in developed countries , 22, 9. A review of the recent literature provided evidence that, despite the changing pattern towards later marriage, Asian countries display considerable variations in marriage patterns. Interestingly, one pattern is shared in all Asian countries: 95 per cent or more of women ultimately marry . Social An increasing trend in age at first marriage was found in Vietnam . The incMarriage change has played a considerable role in the recent fertility declines in a number of Asian countries . Both deUnlike in Western countries where marriage is not a pre-condition for child bearing, in most Asian countries child bearing prior to marriage is not socially acceptable and is therefore extremely uncommon. Postponement of marriage therefore contributes significantly towards a reduction in the level of fertility by shortening the total reproductive span of women, which in turn reduces the number of children a woman is likely to have and hence reduces the population growth rate of a country. The age at marriage indeed has a significant effect on the fertility of women—an increase in the age at marriage significantly reduces total fertility of women. Further, the higher the education level of the woman the stronger is the effect of education on the age at marriage and total fertility. So women’s education not only has a direct effect in fertility reduction, it also has an indirect effect through the effect on the age at marriage .The examination of the estimated age at completion of childbearing and the average length of the childbearing span by age at marriage showed that women who married younger had a longer childbearing span, which allowed them to produce more children, than their counterparts who married older. This increase of fertility with increased exposure time is consistent with natural fertility .Large fertility decline in the developing world occurred due to a major change in reproductive behaviour of couples in the childbearing ages . More spIn less developed countries there was a wide gap in contraceptive prevalence rate between the highest and lowest wealth quintiles . This gaThe primary reason for the growth in contraceptive prevalence from the 1970s to the late 1980s and 1990s in Latin America, Asia and Africa was that couples who in the earlier period wished to avoid pregnancy but were not using contraceptives were far more likely to be doing so in the more recent period, presumably because of the weakening of obstacles to use that previously prevented them from implementing their fertility preferences .It was argued that significant decrease in fertility was due to social and economic development, and had nothing to do with promotion of family planning. However, Taiwan’s experience shows that, although social and economic development contributed to the decline of fertility after the Second World War, the promotion of a family planning program expedited the process. Moreover, the universal provision of effective and low-cost contraceptives to eligible couples helped the contraceptive practice rate to rise very quickly. These actions enabled couples to control their fertility to the declining level of ideal number of children . AnotherContraceptive knowledge significantly reduces fertility. Besides, mass media exposure and social networks play important roles in obtaining knowledge of modern contraceptive techniques. Women, who regularly watch TV, listen to the radio, or read newspapers and magazines are more likely to be exposed to contraceptive-related information and hence have more knowledge of contraceptives. Similarly, women who participate in women’s organizations are more likely to obtain contraceptive information through word-of-mouth communication .Ross and Stover (2001) concluded that countries with high social and economic development had high contraceptive prevalence . StudiesWhile women’s education continues to be strongly associated with lower fertility in India, an important feature of India’s current fertility transition is the spread of contraceptive use among uneducated women. Indeed, changes in their fertility are now making the major contribution to the country’s overall fertility decline. The analysis by McNay (2003) suggested that, while many of the expected socio-economic variables play their part, there are also considerable diffusion effects in progress, many of which operate at levels beyond the uneducated women’s own individual circumstances . AnotherAnother study in Indian context found that women who have received family planning messages from health care workers are more likely to use contraceptives as compared to other women. Most of the increase in propensity has been explained by the increase in use rate among women of urban areas and rural women who had access to health facilities. Education continues to have a significant positive influence on contraceptive use however; the differential by educational groups has become much smaller. This change reflects an increase in use rate among women with no education. Therefore, the change in the fertility level of uneducated women is the major factor, which, contributed to a decline in the overall fertility level .Choice of contraceptive depends a lot on the socio-economic and cultural set up of the country. Experience showed that as the contraceptive prevalence increased and people started opting for small family size, use of sterilization increased. The only exception is India where sterilization has dominated the scene right from the beginning, may be more because of programme effort than people choice .Induced abortion has long been recognized as one of the principal determinants of fertility levels and is thought to be practiced throughout the world, regardless of its legal status . HoweverEven in the countries with high rates of legal induced abortion, contraceptive use and marital patterns nearly always had a greater impact on fertility levels than abortion. As a rule, extremely high rates of abortion—three or more abortions per woman of childbearing age during the reproductive years—are required for the fertility-inhibiting effect of abortion to rival that of contraceptive use. Nevertheless, the absolute effect of abortion on fertility is often substantial .An analysis of Demographic and Health Survey data provided indirect estimates of the prevalence of abortion in 21 developing countries by rearranging Bongaarts’s proximate determinants model to allow calculation of the index of abortion from other principal proximate determinants of fertility , average total fecundity and total fertility. On average, abortion appears to have an influence on fertility similar to that of contraceptive use .The prevalence of abortion was high in Vietnam and it was more common among married women aged 20 or older, those with more years of schooling and those with one or two children, as well as among women from the Kinh majority group and the more socio-economically privileged ethnic minorities. It was also found that the abortion rate was higher among women who used a traditional method than among those who used a modern method . VietnamUnsafe abortion is a leading cause of reproductive morbidity and mortality in countries where abortion is illegal or severely restricted. Although Guatemalan law permits induced abortion only to save a woman’s life, many women obtained abortions, often under unsafe conditions and in response to an unintended pregnancy . AnotherThe legal status and the availability of induced abortion are highly variable in Asia . Rising A woman’s exposure to the risk of pregnancy is influenced by postpartum factors: postpartum amenorrhea, which is largely determined by the duration and intensity of breastfeeding and postpartum abstinence, are the two determinants of the duration of postpartum insusceptibility to becoming pregnant. A conception may not always result in a live birth. The outcome of a pregnancy may end in a spontaneous abortion, in an induced abortion, or in a still birth. Postpartum amenorrhea is a biological variable associated with each conception regardless of its outcome . It depeAverage birth interval may increase due to longer duration of breastfeeding which in turn reduce fertility particularly in societies where contraceptive use is limited , 65, 66.The primary sources of data for