Reproductive Health

Reproductive Health – Problems And Strategies

According to the World Health Organization (WHO), reproductive health is defined as a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes.

A reproductively healthy society is one that has people with physically and functionally normal reproductive organs and normal emotional and social interactions in sex-related aspects.

Reproductive Health Problems:

Population growth: Rapid increase in population poses significant socio-economic challenges.
Lack of awareness: Ignorance about reproduction, reproductive organs, safe sexual practices, and reproductive health issues.
Sexually Transmitted Infections (STIs): Spread of infections through sexual contact.
Unwanted pregnancies: Leading to unsafe abortions and maternal mortality.
Infertility: Difficulty in conceiving.
Sexual abuse and related problems: Affecting physical and mental health.
Social taboos: Regarding sex and sexuality, leading to lack of open discussion and access to information/services.

Strategies to Achieve Reproductive Health:

India was among the first countries in the world to initiate family planning programmes at a national level in 1951. These programmes have been periodically assessed and updated. Currently, the programmes are known as 'Family Welfare Programmes' or, more comprehensively, 'Reproductive and Child Health (RCH) Programmes'.

National Programmes (RCH):

The RCH programmes aim to create awareness among people about various reproduction related aspects and to build up a reproductively healthy society.

Key areas addressed by RCH programmes:

Creating awareness about sexual reproduction and reproductive health.
Providing facilities and support for building a reproductively healthy society.

Awareness And Education:

Promoting awareness among people about reproduction-related aspects using audio-visual aids, print media, and government/non-government agencies.
Introducing sex education in schools to provide correct information to young people, avoiding misconceptions and myths.
Educating people about the reproductive organs, adolescence and associated changes, safe and hygienic sexual practices, STIs, AIDS, etc.
Involving parents, close relatives, and friends in spreading awareness.

Medical Care And Support:

Developing infrastructure and services for providing medical assistance and care.
Providing support for pregnancy, childbirth, post-natal care, and child health.
Offering methods for contraception and birth control.
Providing care for STIs and related problems.
Offering medical assistance for infertility cases.
Providing counselling and care for maternal and child health issues.

Successful implementation of these strategies requires strong infrastructural facilities, professional expertise, and social support.

Population Stabilisation And Birth Control

A major challenge to reproductive health and societal progress is the rapid growth of the human population (population explosion). Controlling population growth is essential for sustainable development.

Population Explosion:

In the 20th century, there was a dramatic increase in the world population, largely due to improvements in healthcare, sanitation, and food production, leading to a decline in death rates.
In India, the population crossed the 1 billion mark in May 2000 and the 1.3 billion mark in 2016/2017.
The rapid population growth poses significant strain on natural resources and leads to socio-economic problems like poverty, unemployment, lack of access to basic necessities (food, shelter, education, healthcare).

Measures To Check Population Growth:

Encouraging smaller families by promoting contraceptive methods.
Increasing the marriageable age legally (18 years for females, 21 years for males).
Offering incentives to couples with small families.
Raising awareness about the benefits of a small family.

Contraceptive Methods:

Various contraceptive methods are available to prevent unwanted pregnancies. An ideal contraceptive should be:

User-friendly
Easily available
Effective
Reversible (if desired)
With few or no side effects
Should not interfere with the sexual act.

Contraceptive methods are broadly classified into:

Natural/Traditional methods
Barrier methods
IUDs (Intra Uterine Devices)
Oral contraceptives
Injectables and Implants
Surgical methods

Contraceptive Methods: Natural And Traditional

These methods work on the principle of avoiding the chance of meeting of sperm and ovum.

Periodic Abstinence (Rhythm method): Avoiding coitus during the fertile period of the menstrual cycle (days 10-17), when ovulation is likely to occur. High chances of failure.
Withdrawal (Coitus interruptus): The male withdraws the penis from the vagina just before ejaculation. High chances of failure as pre-ejaculation fluid may contain sperm.
Lactational Amenorrhea: Absence of menstruation during intense lactation following parturition. Ovulation does not occur as levels of gonadotropins are suppressed. Effective only up to maximum 6 months postpartum, and only if the mother exclusively breastfeeds. Chances of failure are high.

Contraceptive Methods: Barrier

These methods prevent the physical meeting of sperm and ovum.

Condoms: Barriers made of thin rubber/latex covering the penis (male condom) or vagina and cervix (female condom). Prevent sperm from entering the female reproductive tract. Provide protection against STIs. Disposable.
Diaphragms, Cervical caps, Vaults: Rubber barriers fitted into the female reproductive tract to cover the cervix. Prevent sperm entry. Reusable. Require professional fitting. Need to be inserted before coitus and removed after. Require spermicidal creams/jellies for increased effectiveness.
Spermicidal Creams, Jellies, Foams: Chemicals applied to the female reproductive tract to kill or immobilise sperm. Used alone or with barrier devices.

Contraceptive Methods: Intra Uterine Devices (IUDs)

Devices inserted by doctors or trained nurses into the uterus through the vagina. Highly effective and popular in India.

