Reproductive Health

Reproductive Health

• Definition:
  • Healthy reproductive organs with normal functioning
  • Inclusion of emotional and social aspects related to reproduction
• According to the World Health Organization (WHO):
  • Reproductive health means total well-being in physical, emotional, behavioural and social aspects of reproduction.
• Thus, a reproductively healthy person has:
  • Physically and functionally normal reproductive organs
  • Normal emotional and behavioural interactions in all sex-related matters

REPRODUCTIVE HEALTH – PROBLEMS AND STRATEGIES

India’s Initiatives

• India was among the first countries to introduce national-level action plans for reproductive health
• Programmes began in 1951 as “family planning”
• These programmes are now known as Reproductive and Child Health Care (RCH) programmes

Aim of RCH Programmes

• Create awareness about reproduction-related aspects
• Provide facilities and support for a reproductively healthy society
• Strengthen maternal and child health services
• Control population growth

CREATING AWARENESS

• Methods Used
  • Audio-visual and print media
  • Posters and public campaigns
  • Media advertisements
  • Guidance by parents, relatives, teachers and friends
  • Introduction of sex education in schools to remove myths and misconceptions

Key Information for Awareness

• Structure and functions of reproductive organs
• Accessory organs and secondary sexual characters
• Changes during adolescence
• Safe and hygienic sexual practices
• Sexually transmitted diseases (STDs) and AIDS
• Birth control options
• Care of pregnant mothers and post-natal care
• Importance of breastfeeding
• Equal importance and opportunities for male and female children

ADDRESSING SOCIAL ISSUES

• Major Problems
  • Uncontrolled population growth
  • Early marriage in some regions after puberty
  • Poor maternal health due to early marriage
  • Social evils such as sex abuse and sex-related crimes
• Preventive awareness is necessary so that people can take responsible decisions and build a healthy society.

IMPLEMENTATION NEEDS

• Requirements for Successful Programmes
  • Strong infrastructural facilities
  • Professional expertise
  • Adequate material support
• Medical Assistance Required For
  • Pregnancy and delivery
  • Menstrual problems
  • Infertility
  • Contraception
  • Abortions
  • Sexually transmitted diseases (STDs)
• Additional Measures
  • Better techniques and improved strategies for effective care
  • Statutory ban on amniocentesis for sex determination to prevent female foeticides. (learn more about amniocentesis below).
  • Massive child immunization programs

RESEARCH AND DEVELOPMENT

• Governmental and non-governmental agencies encourage research in reproductive health
• Example:
  • “Saheli” – an oral contraceptive developed by Central Drug Research Institute (CDRI), Lucknow

BENEFITS OF IMPROVED REPRODUCTIVE HEALTH

• Better awareness about sex-related matters
• Increased medically assisted deliveries
• Improved post-natal care
• Reduction in maternal and infant mortality rates
• More couples opting for small families
• Early detection and treatment of STDs
• Improved medical facilities for sex-related problems

1.2 Population Explosion and Birth Control

Population Growth (Explosion)

• Population explosion refers to rapid increase in population over a short period.
• Improved health facilities and better living conditions have significantly increased population size.

• Statistical Data
  • World population increased from about 2 billion in 1900 to about 6 billion in 2000
  • In India, population increased from about 350 million at independence to over 1 billion by 2000
• Causes
  • Decline in death rate
  • Decrease in maternal mortality rate (MMR)
  • Decrease in infant mortality rate (IMR)
  • Increase in number of people in reproductive age group
• Consequence
  • Uncontrolled growth can create scarcity of basic needs such as:
    • Food
    • Shelter
    • Clothing

Measures to Control Population:

• Family Planning and RCH Programs:
  • Initiated in 1951
  • Aim to control population growth
  • Promote awareness and provide reproductive health facilities
• Creating Awareness:
  • Media advertisements and posters
  • Slogans such as “Hum Do Hamare Do”
  • Encouragement of smaller families
  • Sex education in schools to remove myths and misconceptions
• Other Measures
  • Raising legal marriageable age to 18 years for females and 21 years for males
  • Incentives to couples with small families
• These measures aim to achieve population stabilisation and improved reproductive health.

Contraceptive Methods

• Definition
  • Birth control or contraception refers to prevention of conception by using methods or devices that stop fertilisation.
  • Contraceptive methods mainly prevent:
    • Meeting of sperm and ovum
    • Ovulation
    • Implantation of early embryo
• Temporary methods are commonly used to delay or space births and require regular use.

