Preview:

The last chapter speaks about the processes by which Reproduction occurs in humans; as a consequence of which, we shall study this chapter on Reproductive Health.

We will begin by discussing the various Problems and Strategies with respect to reproductive health of individuals. We will see why sex education and awareness programmes are necessary for maintaining good reproductive health and to control the problem of population explosion prevalent in our country.

We shall look into the various birth control measures in detail which include: use of barriers like, condoms, Copper-T, diaphragms which prevent the fusion of male and female gametes, thus, preventing fertilization. These are called Barrier methods. You would be interested to find that, fertilization can also be prevented by Natural methods without the need for using barriers like say, by avoiding intercourse when the female is ovulating in which case it is called, Periodic Abstinence. Other methods of contraception include: Hormonal and Surgical methods. In Hormonal method, progestogen or progesterone is administered to stop one from getting pregnant. Surgical methods are permanent and adopted by couples who do not wish to have any children further. It is achieved through vasectomy (a small part of the vas deferens is removed or tied up) in males and tubectomy (a small part of the fallopian tube is removed or tied up) in females.

Next, we will look at an important topic called MTP Medical termination of Pregnancy as the Intentional or voluntary termination of pregnancy before full term. It is significant to avoid unwanted pregnancies or in certain cases where continuation of the pregnancy could be harmful or even fatal either to the mother or to the foetus or both.

Then, we will study about Sexually Transmitted Diseases (STD) asDiseases or infections which are transmitted through sexual intercourse. These diseases are passed during blood transfusions, infected mother to foetus or by unsterilized needles and surgical instruments used on infected patients. Although some may show symptoms like Itching, fluid discharge, slight pain and swelling in the genital region, most STDs remain undetected for a long time. It is important to control them by implementing preventive measures about which we will study in the corresponding section.

Finally, we shall look at why infertility is caused and how the condition can be overcome. Infertility is the condition in which couples are unable to produce children despite of unprotected sexual co-habitation (or sexual relationship) is called infertility.

4.0 Introduction:

• According to the World Health Organisation (WHO), a good reproductive health means: a total well-being in all aspects of reproduction, that is, physical, emotional, behavioural and social.
• Therefore, a society with people having physically and functionally normal reproductive organs; and normal emotional and behavioural interactions among themselves in all sex-related aspects might be called reproductively healthy.
• In this chapter, we shall see why it is significant to maintain reproductive health and what are the methods taken up to achieve it.

Questions for the section:

1. When do you call a society reproductively healthy ?

4.1 Reproductive Health Problems and Strategies

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

1. Over population: The large population of our country is a major problem; which was the root cause for all reproductive health issues. India was amongst the first countries in the world to initiate action plans and programmes at a national level to attain total reproductive health as a social goal. These programmes called family planning were initiated in 1951 and were periodically assessed over the past decades. Improved programmes covering wider reproduction-related areas are currently operational under the popular name Reproductive and Child Health Care programmes (RCH). Creating awareness among people about various aspects related to reproduction, providing facilities and support for building up a reproductively healthy society are the major tasks under these programmes.

2. Awareness about reproduction: Governmental and Non-governmental agencies have taken various steps to create awareness among the people about reproduction-related aspects. Parents, other close relatives, teachers and friends, also have a major role in passing such information.

3. Sex education: Introduction of sex education in schools should also be encouraged to provide right information to young children. Providing such education would discourage children from believing in myths and having misconceptions about sex-related aspects.

4. Knowledge of growth of reproductive organs and STDs: Proper information about reproductive organs, adolescence and related changes, safe and hygienic sexual practices, sexually transmitted diseases (STD) like: AIDS, would help people, especially those in the adolescent age group to lead a reproductively healthy life.

5. Birth control and care of mother and child: Couples and those in marriageable age group need to be informed about available birth control options, care of pregnant mothers, post-natal care of the mother and child, importance of breast feeding and about importance of bearing male and the female child without any discrimination, eliminating the threat of female infanticide.

