Study Notes on Reproductive Health

  • Reproductive health refers to healthy reproductive organs with normal functions.
  • However, it has a broader perspective as it involves well-being in other aspects too.
  • According to World Health Organisation (WHO) reproductive health means well being in physical, emotional, behavioural and social aspects of reproduction.
  • Therefore, reproductively, a healthy society comprises of people having physically and functionally normal reproductive organs and normal emotional and behavioural interactions among them in all sex-related aspects.

REPRODUCTIVE HEALTH – PROBLEMS AND STRATEGIES

Problems and strategies of reproductive health in human beings are explained as follows.

(1)Over population

  • The main problem of India is its excessive population which is directly connected with reproductive health and to achieve total reproductive health, some plans and programmes were started.
  • Family planning programme was initiated in 1951 in India and were popularly named as Reproductive and Child Health Care (RCH) programmes.
  • The major tasks carried out under these programmes are to provide facilities and support for building up a reproductively healthy society.

(2) Awareness about reproduction

  • Audio-visual and print media, governmental and non-governmental agencies are doing a good job to create awareness among people about reproduction in humans.

(3) Sex Education

  • Sex education in schools should also be introduced and encouraged to provide right information about myths and misconceptions about sex-related aspects.

(4) Knowledge of growth of reproductive organs and STDS

  • Proper information about reproductive organs, adolescence (period of rapid growth between childhood and adulthood), safe and hygienic sexuai practices, sexually transmitted diseases (STDS), e.g., AIDS etc., would help to lead a repraductively healthy life.

(5) Birth control devices and care of mother and child

  • Fertile couples and people of marriageable age group should know about available birth control devices, care of pregnant mothers, postnatal (after birth) care of the mother and child, importance of breast feeding, equal importance for the male and female child, etc.

(6) Prevention of sex abuse and sex related crimes

  • Awareness of problems due to uncontrolled population growth, social evils like sex abuse and sex-related crimes, etc. need to be created so that people should think and take up necessary steps to prevent them and thereby build up a reproductively healthy society,

(7) Information about reproduction related problems

  • The success of plans to attain reproductive health requires good infrastructural facilities, professional expert knowledge and material support.
  • These are necessary to provide medical help and care for reproduction related problems like menstrual problems, infertility, pregnancy, delivery, contraception, abortions, sexually transmitted diseases (STDS

(8) Amniocentesis

  • Amniocentesis is a foetal sex and disorder determination test based on the chromosomal pattern of the embryo’s cells in the amniotic fluid surrounding the developing embryo.
  • Amniotic fluid contains cells from the skin of the foetus and other sources.
  • These cells can be used to determine the sex of the infant, to identify some abnormalities in the number of chromosomes and to detect certain biochemicals and enzymatic abnormalities.
  • Misuse of Amniocentesis : It is being misused to know the sex of unborn baby followed by medical termination of foetus, in case its female.

(9) Research in reproductive health area

  • It should be encouraged and supported to find out new methods.
  • “Saheli” a new oral contraceptive for the females was developed by our scientists at Central Drug Research Institute (CDRI) in Lucknow, India.

(10) Medical facilities

  • Better awareness about sex related problems, prenatal care of mother, medically assisted deliveries and post natal care of mother and infant decrease maternal and infant mortality.
  • Small families, better detection and cure of sexually transmitted diseases (STDS) and increased medical facilities for sex-related problems, etc. indicate improved reproductive health of male and female individuals and children

Measures to Control Over Population

  1. Education : People, particularly those in the reproductive age group, should be educated about advantage of a small family. Mass media and educational institutions can play an important role in this campaign. Posters showing a happy couple with two children with a slogan “Hum Do Humare Do” should be displayed. Many couples have even adopted “one child norm”.
  2. Marriageable Age : Raising of the age of marriage is a more offective means to control the population (now marriageable age of female is 18 years and that of male is 21 years).
  3. Incentives: Couples with small families should be given incentives.
  4. Family planning: There are many birth control measures which can check birth rate.

HUMAN POPULATION GROWTH

  • Census gives information about the number of individuals present in a given region at a given time.
  • The time required for a population to double itself is called the doubling time.
  • The present growth rate of approximately 1.7percent per year (17 individuals per 1000 of population) for India is smaller than the peak of about 2.1 percent per year during 1965-1970.
  • Population growth rate is indicated by

        (i)the annual average growth rate and

        (ii) the doubling time.

Growth rate depends on birth (fertility) rate, death (mortality) rate, migration and age sex ratio.