NATURAL METHODS

• These methods work by avoiding the meeting of sperm and ovum.
  • No medicines or devices are used
  • Chances of failure are comparatively high

1. Periodic Abstinence (Rhythm Method)
   • Couples avoid intercourse during the fertile phase of the menstrual cycle (approximately day 10–17)
   • During this phase, chances of ovulation and fertilisation are high
   • Effectiveness is limited because ovulation timing may vary
2. Withdrawal (Coitus Interruptus)
   • Male withdraws the penis from the vagina just before ejaculation
   • Prevents semen entry into the female reproductive tract
   • Only moderately effective because lubricating fluid released before ejaculation may contain sperms
3. Lactational Amenorrhea
   • Based on absence of ovulation and menstruation during intense breastfeeding after childbirth
   • Breastfeeding prevents ovulation up to 6 months
   • Effective only up to a maximum of six months following parturition
   • Provides a safe period for intercourse during this time

BARRIER METHODS

• These methods prevent physical contact between sperm and ovum by using barriers.

1. Condoms
   • Thin rubber or latex sheaths used:
     • By males over the penis
     • By females in the vagina before intercourse
   • Functions:
     • Prevent semen entry into the female reproductive tract
     • Prevent fertilisation
     • Provide protection against sexually transmitted infections (STIs) and AIDS
     • Disposable and self-inserted
2. Diaphragms, Cervical Caps and Vaults
   • Rubber barriers inserted into the female reproductive tract to cover the cervix during coitus.
   • Functions:
     • Block entry of sperms into the uterus
     • Reusable
     • Often used along with spermicidal creams or jellies
3. Chemical Support (with Barriers)
   • Spermicidal creams, jellies and foams are inserted into the vagina before intercourse
   • Capable of killing sperms
   • Improve contraceptive efficiency

INTRAUTERINE DEVICES (IUDs / IUCDs)

• Inserted into the uterus by trained doctors
• Widely accepted and effective
• Especially useful for women who wish to delay or space pregnancies

Types and Action Mechanism

1. Non-medicated IUDs
   • Example: Lippes Loop
   • Prevent sperm motility
   • Prevent fertilisation
   • Affect sperm movement
2. Copper-releasing IUDs
   • Examples: Copper T, Cu7, Multiload 375
   • Copper ions reduce sperm motility
   • Reduce fertilisation capacity
   • Increase phagocytosis of sperms
   • Prevent fertilisation
   • Prevent implantation
3. Hormone-releasing IUDs
   • Examples: LNG-20, Progestasert
   • Make uterus unsuitable for implantation
   • Make cervix hostile to sperms
   • Prevent fertilisation
   • Prevent implantation

Possible Limitations

• Risk of expulsion
• Risk of infection
• Uterine perforation
• Increased menstrual bleeding in some women

ORAL CONTRACEPTIVES (PILLS)

• These involve oral intake of small doses of:
  • Progestogens
  • Progestogen–estrogen combinations
  • Levonorgestrel
• Mode of Action
  1. Inhibit ovulation
  2. Alter cervical mucus to prevent sperm entry
  3. Prevent ovulation
  4. Inhibit implantation
  5. Eventually inhibit implantation

Types

1. Combined Oral Contraceptives (COCs)
   • Contain synthetic progesterone and estrogen
   • Taken daily for 21 days followed by a 7-day break
2. Progestin-Only Pills (Mini Pills / POPs)
   • Contain only progestin
3. Extended-Cycle Pills
   • Mentioned as additional type
4. Emergency Contraceptive Pills (ECPs)
   • Taken within 72 hours of unprotected intercourse (coitus)
   • Prevent possible pregnancy
   • Used in cases of rape or unplanned sex

Example

• “Saheli” introduced by Central Drug Research Institute (CDRI), Lucknow
• Contains centchroman
• Mainly inhibits implantation

Side Effects and Precautions

• May increase risk of intravascular clotting
• Not advised for women with clotting disorders
• Not advised for women with hypertension
• Not advised for women with heart disease
• Possible nausea
• Weight gain
• Breast pain
• Menstrual irregularities

INJECTABLES AND IMPLANTS

• Hormonal preparations containing progestogens alone or combined with estrogen
• Administered as injections or subcutaneous implants
• Long-term contraception similar to pills
• Long-term and highly effective

Mechanism of Action

1. Block ovulation
2. Thicken cervical mucus to prevent sperm transport

Subcutaneous Implants

• Release synthetic hormone gradually
• Can remain effective for several years

SURGICAL METHODS (STERILIZATION)

• Definition and Principle
  • Surgical methods are permanent methods of contraception.
• Prevent conception by blocking the transport of gametes
• Generally advised when no more pregnancies are desired
• Highly effective
• Demerit: Very poor / low reversibility

VASECTOMY (Male Sterilization)

