Reproductive Health

Reproductive Health – Problems and Strategies

Reproductive health refers to a total well-being in all aspects of reproduction, including physical, emotional, behavioural, and social aspects, according to the World Health Organisation (WHO) [1, 2]. A reproductively healthy society has people with physically and functionally normal reproductive organs, and normal emotional and behavioural interactions related to sex .

India’s Initiatives

• India was among the first countries globally to initiate national action plans and programmes to achieve total reproductive health as a social goal [3, 4].
• These programmes, initially called ‘family planning’, began in 1951 and have been periodically assessed .
• Currently, improved programmes under the name ‘Reproductive and Child Health Care (RCH) programmes’ cover wider reproduction-related areas [5, 6].
• Major tasks under these programmes include creating awareness and providing facilities and support for a reproductively healthy society .

Strategies for Awareness and Education

• Governmental and non-governmental agencies use audio-visual and print-media .
• Parents, relatives, teachers, and friends play a significant role in information dissemination .
• Sex education in schools is encouraged to provide accurate information to young people, discouraging myths and misconceptions about sex .
• Proper information should cover:
  • Reproductive organs, adolescence, and related changes .
  • Safe and hygienic sexual practices .
  • Sexually transmitted diseases (STDs) and AIDS .
  • Available birth control options .
  • Care for pregnant mothers and post-natal care for mother and child .
  • Importance of breastfeeding .
  • Equal opportunities for male and female children .
  • Problems associated with uncontrolled population growth .
  • Social evils like sex-abuse and sex-related crimes .

Requirements for Success

• Successful implementation needs strong infrastructural facilities, professional expertise, and material support .
• Regular implementation of better techniques and new strategies is crucial for efficient care .

Notable Programmes and Research

• Statutory ban on amniocentesis for sex-determination to legally check the increasing menace of female foeticides . Amniocentesis is a procedure where amniotic fluid from the developing foetus is analysed for fetal cells and dissolved substances to test for genetic disorders (e.g., Down syndrome, haemophilia, sickle-cell anemia) and foetal survivability .
• Massive child immunisation programmes .
• Research in reproduction-related areas is encouraged; for example, ‘Saheli’, a new oral contraceptive for females, was developed by scientists at the Central Drug Research Institute (CDRI) in Lucknow, India [11, 13].

Indicators of Improved Reproductive Health

• Better awareness about sex-related matters .
• Increased number of medically assisted deliveries .
• Better post-natal care, leading to decreased maternal and infant mortality rates [6, 14].
• Increased number of couples with small families .
• Better detection and cure of STDs [6, 14].
• Overall increased medical facilities for sex-related problems .

Population Stabilisation and Birth Control

Population Growth Trends

• The world population rocketed from approximately 2 billion (1900) to about 6 billion (2000) and 7.2 billion (2011) .
• India’s population similarly grew from about 350 million (at independence) to nearly 1 billion (2000) and over 1.2 billion (May 2011) .
• Probable reasons for this rapid growth include a decline in death rate, maternal mortality rate (MMR), infant mortality rate (IMR), and an increase in the number of people in the reproducible age group .
• Despite RCH programmes, the population growth rate in India (less than 2% or 20/1000/year in 2011) is alarming, potentially leading to scarcity of basic requirements like food, shelter, and clothing .

Measures to Control Population Growth

• Motivating smaller families using various contraceptive methods .
• Public slogans like “Hum Do Hamare Do” (we two, our two) .
• Adoption of an “one child norm” by some couples .
• Statutory raising of marriageable age: female to 18 years and male to 21 years .
• Incentives for couples with small families .

Ideal Contraceptive Characteristics

An ideal contraceptive should be :

• User-friendly
• Easily available
• Effective and reversible
• Have no or least side-effects
• Not interfere with the user’s sexual drive, desire, or act

Categories of Contraceptive Methods

Contraceptive methods are broadly grouped into :

1. Natural/Traditional
2. Barrier
3. IUDs (Intra Uterine Devices)
4. Oral contraceptives
5. Injectables
6. Implants
7. Surgical methods

Details of Contraceptive Methods

Natural/Traditional Methods

These methods work by avoiding the chances of ovum and sperm meeting, with almost nil side effects due to no medicines or devices, but have high chances of failure [19, 20].

• Periodic Abstinence: Avoiding coitus from day 10 to 17 of the menstrual cycle, when ovulation is expected and fertilisation chances are very high (the fertile period) [19, 21].
• Withdrawal or Coitus Interruptus: The male partner withdraws his penis from the vagina just before ejaculation to avoid insemination .
• Lactational Amenorrhea: Based on the fact that ovulation and the menstrual cycle do not occur during intense lactation following parturition. Effective for a maximum of six months post-parturition, as long as the mother fully breastfeeds [20, 21].

Barrier Methods

These methods physically prevent ovum and sperms from meeting and are available for both males and females .