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 need to be created to enable people to think and take up necessary steps to prevent them and thereby build up a socially responsible and healthy society.

7. Infra-structural facilities and material support can be achieved through:

a) Successful implementation of various action plans for improved reproductive health requires strong infrastructural facilities, professional expertise and material support. These are essential to provide medical assistance like: Care to people in reproduction-related problems like pregnancy, delivery, STDs, abortions, contraception, menstrual problems and infertility.

b) A Statutory ban on amniocentesis, a foetal sex determination test based on the chromosomal pattern in the amniotic fluid surrounding the developing embryo to legally check increasing female foeticides.

c) Massive child immunisation programmes need to be implemented to achieve better reproductive health of the overall population.

8. Research on reproduction related areas: Research on various reproduction-related areas are encouraged and supported by governmental and non-governmental agencies to find out new methods to improve upon the existing research work in the field. For instance, Saheli, a new oral contraceptive for the females was developed by the scientists at Central Drug Research Institute (CDRI).

9. Medical Facilities: Better detection and cure of STDs and overall increased medical facilities for all sex-related problems indicate an improved reproductive health of the society.

Note box: Amniocentesis: It is afoetal sex determination test based on the chromosomal pattern in the amniotic fluid surrounding the developing embryo. Procedure: It involves collection of a small sample of amniotic fluid, which contains foetal tissues. It is taken from the amniotic sac that surrounds a developing foetus, and then the foetal DNA is examined for genetic abnormalities. The most common reason to have the test is to determine whether a baby has certain genetic disorders or a chromosomal abnormality, such as Down syndrome. If it is found that the baby is likely to suffer from a serious congenital defect, the mother should get the foetus aborted.

Questions for section 4.1:

1. List and explain the problems with regard to reproductive health of our country and strategies adopted to mitigate them.
2. What is Amniocentesis? Explain the procedure.

4.2 Population Explosion and Birth Control

Definition box: 1. Population: Population is defined as the total number of individuals of a species present in a particular area at a given time. 2. Demography: The statistical study of human population is called demography. This includes: Rates of birth, death, incidence of diseases and other factors that affect the human population. 3. Census: The official counting of population and preparing data about births, deaths, sex ratio, education is called census. In India, the first census was carried out in 1891 and has been conducted every 10 years since then.

Three important aspects of demography:

1. Changes in population
2. Composition of population
3. Distribution of population

Reasons for population explosion:
Population explosion: A sudden, large increase in the size of a population is called Population Explosion.

1. A rapid decline in death rate, Maternal Mortality Rate (MMR) and Infant Mortality Rate (IMR) due to better medical facilities.
2. An increase in number of people in the reproducible age.
3. Better public health care and greater medical attention.
4. Control of certain diseases like plague and small pox.
5. Protection from natural communities.
6. Better availability of food due to advancement in agriculture, improvement in storage facility and transport facilities.

Though Reproductive and Child-care (RCH) programmes 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, which is, just 17 deaths per 1000 infants born per year.

Measures to control over population:

1. Education: For educating people to accept a small family norm, the government has to create awareness about population explosion and change people s minds to have small families especially those in the reproductive age group. Non-government organizations (NGOs), mass media and educational institutions can play significant role in this campaign. For instance, the advertisements in the media and posters showing a happy couple with two children and a slogan that says: Hum do, Hamare do is one such example.
2. Raising of marriageable age: Raising of marriageable age is one of the effective means to control population. Presently, the marriageable age for females is 18 years and that for males is 21 years.
3. Incentives: Certain incentives can be given to the couples with small families. They maybe in the form of promotion in the service of couples adopting one child norm or by providing free education to single child.
4. Family planning: The couples of reproductive age can be motivated to plan their families by adopting birth control measures.

Definition box: Birth control: Birth control is the prevention of birth by using some kind of contraceptive measure.

