Reproductive Health — Notes

Reproductive health (WHO): a total well-being in all aspects of reproduction — physical, emotional, behavioural and social. A reproductively healthy society has people with physically and functionally normal reproductive organs and normal emotional and behavioural interactions in all sex-related aspects.

Programmes. India initiated family planning in 1951; improved programmes now cover wider areas under Reproductive and Child Health Care (RCH). Actions include: creating awareness through audio-visual and print media; sex education in schools to provide right information and discourage myths and misconceptions; educating people about birth control, care of pregnant mothers, post-natal care, breast-feeding, equal opportunities for male and female children; medical facilities for pregnancy, delivery, STDs, abortions, contraception, menstrual problems and infertility; the statutory ban on amniocentesis for sex determination to check female foeticide; and mass child immunisation. Better care has reduced maternal and infant mortality and increased medically assisted deliveries.

Population explosion. India’s population was about 350 million at independence, close to 1 billion in 2000 and about 1.2 billion in 2011. Causes: rapid decline in the death rate, maternal mortality rate (MMR) and infant mortality rate (IMR), and an increase in the number of people in the reproducible age. The growth rate in 2011 was below 2 percent (about 20 per 1000 per year), which still increases the population quickly. Consequences: scarcity of basic requirements such as food, shelter and clothing.

Government measures: motivating smaller families through contraception (slogan “Hum Do Hamare Do”; many couples adopt a one-child norm); raising the marriageable age to 18 years for females and 21 years for males; incentives to couples with small families.

An ideal contraceptive is user-friendly, easily available, effective and reversible, with no or least side-effects, and does not interfere with sexual drive, desire or the sexual act.

Natural methods (avoid chances of ovum and sperm meeting):

• Periodic abstinence: avoid coitus from day 10 to 17 of the menstrual cycle, when ovulation is expected.
• Withdrawal (coitus interruptus): the male withdraws before ejaculation, avoiding insemination.
• Lactational amenorrhea: absence of menstruation and ovulation during intense lactation after parturition; effective only up to about six months. These have no side-effects but high failure rates.

Barrier methods (prevent ovum and sperm from meeting): condoms (male and female; disposable; also protect against STDs and AIDS); diaphragms, cervical caps and vaults (rubber barriers inserted to cover the cervix; reusable). Spermicidal creams, jellies and foams are used with them to increase efficiency.

Intrauterine devices (IUDs), inserted by doctors or trained nurses into the uterus through the vagina:

• Non-medicated: Lippes loop.
• Copper-releasing: CuT, Cu7, Multiload 375 — copper ions suppress sperm motility and fertilising capacity.
• Hormone-releasing: Progestasert, LNG-20 — make the uterus unsuitable for implantation and the cervix hostile to sperms. IUDs increase phagocytosis of sperms within the uterus. They are ideal for females who want to delay pregnancy or space children; one of the most widely accepted methods in India.

Hormonal methods (pills, injections, implants of progestogens or progestogen–estrogen combinations): pills are taken daily for 21 days starting within the first five days of the cycle, then after a gap of 7 days repeated. They inhibit ovulation and implantation and alter the quality of cervical mucus to prevent or retard entry of sperms. Saheli, a new oral contraceptive for females, is a once-a-week, non-steroidal pill developed at the Central Drug Research Institute (CDRI), Lucknow. Injections and implants under the skin act in the same way but over a much longer period. Progestogens, combinations or IUDs used within 72 hours of coitus are effective as emergency contraceptives.

Surgical methods (sterilisation) — terminal methods that block gamete transport: vasectomy (a small part of the vas deferens removed or tied through a small incision on the scrotum) and tubectomy (a small part of the fallopian tube removed or tied through a small incision in the abdomen or through the vagina). Highly effective, but reversibility is very poor.

Possible side-effects of improper use include nausea, abdominal pain, breakthrough bleeding, irregular menstrual bleeding and even breast cancer, though these are not very significant.

Medical termination of pregnancy (MTP) is the intentional or voluntary termination of pregnancy before full term (induced abortion). Nearly 45 to 50 million MTPs are performed in a year all over the world. The Government of India legalised MTP in 1971, with strict conditions to avoid its misuse, such as indiscriminate and illegal female foeticide, which is reported to be high in India.

• Reasons: to get rid of unwanted pregnancies due to casual unprotected intercourse or failure of contraception during coitus or rapes; and in cases where continuing the pregnancy could be harmful or even fatal to the mother or the foetus.
• MTPs are considered relatively safe during the first trimester. They must be performed by registered medical practitioners within the time limits and conditions laid down by law; MTP by unqualified quacks is unsafe and can be fatal. MTP is not a contraceptive.

Amniocentesis is a foetal sex-determination test based on the chromosomal pattern in the amniotic fluid surrounding the developing embryo. It can detect genetic and chromosomal disorders (for example Down’s syndrome) in the foetus, but its misuse to find the sex of the foetus led to female foeticide; its use for sex determination is banned by law in India.

A large number of couples all over the world, including India, are infertile: unable to produce children in spite of unprotected sexual cohabitation. The reasons could be physical, congenital, diseases, drugs, immunological or even psychological. In India the female is often blamed, but the problem is quite often in the male partner. Specialised health-care units (infertility clinics) help in diagnosis and corrective treatment, and where correction is not possible, assisted reproductive technologies (ART) help.

• In vitro fertilisation (IVF) — fertilisation outside the body in almost similar conditions as in the body, followed by embryo transfer (ET): popularly the test-tube baby programme. Ova from the wife or a donor and sperms from the husband or a donor are collected and induced to form a zygote under simulated conditions in the laboratory.
• ZIFT (zygote intra-fallopian transfer): the zygote or early embryo (up to 8 blastomeres) is transferred into the fallopian tube.
• IUT (intra-uterine transfer): an embryo with more than 8 blastomeres is transferred into the uterus.
• GIFT (gamete intra-fallopian transfer): transfer of an ovum from a donor into the fallopian tube of another female who cannot produce ova but can provide a suitable environment for fertilisation and development.
• ICSI (intra-cytoplasmic sperm injection): a sperm is directly injected into the ovum to form an embryo in the laboratory.
• AI (artificial insemination) / IUI (intra-uterine insemination): semen from the husband or a healthy donor is introduced into the vagina or into the uterus — useful when the male cannot inseminate or has a very low sperm count. Embryos formed by in vivo fertilisation (in the female) can also be transferred for further development.

ART needs high precision, specialised professionals and expensive instruments, so it is available only in a few centres; emotional, religious and social factors are also deterrents. Legal adoption is one of the best methods for couples looking for parenthood.

Diseases or infections transmitted through sexual intercourse are sexually transmitted diseases (STDs), also called venereal diseases (VD) or reproductive tract infections (RTI).

Transmission: mainly sexual; hepatitis B and HIV also by sharing injection needles and surgical instruments, transfusion of infected blood, or from an infected mother to the foetus.

Curability: except for hepatitis B, genital herpes and HIV infections, the others are completely curable if detected early and treated properly.

Symptoms: early symptoms are minor — itching, fluid discharge, slight pain, swellings in the genital region. Infected females may often be asymptomatic, so they may remain undetected for long; the social stigma attached also deters people from timely detection and treatment.

Complications: pelvic inflammatory diseases (PID), abortions, still births, ectopic pregnancies, infertility or even cancer of the reproductive tract. People in the 15–24 years age group are most at risk.

Prevention: avoid sex with unknown partners or multiple partners; always try to use condoms during coitus; in case of doubt, go to a qualified doctor for early detection and complete treatment.