• Condoms: Made of thin rubber/latex sheath, used to cover the penis (male) or vagina and cervix (female) before coitus . They prevent ejaculated semen from entering the female reproductive tract, thus preventing conception .
  • ‘Nirodh’ is a popular brand for males .
  • Provide additional benefit of protection against STIs and AIDS .
  • Disposable, self-inserted, offering privacy .
• Diaphragms, Cervical Caps, and Vaults: Rubber barriers inserted into the female reproductive tract to cover the cervix during coitus, blocking sperm entry .
  • Reusable .
  • Often used with spermicidal creams, jellies, and foams to increase contraceptive efficiency .

Intra Uterine Devices (IUDs)

These are effective and popular devices inserted into the uterus by doctors or expert nurses .

• Types:
  • Non-medicated IUDs: e.g., Lippes loop .
  • Copper releasing IUDs: e.g., CuT, Cu7, Multiload 375 .
  • Hormone releasing IUDs: e.g., Progestasert, LNG-20 .
• Mechanism of Action:
  • Increase phagocytosis of sperms within the uterus .
  • Copper ions suppress sperm motility and fertilising capacity .
  • Hormone-releasing IUDs also make the uterus unsuitable for implantation and the cervix hostile to sperms [24, 25].
• Ideal for: Females who want to delay pregnancy and/or space children . Widely accepted in India .

Oral Contraceptives (Pills)

Oral administration of small doses of either progestogens or progestogen-estrogen combinations .

• Usage: Taken daily for 21 days (preferably starting within the first five days of the menstrual cycle), followed by a 7-day gap (when menstruation occurs), then repeated .
• Mechanism: Inhibit ovulation and implantation, and alter the quality of cervical mucus to prevent/retard sperm entry .
• Effectiveness: Very effective with fewer side effects and are well accepted by females .
• Saheli: A new non-steroidal oral contraceptive, a ‘once a week’ pill with very few side effects and high contraceptive value [13, 26].

Injectables and Implants

Progestogens alone or in combination with estrogen can be used by females as injections or implants under the skin .

• Mechanism: Similar to pills .
• Effective Period: Much longer than pills .

Emergency Contraceptives

Progestogens or progestogen-estrogen combinations or IUDs administered within 72 hours of coitus are highly effective .

• Purpose: To avoid possible pregnancy due to rape or casual unprotected intercourse .

Surgical Methods (Sterilisation)

Generally advised as a terminal method for male/female partners to prevent any more pregnancies . These interventions block gamete transport, preventing conception . Highly effective but with very poor reversibility .

• Vasectomy (Male Sterilisation): A small part of the vas deferens is removed or tied up through a small incision on the scrotum .
• Tubectomy (Female Sterilisation): A small part of the fallopian tube is removed or tied up through a small incision in the abdomen or through the vagina .

Important Considerations for Contraceptives

• Selection and use of contraceptive methods should always be undertaken in consultation with qualified medical professionals .
• Contraceptives are not regular requirements for the maintenance of reproductive health; they are used against natural reproductive events (conception/pregnancy) to prevent, delay, or space pregnancy [29, 30].
• While they play a significant role in checking uncontrolled population growth, their possible side effects (nausea, abdominal pain, breakthrough bleeding, irregular menstrual bleeding, breast cancer) should not be totally ignored, even if not very significant .

Medical Termination of Pregnancy (MTP)

Definition and Incidence

• MTP (Medical Termination of Pregnancy) or induced abortion is the intentional or voluntary termination of pregnancy before full term [30, 31].
• Approximately 45 to 50 million MTPs are performed globally each year, accounting for about one-fifth of total conceived pregnancies .

Legal Status in India

• The legality of MTP is debated globally due to emotional, ethical, religious, and social issues .
• The Government of India legalised MTP in 1971 with strict conditions to prevent misuse, especially to check indiscriminate and illegal female foeticides [30, 32].
• The Medical Termination of Pregnancy (Amendment) Act, 2017, was enacted to reduce illegal abortions and associated maternal mortality and morbidity .
  • A pregnancy may be terminated within the first 12 weeks based on the opinion of one registered medical practitioner .
  • If the pregnancy is between 12 and 24 weeks, the opinion of two registered medical practitioners, formed in good faith, is required .
• Grounds for MTP:
  • Continuation of pregnancy would pose a risk to the pregnant woman’s life or cause grave physical or mental health injury .
  • There is a substantial risk that the child, if born, would suffer from physical or mental abnormalities leading to serious handicap .

Reasons for MTP

• To get rid of unwanted pregnancies resulting from casual unprotected intercourse, contraceptive failure, or rapes [30, 32].
• Essential in cases where continuing the pregnancy could be harmful or fatal to the mother, foetus, or both [12, 30].

