Coronavirus disease 2019 (COVID-19) was declared a pandemic on 11 March 2020 by the World Health Organization, halting the principal income activities worldwide. The International Monetary Fund predicts that the imminent economic recession will be worse than the global financial crisis of 2008, which severely affected the economy of Southern European countries such as Greece, Italy and Spain. There was then an abysmal drop in the Spanish yearly population growth curve as families could not afford to have children in that economic context; this only worsened the already existing demographic problems in that Spain has a constantly ageing population and one of the lowest fertility indicators in Europe. Taking into consideration that female age is the most important independent variable of success at the time of conception, probably thousands of potentially fertile couples were lost while waiting for more promising circumstances. With the COVID-19 pandemic a similar situation is being faced, where reproductive rights are imperiled by not being able to choose when to have children due to economic coercion. Therefore, governments worldwide should take measures to palliate the possible sociodemographic crisis that will follow the economic recession and try to ease the burden that many families might face during the following years.

Objective To determine if uterine adenomyosis is associated with worse perinatal outcomes in ovum donation assisted reproductive treatment cycles. Materials and Methods A multicenter and retrospective cohort study in which a total of 3307 patients undergoing an ovum donation cycle in 2018–2019 were included and divided into two groups: adenomyosis (n = 179) and controls (n = 3128). Clinical, obstetrical, and perinatal outcomes were analyzed. Results A lower live birth rate per embryo transfer was observed in women diagnosed with adenomyosis versus control women: 67/179 (37%) versus 1560/3128 (49.9%), respectively (odds ratio 0.6, 95% confidence interval 0.43–0.83, P = 0.002). There was no statistically significant difference in childbirth delivery method (vaginal versus cesarean section) between the adenomyosis and control groups. Mean gestational age at the time of delivery, newborn length and weight, and incidences of low birth weight, preterm birth, and admission to the neonatal intensive care unit did not differ between the two groups. In addition, in vitro fertilization and perinatal outcomes were similar in patients with diffuse compared with focal adenomyosis. Conclusions Adenomyosis affects clinical but may not affect perinatal outcomes in ovum donation cycles.

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Study question Even when considering the right to reproduction as a negative right are there actions to be taken in order achieve a better reproductive autonomy? Summary answer Specific actions become a necessary positivisation of the right to reproduction. Ensuring socio-economic stability and promoting specific education are key parameters for promoting fertility. What is known already The reproductive autonomy of individuals consists of being able to choose the number of children desired and the appropriate timing between deliveries. However, there are many factors that prevent reproductive autonomy from being fully developed in Spain, being the country with the second lowest fertility indicator in Europe. There are texts that argue that reproductive autonomy should be approached from a Human Rights perspective and urge governments to adopt positive measures in accordance. However, the European Court of Human Rights' rulings on this issue are far from this perspective. Nevertheless, states have obligations to enhance the reproductive autonomy of individuals. Study design, size, duration In order to stablish this position, we studied the Spanish demographic and fertility indicator data and examined the existing Spanish laws regarding assisted reproductive techniques (such as Law 14/2006), the European Court of Human Rights' ruling on this matter, United Nations consensus related to this field, the Guttmacher-Lancet commission and recommendations of scientific societies such as ESHRE. Participants/materials, setting, methods Bibliography was achieved using the European Court Human Rights' ruling HUDOC database, the Spanish State Official Newsletter and United Nations Library, between others. Socio-economic and demographic indexes were obtained with Eurostat and the Spanish National Statistics Office. Selected legal aspects were included in the revision and manuscript. Main results and the role of chance The Spanish socio-economic panorama is unfavorable for the emancipation of young people and the consequent formation of families with offspring, which aggravates the existing demographic crisis and generational turnover. Importantly, people are not being fully autonomous in their reproductive decisions, mainly due to a lack of information and foresight regarding real fertility and infertility expectations. States must ensure comprehensive sexual and reproductive health promotion, which includes reproductive autonomy. The wide range of rights that constitute the so-called reproductive rights is encompassed within the framework of human rights. However, the right to reproduction is not always considered as a positive right, although the legislator must ensure that people can fully exercise their autonomy. The fact that the full positivisation of the right to reproduction is not considered does not exempt the State from obligations to ensure the reproductive autonomy of its citizens. Therefore, the positivisation of the right to reproduction must ensure socio-economic stability and reproductive health education, thus preventing future infertility problems. Public and private clinics and health centers must be provided with the necessary means to diagnose possible reproductive pathologies. Education and economic stability are solutions to most of the problems related to population growth and infertility. Limitations, reasons for caution In this study we have interpreted international Law, soft-law and reccommendations according to the actual Spanish socio-economic and demographic context, which may not be adequate to extrapolate to other countries or populations. Wider implications of the findings To consider the right to reproduction as a positive right may mean converting the State into a provider of resources for this purpose. However, positivisation of the right to reproduction materializes in education and socio-economic stability, actions worth considering, such as creating public campaigns aimed at fertility education and awareness. Trial registration number Not applicable

Study question Which are the perceptions and knowledge regarding female fertility and infertility of Spanish women? Summary answer Infertility carries a social stigma that prevents women from sufficient knowledge or professional aid to take their reproductive choices adequately. What is known already Infertility is a pathology that remains on an invisible plane for society. It is estimated that up to a third of all IVF cycles performed due to low ovarian reserve would be avoidable if women had received sufficient information at the right time. The factors that mainly contribute to this phenomenon are the marked social stigma that it entails, the lack of knowledge regarding tools, possibilities and real expectations in fertility and the low socio-sanitary involvement regarding tasks and campaigns to increase social awareness in this specific field. Study design, size, duration This is a cross-sectional study carried out using a population-based survey to identify different attitudes, knowledge and opinions regarding fertility and infertility. The survey was made public on April 30, 2019 and closed on May 10, 2019. Participants/materials, setting, methods A total of 1569 Spanish women answered all the questions included in the survey. No response or subject participation was excluded from the study. The platform used to create the questionnaire was Google Forms, which anonymizes the responses automatically. Data processing was performed using RStudio, an integrated development for R scripting. Main results and the role of chance Up to 1231 women had not had children at the time of the survey and 46% (566) of these cohort were either worried or very concerned about not being able to conceive naturally in the future. Also, 71% (871) of the same cohort were willing to have children of their own. In addition, 65% (1015) among those surveyed though that infertility had an important social stigma. With respect to gynecological health, 89% (1376) of women surveyed had had at least a gynecologic check-up at the time of answering the survey. However, up to 78% (921) of this cohort had never consulted their gynecologist regarding female fertility. Women surveyed were asked to predict the age at which conceiving a child both naturally and via assisted reproductive techniques started to become difficult. Respondents predicted that age to be 36.74 (IC95% [36.52, 36.96]) years and 39.79 (IC95% [39.58, 40.01]) years, respectively. Plus, 86% (1328) of women surveyed were in favor of elective fertility preservation and up to 72% (1127) thought that the Spanish State should either cover or aid economically this process. Finally, up to 72% (1115) of them thought they lacked important information to take their reproductive choices adequately. Limitations, reasons for caution Participants in the survey were exclusively contacted virtually. Even with the number of responses obtained and due to the descriptive nature of this study, it might not be representative of Spanish female society regarding the topics addressed. Also, the results here presented might not be extrapolable to other populations. Wider implications of the findings Considering the data presented in this work, education in fertility should start as soon as possible, ideally in high school. Finally, reproductive autonomy is being able to choose whether to have or not to have children, but the key is to always be able to make that decision. Trial registration number Not applicable