  • In the last century an all-round development in various fields significantly improved the quality of life of the people. However, increased health facilities along with better living conditions had an explosive impact on the growth of population.
  • The world population which was around 2 billion (2000 million) in 1900 rocketed to about 6 billions by 2000. A similar trend was observed in India too.
  • Our population which was approximately 350 million at the time of our independence reached close to the billion mark by 2000 and crossed 1 billion in May 2000. That means, every sixth person in the world is an Indian.
  • A rapid decline in death rate, maternal mortality rate (MMR) and infant mortality rate (IMR) as well as an increase in number of people in reproducible age are probable reasons for this.
  • Through our RCH programmes, though we could bring down the population growth rate, it was only marginal. According to the 2001 census report, the population growth rate was still around 1.7 per cent, i.e., 17/1000/year, a rate at which our population could double in 33 years.

METHODS OF BIRTH CONTROL

Contraceptives

  • They are the devices which prevent conception or pregnancy without interferring in the reproducive hearh of the individuals in any way.
  • Characteristics of an ideal contraceptive are

(i)User friendly, ie., comfortable and easy to use.

(ii)Absence of side affects

(iii)Reversible, ie., when the user wants to conceive, it should be easy to be interrupted

(iv)Completely effective against pregnancy.

There are several methods of contraception-natural or traditional, barriers, IUDS, oral contraceptives, Injectables,implants and surgical methods.

Couple protection is the process of bringing eligible couples under family planning measures. In India, Ais over 55% at present and is voluntary in nature.

In 2004, there were 60-79 lakh IUD insertions, 48 74 lakh sterilisations or surgical interventions, 249.9 lakh condom users and 87 54 lakh oral pill users

1.Natural Methods : They are the methods which do not require any device, medicine or religious sanction. Natural methods are of three kinds-safe period, withdrawal and breast feeding

(i)Safe period (Rhythm Method) :

  • Ovulation occurs roughly about the middle of menstrual cycle.
  • Fertility period when fertilisation can occur is upto 24 hours after ovulation.
  • Avoiding sex during the fertility period will naturally prevent conception
  • It is however, always better to avoid sex from day 10-17 of the menstrual cycle.

(ii) Withdrawal Method (Coitus Interruptus)

  • The method is based on withdrawal of penis before ejaculation.
  • This method has a high failure rate due to pre-ejaculatory emission of sperms to withdraw penis before ejaculation.

(iii) Lactational Amenorrhoea

  • Just after parturition, there is a phase of amenorhoea or absence of menstruation. It is also the phase of intense lactation.
  • Breast feeding the child fully prevents conception, The method is however, effective only upto a maximum period of six months.

2.Barrier Methods

  • They are mechanical devices which prevent the deposition of sperms into vagina and their passage into uterus.
  • Further, they can be self-inserted by the user in complete privacy.
  • The common barrier methods are condoms, diaphragms, fem shields and cervical caps.

(i)Condom : It is a tubular latex sheath which is rolled over the male copulatory organ during sex.The common brand provided by family welfare services is Nirodh. The device also provides protection against sexually transmitted diseases including AIDS.

(ii) Fem Shield (Female Condom) : The device is a polyurethane pouch with a ring at either end.The inner ring is smaller and present at the inner closed end. The device covers the external genital as well as lines the vagina. Fem shield provides protection from sexually transmitted diseases also.

(iii) Diaphragm : It is a tubular rubber sheath with a flexible metal or spring ring at the margin which is fitted inside the vagina.

(iv) Cervical Cap : It is a rubber nipple which is fitted over the cervix and is designed to remain there by suction. The device prevents the entry of sperms into uterus.

(v)Vault Cap : It is a hemispherical dome-like rubber or plastic cap with a thick rim which is meant for fitting over the vaginal vault over the cervix.

3.Chemical Methods :

  • They are the contraceptives which contain spermicidal chemicals.
  • The chemical contraceptives are available in the form of creams (e.g., delfen), jellies (perceptin, volpar paste), foam tablets (e.g., aerosol foam, chlorimin T or contab).
  • They commonly contain lactic acid, boric acid, citric acid, zinc sulphate and potassium permanganate.
  • The contraceptives are introduced in vagina prior to sex.
  • Sponge (Today) is a foam suppository or tablet containing nonoxynol-9 as spermicide. It kills the sperm by disrupting the membrane. It is moistened before use to activate the spermicide
  • The device also absorbs ejaculate.

