Reproductive Health

REPRODUCTIVE HEALTH – PROBLEMS AND STRATEGIES

**Definition:** Reproductive health refers to a state of complete physical, mental, and social well-being in all aspects of reproduction, as defined by the World Health Organisation (WHO). It encompasses not only the normal functioning of reproductive organs but also healthy emotional and behavioural interactions in sex-related matters.

**Significance of Reproductive Health:**

Ensures physically and functionally normal reproductive organs

Promotes healthy emotional and social relationships

Reduces maternal and infant mortality rates

Prevents sexually transmitted infections and reproductive tract infections

Addresses social issues like sex abuse and gender-based crimes

Creates socially responsible and healthy families

**National Reproductive Health Programmes in India:**

India initiated action plans at the national level in **1951 under the 'Family Planning' programme**, becoming one of the first countries to address reproductive health as a social goal. These have evolved into the **Reproductive and Child Health Care (RCH) programmes**, which now operate under broader, comprehensive frameworks.

**Role of RCH Programmes:**

Create awareness about reproduction-related aspects through audio-visual and print media

Provide facilities and support for building reproductively healthy society

Involve governmental and non-governmental agencies

Engage parents, relatives, teachers, and friends in disseminating information

**Strategies for Achieving Reproductive Health:**

1. **Sex Education in Schools:** Introduction of proper sex education provides correct information about reproductive organs, adolescence-related changes, safe and hygienic sexual practices, STDs, and AIDS. This discourages myths and misconceptions among young people.

2. **Public Awareness Campaigns:**

Information about birth control options

Care of pregnant mothers and post-natal care

Importance of breast feeding

Equal opportunities for male and female children

Problems due to uncontrolled population growth

3. **Infrastructure and Professional Support:**

Establishment of medical facilities for pregnancy, delivery, and contraception

Professional expertise in STD management, abortion services, and infertility treatment

Implementation of better techniques and new strategies

4. **Legal and Statutory Measures:**

**Statutory ban on amniocentesis for sex-determination** to prevent female foeticide

Massive child immunisation programmes

Strict regulations on medical termination of pregnancy (MTP)

5. **Research and Development:**

Example: **'Saheli' – a non-steroidal oral contraceptive** developed by scientists at Central Drug Research Institute (CDRI), Lucknow, India, representing indigenous research in reproductive health

**Indicators of Improved Reproductive Health:**

Increased awareness about sex-related matters

Higher number of medically assisted deliveries

Improved post-natal care

Decreased maternal mortality rates (MMR) and infant mortality rates (IMR)

Increased prevalence of small families

Better detection and treatment of STDs

Expanded medical facilities for sex-related problems

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POPULATION STABILISATION AND BIRTH CONTROL

**Population Growth Problem in India:**

**Historical Data:**

**1900:** World population was approximately 2 billion

**2000:** World population reached 6 billion

**2011:** World population reached 7.2 billion

**India's Population Growth:**

**Independence (1947):** ~350 million

**2000:** ~1 billion

**May 2011:** >1.2 billion

**Reasons for Rapid Population Growth:**

Decline in death rate

Reduction in maternal mortality rate (MMR)

Reduction in infant mortality rate (IMR)

Increased proportion of people in reproductive age group

**Population Growth Rate in India:**

According to the 2011 census, the population growth rate was less than 2%, i.e., **20 per 1000 per year**. This rate could lead to rapid increase in population despite progress in food production, housing, and clothing sectors.