this study are the latest available Demographic and Health Surveys (DHS) for six Asian countries. DHS evolved from World Fertility Surveys and Contraceptive Prevalence Surveys implemented in the 1970s and 1980s . SimilarSix Asian countries namely Bangladesh, India, Indonesia, Nepal, Philippines, and Vietnam have been selected for the study purpose. These countries are chosen because their fertility transition has occurred at relatively low socio economic levels, and they are in different stages of fertility transition. Three rounds of DHS surveys for each country (two rounds in Vietnam) are considered for purpose of analysis . All DHSDifferent statistical analyses are used to fulfil the particular objectives considered for the study and the detailed description of the same are as following:DHS does not collect information on income or expenditure, however, it does include at least 25–30 (and often many more) questions about household characteristics and possessions: materials used for house floors, walls, and roofs; source of water like a stream, open well, or piped system; and presence of durable possessions like a fan, radio, radio receiver, watch, bicycle, or automobile; and other attributes related to economic status . From thFor the study, economic status is measured by computing a ‘wealth index’ using principal component analysis (PCA). Computed wealth index has been standardized by taking the same asset indicators for each of the three time periods. For example, while computing the wealth index for ‘First period’, those variables have been included which are available for all the study countries. Likewise the wealth index for ‘Middle’ and ‘Recent period’ has been constructed. Number of assets under consideration varies across the three time periods but not across the countries. It is observed that over the period of time inclusion of the asset indicators has been increased in DHS surveys which are representative of the economic status of households for that particular time period. So, it is quite obvious that number of assets included in ‘First period’ (11 common assets) are lesser than the ‘Middle period’ (21 common assets) as well as ‘Recent period’ (28 common assets). For enough sample size the computed household wealth index are classified into three equal parts (33.3 percent each). The lowest 33.3 percent is considered as ‘poor’ and the upper 33.3 percent is considered as ‘non-poor’.The fertility data were collected by asking all women of reproductive age (15–49 years) to provide complete birth histories of all children they had given birth to, those who were currently living with them, those who were living away, and those who had died. In addition, the following information was collected for each live birth: name, sex, date of birth, survival status, current age , and age at death (if dead).Total fertility rate (TFR) is considered as the dependent variable for the purpose of the study. This is an overall summary measure of fertility and is computed from the age-specific fertility rates. Age-specific fertility rates (ASFRs) are computed from the birth history by dividing the number of births to women in a specified age group, during a specified period of time, by the number of woman-years of exposure during the same period. The total fertility rate (TFR) is then obtained by summing the age-specific fertility rates for five-year age groups and multiplying by 5. The total fertility rate therefore indicates the number of children on an average woman would bear from age 15 to age 49 if she experienced the age-specific fertility rates observed during the period for which the total fertility rate is computed. The total fertility rate is estimated by economic status for each country across time periods.TFR is expressed as the product of four indices measuring their fertility inhibiting effect and the total fecundity rate (TF). Total fecundity rate is the average number of live births expected among women who during their entire reproductive period remain married, do not use any contraception, do not have any induced abortion and do not breastfeed their children. In such a hypothetical situation the value of varies between 13 and 17 but, the mean value of 15.3 births has been suggested by Bongaarts. The value of most important four indices, based on the proximate determinants explained above, ranges between 0 and 1. When the index is close to 1, the proximate determinant will have a negligible inhibiting effect on fertility, whereas when it takes a value of 0 meaning very low value as zero has not been empirically observed so far, it will have a large inhibiting effect. According to the model:Values of each proximate determents of fertility among poor and non-poor are calculated using Bongaart’s proximate determinants of fertility model. Bongaarts demonstrated that 96 percent of the variance in fertility level in a given society is explained by the four principal proximate determinants of regulated fertility viz. the proportion of females married, the prevalence of contraceptive use, the incidence of induced abortion and the fertility inhibiting effect of breast-feeding. In the model, Cm = index of marriage Cc = index of contraception Ca = index of abortion Ci = index of postpartum infecundability TF = Total FecundityTFR = Total fertility ratem(i) = age − specific proportions currently married among femalesIn Asian countries, sexual intercourse and child-bearing generally occur only within marriage. Thus, the variables which determine the formation and dissolution of marital unions are very important in determining fertility. Among the various variables related to the formation and dissolution of marital unions, the female age at first marriage and the proportion currently married among women of child-bearing ages are important since they have a major share in determining fertility levels and differentials. The index Cm is calculated as follows:g(i) = age − specific marital fertility ratesm is the weighted average of the age-specific proportion of females currently married, with the distribution of TMFR by age of women used as weights. This definition takes into account the dependence of the fertility impact of marriage on the age distribution of married women.Thus, the index Cg(i), was obtained by dividing the age-specific fertility rate by the proportion of currently married women to total women in each 5-year age group. However, because there were very few married women in the age group 15–19, the calculated g(15–19) could be subject to large random errors. To overcome this problem, the marital fertility rate for this age group was computed as: g(15–19) = 0.75*g(20–24). The multiplication factor 0.75 is based on Leridon’s observation of associations in marital fertility among age groups [In this application, the age-specific marital fertility rate, e groups , 83.u = prevalence of current contraceptive use among married women of reproductive ageThe index of contraception is inversely related to the prevalence and use effectiveness of contraception. In this application the index Cc is calculated by the following formula:average use − effectiveness of contraceptione = According to Bongaarts, the average effectiveness is assumed to be 1.0 for sterilization and injectables, 0.95 for IUD, 0.90 for oral pills and 0.70 for all other methods, including condoms .The coefficient 1.08 in this equation is an adjustment factor required because women (couples) do not use contraception if they know or believe that they are sterile. The absence of contraception among such sterile couples implies that contraception is therefore concentrated among non-sterile couples. To take into account the stated concentration of contraception, the variable u, which measures prevalence among all couples, has to be inflated by the sterility correction factor.Index of abortion is calculated from the information of lifetime experience of induced abortions (TA), contraceptive use (u) and total fertility rate (TFR).The number of births averted per induced abortion is largely independent of the age of woman, however, is strongly related to the practice of contraception following the induced abortion. In Bongaarts model (1983) it is defined as:TAR has serious problems. So, for this study we have assumed such terminations took place in the last two