Safety and Concerns

• MTPs are considered relatively safe during the first trimester (up to 12 weeks); second trimester abortions are much riskier .
• A disturbing trend is that many MTPs are performed illegally by unqualified quacks, which are unsafe and potentially fatal .
• Another dangerous trend is the misuse of amniocentesis for sex determination, often followed by MTP if the foetus is female, which is illegal .

Reversing Unhealthy Trends

• Effective counselling on avoiding unprotected coitus .
• Counselling on the risk factors involved in illegal abortions .
• Providing more healthcare facilities .

Sexually Transmitted Infections (STIs)

Definition and Types

• STIs (Sexually Transmitted Infections), also known as venereal diseases (VD) or reproductive tract infections (RTI), are infections or diseases transmitted through sexual intercourse [35, 36].
• Common STIs include: Gonorrhoea, syphilis, genital herpes, chlamydiasis, genital warts, trichomoniasis, hepatitis-B, and HIV (leading to AIDS) [35, 37]. (HIV is discussed in more detail in Chapter 7, not provided here) .

Transmission Routes

• While primarily transmitted through sexual intercourse, some infections like Hepatitis-B and HIV can also spread through :
  • Sharing injection needles or surgical instruments with infected persons.
  • Transfusion of blood.
  • From an infected mother to her foetus.

Curability and Symptoms

• Most STIs (except Hepatitis-B, genital herpes, and HIV) are completely curable if detected early and treated properly .
• Early symptoms are often minor, including itching, fluid discharge, slight pain, or swellings in the genital region .
• Infected females may frequently be asymptomatic, leading to prolonged undetected infections .

Challenges and Complications

• The absence or less significant early symptoms, coupled with the social stigma attached to STIs, deter infected persons from seeking timely detection and proper treatment .
• Untreated STIs can lead to serious complications such as [36, 38]:
  • Pelvic Inflammatory Diseases (PID)
  • Abortions
  • Still births
  • Ectopic pregnancies
  • Infertility
  • Cancer of the reproductive tract
• STIs pose a major threat to a healthy society .

Prevention and Vulnerable Groups

• Prevention or early detection and cure of STIs are given prime consideration in reproductive health-care programmes .
• While all persons are vulnerable, the incidence is reported to be very high among those in the 15-24 year age group .
• Simple prevention principles:
  • Avoid sex with unknown partners or multiple partners [36, 40].
  • Always try to use condoms during coitus [36, 40].
  • In case of doubt, consult a qualified doctor for early detection and complete treatment if diagnosed with an infection .

Infertility

Definition and Causes

• Infertility is the inability of couples to produce children despite unprotected sexual co-habitation [40, 41].
• Reasons can be many: physical, congenital, diseases, drugs, immunological, or even psychological .
• In India, the female is often blamed for childlessness, but the problem more often lies in the male partner .

Assisted Reproductive Technologies (ART)

Specialised healthcare units like infertility clinics offer diagnosis and corrective treatment . Where corrections are not possible, couples can be assisted through Assisted Reproductive Technologies (ART) .

• In Vitro Fertilisation (IVF) and Embryo Transfer (ET):

  • Popularly known as the ‘test tube baby programme’ [41, 43].
  • Ova (from wife/donor) and sperms (from husband/donor) are collected .
  • Zygote formation is induced under simulated conditions in the laboratory (fertilisation outside the body) .
  • Transfer methods:
    • Zygote Intra Fallopian Transfer (ZIFT): Zygote or early embryos (up to 8 blastomeres) are transferred into the fallopian tube [43, 44].
    • Intra Uterine Transfer (IUT): Embryos with more than 8 blastomeres are transferred into the uterus for further development .
  • Embryos formed by in-vivo fertilisation (fusion of gametes within the female) can also be used for transfer to assist females who cannot conceive .

• Gamete Intra Fallopian Transfer (GIFT):

  • An ovum collected from a donor is transferred into the fallopian tube of another female who cannot produce an ovum but can provide a suitable environment for fertilisation and further development [44, 45].

• Intra Cytoplasmic Sperm Injection (ICSI):

  • A specialised laboratory procedure where a sperm is directly injected into an ovum to form an embryo .

• Artificial Insemination (AI):

  • Used for infertility due to the male partner’s inability to inseminate the female or very low sperm counts in ejaculates .
  • Semen (from husband or a healthy donor) is artificially introduced either into the vagina or into the uterus (Intra-Uterine Insemination - IUI) of the female .

Challenges and Alternatives

• These ART techniques require extremely high precision handling by specialised professionals and expensive instrumentation .
• Facilities are currently available in very few centres in India, making their benefits affordable to only a limited number of people .
• Emotional, religious, and social factors can also deter the adoption of these methods .
• As an alternative for parenthood, legal adoption of orphaned and destitute children is considered one of the best methods in India, ensuring these children are cared for and survive to maturity .