**Government Measures to Control Population Growth:**

1. **Motivating Smaller Families:**

Public campaigns with slogans like **"Hum Do Hamare Do"** (We two, our two)

Many young, urban, working couples have adopted **"one child norm"**

2. **Legal Measures:**

Statutory raising of **marriageable age of females to 18 years** and **males to 21 years**

Incentives given to couples with small families

3. **Promotion of Contraceptive Methods:**

Wide range of contraceptive options made available

Counselling on family planning

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CONTRACEPTIVE METHODS

**Characteristics of an Ideal Contraceptive:**

User-friendly and easily available

Effective in preventing pregnancy

Reversible with no or minimal side effects

Does not interfere with sexual drive, desire, or sexual act

Low cost and culturally acceptable

**Classification of Contraceptive Methods:**

**1. NATURAL/TRADITIONAL METHODS**

**Mechanism:** Work on the principle of avoiding chances of ovum and sperms meeting.

**a) Periodic Abstinence (Rhythm Method):**

Couples avoid coitus from **day 10 to 17 of menstrual cycle** when ovulation is expected

This period is called the **fertile period** due to high chances of fertilisation

Abstinence during this period prevents conception

**Advantages:** No medicines or devices; no side effects

**Disadvantages:** High failure rate; requires accurate knowledge of ovulation timing; unreliable in women with irregular cycles

**b) Withdrawal or Coitus Interruptus:**

Male partner withdraws penis from vagina just before ejaculation

Prevents sperms from entering female reproductive tract

**Advantages:** No devices or medicines; no side effects

**Disadvantages:** High failure rate; requires great self-control; may reduce sexual satisfaction

**c) Lactational Amenorrhea Method (LAM):**

Based on the fact that ovulation and menstrual cycle do not occur during intense lactation following parturition

As long as mother exclusively breast-feeds, chances of conception are almost nil

**Effective only for maximum 6 months** following parturition

**Advantages:** Natural; no side effects; promotes breast feeding

**Disadvantages:** Limited effectiveness; works only during exclusive breast feeding

**Overall Limitation:** All natural methods have high failure rates and are least reliable.

**2. BARRIER METHODS**

**Mechanism:** Prevent physical meeting of ovum and sperms using barriers.

**a) Male Condoms:**

Thin rubber/latex sheath that covers penis before coitus

Prevents ejaculated semen from entering female reproductive tract

**Popular brand:** 'Nirodh'

**Advantages:**

Disposable; self-inserted; provides privacy

Additional benefit of protecting against STIs and AIDS

No side effects; easily available

**Disadvantages:** Requires correct usage; may reduce sensation; slight failure rate

**b) Female Condoms:**

Covers vagina and cervix

**Advantages:** Provides protection from STIs and AIDS; gives woman control over contraception

**Disadvantages:** Less commonly used; requires insertion practice

**c) Diaphragms, Cervical Caps, and Vault:**

Rubber barriers inserted into female reproductive tract

Cover cervix during coitus

Block entry of sperms through cervix

**Reusable** (unlike male condoms)

Usually used with **spermicidal creams, jellies, or foams** to increase efficiency

**Advantages:** Reusable; no systemic side effects

**Disadvantages:** Requires proper fitting; requires insertion before each coitus; may cause discomfort

**3. INTRA-UTERINE DEVICES (IUDs)**

**Definition:** Devices inserted into uterus by doctors or expert nurses through vagina to prevent conception.

**Types of IUDs:**

**a) Non-Medicated IUDs:**

Example: Lippes loop

Mechanism: Increase phagocytosis of sperms within uterus

No chemical components

**b) Copper-Releasing IUDs:**

Examples: CuT (Copper T), Cu7, Multiload 375

Mechanism:

Cu² ions released suppress sperm motility

Reduce fertilising capacity of sperms

Increase phagocytosis of sperms

**Figure 3.2 in NCERT shows Copper T (CuT)**

**c) Hormone-Releasing IUDs:**

Examples: Progestasert, LNG-20

Mechanism:

Make uterus unsuitable for implantation

Make cervix hostile to sperms

Suppress ovulation

**Advantages:**

Ideal for females wanting to delay or space pregnancies

Long-acting (3-10 years depending on type)

