Reproductive Health

Written and reviewed by Anjali Sharma, Biology faculty at UniDrill (M.Sc. Botany, Banaras Hindu University · 8 years teaching NCERT Biology). Based on NCERT Biology Class XII, Chapter 3.

Is reproductive health just about avoiding pregnancy?

No, and that is the first idea this chapter corrects. The WHO defines reproductive health as total well-being in all aspects of reproduction: physical, emotional, behavioural and social. A society is reproductively healthy when its people have normal reproductive organs that work normally, and when the emotional and behavioural side of sexual life is healthy too. So the chapter you are about to read covers far more than contraception. It covers population, safe choices, infections, and what to do when a couple cannot conceive.

India's programme: from family planning to RCH

India was among the first countries in the world to start a national action plan for this. The family planning programme began in 1951 and has been reassessed from time to time. Its improved version today is called Reproductive and Child Health Care (RCH).

RCH works on awareness first, because people cannot make safe choices without correct information. Its tasks include spreading knowledge about reproductive organs, adolescence and safe sex through audio visual and print media, and introducing sex education in schools to replace myths with facts. Couples are also taught about birth control, care during pregnancy and after delivery, breast feeding, and giving girls and boys equal opportunity.

Amniocentesis belongs here for a reason. It samples the fluid around the foetus to test for genetic disorders such as Down syndrome, haemophilia and sickle cell anaemia. Because the same test can reveal the sex of the foetus, it was misused to abort female foetuses, so the law bans its use for sex determination. The test is legal for medical diagnosis, and illegal for sex selection.

Why the population exploded

The 2011 census recorded a growth rate below 2 percent a year (under 20 per 1000), which was still adding people at an enormous rate because the base was so big.

Why did it happen? Medical care improved, so the death rate, the maternal mortality rate (MMR) and the infant mortality rate (IMR) all fell sharply. More babies survived, more mothers survived, and people lived longer. At the same time a larger number of people reached reproductive age. Births did not fall as fast as deaths, so the population kept climbing.

The government's answer was a mix of law and persuasion: a statutory minimum marriage age of 18 years for females and 21 years for males, incentives for small families, and the slogan "Hum Do Hamare Do". Contraception is the most direct tool.

What makes a good contraceptive

An ideal contraceptive is user friendly, easily available, effective, reversible, and has few or no side effects. It must also not interfere with sexual drive, desire or the act itself. Judge each method below against this list, and you will see why every family has a trade off. The most effective methods (surgery) are the least reversible, and the most reversible ones (natural methods) fail most often.

Natural methods: timing instead of tools

Periodic abstinence means avoiding coitus from day 10 to day 17 of the menstrual cycle. Ovulation is expected in this window, so the chances of fertilisation are highest. The ovum survives only a short time after ovulation and sperm survive a few days, which is why the couple abstains on both sides of ovulation, not on a single day.

Withdrawal (coitus interruptus) means the male withdraws his penis from the vagina just before ejaculation, so no semen enters the female tract.

Lactational amenorrhea works because ovulation and menstruation do not return while the mother is breast feeding intensely after delivery. The protection is almost complete only up to six months after parturition, and only while lactation is intense.

Barrier methods and spermicides

Condoms are thin rubber or latex sheaths that cover the penis (male) or line the female tract (female) before coitus. They are disposable, easy to use and can be used without medical help. "Nirodh" is a well known Indian brand of male condom. Because they also stop infected fluids from passing, they protect against STIs and AIDS, which most other contraceptives do not.

Diaphragms, cervical caps and vaults are reusable rubber barriers placed in the female tract to cover the cervix. Spermicidal creams, jellies and foams are used with them to increase effectiveness.

Intra Uterine Devices (IUDs)

A doctor or trained nurse places an IUD in the uterus through the vagina. They are ideal for delaying or spacing pregnancies, and in India they are one of the most widely accepted methods. The three types are told apart by what they release.

Pause and predict: a woman wants to space her second child four years after her first, and does not want to remember a daily tablet. Which family fits best?

Check your answer: an IUD. It is inserted once, works for a long time, and is reversible. Once it is removed, fertility returns.

