Reproductive Health

The World Health Organisation (WHO) defines reproductive health as total well-being in all aspects of reproduction, i.e., physical, emotional, behavioural and social. So a reproductively healthy society is one whose people have physically and functionally normal reproductive organs and normal emotional and behavioural interactions among themselves in all sex-related matters. Write this WHO wording exactly; the examiner looks for the four adjectives.

India was among the first countries in the world to start action plans and programmes at the national level to achieve total reproductive health. These began as 'family planning' in 1951 and were assessed and improved periodically. The improved programmes now run under the popular name Reproductive and Child Health Care (RCH) programmes. Their major task is to create awareness about the wide range of reproduction-related aspects and to provide facilities and support for building a reproductively healthy society.

How is awareness created? Through audio-visual and print media, with governmental and non-governmental agencies taking part. Parents, close relatives, teachers and friends also have a role. Sex education in schools should be encouraged, because it gives young people correct information, helps them discard myths and misconceptions, and lets them understand reproductive organs, adolescence and its changes, safe and hygienic sexual practices and STIs. The people who most need educating are fertile couples and those of marriageable age: they should know about the available birth-control options, care of pregnant mothers, post-natal care of mother and child, the importance of breast-feeding, and equal opportunities for the male and the female child. Awareness of the problems of uncontrolled population growth and of social evils such as sex-abuse and sex-related crimes is also part of the programme.

Successful implementation needs strong infrastructural facilities, professional expertise and material support for problems ranging from pregnancy, delivery and contraception to STIs, abortions and infertility. Two other strategies are exam favourites: a statutory ban on amniocentesis for sex determination, to check the rising number of female foeticides, and massive child immunisation programmes.

Has it worked? The indicators of an improved reproductive health NCERT lists are: better awareness about sex-related matters, an increased number of medically assisted deliveries and better post-natal care (hence lower maternal and infant mortality rates), an increased number of couples with small families, better detection and cure of STIs, and overall increased medical facilities for all sex-related problems.

Better health facilities and living conditions raised the size of the world population sharply. The world population was around 2 billion in 1900, rocketed to about 6 billion by 2000 and to 7.2 billion in 2011. India followed the same curve: 350 million at independence, crossing 1 billion by May 2000 and reaching 1.2 billion in May 2011. Such an alarming growth rate could lead to an absolute scarcity of even basic requirements, food, shelter and clothing, whatever the country's development.

NCERT gives three reasons for the explosion, and the paper asks for two of them: a rapid decline in the death rate, a decline in the maternal mortality rate (MMR) and in the infant mortality rate (IMR), and an increase in the number of people of reproducible age. Note that the reason is not a rise in the birth rate; births stayed high while deaths fell.

According to the 2011 census report, the population growth rate was less than 2 per cent, i.e., 20/1000/year, a rate at which the population could still increase rapidly. The government therefore took serious measures: the most important step was to motivate smaller families by using various contraceptive methods. Media advertisements of 'Hum Do Hamare Do' (we two, our two) and, in many urban families, the 'one child norm' are the visible face of this. Statutory raising of the marriageable age to 18 years for females and 21 years for males, and incentives to couples with small families, are the other measures. Remember the pairing: two reasons for the rise, two government steps, and you have the standard 3-mark answer.

The rest of section 3.2 describes the contraceptive methods themselves. Before the methods, learn what an ideal contraceptive is, because it is a 2-mark question by itself: it should be user-friendly, easily available, effective and reversible with no or least side-effects, and it should in no way interfere with the sexual drive, desire and/or the sexual act. NCERT groups the available methods as natural/traditional, barrier, IUDs, oral contraceptives, injectables, implants and surgical methods; the next three sections take them in that order.

Natural or traditional methods work on the principle of avoiding the chance of meeting of the sperm and the ovum. There are three. In periodic abstinence, the couple avoids coitus from day 10 to day 17 of the menstrual cycle, the fertile period, when ovulation is expected; since the chance of fertilisation is very high in these days, abstaining prevents conception. In withdrawal or coitus interruptus, the male partner withdraws the penis from the vagina just before ejaculation so that insemination is avoided. Lactational amenorrhea (absence of menstruation) is based on the fact that ovulation, and therefore the menstrual cycle, does not occur during the period of intense lactation following parturition; as long as the mother breast-feeds the child fully, the chance of conception is almost nil. The method is effective only up to a maximum of six months after parturition. Natural methods have no side-effects because no medicine or device is used, but their chances of failure are high.

Barrier methods prevent the ovum and sperms from physically meeting with the help of barriers, and are available for both sexes. Condoms are barriers made of thin rubber or latex sheath, used to cover the penis in the male or the vagina and cervix in the female, just before coitus, so that the ejaculated semen is not retained in the female reproductive tract. 'Nirodh' is a popular brand of the male condom. Condom use has gone up in recent years because of the additional benefit of protection from STIs and AIDS. Both male and female condoms are disposable, can be self-inserted, and give the user privacy. Diaphragms, cervical caps and vaults are also barriers made of rubber, inserted into the female reproductive tract to cover the cervix during coitus, 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.

