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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
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Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
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Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : March | Volume : 16 | Issue : 3 | Page : QC05 - QC08 Full Version

Fertility Awareness and its Association with Socio-demographic and Reproductive Variables among Women Seeking Fertility Treatment: A Cross-sectional Study


Published: March 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/52185.16131
Nisha Malik, Pooja Sinha, Smiti Nanda, Namita Batra, Vikram Singh, Ravishekar N Hiremath

1. Assistant Professor, Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Bilaspur, Himachal Pradesh, India. 2. Assistant Professor, Department of Obstetrics and Gynaecology, Pandit Bhagwat Dayal Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India. 3. Senior Professor and Head, Department of Obstetrics and Gynaecology, Pandit Bhagwat Dayal Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India. 4. Postgraduate Student, Department of Obstetrics and Gynaecology, Pandit Bhagwat Dayal Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India. 5. Assistant Professor, Department of General Surgery, Gian Sagar Medical College, Rajpura, Patiala, Punjab, India. 6. Public Health Specialist, Department of Community Medicine, Command Hospital Air Force, Bangalore, Karnataka, India.

Correspondence Address :
Dr. Pooja Sinha,
Assistant Professor, Department of Obstetrics and Gynaecology, Pandit Bhagwat Dayal Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India.
E-mail: captpoojasinha@gmail.com

Abstract

Introduction: In the last decade, there was a substantial reduction in fertility rates in Indian women. Despite a high burden of infertility, Fertility Awareness (FA) among people of reproductive age group is generally poor. Infertility is associated with significant negative impact on social and psychological well-being of the married couple. Therefore there is a need for awareness on fertility among Indian women.

Aim: To assess the level of fertility awareness and determine the impact of socio-demographic and reproductive variables on FA among a cohort of Indian women seeking fertility treatment.

Materials and Methods: A cross-sectional study was conducted in the Department of Obstetrics and Gynaecology at Pandit Bhagwat Dayal Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India, including 108 women seeking fertility treatment over a period of six months. Participants were interviewed with a 10 item questionnaire and categorised into low (score <40%), moderate (score 40-59%) or high FA level (score ≥60%) according to percentage of correct answers. The association of socio-demographic and fertility characteristics with FA levels was statistically analysed using Statistical Package for the Social Sciences (SPSS) software version 18.0.

Results: Of the total 108 participants, majority (90.7%) of women were aged between 21-35 years and primary infertility (67.6%) was the most common type. The overall FA level was low in 27.8%, moderate in 44.4% and high in 27.8% study participants. Majority answered incorrectly about fertile period (60%) and age related fertility decline (55.6%). Nearly, two-thirds respondents believed that conception is not possible by any means if fallopian tubes are blocked. FA levels differed significantly between the age groups (p-value=0.001). The other socio-demographic and reproductive variables did not demonstrate any significant association with FA levels.

Conclusion: Considerable gaps in knowledge and understanding of fertility issues were identified irrespective of their socio-demographic and fertility characteristics which warrant urgent attention. Targeted interventions are required to ensure easy to access accurate fertility information for couples’ informed decision making.

Keywords

Infertility, Knowledge, Socio-economic scale

It is an old dictum that ‘the eyes do not see what the mind does not know’. This dictum seems to be true in the current scenario of poor fertility knowledge worldwide (1),(2),(3). As we know that the prevalence of infertility is on the rise, the global estimates suggest an estimated prevalence of infertility among 48 million couples worldwide (4),(5). Recent data indicate a substantial reduction in fertility rates in Indian women in last 40 years (6). A number of factors may be potentially contributing to this worrisome situation such as trend of delaying marriages, increasing parental age, wish to postpone childbirth, focus on education and career, financial constraints, obesity, negative lifestyle factors, misconceptions related to fertility and fertility treatment (7). Addressing infertility is an important issue as it is associated with significant negative impact on social and psychological well-being of the couples. Despite the high burden of infertility, prior literature suggests poor FA among people of reproductive age group and it may be an attributing factor to many couples not fulfilling their aspirations of parenthood (1),(2),(3). Although timing of childbearing should be couples’ own decision, but they often overestimate the chances of conception and are not fully aware about natural age related fertility decline and are then faced with unintended infertility. Therefore, there is an urgent need for couples to understand the actual facts about fertility and ideal child bearing age range for making informed decisions regarding parenthood and family planning.

To date, most research on FA has been done in developed nations and to best of our knowledge, only two previous studies have assessed FA and knowledge about reproductive health among Indian population (7),(8),(9). The purpose of this study was to assess the FA level and evaluate the impact of age, residence, women’ education, Socio-economic Scale (SES) and duration of infertility on FA among a cohort of Indian women seeking fertility treatment at a tertiary care teaching centre.

