Reproductive Health: NEET notes

1. Reproductive health and the RCH programmes

NCERT §3.1

• Reproductive health is more than healthy, normally working reproductive organs. WHO defines it as total well-being in every aspect of reproduction: physical, emotional, behavioural and social.
• A society counts as reproductively healthy when its people's reproductive organs are normal in structure and function, and their emotional and behavioural dealings in all sex-related matters are normal too.
• India began national 'family planning' programmes in 1951 and reviewed them over the decades. The wider programmes running today are called Reproductive and Child Health Care (RCH) programmes.
• Their two main jobs: make people aware of reproduction-related matters, and provide the facilities and support a reproductively healthy society needs.
• Awareness spreads through audio-visual and print media, government and non-government agencies, parents, relatives, teachers and friends. Sex education in schools gives the young correct information and stops myths and misconceptions.
• Useful information includes reproductive organs, adolescence and its changes, safe and hygienic sexual practices, STDs and AIDS; couples also need to know about birth control, care of pregnant mothers, post-natal care of mother and child, breast feeding, and equal opportunities for boys and girls.
• Medical care is needed for pregnancy, delivery, STDs, abortions, contraception, menstrual problems and infertility, which needs infrastructure, trained professionals and material support.
• Amniocentesis draws some amniotic fluid to study the foetus's cells and dissolved substances; it tests for genetic disorders such as Down syndrome, haemophilia and sickle-cell anaemia and for the foetus's survivability. Its use for sex determination is banned by law to check female foeticide.
• Research is supported too: Saheli, an oral contraceptive for females, was developed by scientists at the Central Drug Research Institute (CDRI), Lucknow.
• Signs of improved reproductive health: better awareness, more medically assisted deliveries, better post-natal care (so lower maternal and infant mortality rates), more small families, STDs found and cured more often, and more medical facilities overall.

2. Population explosion

NCERT §3.2

• Better health facilities and living conditions in the last century made the population grow explosively.
• World population: about 2 billion in 1900; roughly 6 billion by the year 2000; 7.2 billion in 2011.
• India: about 350 million at Independence, close to 1 billion by 2000, and past 1.2 billion in May 2011.
• Probable reasons: a rapid fall in the death rate, the maternal mortality rate (MMR) and the infant mortality rate (IMR), and a rise in the number of people of reproducible age.
• The RCH programme lowered the growth rate only marginally. The 2011 census put it below 2 per cent, that is 20 per 1000 per year, which can still make the population rise fast and threaten food, shelter and clothing.
• Measures taken: motivating small families with contraceptives (the 'Hum Do Hamare Do' slogan; some young urban working couples follow a one-child norm), raising the legal marriageable age to 18 years for females and 21 years for males, and incentives for couples with small families.
• An ideal contraceptive is easy to use and to obtain, effective, reversible, has few or no side effects, and leaves sexual drive, desire and the sexual act untouched.
• Contraceptive methods fall into seven groups: natural (traditional) methods, barriers, IUDs, oral pills, injectables, implants and surgical methods.

3. Natural and barrier methods

NCERT §3.2

• Natural methods work by avoiding any meeting of ovum and sperms.
• Periodic abstinence: the couple avoids coitus from day 10 to day 17 of the menstrual cycle, when ovulation is expected. Because fertilisation is most likely then, this stretch is called the fertile period.
• Withdrawal (coitus interruptus): the male withdraws the penis from the vagina just before ejaculation, so no semen is deposited.
• Lactational amenorrhea (absence of menstruation): during intense breast-feeding after parturition, ovulation and the cycle do not occur, so while the mother feeds the baby fully the chance of conception is almost nil. It works only up to at most six months after parturition.
• Natural methods use no drugs or devices, so side effects are almost nil, but their failure rate is high.
• Barrier methods physically stop ovum and sperms from meeting; they exist for both males and females.
• Condoms are thin rubber or latex sheaths that cover the penis (male) or the vagina and cervix (female) just before coitus, so semen does not enter the female tract. Nirodh is a popular brand of male condom.
• Condoms also protect the user from STIs and AIDS, which has raised their use. Both kinds are disposable and can be self-inserted, giving privacy.
• Diaphragms, cervical caps and vaults are rubber barriers placed in the female tract to cover the cervix during coitus, blocking sperm entry. Unlike condoms, they are reusable.
• Spermicidal creams, jellies and foams are usually used with these barriers to make them more effective.

4. Intra-uterine devices

NCERT §3.2

• IUDs are placed in the uterus through the vagina by doctors or expert nurses.
• Three kinds: non-medicated (e.g. Lippes loop); copper-releasing (e.g. CuT, Cu7, Multiload 375); hormone-releasing (e.g. Progestasert, LNG-20).
• All IUDs increase phagocytosis of sperms inside the uterus.
• Copper IUDs also release Cu ions, which suppress sperm motility and the sperms' fertilising capacity.
• Hormone-releasing IUDs do more: the uterus becomes unfit for implantation and the cervix becomes hostile to sperms.
• IUDs suit females who want to delay pregnancy or space children, and they are one of the most widely accepted contraceptive methods in India.

5. Pills, injectables and implants

NCERT §3.2

• Oral contraceptives ('pills') are small doses of progestogens alone or of progestogen-estrogen combinations, taken by females as tablets.
• Schedule: take one pill every day for 21 days, ideally beginning in the first five days of the cycle; stop for 7 days, when the period comes; then repeat the pattern for as long as pregnancy is to be avoided.
• Pills inhibit ovulation and implantation and change the quality of cervical mucus so that sperm entry is prevented or slowed.
• Pills are very effective, have fewer side effects and are well accepted by females.
• Saheli, developed at CDRI Lucknow, is a non-steroidal oral contraceptive taken once a week, with very few side effects and high contraceptive value.
• Progestogens alone or with estrogen can also be given as injections or as implants under the skin. They act like pills but stay effective for much longer.
• Emergency contraception: progestogens, progestogen-estrogen combinations or IUDs given within 72 hours of coitus are very effective, for example after rape or casual unprotected intercourse.

6. Sterilisation and side effects

NCERT §3.2

• Surgical methods (sterilisation) are advised to the male or female partner as a terminal method, when no more pregnancies are wanted.
• They block gamete transport and so prevent conception; gametes and hormones are still made.
• Vasectomy (male): through a small cut in the scrotum, a short piece of the vas deferens is cut out or tied.
• Tubectomy (female): through a small cut in the abdomen, or through the vagina, a short piece of the fallopian tube is cut out or tied.
• Both are highly effective, but their reversibility is very poor.
• The choice of method should always be made with qualified medical professionals.
• Contraceptives are not regular requirements for reproductive health; they work against a natural event, conception, and are used to prevent, delay or space pregnancy.
• Their wide use has helped check population growth. Possible ill-effects such as nausea, abdominal pain, breakthrough bleeding, irregular menstrual bleeding and even breast cancer are not very significant, yet they must not be ignored.

7. Medical termination of pregnancy

NCERT §3.3

• Medical termination of pregnancy (MTP), or induced abortion, is intentional or voluntary ending of a pregnancy before full term.
• About 45 to 50 million MTPs are done worldwide every year, roughly one-fifth of all pregnancies conceived in a year.
• Many countries still debate legalising it because of emotional, ethical, religious and social issues.
• India legalised MTP in 1971, with strict conditions to prevent misuse, especially to check illegal female foeticide.
• Reasons for MTP: unwanted pregnancy after casual unprotected intercourse, contraceptive failure or rape; and cases where continuing the pregnancy could harm or kill the mother, the foetus or both.
• Under the MTP (Amendment) Act, a pregnancy may be ended on stated grounds within the first 12 weeks on the opinion of one registered medical practitioner; between 12 and 24 weeks, two registered medical practitioners must agree.
• The grounds: continuing would risk the woman's life or gravely injure her physical or mental health; or there is a substantial risk that the child would be born with physical or mental abnormalities severe enough to be seriously handicapped.
• The Act aims to reduce illegal abortions and the maternal deaths and illness they cause.
• MTP is relatively safe in the first trimester (up to 12 weeks); second-trimester abortions are much riskier.
• Worrying trends: most MTPs are done illegally by unqualified quacks, which is unsafe and can be fatal; and amniocentesis is misused to learn the foetus's sex, followed by MTP if it is female, which is illegal. Counselling and more health-care facilities can reverse this.