Two points the examiner likes: condoms are the only method that also prevents STIs, and the fertile period of days 10–17 assumes a regular 28-day cycle, which is why periodic abstinence fails in women with irregular cycles.

Intra Uterine Devices (IUDs) are inserted into the uterus by doctors or expert nurses through the vagina. Three kinds are available: non-medicated IUDs (e.g., Lippes loop), copper-releasing IUDs (CuT, Cu7, Multiload 375) and hormone-releasing IUDs (Progestasert, LNG-20). Their mechanism is asked repeatedly, so learn it in three layers. All IUDs increase phagocytosis of sperms within the uterus. Copper IUDs in addition release Cu ions that suppress sperm motility and the fertilising capacity of sperms. Hormone-releasing IUDs in addition make the uterus unsuitable for implantation and the cervix hostile to the sperms. IUDs are the ideal contraceptive for females who want to delay pregnancy and/or space children, and they are one of the most widely accepted methods of contraception in India.

Oral contraceptives are pills containing small doses of either progestogens or progestogen–estrogen combinations. The schedule is a marking point: the pill is taken daily for 21 days, starting preferably within the first five days of the menstrual cycle; after a gap of 7 days (during which menstruation occurs) it is repeated in the same pattern until the female wants to prevent conception. They work by inhibiting ovulation and implantation and by altering the quality of cervical mucus to prevent or retard the entry of sperms. Pills are very effective with fewer side-effects and are well accepted by females. Saheli, the new oral contraceptive for females developed by scientists at the Central Drug Research Institute (CDRI), Lucknow, contains a non-steroidal preparation; it is a 'once a week' pill with very few side-effects and a high contraceptive value.

Progestogens alone, or in combination with estrogen, can also be given as injections or implants under the skin. Their mode of action is similar to that of pills, but their effective periods are much longer, which is the advantage of implants over pills. Emergency contraception means the administration of progestogens, progestogen–estrogen combinations, or IUDs within 72 hours of coitus, to avoid a possible pregnancy after rape or a casual unprotected intercourse.

Small trap: Saheli is non-steroidal and weekly; the ordinary combined pill is steroidal and daily. Another: a hormone-releasing IUD does not 'kill' sperms, it makes the cervix hostile to them and the endometrium unfit for implantation.

Surgical methods, also called sterilisation, are generally advised for the male or the female partner as a terminal method to prevent any more pregnancies. Surgical intervention blocks gamete transport and thereby prevents conception; it does not stop gamete formation, which is the correction NCERT expects in exercise question 12(a). Vasectomy is the procedure in the male: a small part of the vas deferens is removed or tied up through a small incision on the scrotum. Tubectomy is the procedure in the female: a small part of the fallopian tube is removed or tied up through a small incision in the abdomen or through the vagina. Sterilisation techniques are highly effective, but their reversibility is very poor; that pair is the standard 'one advantage and one disadvantage'.

Why not just remove the gonads? Because the testes and ovaries also make the sex hormones. Removing them would stop testosterone or estrogen and progesterone, cause loss of secondary sexual characters and sexual drive, and be irreversible. A contraceptive must not interfere with the sexual drive or act, so gonadectomy fails the definition of a contraceptive. Vasectomy, by contrast, leaves the testes intact: sperms are still produced (and reabsorbed), testosterone is still secreted and the man's sexual life is unaffected, which is why it counts as a contraceptive and is a common Assertion–Reason item.

NCERT ends the section with a caution that is often converted into a question of values. The selection of a suitable contraceptive and its use should always be done in consultation with qualified medical professionals. Contraceptives are not regular requirements for maintaining reproductive health; they are, in fact, practised against a natural reproductive event, i.e., conception or pregnancy. One is using these devices to prevent pregnancy either to avoid it altogether or to delay or space it, for personal reasons, and that is justified because unchecked population growth harms everyone. But the possible ill-effects must be known: nausea, abdominal pain, breakthrough bleeding, irregular menstrual bleeding, or even breast cancer. NCERT adds that these are not very significant, but they should not be totally ignored.

Intentional or voluntary termination of pregnancy before full term is called medical termination of pregnancy (MTP) or induced abortion. Nearly 45 to 50 million MTPs are performed in a year all over the world, which is about one-fifth of the total number of conceived pregnancies in a year. MTP is significant in decreasing the population, though it is not meant to be a contraceptive.

Whether to accept or legalise MTP is debated in many countries because of emotional, ethical, religious and social issues. The Government of India legalised MTP in 1971 with some strict conditions to avoid its misuse; the restrictions are essential to check indiscriminate and illegal female foeticide, which is reported to be high in India. The Act was amended in 2017. Why is MTP done? To get rid of unwanted pregnancies due to casual unprotected intercourse or failure of the contraceptive used, or rape; and in cases where continuation of the pregnancy could be harmful or even fatal to the mother, the foetus or both.