Material and Methods

This was a cross-sectional study conducted in the Department of Obstetrics and Gynaecology at Pandit Bhagwat Dayal Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India from March 2020 to September 2020. All the subjects fulfilling the inclusion criteria who came to the Outpatient Department (OPD) during the study period of six months were included. A total of 108 women were finally enrolled in the study who gave informed consent. Ethical approval for the study was obtained (Approval number BREC/20/21 dated 06-03-2020).

Inclusion criteria: All sub fertile women in the age group of 18-45 years who experienced difficulty in conceiving for more than six months were included in the study.

Exclusion criteria: The women who were not in the reproductive age group and those who declined to participate in the study were excluded from the study.

Questionnaire

A 10 item FA questionnaire was prepared based on previous research studies (1),(7),(8). The questionnaire was discussed with topic experts and modified according to the level of understanding of the study population. The questionnaire was converted into local language and pretested on a pilot sample of 30. It included questions related to natural fertility (4 questions), factors affecting fertility (3 questions), fertility related misconceptions and treatment options (3 questions). The same investigator interviewed all the study participants and filled the questionnaire by asking the women to select one answer from the options provided after each question. Average time taken to fill the questionnaire was 10-15 minutes. The participants’ socio-demographic details and fertility characteristics were noted. FA score was determined by the percentage of correct responses to 10 questions. Each right answer was given score as 1 and wrong answer as score 0. The participants were classified into three levels of FA based on their overall FA score: low FA (score <40%); moderate FA (score 40-59%) and high FA (score >60%) (7). The association of socio-demographic and fertility characteristics (age, type of residence, women’ education, SES and duration of infertility) with FA was statistically analysed. The revised BG Prasad’s SES classification for the year 2020 which is based on the per capita monthly income and applicable to both rural and urban Indian population was used to determine the SES of the participants (10).

Statistical Analysis

Data analysis was carried out using SPSS software version 18.0. Descriptive statistics such as mean and standard deviation were calculated for normally distributed data. Categorical data were presented as frequency and percentage values. Comparison of frequency data across categories were performed using Chi-square test. For all statistical tests a two-sided probability of p-value <0.05 was considered as statistically significant.

Results

A total of 108 women participated in the study and completed the questionnaire. Majority (90.7%) of women aged between 21-35 years (Table/Fig 1). Primary infertility was the most common type (67.6%) and maximum had period of infertility for ≤5 years (Table/Fig 2).

Majority answered incorrectly about fertile period (60%), age related fertility decline (55.6%). Only 31 (28.7%) respondents believed that conception is not possible by any means if fallopian tubes are blocked (Table/Fig 3).

The overall FA level was low in 30 (27.8%), moderate in 48 (44.4%) and high in 30 (27.8%) study participants. Regarding its association with socio-demographic and reproductive characteristics, the FA levels significantly differed between the three age groups of participants (p-value=0.001). The other variables did not demonstrate any significant association with FA levels (Table/Fig 4).

Discussion

The present cross-sectional study observed a moderate FA level among majority of study participants. This almost fits with the findings of a recent systematic review by Pedro J et al., on FA which demonstrated an overall low to moderate FA levels among the participants (7). The studies by, Bunting L et al., (2013), Maeda E et al., (2016) and Fulford B et al., (2013) also found a moderate level of FA based on the total FA score (2),(11),(12). The prior literature suggests that both men and women in reproductive age group were included as the study participants in a majority of studies (13),(14),(15),(16). Taken into account the fact that women are often socially stigmatised for childlessness in developing countries like India, the present study included a cohort of women seeking fertility treatment at a government hospital.

Evidence shows a paucity of literature on assessment of FA levels among Indian women. Of the two such reported studies, Mahey R et al., conducted a cross-sectional study to evaluate the FA among 205 Indian women attending an infertility clinic and found an overall low knowledge about fertility and reproduction (8). Another study by Bloom SS et al., evaluated knowledge about male reproductive health among 120 men from rural India through structured interviews (9). The present study was one of its kind due to two reasons, first it assessed the FA levels among the study cohort attending the Gynaecology OPD where there was no specialised assisted reproduction unit as these women are supposed to have less knowledge as compared to those attending specialised fertility centres. Secondly, it investigated the association of socio-demographic and reproductive variables with FA levels which has not been done earlier in an Indian study population.

Nearly, 60% of respondents in the present study were not aware about the concept of fertile window and ovulatory period. Similar findings were also reported by Mahey R et al., in which approximately 85% participants failed to identify the best phase of menstrual cycle for conception (8). Hammarberg K et al., also reported a low awareness (<32%) about the fertile period among a cohort of Australian population (17). In contrary, Bennett LR et al., and Swift BE and Liu KE reported high awareness level of 70% (Indonesian women) and 76.4% (Canadian women) respectively about the fertile period among women seeking fertility treatment (18),(19). This may be due to different geographic and ethnic background of the study population.