Non-medicated IUDs: (e.g., Lippes loop) Increase phagocytosis of sperm within the uterus.
Copper Releasing IUDs: (e.g., CuT, Cu7, Multiload 375) Release copper ions, which suppress sperm motility and fertilising capacity.
Hormone Releasing IUDs: (e.g., Progestasert, LNG-20) Make the uterus unsuitable for implantation and the cervix hostile to sperm.

IUDs are effective for several years and reversible. They can increase menstrual bleeding or cause abdominal pain in some users.

Contraceptive Methods: Oral Contraceptives

Pills containing hormones (progesterone or a combination of oestrogen and progesterone).

Taken daily for a period of 21 days (usually starting within the first 5 days of the menstrual cycle), followed by a break.
Mechanism: Inhibit ovulation and implantation, and alter the quality of cervical mucus to prevent sperm entry.
Highly effective if taken correctly. Side effects can include nausea, weight gain, mood changes.
"Saheli" is a new oral contraceptive pill for females. It is a non-steroidal preparation, taken once a week, with very few side effects and high contraceptive value. Developed by scientists at CDRI, Lucknow.
Emergency contraceptive pills (e.g., morning-after pills) are taken within 72 hours of unprotected intercourse. Contain high doses of progestogens or progestogen-oestrogen combination. Inhibits ovulation, prevents implantation.

Contraceptive Methods: Injectables And Implants

Hormonal preparations (progesterone or combined) that are either injected or implanted under the skin.

Mechanism: Similar to oral pills - inhibit ovulation, prevent implantation.
Effective for a longer duration than pills (several months).
Requires professional administration. Side effects are similar to oral pills but may be more pronounced.

Contraceptive Methods: Surgical (Sterilisation)

Methods that permanently block gamete transport, thereby preventing conception. These are surgical procedures and are generally irreversible.

Vasectomy (Male sterilisation): Small part of the vas deferens is tied up or removed through a small incision in the scrotum. Prevents sperm from reaching the urethra.
Tubectomy (Female sterilisation): Small part of the fallopian tube (oviduct) is tied up or removed through a small incision in the abdomen or through the vagina. Prevents the ovum from reaching the uterus and sperm from reaching the ovum.

These methods are highly effective and have no impact on sexual drive. Surgical procedures require trained medical professionals.

Diagrams showing vasectomy and tubectomy procedures

*(Image shows diagrams illustrating vasectomy (cutting/tying vas deferens) and tubectomy (cutting/tying fallopian tubes))*

Selection And Use Of Contraceptives:

The selection of a suitable contraceptive method should be made in consultation with a qualified medical professional, considering the individual's health status, lifestyle, and reproductive goals. It is important to be aware of the effectiveness and potential side effects of each method.

Medical Termination Of Pregnancy (Mtp)

Medical Termination of Pregnancy (MTP), or induced abortion, is the intentional termination of pregnancy before full term. It is a significant aspect of reproductive health.

Definition And Legal Aspects:

MTP is the deliberate termination of pregnancy.
Globally, MTP is widely practiced, with an estimated 45 to 50 million abortions performed worldwide per year.
In India, MTP was legalised in 1971 with the enactment of the Medical Termination of Pregnancy Act (MTP Act), and recently amended in 2017 and 2021.
The Act specifies the conditions under which MTP can be performed legally and safely by qualified medical professionals.

Reasons And Safety Considerations:

MTP is performed for various reasons:
- To avoid unwanted pregnancies (e.g., due to unprotected intercourse, failure of contraceptive).
- When continuation of pregnancy could be harmful to the mother's physical or mental health.
- When there is a high risk of the child being born with severe physical or mental abnormalities.
Safety: MTP is relatively safe during the first trimester (up to 12 weeks of pregnancy). Abortions performed during the second trimester (12-24 weeks) are riskier. Abortions after 24 weeks are generally not permitted unless there is a grave risk to the mother's life.
Legal MTPs are performed by trained medical professionals in approved facilities. Unsafe abortions performed by untrained persons or in unhygienic conditions are a major cause of maternal mortality and morbidity.

Issues And Prevention:

Misuse of MTP: MTP should not be used as a substitute for contraception.
Illegal abortions: Unsafe, illegal abortions are a significant public health problem.
Sex-selective abortion: The MTP Act strictly prohibits MTP for sex determination and foeticide. Amniocentesis (foetal sex determination) is legally banned in India for identifying the sex of the foetus to prevent sex-selective abortions.

Increased awareness about contraception, safe sexual practices, and the availability of safe, legal MTP services are crucial to reduce the incidence of illegal and unsafe abortions.

The Mtp Act, 2017 (and subsequent amendments):

The Medical Termination of Pregnancy (Amendment) Act, 2017, modified certain provisions of the original Act, primarily regarding the gestation period for MTPs.

The MTP Act, 2021 further extended the upper limit for termination of pregnancy from 20 to 24 weeks for certain categories of women (e.g., survivors of sexual assault, minors, women with disabilities) after the opinion of two registered medical practitioners.
MTP up to 20 weeks requires the opinion of one registered medical practitioner.
MTP beyond 24 weeks in cases of substantial foetal abnormalities requires a medical board's opinion.
The Act aims to provide access to safe and legal abortion services while preventing misuse.