• Male sterilization by cutting or tying a small portion of the vas deferens
• Performed through a small incision in the scrotum
• Prevents passage of sperms into the semen

TUBECTOMY (Female Sterilization)

• Female sterilization by cutting or tying a small part of the fallopian tubes
• Performed through a small incision in the abdomen or via the vagina
• Blocks transport of ovum
• Prevents fertilisation

CHOOSING CONTRACEPTIVES

• Medical Consultation
  • Selection and use should always be done in consultation with qualified medical professionals
• Purpose
  • Not regular health requirements
  • Used to control or space pregnancies
  • Help in controlling population growth
• Possible Side Effects
  • Though generally not severe, may include:
    • Nausea
    • Abdominal pain
    • Breast pain
    • Irregular or breakthrough menstrual bleeding
    • Risk of breast cancer (in some cases)
• Features of an Ideal Contraceptive
  • User-friendly
  • Easily available
  • Effective
  • Reversible (except permanent methods)
  • With least side effects
  • Should not interfere with sexual drive
  • Should not interfere with the sexual act

1.3 Medical Termination of Pregnancy (MTP)

• Definition
  • MTP stands for Medical Termination of Pregnancy or induced abortion.
    • Intentional termination of pregnancy before full term
• Statistics
  • Around 45–50 million MTPs are performed worldwide every year
  • Accounts for nearly one-fifth (1/5th) of total pregnancies
• Legal and Ethical Issues
  • In India, MTP was legalized in 1971 under strict conditions to prevent misuse
  • Legal restrictions are important to prevent illegal female foeticide
  • Debated due to emotional, ethical, religious and social concerns
  • Though it may indirectly reduce population growth, this is not its primary purpose
• Why is MTP Done?
  • Unwanted pregnancies due to unprotected intercourse
  • Failure of contraceptives
  • Pregnancies resulting from rape
  • When continuation of pregnancy may harm or be fatal to the mother, foetus, or both
• Safety and Risks
  • Relatively safer during the first trimester (up to 12 weeks)
  • Second trimester abortions are much more risky
  • Illegal procedures by unqualified persons are unsafe and may be fatal
• Misuse and Dangers
  • Misuse of amniocentesis for sex determination may lead to illegal abortion of female foetuses
  • Such practices are illegal and dangerous for both mother and foetus
• Preventive Measures
  • Effective counselling to avoid unprotected intercourse
  • Awareness about risks of illegal abortions
  • Improved healthcare facilities to discourage unsafe practices

1.4 Sexually Transmitted Diseases (STDs)

• Definition
  • Sexually transmitted diseases (STDs) are infections transmitted through sexual intercourse.
• Also called:
  • Sexually transmitted infections (STIs)
  • Venereal diseases (VD)
  • Reproductive tract infections (RTI)

Common STDs

• Gonorrhoea
• Syphilis
• Genital herpes
• Chlamydiasis
• Genital warts
• Trichomoniasis
• Hepatitis-B
• HIV/AIDS (most dangerous)

Other Modes of Transmission

• Sharing infected needles or surgical instruments
• Blood transfusion from infected donor
• From infected mother to foetus
• Contact with infected body fluids (in some cases)

Curability

• Most STDs are curable if detected early and treated properly.
• However, the following are not completely curable:
  • Hepatitis-B
  • Genital herpes
  • HIV/AIDS

Early Symptoms

• Itching
• Abnormal fluid discharge
• Mild or slight pain
• Swellings in genital region
• Females may remain asymptomatic and undetected

Complications (If Untreated)

• Pelvic inflammatory disease (PID)
• Abortions
• Stillbirths
• Ectopic pregnancies
• Infertility
• Cancer of the reproductive tract

Prevention and Early Detection

• STDs are highly prevalent in the age group of 15–24 years
• Early detection is important for a healthy society

• Prevention Tips
  • Avoid sexual contact with unknown or multiple partners.
  • Use condoms during intercourse.
  • In case of doubt, consult a qualified doctor for early diagnosis and complete treatment.

1.5 Infertility

• Definition
  • Inability of a couple to conceive or produce children despite unprotected sexual intercourse is called infertility.

Causes of Infertility:

• Infertility may arise due to:
  • Physical disorders
  • Congenital (from birth) abnormalities
  • Genetic factors
  • Diseases
  • Effects of certain drugs
  • Immunological factors
  • Psychological disorders

Common Misconceptions

• In many cases, especially in India, females are blamed for childlessness.
• However, infertility can be due to problems in either the male or the female partner.

Help for Infertile Couples

• Infertility Clinics
  • Specialised healthcare units (infertility clinics) help in:
    • Diagnosis of the cause
    • Corrective treatment, where possible
• When natural correction is not possible, couples can be assisted through special techniques.