There was a substantial misconception among the study participants (only 36% answered correctly) regarding the right time to consult a doctor if a couple faces trouble in conceiving. This may be a contributory factor for unnecessarily delay of diagnosis and prevents early access to fertility treatment. Similar findings were demonstrated by Mahey R et al., who found that only 38.5% respondents knew the correct information about when to seek help from a fertility specialist in case of problem in conception (8). A study conducted by Swift BE and Liu KE among Canadian women reported that 52.9% women sought medical help in less than a year, 28.9% in one to two years, 12.9% in two to three years and 5% in even four or more years of duration of infertility (19). As we know that management of infertility is time sensitive, therefore it needs to be emphasised that it requires appropriate timing for initiating the infertility workup and begin the treatment for achieving favourable results (20).

The study reported that 44.4% were aware of the biological clock and overestimated the natural age of decline in women’ fertility. These results are consistent with those of a study by Mahey R et al., in which only 26% women identified the correct cut-off age of 35 years after which fertility declines rapidly (8). Another study by Peterson BD et al., among 206 American undergraduate students demonstrated a lack of knowledge of age related fertility reduction (21).

With regards to fertility related misconceptions, majority of women (72.3%) thought that coming out of vaginal fluid after intercourse affects chances of conception. Nearly two-thirds women in present study believed that use of Oral Contraceptive Pills (OCPs) in past may hamper chances of future pregnancy. These observations were consistent with those of Mahey R et al., who found a relatively higher rate of misconception about OCPs and future fertility in approximately 97% women (8). This reflects the lack of proper counselling at the time of providing contraceptive advice. In the present era of advanced assisted reproduction techniques, it was surprising to know that less than one third respondents knew about the fertility treatment options in cases of tubal blockage. Swift BE and Liu KE also reported that around 45% Canadian women answered incorrectly about infertility treatment options (20).

Regarding the relationship between socio-demographic variables and FA, the present study demonstrated that FA levels differed significantly between the three age groups whereas, no association was observed with other factors such as type of residence, women education and SES. This reflects an overall lack of exposure to fundamental fertility knowledge among Indian women irrespective of their socio-demographic environment and an urgent need to address this issue. A positive association of FA with age was also reported by Bunting L et al., Garcia D et al., and Holton S et al., (2),(22),(23). Swift BE and Liu KE found an increasing trend of FA with increasing age of participants though it was not statistically significant. Their findings also found a significant association with ethnicity (p-value=0.025) and level of education of participants (p-value=0.007) (19). Mahey R et al., compared the FA among various SES categories and found upper and upper middle SES classes had better knowledge regarding age related fertility decline and assisted reproduction techniques but almost similar knowledge about fertile period as compared to lower SES classes (8).

With regards to duration of infertility, no association with FA was found in the present study. This was in contrast to a positive association as reported by Al Khazrajy LA and Al Abayechi MA among the infertile male patients (24). This may reflect towards a hesitant attitude of Indian women to discuss their fertility issues timely with health professionals and are then, faced with unintended infertility. Reproductive health education should incorporate the information about male and female reproductive health, declining fertility rates, concept of fertile window, effect of age and health related behaviours on fertility and fertility treatment options.

Limitation(s)

The present study was limited by its small sample size, further research with large sample size is recommended to see the effectives of targeted educational interventions on the level of FA among Indian population.

Conclusion

The present study has highlighted considerable gaps in knowledge and understanding of fertility issues among study participants which warrants urgent attention. There is a need for a multistranded approach including educational curriculum based programs in adolescent education, public education campaigns in communities, villages, health centres, grabbing the opportunities for fertility counselling of reproductive age group men and women during routine health visits and web based approaches.

Acknowledgement

The authors acknowledge the women who participated in the study.

References

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Daniluk JC, Koert E. The other side of the fertility coin: A comparison of childless men’s and women’s knowledge of fertility and assisted reproductive technology. Fertil Steril. 2013;99(3):839-46. [crossref] [PubMed]
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Bunting L, Tsibulsky I, Boivin J. Fertility knowledge and beliefs about fertility treatment: Findings from the international fertility decision-making study. Hum Reprod. 2013;28(2):385-97. [crossref] [PubMed]
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Daniluk JC, Koert E, Cheung A. Childless women’s knowledge of fertility and assisted human reproduction: Identifying the gaps. Fertil Steril. 2012;97(2):420-26. [crossref] [PubMed]
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DOI and Others

DOI: 10.7860/JCDR/2022/52185.16131

Date of Submission: Aug 30, 2021
Date of Peer Review: Nov 25, 2021
Date of Acceptance: Jan 01, 2022
Date of Publishing: Mar 01, 2022

AUTHOR DECLARATATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Sep 01, 2021
• Manual Googling: Dec 31, 2021
• iThenticate Software: Jan 03, 2022 (7%)

ETYMOLOGY: Author Origin

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)
  • www.omnimedicalsearch.com