4.Intrauterine Devices (IUDS) (Intrauterine Contraceptive Devices or IUCDS)

  • The devices are made of plastic, metal or a combination of the two and are inserted into the uterus to prevent conception.
  • IUDS are called loops, spirals, rings, bows, shields or Ts depending upon the shape.
  • IUDS are of three types- inert, copper releasing and hormone releasing.
  • The inert IUDS are made of polyethylene impregnated with barium sulphate or stainless steel e.g., Lippe’s loop. The exact mechanism of inert IUD contraception is not clear.
  • There is impairment of sperm ascent.
  • There is quick tubal motility resulting in premature migration of fertilised eggs into uterus before it is ready for receiving it.
  • Histological and biochemical changes in endometrium which have gametotoxic and spermicidal effect.

Copper IUDS commonly called Copper-Ts have ionised copper which slowly diffuses at the rate of some 50 ug/day. It has a local antifertility effect by bringing about release of toxic cytokines. They suppress sperm motility and their ability to fertilize the ovum.

Hormone releasing IUDS include progesterone IUD (e.g., progestasert) etc. These devices release small quantities of hormones which supress endometrial changes and changes in cervical mucus, cause anovulation and insufficient luteal activity.

5.Oral Contraceptives (Oral Pills)

  • They are preparations containing either progestin (progestogen or synthetic progesterone) alone or a combination of progestogen and oestrogen (estrogen).
  • The pills are taken orally for 21 days in a menstrual cycle starting from 5th day and ending on 25″ day. However, it is advisable to restart the course after a gap of 7 days, irrespective of the onset or nonset of menstruation during the pill free days
  • When a pill is missed, it should be taken whenever one remembers, sometimes two at a time
  • This helps in keeping the hormonal level required for contraception. Hormonal pills act by four ways

(a) Inhibition of ovulation

(b) Alteration in uterine endometrium to make it unsuitable for implantation

(c) Changes in cervical mucus impairing. Its ability to allow passage and transport of sperms.

(d) Inhibition of motility and secretory activity of fallopian tubes.

  • Oral pills are of two types, combined pillis and minipills.
  • Combined pills contain both oestrogen and progestin. They are synthetic products. Oestrogen is anovulatory (inhibits FSH production). Progestin is also anovulatory (inhibits LH production). It protects the endometrial lining from adverse effect of oestrogen.

6.Implants :

  • They are hormone containing devices which are implanted subdermally for providing long term contraception.

7.Emergency Contraception

  • It is the treatment for unprotected sex, sexual assault, missed pills and other reasons which have risk of pregnancy.
  • The drugs used for treating emergency contraceptions are called morning-after pills
  • Two oral tablets to start and two tablets after 12 hours provide relief.

8.Surgical Methods of Family Planning

  • They are also called terminal methods of family planning.
  • Surgical methods are permanent methods of family planning where there is no need of replacement orpassage of semen in males and ova in females. The techniques are also called sterilization
  • They are called vasectomy in males and tubectomy in females,

Vasectomy-  It is a surgical method of sterilisation of males. Vasa deferentia are blocked by cutting and occluding them so that sperms are unable to pass down the male reproductive system.

Tubectomy– It is a surgical procedure of female sterilisation where a portion of both the fallopian tubes is excised or ligated to block the passage of ovum through them.

Side Effects of Contraceptive Methods

  • Except the natural methods, all other contraceptive procedures are unnatural.
  • Therefore, they must have some side effects like nausea, abdominal pain, breakthrough bleeding, irregular menstrual bleeding etc. Some even try to link breast cancer with them.
  • However, the major cause of these discomforts is mental burden about accepting an artificial procedure for preventing unwanted pregnancy.
  • The benefits are several times the side effects experienced by some persons. Condoms protect the users from catching STDS, including AIDS, One or two children by a couple means a long and satisfying family life, happy reproductive health and well brought-up children.

Induced Abortion : Abortion refers to the premature expulsion of the conception products from the uterus, usually before the 20th week of pregnancy. An abortion may be spontaneous (naturally occurring), sometimes called a miscarriage or induced (intentionally performed)

Medical Termination of Pregnancy (MTP)

  • It is voluntary or intentional abortion, induced and performed to end pregnancy before the completion of full term.
  • Worldwide, nearly 20% of the total pregnancies get aborted. The number of MTPS is 40-50 million/yr.
  • Therefore, MTPS have a significant role in containment of population though they are not performed for this purpose.
  • They are mainly meant for removing unsustainable pregnancies. Many countries do not have a law about MTPS because the latter is a proper act, Medical Termination of Pregnancy Act, 1971. It is mainly meant for preventing unnatural maternal deaths due to unsafe abortions (8.9% of the total maternal deaths).
  • The act was amended in 2002. Under this act, termination of pregnancy can be done upto 20 weeks, if the pregnancy is likely to produce a congenitally malformed child, is a result of rape or contraceptive failure or is likely to harm the mother. emotional, ethical, religious and social isues.
  • However, in India there MTP is safe if it is performed upto 12 weeks (first trimester) of pregnancy,
  • Second trimester abortions are risky. They are generally performed after testing the sex of the baby through amniocentesis or sonography.
  • It has resulted in large scale female foeticide and complications due to unsafe abortions in the hands of untrained persons.
  • To prevent such mis-happenings, the government has enacted a law, Pre-natal diagnostic techniques (Regulation and Prevention of Misuse) Act, 1994 with amendments in 2003. It prohibits preconception and prenatal sex determination.