Assisted Reproductive Technologies (ART)

• ART includes specialised medical techniques that help infertile couples to have children.

1. In Vitro Fertilisation (IVF)

• Also known as the test tube baby programme.
• Procedure
  • Ova from the wife or a donor and sperms from the husband or a donor are collected
  • Fertilisation occurs outside the body (in vitro) under laboratory conditions
  • Eggs and sperm are combined outside the body to form a zygote
  • The formed zygote or embryo is transferred into the female reproductive tract

Embryo Transfer Techniques

1. Zygote Intra Fallopian Transfer (ZIFT)
   • Embryo up to 8 blastomeres (cells) is transferred into the fallopian tube
2. Intra Uterine Transfer (IUT)
   • Embryo with more than 8 blastomeres (cells) is transferred into the uterus

• In some cases:
  • A developing embryo may be transferred into the uterus of another female (surrogate mother)

2. Gamete Intra Fallopian Transfer (GIFT)

• Used when a female cannot produce ova but can provide a suitable environment for fertilisation and development.
  • Ovum (egg) from a donor and sperm are introduced into the fallopian tube
  • Fertilisation occurs inside the body

3. Intra Cytoplasmic Sperm Injection (ICSI)

• A sperm is directly injected into the cytoplasm of an ovum in the laboratory
• The resulting embryo is later transferred by ZIFT or IUT

4. Artificial Insemination (AI)

• Used when:
  • Male partner is unable to inseminate
  • Male has very low sperm count
• Procedure:
  • Semen from the husband or a healthy donor is introduced artificially into the vagina or uterus
• When introduced into the uterus:
  • It is called Intra Uterine Insemination (IUI)

CHALLENGES

• Require highly precise handling by specialised professionals
• Need expensive equipment
• Available only in limited centres
• Associated with emotional, religious and social concerns

ALTERNATIVE SOLUTION

• Adoption
  • Legal adoption of orphaned children is a suitable option for couples seeking parenthood
  • Provides care and security to orphaned children

Chapter Summary

Reproductive Health

• Reproductive health refers to total well-being in physical, emotional, behavioural and social aspects of reproduction.
• India was among the first countries to initiate national-level action plans for reproductive health through family planning and Reproductive and Child Health (RCH) programmes.
• Key steps include counselling and awareness regarding:
  • Structure and function of reproductive organs
  • Adolescence and related changes
  • Safe and hygienic sexual practices
  • Sexually transmitted diseases (STDs), including AIDS

Medical Facilities and Care

• Important areas covered under reproductive healthcare include:
  • Menstrual problems and irregularities
  • Pregnancy and safe delivery
  • Medical Termination of Pregnancy (MTP)
  • Prevention and treatment of STDs
  • Birth control methods
  • Diagnosis and treatment of infertility
  • Postnatal care of mother and child

Improvement in Reproductive Health

• Indicators showing improvement in reproductive health include:
  • Reduction in maternal mortality rate (MMR) and infant mortality rate (IMR)
  • Early detection and proper treatment of STDs
  • Increased medical assistance during childbirth
  • Support to infertile couples through specialised techniques

Population Growth and Contraceptives

• Population growth increased due to improved health facilities and better living conditions.
• To control population growth, promotion of contraceptive methods is necessary. These include:
  • Natural and traditional methods
  • Barrier methods
  • Intrauterine devices (IUDs)
  • Oral contraceptive pills
  • Injectables and implants
  • Surgical (sterilisation) methods
• Contraceptives are used to avoid, delay or space pregnancies.

Medical Termination of Pregnancy (MTP)

• MTP is the intentional termination of pregnancy before full term and is legally permitted in India under specified conditions.
• Reasons for MTP include:
  • Unwanted pregnancy due to rape or unprotected intercourse
  • Contraceptive failure
  • Risk to the life or health of the mother or foetus

Sexually Transmitted Diseases (STDs)

• STDs are infections transmitted mainly through sexual contact.
• Possible complications if untreated include:
  • Pelvic inflammatory disease (PID)
  • Stillbirth
  • Infertility
• Prevention and early detection are essential:
  • Avoid sexual contact with unknown or multiple partners
  • Use condoms during intercourse
  • Seek medical advice for early diagnosis and complete treatment

Infertility

• Infertility refers to inability to conceive after prolonged unprotected intercourse (commonly considered around two years).
• Methods to assist infertile couples include:
  1. In vitro fertilisation (IVF)
  2. Embryo transfer techniques (Test Tube Baby Programme)
• These techniques help couples achieve parenthood when natural conception is not possible.