Timing is a certain examination point. MTPs are considered relatively safe during the first trimester, i.e., up to 12 weeks of pregnancy; second-trimester abortions are much riskier. That is the reason an examiner accepts 'during the first trimester' as the safe period and nothing else.

The disturbing side is that the majority of MTPs performed in India are illegal. Many are done by unqualified quacks, which is unsafe and even fatal. A dangerous trend is misusing amniocentesis to determine the sex of the unborn child, followed by MTP if the foetus is female. In amniocentesis, some of the amniotic fluid surrounding the foetus is withdrawn and the foetal cells and dissolved substances in it are analysed; its proper use is to test for congenital disorders and metabolic disorders in the foetus (Down's syndrome, haemophilia, sickle-cell anaemia) and to assess the survivability of the foetus. Its misuse is sex determination leading to female foeticide, so there is a statutory ban on amniocentesis for sex determination. Effective counselling on MTP, awareness of the dangers of illegal abortions, and more health-care facilities are needed to stop the trend.

Infections or diseases transmitted through sexual intercourse are collectively called sexually transmitted infections (STIs), venereal diseases (VD) or reproductive tract infections (RTI). NCERT names eight common ones, and you should be able to list them: gonorrhoea, syphilis, genital herpes, chlamydiasis, genital warts, trichomoniasis, hepatitis-B and HIV leading to AIDS.

Not all of them spread only by sex. Hepatitis-B and HIV are also transmitted by sharing of injection needles and surgical instruments with infected persons, by transfusion of blood, or from an infected mother to the foetus. Except for hepatitis-B, genital herpes and HIV infections, the other STIs are completely curable if detected early and treated properly. That trio, the viral ones, is the answer to every 'which cannot be cured' question and the correction to exercise 12(b).

The early symptoms of most STIs are minor: itching, fluid discharge, slight pain and swellings in the genital region. Infected females are often asymptomatic, so the infection goes undetected. The absence or lack of significant symptoms in the early stages, and the social stigma attached to STIs, deter people from timely detection and treatment. This leads to complications later: pelvic inflammatory diseases (PID), abortions, still births, ectopic pregnancies, infertility or even cancer of the reproductive tract. STIs are a major threat to a healthy society, so their prevention or early detection and cure is a prime consideration of the RCH programmes.

Though all persons are vulnerable, the incidence is reported to be very high among persons in the age group 15–24 years. Prevention is simple and NCERT gives three rules: avoid sex with unknown partners or multiple partners; always use condoms during coitus; and, in case of doubt, consult a qualified doctor for early detection and complete treatment if diagnosed. Mention all three when the question is 'measures to prevent STIs', and add that the infected person should not be stigmatised, since stigma delays treatment and spreads the disease.

A large number of couples all over the world, including India, are infertile, i.e., unable to produce children in spite of unprotected sexual co-habitation. The reasons may be physical, congenital, diseases, drugs, immunological or even psychological. In India the female partner is often blamed, but the problem may be in the male partner just as often; exercise 11(b) makes this point. Specialised health-care units (infertility clinics) can diagnose and correct many of these disorders. Where correction is not possible, assisted reproductive technologies (ART) can help.

In vitro fertilisation (IVF) followed by embryo transfer (ET) is the method popularly called the test-tube baby programme. Ova from the wife or a donor female and sperms from the husband or a donor male are collected and induced to form a zygote under simulated conditions in the laboratory. The zygote or early embryos with up to 8 blastomeres can be transferred into the fallopian tube, which is ZIFT (zygote intra fallopian transfer); embryos with more than 8 blastomeres are transferred into the uterus, which is IUT (intra uterine transfer). Embryos formed by in vivo fertilisation (fusion inside the female) can also be transferred to assist females who cannot conceive.

GIFT (gamete intra fallopian transfer) is the transfer of an ovum collected from a donor into the fallopian tube of another female who cannot produce one but can provide a suitable environment for fertilisation and further development. Fertilisation here is in vivo, inside the recipient's tube; that is how GIFT differs from ZIFT. ICSI (intra cytoplasmic sperm injection) is a specialised procedure in which a sperm is directly injected into the ovum to form an embryo in the laboratory; it suits a male with very low sperm count or immotile sperms. When infertility is due to the male's inability to inseminate the female or to very low sperm counts in the ejaculate, artificial insemination (AI) is used: semen collected from the husband or a healthy donor is artificially introduced into the vagina, or into the uterus (IUI, intra-uterine insemination).

All these techniques need extremely high precision, specialised professionals and expensive instrumentation, so they are available only in very few centres and only a limited number of people can afford them. Emotional, religious and social factors also stop many from adopting them. NCERT's closing point: since infertility is not always correctable, legal adoption of orphaned and destitute children is one of the best methods for couples looking for parenthood. In a values-based question, write it.