years prior to the survey. Here, the assumption is, it is quite rare to find women experiencing more than one such termination in two years and small number of such cases may not affect our estimation. In particular cases, where the only information of total number of non-live births are available instead of type of non-live births (stillbirth/miscarriage/induced abortion), then all non-live birth pregnancies (last) which occurred within 24 months prior to the survey are tabulated according to mothers age. As it is assumed that, there will not be more than one such pregnancy within two years (restricted to two years), then among these non-live birth terminations, those terminations which occurred before seven months of gestations are assumed to be induced abortions or miscarriages. Further, it is assumed that half of such terminations are induced abortion and remaining half are miscarriages.Although reliable measurements of the prevalence of induced abortion are often lacking, it is well known that induced abortion is practiced in many societies . Data onBongaarts estimated that the duration of the postpartum sterility (the period prior to the resumption of ovulation following a birth) is one of the four proximate determinants accounting for most variation in fertility levels among populations. Postpartum sterility varies considerably, not only among individuals, but between different populations. It is more or less coincident with the period of postpartum amenorrhea and is primarily determined by the duration and intensity of breastfeeding.TN) in the presence and absence of postpartum infecundability. TN is estimated as the number of birth intervals that can be fitted between age 15 and the end of childbearing years. Because postpartum infecundability does not affect the duration of the reproductive years, its effect works through modifications of the birth interval. Thus the ratio of natural fertility in the presence and absence of postpartum infecundability is equal to the ratio of the average birth interval without and with postpartum infecundability. In the case of no breastfeeding and no postpartum abstinence, the birth interval, on average, is about 20 months, the sum of 1.5 months of minimum postpartum anovulation, 7.5 months of waiting time to conception, 2 months of time added by spontaneous intrauterine mortality, and 9 months for a full-term pregnancy. In the presence of breastfeeding and postpartum abstinence, the average birth interval is approximately equal to 18.5 months (7.5 + 2 + 9), plus the duration of postpartum infecundability. Hence, Bongaarts proposed the following formula for estimating the index Ci.i is the duration of postpartum infecundabilityAccording to Bongaarts, the index Ci equals the ratio of the total natural fertility rate  from the indexes Cm, Cc, Ca, and I is the interaction factor [Any change in the level of fertility of a population is necessarily caused by a change in one or more of the proximate determinants. In order to quantify the contribution made by each proximate determinant, a decomposition procedure is applied to evaluate the impact of the four principal factors on fertility between first and recent survey period by economic status for each study countries. The decomposition of the proportional change in the n factor .TFR from TFR1992 in the year 1992 to TFR1998 in the year 1998 and with simultaneous changes in the indexes from Cm1992 to Cm1998, from Cc1992 to Cc1998, from Ca1992 to Ca1998, from Ci1992 to Ci1998 and from TF1992 to TF1998 between the years 1992 and 1998, the ratio TFR1998/TFR1992 can be expressed as:Let 1992 and 1998 be the first and recent years of the time period for which decomposition is done. Then, with a change in the Proportional change in TFR due to a change in the index of marriage between the years 1992 and 1998: Pm = Cm1998/Cm1992–1Proportional change in TFR due to a change in the index of contraception between the years 1992 and 1998: Pc = Cc1998/Cc1992–1Proportional change in TFR due to a change in the index of induced abortion between the years 1992 and 1998: Proportional change in TFR due to a change in the index of postpartum infecundability between the years 1992 and 1998: Pi = Ci1998/Ci1992–1Therefore, Pf = Pm + Pc + Pa + Pi + II is the interaction factorWhere, Thus, the proportional change in TFR between 1992 and 1998 is “equal to the sum of the proportional fertility changes due to the different proximate determinants plus an interaction term” . DecompoThe TFR can be interpreted as the number of children a woman would have throughout her life time, if she experiences the same level and pattern of fertility as measured at the time of survey . The TFRBifurcation of total fertility rate by economic status presents a far clearer picture about fertility behavior among poor and non-poor women in six Asian countries. Results  indicateIn India, fertility level was comparatively higher among poor women than non-poor women. However, over the period of time fertility had shown a declining trend among both groups of women. During the fifteen years time period total fertility rate among poor had declined from 3.71 in 1992–93 to 3.42 in 2005–06. On the other hand, pace of fertility decrease was comparatively faster among non-poor women in India. According to 1992–93 data, on an average one non-poor woman had almost 3 children during her reproductive span which had declined to 2.54 in 1998–99 and finally it was below the replacement level fertility (1.82) in 2005–06. Data also revealed that, fertility decline among non-poor women in India was much consistent compared to their poor counterparts .Interesting result  was notiFertility level was quite high among poor women in Nepal . On an aAmong all the study countries, the fertility scenario was entirely different in Philippines and there was a sharp contrast among poor and non-poor women . A poor Vietnam was one such country where the fertility was well controlled by both poor and non-poor women . ResultsAcross country comparison indicate that, the six Asian countries had considerable diversity with regards to TFR, in poor women aged 15–49, TFR ranged from 4.82 in Philippines to 2.02 in Vietnam according to most recent survey. Further, between the highest and lowest fertility mentioned earlier, total fertility rate among other Asian countries was 4.31 in Nepal, 3.42 in India, 2.89 in Bangladesh and 2.68 in Indonesia. It signifies that, fertility level differed among poor women from one country to another and women have experienced different kind of fertility behavior and child bearing practices. However, compared to poor women, non-poor women’s fertility level was lower and it was more or less at the same level in Indonesia (2.59 in 2007), Bangladesh (2.45 in 2007), Philippines (2.22 in 2008) and Nepal (2.18 in 2006). Thus, they were either very close to near replacement level or had already achieved replacement level fertility according to the recent surveys in respective countries. Interestingly, non-poor women in India (1.82) have achieved below replacement level fertility in 2005–06 and out of six countries both poor (2.02) and non-poor (1.88) women in Vietnam reached below replacement level fertility much earlier in 2002 .In order to improve the understanding of fertility behavior, its variations among different sub-groups and underlying causes of the variations, it is necessary to analyze the mechanisms through which proximate determinants influence fertility. Kingsley Davis and Judith Blake were the first to identify the factors which influence fertility directly with the help of eleven “intermediate fertility variables” . FurtherAccording to Bongaarts’s (1982) framework, all important variations in fertility are captured by variation in the proximate determinants of fertility. Bongaarts demonstrated that almost 96 percent variability in fertility within a society can be explained by the above mentioned first four variables and the effect of the last four variables are almost negligible. Therefore, if we have good enough individual-level data on marriage, contraceptive use, abortion (not mandatory), post-partum amenorrhoea and the other proximate determinants, all variations in individual-level fertility can be captured. Evidence suggests that, DHS calendar data are among the most detailed