An ideal contraceptive should be:

1. User friendly
2. Easily available and reversible
3. with none or least side-effects
4. Should not interfere with sexual drive or desire of the user.

Contraceptive methods:

1. Natural methods: These methods work on principle of avoiding chances of meeting of ovum and sperms. The various natural methods are listed below:

a) Periodic Abstinence (Avoiding of sex): It is one such method in which the couples avoid or abstain from coitus from day 10 to 17 of the menstrual cycle when ovulation could be expected. This period is called the fertile period. The chances of fertilization of the egg are very high at this time of the cycle. Conception can thus be prevented by abstaining from coitus during this fertile period.

b) Withdrawal or coitus interrupts: This method needs good understanding between the wife and husband. The male partner withdraws his penis just before ejaculation so as to avoid insemination.

c) Lactational Amenorrhea (absence of menstruation): This method is based on the fact that ovulation and therefore, the menstrual cycle do not occur during the period of inters lactation the period following parturition. In the absence of menstrual cycles, there is no ovulation. Therefore, as long as the mother s breast feeds the child, full chances of conception are almost nil. However, this method is possible only up to 6 months after child birth.

2. Barrier methods: In barrier methods, ovum and sperms are prevented from physically meeting with the help of barriers. Such methods are available for both males and females.

a) Condoms: (Refer figure 4.1 a and b) Condoms are barriers made of thin rubber or latex sheath that are used to cover the penis in the male; or vagina and cervix in the female, just before coitus so that the ejaculated semen would not enter into the female reproductive tract. This can prevent conception.

For example: Nirodh is a popular brand of condom for the male.

Advantages of using condoms:

• Provides additional benefit of protecting the user from contacting STDs like AIDS.
• Both the male and the female condoms are disposable.
• They can be self-inserted and thereby gives privacy to the user.

b) Diaphragms, cervical caps and vaults: These barriers are made of rubber and are inserted into the female reproductive tract to cover the cervix during coitus. They prevent conception by blocking the entry of sperms through the cervix. They are reusable. Spermicidal creams, jellies and foams are usually used along-with these barriers to increase their contraceptive efficiency.

3. Intra Uterine Devices (IUDs): These devices are inserted by doctors or expert nurses in the uterus through vagina. These Intra Uterine Devices are presently available as:

a) Non-medicated IUDs: These increase phagocytosis of sperms within the uterus.

Example: Lippes loop

b) Copper releasing IUDs: TheseIUDs release Cu ions which suppress sperm motility and thus bring down the fertilising capacity of sperms. Examples: CuT, Cu7, Multiload 375, Progestasert, LNG-20 (see Figure 4.2).

c) Hormone releasing IUDs: They are hormone releasing IUDs which make the uterus unsuitable for implantation and the cervix hostile to the sperms.

IUDs are ideal contraceptives for the females who want to delay pregnancy and to give space between consecutive children. It is one of most widely accepted methods of contraception in India.

4. Oral contraceptive pills:

• They are used in the form of tablets and hence are popularly called the pills. They contain small doses of either progesterone or progesterone estrogen combinations and is a contraceptive method used by the females.
• Pills have to be taken daily for a period of 21 days starting preferably within the first five days of menstrual cycle. After a gap of 7 days (during which menstruation occurs) it has to be repeated in the same pattern till the female desires to prevent conception.
• These pills inhibit ovulation and implantation by inhibiting secretion of FSH and LH from pituitary.
• They also alter the quality of cervical mucus to prevent the entry of sperms.
• Pills are very effective with lesser side effects and are well accepted by the females. For example: Saheli the new oral contraceptive for the females contains a non-steroidal preparation. It is a once a week pill with very few side effects and high contraceptive value.

5. Injections and Implants:

Implants:

• The birth control implant is a tiny, thin rod about the size of a matchstick.
• A doctor inserts the implant under the skin of the females upper arm.
• It releases the hormone progestogen or progesterone to stop one from getting pregnant. (Figure 4.3).