Highly effective

**One of most widely accepted contraceptive methods in India**

Reversible

No systemic side effects

**Disadvantages:**

Requires insertion by trained personnel

Slight risk of uterine perforation

May cause irregular bleeding

Does not protect against STIs

**4. ORAL CONTRACEPTIVES (PILLS)**

**Composition:** Small doses of either:

Progestogens alone, OR

Progestogen-estrogen combinations

**Mode of Action:**

Inhibit ovulation

Inhibit implantation

Alter cervical mucus quality to prevent/retard entry of sperms

**Administration Schedule:**

Taken as tablets orally

Taken daily for **21 days starting preferably within first 5 days of menstrual cycle**

After **7-day gap** (during which menstruation occurs), same pattern repeated

Continued till female desires to prevent conception

**Special Oral Contraceptive – Saheli:**

**Non-steroidal preparation**

**"Once a week" pill** (major advantage over conventional daily pills)

Developed in India

Very few side effects

High contraceptive value

**Advantages:**

Very effective when taken correctly

Lesser side effects compared to other hormonal methods

Well accepted by females

Reversible; fertility returns after discontinuation

Regulate menstrual cycles in some cases

**Disadvantages:**

Requires daily compliance

Must be remembered to take

May cause nausea, breakthrough bleeding, irregular bleeding

Slight increased risk of breast cancer (though not very significant)

Does not protect against STIs

Contraindicated in certain medical conditions

**5. INJECTABLES AND IMPLANTS**

**Injectables:**

Progestogens alone or in combination with estrogen

Administered as injections

Mode of action: Same as pills

**Effective periods much longer than pills**

Examples: Depo-Provera (3 months), Depo-Medroxyprogesterone Acetate (DMPA)

**Implants:**

**Figure 3.3 shows implants**

Progestogens placed under skin

Slow, sustained release of hormone

Effective for **3-5 years** depending on type

Mode of action: Similar to pills

Reversible by removal

**Advantages:**

Long-acting

Don't require daily compliance

Highly effective

Reversible

**Disadvantages:**

Requires trained personnel for insertion and removal

May cause irregular bleeding

Doesn't protect against STIs

**6. EMERGENCY CONTRACEPTIVES**

**Definition:** Contraceptives administered within 72 hours of coitus to prevent pregnancy.

**Types:**

Progestogens alone

Progestogen-estrogen combinations

IUDs

**Uses:**

After rape

After casual unprotected intercourse

Contraceptive failure

**Advantages:**

Very effective when used within 72 hours

Prevents unwanted pregnancy

**Disadvantages:**

Less effective if used beyond 72 hours

Not meant for regular contraception

Should not replace regular contraceptive methods

**7. SURGICAL METHODS (STERILISATION)**

**Definition:** Terminal methods that permanently prevent conception by blocking gamete transport.

**Mechanism:** Surgical intervention blocks gamete transport and prevents fertilisation.

**a) Vasectomy (Male Sterilisation):**

**Figure 3.4(a) shows vasectomy**

Procedure: Small part of vas deferens is removed or tied up through small incision on scrotum

Results in blockage of sperm transport

Sperm production continues but cannot be ejaculated

Does not affect testosterone production or sexual function

**b) Tubectomy (Female Sterilisation):**

**Figure 3.4(b) shows tubectomy**

Procedure: Small part of fallopian tube is removed or tied up

Performed through small incision in abdomen or through vagina

Prevents ovum transport through fallopian tube

**Advantages:**

Highly effective (>99%)

Permanent solution

No regular compliance needed

No systemic side effects (hormonal changes absent)

**Disadvantages:**

**Very poor reversibility** – difficult or impossible to restore fertility

Requires surgical procedure

Risk of surgical complications though minimal

Does not protect against STIs

**Important Note on Contraceptive Selection:** Selection of suitable contraceptive method and its use should always be undertaken in consultation with qualified medical professionals. Contraceptives are not regular requirements for maintenance of reproductive health but are used against natural reproductive events due to personal or health reasons.