data which can capture the measurable variation in fertility.Thus, in this paper, we have quantified the proximate determinant indices to capture the relative contribution of each proximate determinant viz. marriage, contraception, postpartum infecundability and abortion on fertility reduction among two distinct group of population i.e. poor and non-poor. Further, we have determined whether the observed total fertility rates based on the DHS data are consistent with the predicted rates based on the Bongaarts proximate determinant model. We then assessed the values of the proximate determinants and their contributions to fertility changes among poor and non-poor.Index of marriage (Cm). Early marriage has direct implications for exposure to childbearing that can lead to higher cumulative fertility over the lifespan [Cm) across economic groups for selected study countries , poor women in Indonesia (0.701 in 1997 to 0.655 in 2007) and non-poor women in Nepal (0.821 in 1996 to 0.689 to 2006). Although, the impact of marriage on fertility was comparatively less among both poor and non-poor women in Bangladesh, and poor women in India and Nepal, nevertheless, the consistent lower index value of Cm indicated that impact of marriage had gradually increased in the above stated countries, however in a sloth pace.Vietnam and Indonesia exhibited that the impact of marriage had increased among poor (0.543 in 1997 to 0.483 in 2002 and 0.701 in 1996 to 0.655 in 2007 respectively) compared to non-poor (0.532 in 1997 to 0.507 in 2002 and 0.679 in 1996 to 0.676 in 2007 respectively) over time. Index value of Index of contraception (Cc). Trends in index of contraception (Cc) by economic status are presented in Cc had decreased from 0.456 in 1992–93 to 0.346 in 2005–06 among non-poor however the corresponding figure for poor women was 0.675 to 0.526 during the same period. The gap between poor and non-poor women in terms of estimated value of Cc had narrowed down in Bangladesh because of the comparatively faster increase in fertility inhibiting effect of contraception among poor (0.089 point increase among poor and 0.021 among non-poor) during 1996/97 to 2007 time period. The estimated lower value of Cc confirmed the increasing inhibiting effect on fertility in Nepal and Philippines also. Despite the differences in pace of decline within and across the study countries, inhibiting effect of contraception on fertility emerged as a very important factor irrespective of economic status.Index of abortion (Ca). It was already recommended by Bongaarts (1983) that the index of abortion may be assumed as one due to lack of data. However, we have tried to estimate the index of abortion (Ca) with the information available in DHS surveys for respective countries. The estimated values of index of abortion by economic status across Asian countries are presented in Ca, it was found that in a broader sense induced abortion had almost negligible inhibiting effect on fertility among both poor and non-poor women across the countries and over time. Nonetheless, in case of Vietnam, the declining value of Ca indicated that the inhibiting effect of abortion might have a little influence on fertility reduction among non-poor (0.884 in 1997 to 0.824 in 2002) and poor women (0.909 in 1997 to 0.890 in 2002).Index of postpartum infecundity (Ci). The magnitude of postpartum infecundity by economic status is presented in Ci among poor compared to their non-poor counterparts indicated that the fertility inhibiting effect due to postpartum infecundity has increased among poor women. Among the study countries the estimated values of Ci were lowest among both poor (0.637 in 1996 to 0.633 in 2006) and non-poor women (0.733 in 1996 to 0.699 in 2006) in Nepal. Another interesting result was found in Vietnam. Among the poor women in Vietnam, the fertility inhibiting effect due to postpartum infecundity has decreased (0.712 in 1997 to 0.816 to 2002) over time however; among non-poor it has slightly increased (0.772 in 1997 to 0.746 in 2002).Any change in the level of fertility of a population is necessarily caused by a change in one or more of the proximate determinants. In order to quantify the contribution made by each proximate determinant, a decomposition procedure was applied to evaluate the impact of the four principal factors on fertility between first to recent survey for respective countries. The decomposition of the proportional change in TFR due to changes in different proximate variables has been estimated from the indexes Cm, Cc, Ca and Ci and it is presented in Results demonstrated that the highest fertility decline occurred among non-poor women in Nepal (44 percent) during 1996 to 2006 time period which can be attributed to a 26 percent decline due to increasing contraceptive practice, 16 percent resulting from a decrease in the proportion of women married, 5 percent fall due to the prolongation of the duration of postpartum infecundability and 4 percent due to an increase in the practice of induced abortions. Compared to non-poor women, total 16 percent fertility had declined among poor women in Nepal. Out of the 16 percent fertility decline, a bulk of fertility (25 percent) had reduced because of increasing contraceptive practices. Other factors i.e. non-marriage (2 percent), induced abortion (2 percent), postpartum infecundity (1 percent) had a minimal contribution on fertility decline in last 10 years in Nepal.In past 13 years, about 38 percent fertility had declined among non-poor women in India however; the corresponding figure for the poor women was 8 percent. The decomposition analysis revealed that 22 percent and 24 percent fertility had declined due to increasing contraceptive practices among poor and non-poor women respectively. Second most important fertility inhibiting factor among non-poor was decrease in the proportion of women married (19 percent fertility decline), however; its impact was very minimal (3 percent fertility decline) on poor women in India. The relative contribution of induced abortion on fertility decline was about 5 percent for non-poor women and only 1 percent among poor in India.Interestingly, substantial fertility had declined among poor women compared to their non-poor counterparts in Vietnam (24 percent against 6 percent), Philippines (18 percent against 15 percent), Bangladesh (17 percent against 13 percent) and Indonesia (15 percent against 1 percent). It was also observed that, majority of the fertility decline in the above stated countries was primarily because of massive increase in contraceptive practices and it was higher, to a great extent, among poor than non-poor women in Bangladesh (16 percent vs. 4 percent fertility decline), Indonesia (13 percent vs. 6 percent fertility decline) and Philippines (11 percent vs. 2 percent fertility decline). The relative contribution of proportion of non-marriage was the second most important fertility inhibiting factor among poor women in Philippines (17 percent fertility decline) and Indonesia (6 percent fertility decline). Fertility decline among poor in Vietnam was largely attributed to increasing contraceptive practices (15 percent fertility decline) followed by proportion of non-marriage (11 percent fertility decline) and a small amount of contribution of induced abortions (2 percent fertility decline). However, fertility decline among non-poor women in Indonesia can be attributed to an increase in practice of contraceptive use and induced abortion (6 percent and 5 percent fertility decline respectively). In case of Philippines, the sole reason for fertility decline was contribution of non-marriage (22 percent fertility decline). Interestingly, fertility decline among non-poor women in Vietnam had occurred mostly because of increase in the practice of induced abortion (7 percent fertility decline) followed by increase in proportion of non-marriage (5 percent fertility decline) and the prolonged duration of postpartum infecundability (3 percent fertility decline).Undoubtedly, fertility transition is well underway in the six study countries. Fifty years back fertility of these countries was at a different paradigm and it had started declining in each of the study countries at different point of time. Overall fertility decline has been a continuous process in these countries