8. Sexually transmitted infections

NCERT §3.4

• Infections spread by sexual intercourse are called sexually transmitted infections (STIs), venereal diseases (VD) or reproductive tract infections (RTI).
• Common STIs: syphilis, gonorrhoea, chlamydiasis, trichomoniasis, genital herpes, genital warts, hepatitis-B, and HIV, which leads to AIDS. HIV infection is the most dangerous of them.
• Hepatitis-B and HIV also spread by sharing injection needles or surgical instruments with infected persons, by blood transfusion, and from an infected mother to the foetus.
• All except hepatitis-B, genital herpes and HIV are completely curable if detected early and treated properly.
• Early symptoms are minor: itching, fluid discharge, slight pain and swellings in the genital region. Infected females are often asymptomatic and may stay undetected for long.
• Mild early symptoms and social stigma keep people from timely testing and treatment.
• Untreated STIs can lead to pelvic inflammatory diseases (PID), abortions, still births and ectopic pregnancies, and to infertility or even cancer of the reproductive tract.
• Anyone can be infected, but incidence is reported to be very high in the 15-24 years age group.
• Prevention: avoid sex with unknown or multiple partners; always use condoms during coitus; if in doubt, see a qualified doctor early and complete the treatment.

9. Infertility and assisted reproduction

NCERT §3.5

• Infertility: a couple has no child even after 2 years of living together with unprotected sex.
• Causes vary: physical, congenital, disease, drugs, immunological, even psychological. In India the female is often blamed, but the problem very often lies with the male partner.
• Infertility clinics can diagnose and correct some disorders; when correction is not possible, assisted reproductive technologies (ART) can help.
• IVF-ET ('test tube baby'): ova from the wife or a donor and sperms from the husband or a donor are made to form a zygote in the laboratory, under conditions close to those in the body; the embryo is then transferred.
• ZIFT (zygote intra fallopian transfer): the zygote or an early embryo with up to 8 blastomeres goes into the fallopian tube. IUT (intra uterine transfer): an embryo with more than 8 blastomeres goes into the uterus.
• Embryos formed by in-vivo fertilisation (gametes fusing inside a female) can also be transferred to help females who cannot conceive.
• GIFT (gamete intra fallopian transfer): an ovum from a donor is placed in the fallopian tube of a female who cannot produce ova but can provide a suitable environment for fertilisation and development.
• ICSI (intra cytoplasmic sperm injection): a sperm is injected directly into the ovum in the laboratory to form an embryo.
• Artificial insemination (AI): used when the male cannot inseminate the female or has very low sperm counts. Semen from the husband or a healthy donor is placed in the vagina or in the uterus (IUI, intra-uterine insemination).
• ART needs highly precise handling by specialists and costly instruments, so it is available in very few centres and to few people; emotional, religious and social factors also hold it back. The law also permits legal adoption, which gives orphaned and destitute children a home.