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MEDICAL TERMINATION OF PREGNANCY (MTP)

**Definition:** Intentional or voluntary termination of pregnancy before full term is called Medical Termination of Pregnancy (MTP) or induced abortion.

**Global Statistics:**

Nearly **45-50 million MTPs performed annually** worldwide

Accounts for **1/5th of total number of conceived pregnancies annually**

**Why MTP is Necessary:**

1. **Due to Contraceptive Failure:**

Casual unprotected intercourse

Failure of contraceptive used during coitus

Rape

2. **Medical Reasons:**

Continuation of pregnancy harmful to mother's life

Risk of grave injury to mother's physical or mental health

Substantial risk of fetal abnormalities leading to serious handicap

Fetal conditions incompatible with life

**Legal Status in India:**

Government of India **legalised MTP in 1971** with strict conditions

Restrictions placed to avoid misuse and prevent indiscriminate female foeticide

**Medical Termination of Pregnancy (Amendment) Act, 2017** enacted to reduce illegal abortion and consequent maternal mortality and morbidity

**Legal Grounds for MTP (Amendment Act, 2017):**

**Within First 12 Weeks:**

Opinion of **one registered medical practitioner** required

Grounds:

Continuation of pregnancy involves risk to life of pregnant woman or grave injury to physical or mental health, OR

Substantial risk that if child were born, it would suffer from physical or mental abnormalities making it seriously handicapped

**Between 12-24 Weeks:**

Opinion of **two registered medical practitioners** required

Must be formed in good faith

Same grounds as above applicable

**Safety of MTP:**

**Safest during first trimester** (up to 12 weeks of pregnancy)

**Second trimester abortions much riskier** with higher complications and mortality rates

**Problems Associated with MTP in India:**

1. **Illegal and Unsafe Abortions:**

Majority of MTPs performed by unqualified quacks

Not only unsafe but potentially fatal

Lead to complications like infections, hemorrhage, uterine perforation

2. **Misuse of Amniocentesis:**

**Amniocentesis:** Procedure where amniotic fluid of developing fetus is taken to analyse fetal cells and dissolved substances

Used legitimately for detecting genetic disorders (Down syndrome, hemophilia, sickle-cell anemia)

**Misuse:** Determining sex of unborn child

**Dangerous Practice:** Female foeticide following detection of female fetus

**Against law and ethics**

3. **Consequences:**

Dangers to young mothers (infection, bleeding, psychological trauma)

Risk to fetus

Promotes gender imbalance in society

**Prevention Strategies:**

Effective counselling on avoiding unprotected coitus

Education on risk factors of illegal abortions

Provision of more health care facilities

Strict enforcement of legal restrictions

Promotion of contraceptive usage

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SEXUALLY TRANSMITTED INFECTIONS (STIs)

**Definition:** Infections or diseases transmitted through sexual intercourse are collectively called Sexually Transmitted Infections (STI), Venereal Diseases (VD), or Reproductive Tract Infections (RTI).

**Common STIs:**

Gonorrhoea

Syphilis

Genital herpes

Chlamydiasis

Genital warts

Trichomoniasis

Hepatitis-B

**HIV/AIDS** (most dangerous; discussed in detail in Chapter 7)

**Alternative Modes of Transmission (for some STIs):**

Sharing of injection needles and surgical instruments

Transfusion of infected blood

From infected mother to fetus (vertical transmission)

Examples: Hepatitis-B, HIV infections

**Curability of STIs:**

**Completely curable if detected early and treated properly:** Gonorrhoea, syphilis, chlamydiasis, genital warts, trichomoniasis

**Not curable (chronic):** Hepatitis-B, genital herpes, HIV infections (though manageable with treatment)

**Early Symptoms of STIs:**

Minor symptoms often present in early stages

Itching in genital region

Fluid discharge

Slight pain

Swellings in genital region

**Important:** Infected females may be asymptomatic and remain undetected for long

**Complications if Untreated:**

Pelvic inflammatory disease (PID)