along with the substantial fertility decline among two distinct groups i.e. poor and non-poor. However, the pace of decline varied within and across the countries. Non-poor women started controlling their fertility much earlier and there was a time lag in case of poor women. In some countries like Nepal, Philippines and India fertility level was still far from satisfactory particularly among poor women. In contrast, fertility decline has been overwhelming among the poor in Bangladesh, Indonesia, Philippines and Vietnam. It was noteworthy that, out of the six countries both poor and non-poor women in Vietnam have achieved the replacement levels of fertility much before the other countries.Thus, the results revealed that there has been a gradual change in fertility behaviour even among the disadvantaged section of the society. The changing behavior among poor women may be due to the perceived benefits of small family size. Therefore, it may be assumed that, fertility behavior of non-poor women will be diffused gradually among poor women and their fertility will continue to decline until and unless they achieve the replacement level of fertility. However; it is imperative to study the determining factors for the changing fertility behaviour among sub-group of population in a particular society.Ci indicated the decreasing inhibiting effect of duration of breastfeeding and menstrual regulations on fertility.While analyzing the determining factors for fertility decline, it was found that fertility has declined among both poor and non-poor women during ten years or more (except Vietnam) time period due to the changes in three principal proximate determinants i.e. increasing proportion of women currently practicing contraception, decreasing proportion of women currently married and an increasing rate of induced abortions with the exception of postpartum infecundibility. The trends in all three factors confirmed that the fertility inhibiting effect has increased among both poor and non-poor women however; the level varied within and across the countries. The increasing index value of There was substantial fertility decline, especially among poor, across all the countries over the period of time. It was quite clear from the analysis that out of four proximate determinants of fertility, contraception had the largest effect and it was the sole reason for fertility decline particularly among poor women in Nepal followed by India, Bangladesh, Vietnam, Indonesia and Philippines between first to recent survey period. However, the magnitude of inhibiting effect of contraceptives varied among poor women in study countries. Nevertheless, the importance of contraceptive practices for fertility regulation among poor should not be overlooked as far as fertility decline in Asian countries is concerned.Cm indicated that gradually the effect of marriage had increased and the marriage pattern had changed gradually among poor. Numerous studies using World Fertility Survey data have shown that the proportion of women married in a population is a major determinant of the level of natural fertility in that population [The second most important fertility inhibiting factor was effect of marriage. Earlier it was observed that marriage was almost universal especially among poor and therefore the relative contribution of marriage on fertility reduction was almost negligible. However, the decreasing estimated values of pulation . We alsoAbortion had a limited fertility inhibiting effect compared to other two proximate determinants and it was the third important proximate determinant for explaining the fertility decline. Analysis showed practice of induced abortion varied across the countries by economic status. For example, fertility inhibiting effect due to induced abortion was higher among non-poor women in Vietnam (7 percent) followed by non-poor women in India (5 percent), Indonesia (5 percent) and Nepal (4 percent). On the other hand, relative contribution of induced abortion on fertility was relatively less among poor women and it brought about 4 percent fertility decline in Indonesia, 2 percent decline in Vietnam, 2 percent decline in Nepal and 1 percent in India. The survey data reflected increase in the number of reported induced abortion by both poor and non-poor women, however; the abortion data were still under reported.Our analysis also showed that breast feeding, operating through postpartum amenorrhea, had a lesser amount of impact on fertility reduction and the impact was primarily in case of non-poor women in Nepal (5 percent fertility decline) and non-poor women in Vietnam (3 percent fertility decline). Otherwise it acted as a fertility enhancing factor irrespective of economic status across study countries.We conclude, out of the four proximate determinants, it was the adoption of contraception that contributed most to fertility changes especially among poor in a given time frame. Of the total decline in TFR across the countries, increased contraceptive use was the single reason for the explanation of fertility reduction in most of the cases. Increased proportions unmarried also contributed in fertility decline. Besides, while marriage had also contributed in reducing the potential level of fertility, however; it has been the increased demand for fertility control, expressed through greater use of contraception. Moreover, abortion has been another emerging factor in the changes in fertility level over time.In the absence of data on direct income and expenditure; this study defined economic status on the basis of household ownership and consumer assets.Despite the usefulness of birth histories, DHS surveys are subject to few data quality problems , 94, 95.It is well known that induced abortion is practiced in many societies  however;We have found that interaction factor arrived while decomposing the TFR in the decomposition analysis varies across the studied countries and among both poor and non-poor women from first to the recent survey period. Such interaction factors may be due to some ‘unexplained’ variables or other proximate determinants of fertility like potential impact of induced abortion, coital frequency, temporary separations, foetal mortality and secondary sterility which were not captured in the model .Finally, it was assumed that the value of total fecundity is same among both poor and non-poor. However, it could differ due to several biological or social factors which lead to higher or lower level of TF.The results of the study should be interpreted considering the few limitations detailed below:


Chronic organ injury leads to fibrosis and eventually organ failure. Fibrosis is characterized by excessive synthesis, remodeling, and contraction of extracellular matrix produced by myofibroblasts. Myofibroblasts are the key cells in the pathophysiology of fibrotic disorders and their differentiation can be triggered by multiple stimuli. To develop anti-fibrotic therapies, it is of paramount importance to understand the molecular basis of the signaling pathways contributing to the activation and maintenance of myofibroblasts. Several signal transduction pathways, such as transforming growth factor (TGF)-β, Wingless/Int (WNT), and more recently yes-associated protein 1 (YAP)/transcriptional coactivator with PDZ-binding motif (TAZ) signaling, have been linked to the pathophysiology of fibrosis. Activation of the TGF-β1-induced SMAD complex results in the upregulation of genes important for myofibroblast function. Similarly, WNT-stabilized β-catenin translocates to the nucleus and initiates transcription of its target genes. YAP and TAZ are two transcriptional co-activators from the Hippo signaling pathway that also rely on nuclear translocation for their functioning. These three signal transduction pathways have little molecular similarity but do share one principle: the cytosolic/nuclear regulation of its transcriptional activators. Past research on these pathways often focused on the isolated cascades without taking other signaling pathways into account. Recent developments show that parts of these pathways converge into an intricate network that governs the activation and maintenance of the myofibroblast phenotype. In this review, we discuss the current understanding on the signal integration between the TGF-β, WNT, and YAP/TAZ pathways in the development of organ fibrosis. Taking a network-wide view on signal transduction will provide a better understanding on the complex and versatile processes that underlie the pathophysiology of fibrotic disorders. ThIn the past, signaling cascades were often studied in isolation, i.e., a ligand signals through its receptor and mediates the nuclear accumulation of one or several transcription factors to modulate target gene expression. This view changed since recent advances suggest that these cascades are in fact organized into complex signaling networks which, dependent on the cellular and environmental context, govern cell function and fate in fibrotic disorders. This inter-pathway communication allows for increased versatility and fine tuning of cellular responses, which may explain the variety of phenotypes found in fibrotic disorders. The aim of this review is to discuss the current understanding on the signal integration between the TGF-β, WNT, and YAP/TAZ pathways in the development of fibrosis. We will start with a short overview of the three pathways, and extend our discussion with a detailed view on how these pathways connect at multiple levels of signal transduction in the context of myofibroblast function and fibrosis. Finally, we touch upon the challenges and considerations in the design of anti-fibrotic therapies, with focus on the cross-talk between the three signal transduction cascades.The TGF-β superfamily of growth factors consists of multiple proteins that govern a wide range of physiological processes, such as stem cell pluripotency, cell fate determination, proliferation, and differentiation. In humans, over 30 members of the TGF-β superfamily have been documented, including TGF-βs, activins, inhibins, nodal, growth/differentiation factors (GDFs), and bone morphogenetic proteins (BMPs). In this review, we focus mainly on the canonical signaling through TGF-β1, since considerable evidence exists for its role in fibrosis   and latent TGF-β-binding proteins (LTBPs) in the so-called large latent complex (LLC) . Upon inin vivo accompanied with an increased expression of TGF-β target genes and decreased levels of the inhibitory Smad6 and Smad7. Despite a tremendous body of experimental work, the mechanisms underlying Smad-induced fibroblast activation are incompletely understood, as both activation and inhibition of Smads can promote fibrogenesis, dependent on the context  as Wingless and in the mouse as Int1, together termed WNT in mammals, canonical WNT signaling comprises the molecular interactions leading to the nuclear translocation of β-catenin . The vaPAI1. Whether the interactions between YAP and Smad7 are of importance in this process remain to be elucidated.One of the examples, through which other pathways interact with Smad recycling describes the temporal regulation by CDK8/9 and GSK3. First CDK8/9 phosphorylate Smad1 on Ser206 and Ser214, which allows binding with YAP and simultaneously triggers phosphorylation by GSK3 on Thr202 and Ser210. The latter phosphorylation events cause YAP to dissociate and Smurf2 to bind with Smad1, and initiate ubiquitination . AlthougRemarkable progress in both biology and pharmacology has led to advances in the development of anti-fibrotic therapies. Many of these therapies aim to target the usual suspects such as ligands and receptors of the TGF-β and WNT signaling cascades using antagonistic antibodies or small-molecule inhibitors. Although the therapeutic efficacy in animal models proves promising , trials COL1A1 may be negatively regulated (The small-molecule intracellular inhibitor LY2157299 specifically targets the kinase pocket of the type I receptor of the TGF-β cascade without inhibiting the type II receptor and thereby attenuates Smad2/3-dependent transcription of target genes . Howeveregulated . Howeveregulated , 78. As egulated . VertepoThe disadvantages of pathway-wide molecular inhibitors challenge the scientific community to develop specific targeting strategies against intracellular processes and protein–protein interactions. The increasing insight in the molecular cross-talk between signaling cascades adds new possibilities in drug development. Additionally, by focusing on the elucidation of the crystal structures of protein complexes, we can pursue the rational design of novel small molecular inhibitors to interfere at the cross-roads of signal transduction cascades.in vivo. Broadening our view on signal transduction will provide a better understanding of how a limited set of growth factors is able to govern the complex processes that underlie the physiology and pathology of fibrotic disorders.Recent advancements in the field of TGF-β, WNT, and YAP/TAZ signaling have revealed that these signaling entities do not act alone. The notion that pathway components can have multiple and even opposed functions within one cell partly explains how the inhibition of a single molecular target often does not result in the desired therapeutic effect. This does not only add to the mere understanding of fibrotic processes, but also promotes the necessity to develop highly specific small-molecule intracellular inhibitors that act on protein–protein interactions at the cross-roads of signaling cascades. It should be noted that several of the studies described in this review used artificial ectopic expression of the proteins investigated. This may introduce artifacts that can influence the activity and functionality of the signaling cascades involved. Thus, more detailed studies in representative models for fibrosis focusing on endogenous proteins are required to completely understand the molecular cross-talk BP, RB, and MB designed the manuscript. BP and MB collected literature and BP drafted the manuscript. All authors critically discussed and revised the content of the manuscript and had final approval of the manuscript in its present form.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Fertility preservation in the cancer setting, known as oncofertility, is a field that requires cross-disciplinary interaction between physicians, basic scientists, clinical researchers, ethicists, lawyers, educators, and religious leaders. Funded by the National Institutes of Health, the Oncofertility Consortium (OC) was formed to be a scientifically grounded, transparent, and altruistic resource, both intellectual and monetary, for building this new field of practice capable of addressing the unique needs of young patients with cancer. The OC has expanded its attention to include other nonmalignant conditions that can threaten fertility, and the work of the OC now extends around the globe, involving partners who together have created a community of shared effort, resources, and practices. The OC creates materials that are translated, disseminated, and amended by all participants in the field, and local programs of excellence have developed worldwide to accelerate the pace and improve the quality of oncofertility research and practice. Here we review the global oncofertility programs and the capacity building activities that strengthen these research and clinical programs, ultimately improving patient care. Established in 2007 as part of a National Institutes of Health center grant, the Oncofertility Consortium (OC) is an interinstitutional, interdisciplinary consortium to expand research in fertility loss in patients with cancer, accelerate clinical translation of fertility preservation techniques, and address the complex health care and quality-of-life issues that concern young patients with cancer whose fertility may be threatened by their disease or its treatment.7 The term oncofertility was originally coined to describe a new discipline that bridges oncology and reproductive medicine to discover and apply new fertility preservation options for young patients with cancer. However, as the OC worked to create fertility preservation technologies and clinical oncology management plans for patients with cancer, it became clear that fertility concerns resulting from nonmalignant diseases and iatrogenic causes were much broader than just those associated with cancer. GI diseases, rheumatologic disorders, nonmalignant hematologic conditions , neurologic disorders, renal disorders, gynecologic conditions, and metabolic diseases can all adversely affect