Must-know facts

1. WHO: reproductive health is total well-being in physical, emotional, behavioural and social aspects of reproduction.
2. India's family planning programmes began in 1951; today's broader ones are the RCH programmes.
3. Amniocentesis tests amniotic fluid for genetic disorders; its use for sex determination is banned by law.
4. Saheli: once-a-week, non-steroidal oral pill for females, developed at CDRI Lucknow.
5. India: about 350 million at Independence, over 1.2 billion by May 2011; 2011 growth rate below 2% (20/1000/year).
6. Legal marriageable age: 18 years for females, 21 years for males.
7. Periodic abstinence avoids days 10-17 of the cycle, the fertile period.
8. Lactational amenorrhea works only while the mother breast-feeds fully, up to at most six months after parturition.
9. Condoms (e.g. Nirodh) also protect against STIs and AIDS; diaphragms, cervical caps and vaults cover the cervix and are reusable.
10. IUDs: non-medicated (Lippes loop), copper (CuT, Cu7, Multiload 375), hormonal (Progestasert, LNG-20).
11. IUDs raise phagocytosis of sperms; Cu ions cut sperm motility and fertilising capacity; hormone IUDs also block implantation and make the cervix hostile.
12. Pills: progestogen or progestogen-estrogen, 21 days from within the first five days of the cycle, then a 7-day gap; they inhibit ovulation and implantation and alter cervical mucus.
13. Emergency contraception: hormones or an IUD within 72 hours of coitus.
14. Vasectomy cuts or ties the vas deferens; tubectomy cuts or ties the fallopian tube; both block gamete transport and are poorly reversible.
15. India legalised MTP in 1971; up to 12 weeks needs one registered medical practitioner, 12-24 weeks needs two.
16. MTP is relatively safe only in the first trimester (up to 12 weeks).
17. Hepatitis-B, genital herpes and HIV are the STIs that are not completely curable; the rest are, if caught early.
18. STI incidence is very high in the 15-24 years age group; complications include PID, still births, ectopic pregnancy, infertility and reproductive tract cancer.
19. Infertility: no children after 2 years of unprotected cohabitation.
20. ZIFT: zygote or embryo up to 8 blastomeres into the fallopian tube; IUT: more than 8 blastomeres into the uterus; GIFT: donor ovum into the fallopian tube; ICSI: sperm injected into the ovum; IUI: semen into the uterus.

Common traps

Key terms

Reproductive health

Total well-being in all aspects of reproduction: physical, emotional, behavioural and social (WHO).

RCH programmes

Reproductive and Child Health Care programmes, the wider successors of India's family planning programmes.

Amniocentesis

Drawing some amniotic fluid to study foetal cells and dissolved substances for genetic disorders; banned for sex determination.

MMR and IMR

Maternal mortality rate and infant mortality rate; their fall helped cause the population rise.

Fertile period

Days 10 to 17 of the menstrual cycle, when ovulation is expected and fertilisation is most likely.

Coitus interruptus

Withdrawal: the penis is withdrawn just before ejaculation to avoid insemination.

Lactational amenorrhea

Absence of menstruation during intense breast-feeding after birth; a natural method effective up to six months.

Barrier method

A contraceptive that physically keeps ovum and sperms apart, such as a condom, diaphragm, cervical cap or vault.

IUD

Intra-uterine device placed in the uterus through the vagina; non-medicated, copper-releasing or hormone-releasing.

Oral pill

Small doses of progestogens or progestogen-estrogen taken daily for 21 days; inhibits ovulation and implantation.

Emergency contraception

Hormones or an IUD used within 72 hours of coitus to avoid a possible pregnancy.

Vasectomy

Male sterilisation: a small part of the vas deferens removed or tied through a small cut in the scrotum.

Tubectomy

Female sterilisation: a small part of the fallopian tube removed or tied through the abdomen or vagina.

MTP

Medical termination of pregnancy: intentional ending of a pregnancy before full term; induced abortion.

STI

Sexually transmitted infection, also called venereal disease (VD) or reproductive tract infection (RTI).

PID

Pelvic inflammatory disease, a complication of untreated STIs.

Infertility

Inability to conceive or produce children after 2 years of unprotected sexual cohabitation.

ART

Assisted reproductive technologies such as IVF-ET, ZIFT, IUT, GIFT, ICSI and AI/IUI.

ZIFT

Zygote intra fallopian transfer: a zygote or embryo of up to 8 blastomeres placed in the fallopian tube.

GIFT

Gamete intra fallopian transfer: a donor ovum placed in the fallopian tube of a female who cannot produce ova.