Abortions

Still births

Ectopic pregnancies

Infertility

Cancer of reproductive tract

**Psychological and Social Impact:**

Social stigma attached to STIs

Deters infected persons from timely detection and treatment

Absence or minor early symptoms delays diagnosis

**Vulnerable Groups:**

All persons vulnerable

**Incidence reported very high in age group 15-24 years** (young adults and adolescents)

**Prevention of STIs – Key Principles:**

1. **Avoid sexual contact with unknown or multiple partners**

Reduces exposure to infection risk

2. **Always use condoms during coitus**

Physical barrier protects against STI transmission

Especially important if partner status unknown

3. **Early detection and treatment**

Go to qualified doctor in case of doubt

Get complete treatment if diagnosed with infection

Early treatment prevents complications

**Importance in Reproductive Health Programs:**

STIs are major threat to healthy society

Prevention and early detection given prime consideration under RCH programmes

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INFERTILITY

**Definition:** **Infertility** is the inability of a couple to produce children despite unprotected sexual co-habitation for a specified period (usually 1-2 years).

**Incidence:** Large number of couples worldwide including India are infertile.

**Causes of Infertility:**

Physical abnormalities

Congenital defects

Diseases of reproductive system

Drugs and medications

Immunological factors

Psychological factors

Nutritional deficiencies

Environmental toxins

**Gender Distribution of Infertility:**

**Social Misconception in India:** Female often blamed for couple being childless

**Reality:** More often problem lies in male partner

Both partners should be investigated

**Diagnosis and Treatment:**

1. **Specialised Health Care Units:**

Infertility clinics

Reproductive medicine centres

Diagnostic procedures for identification of problems

2. **Corrective Treatment:**

Some disorders can be treated medically or surgically

Hormonal therapy

Surgical correction of anatomical defects

3. **Where Correction Not Possible:**

Couples assisted to have children through Assisted Reproductive Technologies (ART)

**ASSISTED REPRODUCTIVE TECHNOLOGIES (ART)**

**Definition:** Special techniques used to assist infertile couples in having children when natural conception is not possible.

**Types of ART:**

**1. In Vitro Fertilisation (IVF) and Embryo Transfer (ET):**

**Process:**

**In Vitro Fertilisation:** Fertilisation occurs outside the body in laboratory conditions almost similar to in vivo conditions

Developed to overcome problems of blocked fallopian tubes in females and low sperm count in males

**Steps:**

1. **Ovum Collection:** Eggs collected from woman's ovaries (after hormonal stimulation to produce multiple eggs)

2. **Sperm Collection:** Semen collected from male partner

3. **In Vitro Fertilisation:** Eggs and sperms mixed in culture medium in laboratory; fertilisation occurs

4. **Embryo Development:** Fertilised eggs (zygotes) allowed to develop to 2-8 cell stage or blastocyst stage in culture

5. **Embryo Transfer (ET):** Healthy embryo(s) transferred into uterus of female through cervix

6. **Implantation:** Embryo implants in uterine wall; pregnancy proceeds normally

**Advantages:**

Overcome tubal blockage

Helpful in male factor infertility

Can use donated eggs or sperms if needed

Allows genetic screening of embryos (PGD) before transfer

**Disadvantages:**

Expensive procedure

Low success rate per attempt (varies 20-40%)

Multiple births possible (if multiple embryos transferred)

Psychological stress

Ethical concerns regarding unused embryos

**Success Factors:**

Quality of eggs and sperms

Skill of laboratory personnel

Health of uterus

Overall health of woman

**2. ZIFT (Zygote Intra-Fallopian Transfer):**

**Process:**

**Similar to IVF but different point of embryo transfer**

Fertilisation occurs in vitro

**Unlike IVF:** Zygote (not blastocyst) transferred into fallopian tube

Zygote travels through fallopian tube and naturally enters uterus for implantation