 SEXUALLY TRANSMITTED DISEASES (STDS)

  • Diseases or infections which are transmitted through sexual intercourse are collectively called sexually transmitted diseases (STD) or venereal diseases (VD) or reproductive tract infections (RTI).
  • Gonorrhoea, syphilis, genital herpes, chlamydiasis, genital warts, trichomoniasis, hepatitis-B and HIV leading to AIDS are some of the common STDs.
  • Among these, HIV infection is most dangerous
  • Some of these infections like hepatitis–B and HIV can also be transmitted by sharing of injection needles, surgical instruments, etc., with infected persons, transfusion of blood, or from an infected mother to the foetus too.
  • Except for hepatitis-B, genital herpes and HIV infections, other diseases are completely curable if detected early and treated properly.
  • Early symptoms of most of these are minor and include itching, fluid discharge, slight pain, swellings, etc., in the genital region.
  • Infected females may often be asymptomatic and hence, may remain undetected for long.
  • Absence or less significant symptoms in the early stages of infection and the social stigma attached to the STDs, deter the infected persons from going for timely detection and proper treatment.
  • This could lead to complications later, which include pelvic inflammatory diseases (PID), abortions, still births, ectopic pregnancies, infertility or even cancer of the reproductive tract.
  • STDs are a major threat to a healthy society. Therefore, prevention or early detection and cure of these diseases are given prime consideration under the reproductive health-care programmes.
  • Though all persons are vulnerable to these infections, their incidences are reported to be very high among persons in the age group of 15-24 years – the age group but Prevention is better than cure.
  • One could be free of these infections if one follow the simple principles
  • Avoid sex with unknown partners/multiple partners.
  • Always use condoms during coitus.
  • In case of doubt, go to a qualified doctor for early detection and get complete treatment if diagnosed with disease.

INFERTILITY

  • A large number of couples all over the world including India are infertile, i.e., they are unable to produce children inspite of unprotected sexual co-habitation.
  • The reasons for this could be many–physical, congenital, diseases, drugs, immunological or even psychological.
  • Specialised health care units (infertility clinics, etc.) could help in diagnosis and corrective treatment of some of these disorders and enable these couples to have children.
  • However, where such corrections are not possible, the couples could be assisted to have children through certain special techniques commonly known as assisted reproductive technologies (ART).

1.IVF(In vitro fertilization)

  • In vitro fertilisation (IVF)–fertilisation outside the body in almost similar conditions as that in the body) followed by embryo transfer (ET) is one of such methods.
  • In this method, popularly known as test tube baby programme, ova from the wife/donor (female) and sperms from the husband/donor (male) are collected and are induced to form zygote under simulated conditions in the laboratory.
  • The zygote or early embryos (with upto 8 blastomeres) could then be transferred into the fallopian tube (ZIFT–zygote intra fallopian transfer) and embryos with more than 8 blastomeres, into the uterus (IUT – intra uterine transfer), to complete its further development.
  • Embryos formed by in-vivo fertilisation (fusion of gametes within the female) also could be used for such transfer to assist those females who cannot conceive.
  • Transfer of an ovum collected from a donor into the fallopian tube (GIFT – gamete intra fallopian transfer) of another female who cannot produce one, but can provide suitable environment for fertilisation and further development is another method attempted.

2.ICSI(Intra cytoplasmic sperm injection)

  • Intra cytoplasmic sperm injection (ICSI) is another specialised procedure to form an embryo in the laboratory in which a sperm is directly injected into the ovum.
  1. AI(Artificial insemination)
  • Infertility cases either due to inability of the male partner to inseminate the female or due to very low sperm counts in the ejaculates, could be corrected by artificial insemination (AI)
  • In this technique, the semen collected either from the husband or a healthy donor is artificially introduced either into the vagina or into the uterus (IUI – intra-uterine insemination) of the female.

Though options are many, all these techniques require extremely high precision handling by specialised professionals and expensive instrumentation.Since the ultimate aim of all these procedures is to have children, in India we have so many orphaned and destitute children, who would probably not survive till maturity, unless taken care of. Our laws permit legal adoption and it is as yet, one of the best methods for couples looking for parenthood