fertility. By expanding its scope, the OC now ensures that all patients facing a disease or treatment that limits reproductive function can benefit from the findings of basic and clinical reproductive research. The word oncofertility was created when few options were available and now provides terminology for a medical field at the intersection of many iatrogenic causes of infertility.Survival rates among young patients with cancer have steadily increased over the past three decades, in part because of the development of more effective cancer treatments.8 Since its inception, the OC has aimed to involve more partners to create a nationwide community of shared resources and practices, with the ultimate goal of improving patient care. Today, there is wide acceptance that partnerships that bring research and clinical teams together catalyze progress, and the global partnerships discussed here are moving quickly to provide broad reproductive care to anyone experiencing an iatrogenic impact on reproduction, fertility, or sexuality.2To facilitate sharing of knowledge and resources, the OC formed the National Physicians Cooperative, which today represents > 60 centers across the United States that provide oncofertility services to men and women, as well as 19 centers focused on pediatric patients.There are currently 19 countries engaged in the global oncofertility community , and theoncofertility.northwestern.edu) and other online resources are made available to global partners, including the iSaveFertility mobile app (savemyfertility.org), patient navigator tools (preservefertility.northwestern.edu), decision aids (myoncofertility.org), and Repropedia (http://www.repropedia.org), an online reproductive lexicon. Branding materials are available at oncofertility.northwestern.edu/branding-materials. Global partners are encouraged to translate these materials and disseminate them to international audiences, while in turn providing our team with new content and links to include on the main OC Web site (oncofertility.northwestern.edu). A complete list of active global partners and the work they have contributed can be found here: http://oncofertility.northwestern.edu/global-oncofertility-partners. Making these materials available to all partners fosters interaction and a shared language and purpose among diverse groups, which enables our global partners to apply these resources, methodologies, and other experiences in the field. Guidelines are not within the scope of the consortium, but the OC does provide a site for aggregation and dissemination of guidelines from formal medical societies, and guidelines for our field from oncology, fertility, pediatric, and nursing specialty groups from around the globe can be found in one central location . Establishing a strong global network not only drives the collaborative nature of the OC, but also helps global partners build their own consortia and fertility preservation networks.9Global partners of the OC receive tools and guidance to set up their own local consortia . The admAs part of the global partners model , the OC 10 with striking success in advancing knowledge.11 Similarly, extending the oncofertility network beyond the confines of the United States and into the international realm not only advances knowledge and promotes discovery, but also provides uniform access for all experts and their unique perspectives. These collaborations benefit the scientific community by accelerating the pace of discovery and decreasing the time to clinical application. The capacity for making landmark breakthroughs in the field is enhanced. Furthermore, research has shown that the trend toward international collaboration and network building attracts attention to issues and leads to a greater number of publications and greater support for basic research and clinical studies.12 Global partnerships, including research collaborations and joint authorships, strengthen the dissemination of scientific results; as the size of the audience increases, so does the reach and influence of the research, thus increasing the potential translational impact the research may have on future patient care.In recent decades, globalization has extended the reach of research universities,Because of the intrinsic value in creating diverse networks and collaborations, the OC continues its efforts to connect local centers of excellence and create a strong global network of diverse collaborators, many of whom may not have worked together otherwise. The OC supports interaction between global and local partners to create momentum for clinical activities , research , and meeting patient needs . By facilitating these interactions, the OC ensures the coordinated effort of the global oncofertility community in conducting cutting-edge research that can continue to be rapidly translated to the clinic and establish an evidence-based standard of care.Today, many global partners are contributing to the worldwide oncofertility network . Here, wIn Australia and New Zealand, a number of cancer and fertility groups have developed specific oncofertility services and are undertaking research studies to bridge the intellectual, disciplinary, and logistic gaps between reproductive medicine and oncology. The Fertility Society of Australia established a special interest group in 2008 with the aim of facilitating collaborative research and improving communication and education between cancer and fertility clinicians.http://www.futurefertility.com.au). They are currently in the process of developing e-learning tools that will also be available for clinicians early in the new year.The Australasian OC was established in 2014 and is committed to interdisciplinary innovation. The consortium endeavors to support the collaborative efforts of cancer and fertility clinicians in Australasia  to improve oncofertility practice and services. The consortium developed the Australasian Oncofertility Charter, which outlines the gold-standard model for care to be implemented at each service. Working closely with consumer groups, > 30 resources on the topics of fertility preservation, sexual health, and sexual dysfunction have been made available on our Web site  Fertility Team is a binational group of researchers who set up the Australasian Oncofertility Registry using a Web-based platform. In 2015, this registry will start collecting oncofertility population data from patients with cancer in Australia and New Zealand ages 0 to 45 years. These data will reveal referral patterns for fertility preservation, uptake, and use of fertility preservation, reproductive risk based on annual follow-up of patients, and pregnancy outcomes . This will be the first population-based national oncofertility registry and will produce invaluable insights into oncofertility care that are highly relevant to the efforts of international colleagues.The Brazilian OC (BOC) was officially created in 2012. Known nationally in Brazil as Rede Brasileira de Oncofertilidade and coordinated by Jhenifer K. Rodrigues, PhD, the group is a network of professional members who share experiences, materials, research protocols, and ideas and engage in collaborative research projects. The network includes the Pró-Criar Medicina Reprodutiva and Human Reproduction Laboratory/Federal University of Minas Gerais from the state of Minas Gerais (southeast), Huntington Medicina Reprodutiva and Medical School of Ribeirão Preto/University of São Paulo from São Paulo state (southeast), Fertilitat Centro de Medicina Reprodutiva from Rio Grande do Sul (south), Laboratory of Oocytes and Preantral Follicles Manipulation/State University of Ceará from Ceará (north), Gênesis Centro de Assistência em Reprodução Humana , and Cenafert Centro de Medicina Reprodutiva from the state of Bahia  and the Japan Society for Fertility Preservation (JSFP). The BOC has also collaborated on publications and research projects with the OC in the United States. The group has already published a native-language oncofertility book with contributions from experts across Brazil and some from abroad. Now the group is working on developing more native-language resources to further connect with patients in Brazil. Efforts in Brazil are being made to bridge the gap between oncologists and reproductive specialists to help inform patients with cancer about their fertility preservation options and reproductive future.