Mimics natural process more closely

**Advantages:**

Zygote placement in natural site for development

More physiological

May have slightly better success rates than IVF in some cases

**Differences from IVF:**

IVF: Embryo at 2-8 cell or blastocyst stage transferred to uterus

ZIFT: Zygote transferred to fallopian tube

**3. GIFT (Gamete Intra-Fallopian Transfer):**

**Process:**

**Fertilisation occurs in vivo (inside the body), not in vitro**

Eggs and sperms collected separately

Both transferred together into fallopian tube

Fertilisation occurs naturally inside fallopian tube

Embryo naturally reaches uterus and implants

**Advantages:**

Preserves natural environment for fertilisation

No in vitro culture needed

May be acceptable to couples with ethical/religious concerns about in vitro fertilisation

Fertilisation confirmed naturally

**Requirements:**

At least one patent fallopian tube

Normal sperm motility

**Indications for GIFT:**

Unexplained infertility

Male factor infertility (low sperm count but mobile sperms)

Female factor (ovulation disorders with patent tubes)

**Comparison of IVF, ZIFT, and GIFT:**

| Feature | IVF | ZIFT | GIFT |

|---------|-----|------|------|

| **Fertilisation Site** | In vitro (lab) | In vitro (lab) | In vivo (fallopian tube) |

| **Embryo Stage at Transfer** | 2-8 cell or blastocyst | Zygote (1-cell) | Gametes (not embryo) |

| **Transfer Site** | Uterus | Fallopian tube | Fallopian tube |

| **Natural Development** | Partially artificial | Partially natural | Completely natural |

| **Requirements** | Good lab facility; healthy uterus | Patent fallopian tube; healthy uterus | At least one patent tube; motile sperms |

**Success Rates:** Success varies based on age of female, quality of gametes, and technique used. Generally 20-40% per cycle.

**Ethical Considerations in ART:**

Fate of unused embryos

Multiple pregnancies and complications

Cost and accessibility

Psychological impact of repeated failures

Informed consent essential

**OTHER CONSIDERATIONS IN INFERTILITY MANAGEMENT**

**Counselling:**

Emotional support essential

Realistic expectations about success rates

Coping with failures

Importance of lifestyle modifications (stress reduction, healthy diet, exercise)

**Lifestyle Factors Affecting Fertility:**

Stress and psychological factors

Smoking and alcohol abuse

Drug use

Nutritional status

Obesity

Environmental toxin exposure

**Cost and Accessibility:**

ART procedures expensive

Government subsidy programmes in some states

Need for counselling on adoption as alternative

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**EXAM IMPORTANT POINTS TO REMEMBER:**

1. Reproductive health includes physical, emotional, and social well-being in reproduction

2. RCH programmes operational since 1951 as Family Planning, now broader

3. Natural methods have high failure rates; barrier methods more reliable

4. IUDs (especially copper-releasing types) are one of most accepted contraceptives in India

5. Saheli is non-steroidal, once-weekly oral contraceptive developed in India

6. Vasectomy and tubectomy are permanent methods with poor reversibility

7. MTP legalised in India in 1971; Amendment Act 2017 allows it up to 24 weeks under specific conditions

8. Amniocentesis used for fetal diagnosis, not for sex-determination (illegal)

9. Female foeticide is major problem due to misuse of amniocentesis

10. STIs highly prevalent in 15-24 age group; condoms provide dual protection (pregnancy and STIs)

11. Infected females often asymptomatic in STIs; untreated STIs lead to infertility and cancer

12. IVF involves fertilisation in laboratory; ZIFT transfers zygote to fallopian tube; GIFT transfers gametes to fallopian tube

13. Success of ART depends on age of female, quality of gametes, and technique expertise

14. Male factor infertility important but often overlooked in India

15. Counselling and emotional support essential in infertility management