Sexually Transmitted Infections (Stis)

Sexually Transmitted Infections (STIs), also known as Sexually Transmitted Diseases (STDs) or Venereal Diseases (VD), are infections that are primarily transmitted through sexual contact.

Definition And Types:

STIs are caused by bacteria, viruses, fungi, or parasites.
Examples: Gonorrhoea, Syphilis, Genital herpes, Chlamydiasis, Genital warts, Trichomoniasis, Hepatitis B, AIDS.

Note: Hepatitis B and HIV (causes AIDS) can also be transmitted by sharing of injection needles, surgical instruments, blood transfusion, or from infected mother to foetus. However, sexual transmission is a major route for these infections.

Transmission Routes:

Sexual contact (vaginal, anal, oral sex) with an infected person.
Sharing of contaminated needles (e.g., among drug users).
Blood transfusion (if the blood is not properly screened).
From an infected mother to her foetus during pregnancy or childbirth (vertical transmission).

Symptoms And Detection:

Early symptoms of many STIs are mild or may be absent (asymptomatic) in the initial stages, especially in females.
Symptoms, when present, may include: itching, fluid discharge, slight pain, swellings in the genital region.
Early detection and diagnosis are crucial for effective treatment and preventing complications. Regular screening is important, especially for individuals at higher risk.

Complications:

If left untreated, STIs can lead to serious complications:
- Pelvic Inflammatory Disease (PID) in females.
- Abortion, stillbirth, ectopic pregnancy, infertility.
- Cancer of the reproductive tract (e.g., cervical cancer linked to Human Papillomavirus - HPV).
HIV infection (AIDS) is a life-threatening STI that weakens the immune system.

Except for Hepatitis B, Genital herpes, and HIV infections, most other STIs are curable if detected early and treated appropriately with antibiotics (bacterial STIs) or antiviral medications.

Prevention:

Prevention is the best approach to STIs. Strategies include:

Avoiding sex with unknown partners or multiple partners.
Always using condoms during coitus.
Avoiding sharing of needles.
Getting tested for STIs before getting married or having sexual contact.
In case of doubt, consulting a qualified doctor for diagnosis and treatment.
Seeking complete treatment for all partners involved.

Providing awareness, especially to young people, about STIs and how to prevent them is essential for reproductive health.

Infertility

Infertility is defined as the inability to conceive or produce children after one year of unprotected sexual cohabitation. It affects a significant number of couples.

Definition And Causes:

Infertility can be due to problems in the male partner, the female partner, or both, or sometimes the cause is unexplained.
Causes in males: Low sperm count, low sperm motility, inability to ejaculate, hormonal imbalances, testicular problems, blockages in reproductive ducts.
Causes in females: Problems with ovulation, damaged or blocked fallopian tubes, uterine abnormalities, endometriosis, hormonal imbalances, age.
Lifestyle factors (smoking, excessive alcohol, stress, obesity), environmental factors, and certain medical conditions can also contribute to infertility.

Assisted Reproductive Technologies (Art):

For couples who are unable to conceive naturally, Assisted Reproductive Technologies (ART) offer various methods to help them have children. These technologies are often complex and expensive.

In vitro Fertilisation (IVF): 'Test tube baby' program. Sperm and ova are collected from the couple (or donors) and fertilisation is carried out externally (in vitro) in a laboratory. The zygote or early embryo (up to 8 blastomeres) is then transferred into the fallopian tube (Zygote Intrafallopian Transfer - ZIFT). If the embryo has more than 8 blastomeres, it is transferred into the uterus (Intrauterine Transfer - IUT).
Gamete Intrafallopian Transfer (GIFT): Transfer of an ovum collected from a donor into the fallopian tube of another female who cannot produce an ovum but can provide a suitable environment for fertilisation and development.
Intracytoplasmic Sperm Injection (ICSI): A specialised IVF procedure where a single sperm is directly injected into the ovum. Useful in cases of male infertility (low sperm count or motility).
Artificial Insemination (AI): Insemination of semen into the vagina or uterus. Used when the male has a very low sperm count or is unable to ejaculate properly. The semen can be from the husband (Artificial Insemination - AI) or a healthy donor (Intrauterine Insemination - IUI, where semen is directly injected into the uterus).

Diagrams illustrating ART procedures like IVF/ZIFT/IUT and ICSI

*(Image shows simplified diagrams illustrating IVF (fertilisation in lab) followed by ZIFT (transfer to fallopian tube) or IUT (transfer to uterus), and possibly ICSI (sperm injected into ovum))*

Challenges And Alternatives (Adoption):

ART procedures can be emotionally, physically, and financially demanding.
Success rates can vary.
Ethical, social, and legal issues are associated with ART, including donor issues and surrogacy.
For couples who cannot or do not wish to pursue ART, adoption is a viable alternative to have a family. Adoption provides a loving home to children who are orphaned or abandoned.

Addressing infertility requires medical intervention, counselling, and support. ART offers hope to many couples, while adoption provides another fulfilling path to parenthood.