© network was founded in May 2006. Two years later, the network was extended to Austria and Switzerland to include not only universities but also private centers offering fertility preservation.Working from an initiative in the Departments for Gynecological Endocrinology and Reproductive Medicine at the Universities of Heidelberg and Bonn in Germany, the FertiPROTEKThttp://www.fertiprotekt.com), which has > 100,000 visitors per year, can be accessed in German or English. Annual meetings involving all participating centers guarantee consistent therapy standards among the centers. The therapy standards of the network are constantly updated and published.15Since January 2014, approximately 100 centers across Germany, Austria, and Switzerland have joined the FertiPROTEKT network. Similar to the OC, the FertiPROTEKT network seeks to improve the standard of care for all patients by implementing standardized protocols and methods of quality control. The main achievements of the network are the optimization of stimulation therapies administered before cytotoxic therapies, the combination of ovarian stimulation with ovarian tissue cryopreservation, and the establishment of overnight transportation of ovarian tissue. Thus far, network members have performed and analyzed approximately 60 ovarian tissue transplantations. Furthermore, an optimized network infrastructure has been established, with two centralized cryobanks for ovarian tissue and 100 in vitro fertilization centers, which perform > 1,000 documented counseling sessions, 250 ovarian stimulations, and 500 cryopreservations of ovarian tissue per year. The homepage of the FertiPROTEKT network (http://www.j-sfp.org) with the aim of improving both the survival and quality of life of young patients with cancer in Japan. As part of this effort, the society is currently building a network for coordinating health care providers, using the OC as a guide, to provide accurate information about fertility preservation to young patients with cancer in a timely manner. The JSFP has hosted a number of conferences aimed at attracting the attention of all health care providers who are concerned with fertility preservation and oncofertility. To date, these conferences have been attended by approximately 280 clinicians, nurses, pharmacists, scientists, and others.In November 2012, the JSFP was founded as a nonprofit corporation . The JSFP has also secured funding from a Health and Labor Sciences research grant for a study titled “Development of a Psychological Support System for Fertility Preservation Aimed at Achieving Improvements for Young Cancer Survivors” . The JSFP is also working to initiate a clinical study titled “Oncofertility! Psychological Education and Couple Enrichment (O!PEACE) Therapy: An Intervention Study Protocol for a Randomized Controlled Trial in Japan.” The aim of this study is to examine whether psychotherapy can reduce concerns about fertility, alleviate psychological distress, and improve communication between patients with cancer and their partners. To expand its efforts, the JSFP is actively engaged in various activities with OC Japan, in cooperation with the OC, which are aimed at expanding oncofertility programs in Asia in association with the KSFP and the Fertility Preservation Society of India (FPI).The Portuguese Centre for Fertility Preservation  was created in 2010 to meet the reproductive needs of patients undergoing treatments that are possibly fertility threatening. Although male fertility preservation had been available in several public institutions since the 1990s, female fertility preservation options were not available in Portuguese public practice. This center is the only one in the country that provides all fertility preservation techniques to both men and women.The team at the center includes six physicians, one embryologist, one psychologist, and one pharmacist. Through a multidisciplinary approach, the main goal is to provide reproductive monitoring and counseling to male and female patients undergoing gonadotoxic treatments. This team supports the patients' decision-making process about fertility preservation and supports their reproductive decisions after treatment through regular follow-up consultations .http://www.myoncofertility.org, and Repropedia tool) were translated into Portuguese to allow the center to better inform the general population and health professionals about fertility preservation, thereby aiding in the decision-making process. The Portuguese Centre for Fertility Preservation Web site is about to be launched and will include information and tools tailored specifically to Portuguese patients and health professionals. The center is working with the Portuguese Society of Reproductive Medicine to develop a network with other public Portuguese institutions that can provide fertility preservation techniques to improve patient referral processes. Finally, research projects are also being developed to examine the fertility preservation decision-making process, the impact of this decision on future individual adaptation, the effect of cancer treatments on patients' reproductive function, and new fertility preservation techniques. Specifically in 2015, the main goals of the Portuguese Centre for Fertility Preservation are: to develop the first telemedicine network in oncofertility so that patients and oncologists anywhere can reach out to the center team to enroll in multidisciplinary consultations to make more informed, shared, and quick decisions about fertility preservation, to produce and disseminate oncofertility decision aids specifically to the pediatric population and to pediatricians, and to create and implement protocols for the cryopreservation of ovarian and testicular tissues for prepubertal patients.Although most of the patients with cancer are referred to the center by their oncologists, a significant number of them ask for a consultation on their own. Thus, another goal of this center is to try to better inform patients, health professionals, and the general population about the impact of cancer on fertility, the techniques available for fertility preservation, and how to assemble a team that can provide patients counseling and assistance in making decisions. To achieve this goal, the center has developed information fact sheets for patients and, in collaboration with the Portuguese Society for Reproductive Medicine, has organized postgraduate courses. Some materials from the OC  to facilitate collaboration between medical physicians and researchers who specialize in reproductive medicine and oncology. The ultimate purpose of the society is to help patients who are undergoing treatments that will affect their fertility and reproductive function. The goals of the KSFP are academic education, networking, advocacy, discussion, and development of standard protocols for fertility preservation.The KSFP was established in 2013  may limit activity in one region, but a common understanding regarding what is possible in another area of the work may provide insight and opportunities to overcome these local barriers. Ultimately, there is no precise formula to success. Because of a variety of factors, what works for one center may not work for another. Our success comes from simply engaging an inspired individual or group of individuals to act and our collective interest in the people with iatrogenic fertility concerns that we serve. The OC has made it possible for individual practices to tap into a worldwide network of knowledge, experience, and discovery to improve patient care. OC partners communicate and work across disciplinary, institutional, and geographic boundaries. Training the next generation of oncofertility collaborators to undertake this multidisciplinary, multinational approach, as well as to engage all stakeholders, is essential to ensure continued rapid transfer of sound science to quality medical practice. With each new partner, particularly those outside the traditional institutional boundaries, a variety of new scientific, cultural, ethical, and personal perspectives are brought to bear on oncofertility research and patient care. Multifaceted approaches to connect cultures, communities, and countries show the most promise for future success.