Injections:

• Injections act in the same way as pills and implants.
• Their effective periods are much longer.
• Administration of progestogens or progestogen-estrogen combinations or IUDs within 72 hours of intercourse have been found to be very effective as emergency contraceptives as they could be used to avoid possible pregnancy due to rape or casual unprotected intercourse.

6. Surgical methods:

• Surgical methods are also called as sterilisation. They are generally advised for the male or female partner as a terminal method to prevent any more pregnancies.
• Surgical method works by blocking gamete transport and thereby preventing conception. There are two ways in which surgical method is adopted: a) Vasectomy b) Tubectomy

Vasectomy:

• Vasectomy is a sterilisation procedure used in males.
• In vasectomy, a small part of the vas deferens is removed or tied up through a small incision on the scrotum (as shown in Figure 4.4a).

Tubectomy:

• Tubectomy is a sterilisation procedure used in females.
• In tubectomy, a small part of the fallopian tube is removed (Figure 4.4b) or tied up through a small incision in the abdomen or through vagina.

Note box: 1. Surgical methods are highly effective but their reversibility is very poor. 2. The selection of a suitable contraceptive method and its use should always be undertaken in consultation with qualified medical professionals. One must also remember that contraceptives are not regular requirements for the maintenance of reproductive health. In fact, they are practiced against a natural reproductive event like conception or pregnancy. Their possible ill-effects like nausea, abdominal pain, breakthrough bleeding, irregular menstrual bleeding or even breast cancer, though not very significant, should not be totally ignored.

4.3 Medical Termination of Pregnancy (MTP)

Introduction:

• Medical termination of pregnancy: Intentional or voluntary termination of pregnancy before full term is called medical termination of pregnancy (MTP) or induced abortion.
• MTP has a significant role in decreasing the population though it is not meant for this purpose. Whether to accept or legalise MTP or not is being debated upon in many countries due to emotional, ethical, religious and social issues involved in it.
• Government of India legalised MTP in 1971 with some strict conditions to avoid its misuse. Such restrictions are all the more important to check indiscriminate and illegal female foeticides which are reported to be high in India.

Why MTP0

1. To get rid of unwanted pregnancies either due to casual unprotected intercourse, failure of the contraceptive used during intercourse or to terminate pregnancy due to rapes.
2. MTPs are also essential in certain cases where continuation of the pregnancy could be harmful or even fatal either to the mother or to the foetus or both.

Disadvantages of MTPs:

• MTPs are considered relatively safe during the first trimester, that is, up to 12 weeks of pregnancy. Second trimester abortions are much more risky.
• Majority of the MTPs are performed illegally by unqualified quacks which are not only unsafe but could also be fatal.
• Another dangerous trend is the misuse of amniocentesis to determine the sex of the unborn child. Frequently, if the foetus is found to be female, it is followed by MTP. Such practices should be avoided because these are dangerous both for the young mother and the foetus.
• Effective counselling on the need to avoid unprotected intercourse and on the risk factors involved in illegal abortions; and providing more health care facilities could reverse the mentioned unhealthy trend.

Questions for sections 4.2 and 4.3:

1. Define:

a) Population

b) Demography

c) Census

d) Birth control.

2. List the three important aspects of demography.

3. What is population explosion? State five reasons for the same.

4. What are the measures that are used to control over population?

5. List the characteristics of an ideal contraceptive.

6. List and explain the six major methods of contraception.

7. What is MTP? Explain two cases where the procedure is performed.

8. What are the disadvantages of MTP?

4.4 Sexually Transmitted Diseases (STDs)

Definition box:   Sexually transmitted diseases: Diseases or infections which are transmitted through sexual intercourse are called sexually transmitted diseases (STD) or venereal diseases (VD) or reproductive tract infections (RTI).

Example box:   Gonorrhoea, syphilis, genital herpes, chlamydiasis, genital warts, trichomoniasis, hepatitis-B and HIV that leads to AIDS are some of the common STDs.

Transmission of STDs occurs by:

a) Sharing of injection needles and surgical instruments with infected persons.

b) Blood transfusion

c) Infected mother to foetus

Symptoms:

• Itching, fluid discharge, slight pain and swelling in the genital region.
• Infected females may often be asymptomatic (condition where there is no symptoms) and hence, the STD may remain undetected for long.

Effects and consequences of STDs:

• Pelvic Inflammatory Diseases (PID)
• Abortions and still births
• ectopic pregnancy (a condition in which the zygote gets implanted outside the uterus)
• infertility
• cancer of the reproductive tract

Note box: 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 to which you also belong!

Prevention of STDs:

a) Avoid sex with unknown and also avoid having sex with multiple partners.

b) Always use condoms during coitus.

c) In case of doubt, one should go to a qualified doctor for early detection and get complete treatment if diagnosed with a STD.

Questions for section 4.4:

1. Define Sexual Transmitted diseases.

2. List the ways by which STDs are transmitted.

3. List the general symptoms of STD.

4. What are the after-effects or consequences of an STD?

5. List the ways in which STDs can be prevented.

4.5 Infertility

Definition box: Infertility: The condition where couples are unable to produce children despite of unprotected sexual co-habitation (or sexual relationship) is called infertility.

Reasons for infertility could be:

• physical or congenital diseases (diseases that are innate or inherent or inherited)
• consumption of drugs
• immunological and psychological defects

Note box:   In India, the female is often blamed for the couple being childless, but more often than not, the problem lies in the male partner. Specialised health care units like infertility clinics could help in diagnosis and corrective treatment of some of these disorders and enable these couples to have children.

Assisted reproductive technologies:

When infertility cannot be treated, the couples could be assisted to have children through certain special techniques commonly known as Assisted Reproductive Technologies (ART). They include:

a) In-vitro fertilisation (IVF):

• IVF involves fertilization of ovum outside the body followed by embryo transfer (ET).
• This method is popularly known as test tube baby programme.

Procedure:

1. Ova from the wife or donor female and sperms from the husband or donor male are collected and are induced to fuse and form the zygote, under stimulated conditions in the laboratory.

2. The zygote is allowed to divide. The resultant embryo (constituted by about 8 blastomeres) could then be transferred into the fallopian tube. This method is called ZIFT zygote intra fallopian transfer. If embryos with more than 8 blastomeres are introduced into the uterus, it is then called, IUT intra uterine transfer. In both cases, the embryo is allowed to complete its further development in the uterus.

b) In-vivo fertilization (IVFO): In-vivo fertilization is the fertilization of egg within the uterus of the fertile-donor-female; so as to avoid surgical transfer of egg into the uterus of a potential infertile female recipient.Embryos formed by in-vivo fertilization could thus be used for such transfer to assist those females who cannot conceive.

c) Gamete intra fallopian transfer (GIFT): If the ovum is transferred from a donor into the fallopian tube of another female who cannot produce one, but can provide suitable environment for fertilisation and further development of zygote, then it is called, GIFT gamete intra fallopian transfer.

d) Intra cytoplasmic sperm injection (ICSI): It is a specialised procedure to form an embryo in the laboratory. In this method, a sperm is directly injected into the ovum.

e) Artificial insemination: Cases of infertility either due to inability of the male partner to inseminate the female or due to very low sperm count in the ejaculate could be corrected by artificial insemination (AI) technique.

Procedure: The semen collected either from the husband or a healthy donor is artificially introduced either into the vagina; or into the uterus.

Note box: IUI intra-uterine insemination: When the semen collected either from the husband or a healthy donor is artificially introduced into the uterus, it will be called, IUI intra-uterine insemination of the female.

Questions for section 4.5:

1. Define infertility. List the reasons for infertility.

2. What are Assisted Reproductive Technologies? List and explain the different procedures by which it is conducted.