Pills, injections, implants and emergency contraception

Oral pills contain small doses of progestogens or a progestogen and oestrogen combination. The course is taken daily for 21 days, starting preferably within the first 5 days of the cycle. After a gap of 7 days, during which menstruation occurs, the course is repeated for as long as the woman wants to avoid conception.

Why they work. The steady hormone level tells the brain that ovulation has already been taken care of, so the pituitary does not release the surge that triggers ovulation. The pills also affect implantation and alter the cervical mucus so that sperm entry is retarded.

Saheli is the exception to every rule of the pills above. It is a non-steroidal, once a week pill with few side effects and high contraceptive value, developed at the Central Drug Research Institute (CDRI), Lucknow.

Injectables and implants use the same progestogens, or progestogen with oestrogen, and act in the same way as the pills. The difference is time: given as injections or as sub-dermal implants (placed under the skin), they protect for a much longer period.

Emergency contraception is for rape or unprotected casual sex. Progestogens, progestogen and oestrogen combinations, or an IUD, work if used within 72 hours of coitus.

Beyond the textbook. For the exam: Saheli is a non-steroidal weekly pill from CDRI, Lucknow. In reality: the drug in Saheli is ormeloxifene (also called centchroman), which acts on oestrogen receptors without being a steroid itself, which is why it is called non-steroidal. Emergency pills are also not abortion pills. They work by delaying or preventing ovulation, and they do nothing once a pregnancy is established.

Surgical methods: the permanent choice

Sterilisation is a terminal method because it blocks the transport of gametes. It is highly effective, but reversibility is very poor.

Pause and predict: after a vasectomy, does the man still make sperm and testosterone?

Check your answer: yes to both. The testes keep working, so hormone levels and sex drive are unchanged. Only the pathway is closed, so sperm cannot join the semen. Vasectomy blocks transport, not production.

Contraceptives are not free of risk. Possible side effects include nausea, abdominal pain, breakthrough bleeding and irregular periods, and even breast cancer in some cases. The effects are not major, but they should never be ignored, so these methods should be used on medical advice.

Medical Termination of Pregnancy (MTP)

MTP is the intentional, voluntary termination of a pregnancy before full term, also called induced abortion. Globally about 45 to 50 million MTPs take place every year, which is about one in five conceived pregnancies. Reasons include unwanted pregnancy from casual unprotected sex or contraceptive failure, and cases where continuing the pregnancy would harm or even kill the mother or the foetus.

India legalised MTP in 1971, with strict conditions to prevent misuse. MTP is relatively safe up to 12 weeks (the first trimester), while a second trimester MTP is much riskier. Using amniocentesis to find a female foetus and then aborting it is illegal.

Under the amendment to the MTP law, up to 12 weeks, the opinion of one registered medical practitioner (RMP) is enough. Between 12 and 24 weeks, the opinion of two RMPs, formed in good faith, is needed. The grounds are a risk to the life or grave physical or mental injury to the woman, or a substantial risk that the child would be seriously handicapped.

Beyond the textbook. For the exam: one RMP up to 12 weeks, two RMPs for 12 to 24 weeks. In reality: the MTP (Amendment) Act, 2021 allows one RMP up to 20 weeks and two RMPs for 20 to 24 weeks in specified categories such as rape survivors and minors, and a medical board decides on later pregnancies with serious foetal abnormalities.

Sexually Transmitted Infections (STIs)

STIs are also called venereal diseases (VD) or reproductive tract infections (RTI). The common STIs are gonorrhoea, syphilis, genital herpes, chlamydiasis, genital warts, trichomoniasis, hepatitis-B and HIV, which causes AIDS and is the most dangerous. Hepatitis-B and HIV also spread without sex: by sharing infected needles or surgical instruments, by blood transfusion, and from an infected mother to the foetus.

What to watch for. Early signs are itching, fluid discharge, slight pain and swelling in the genital area. Infected women are often asymptomatic, so the infection is detected late. Untreated infections lead to pelvic inflammatory disease (PID), abortions, stillbirths, ectopic pregnancies, infertility, and cancer of the reproductive tract. The highest incidence is in the age group of 15 to 24 years.

Curability. All of these are completely curable if detected early and treated fully, except hepatitis-B, genital herpes and HIV. Prevention rests on three rules: avoid sex with unknown or multiple partners, use condoms during coitus, and consult a qualified doctor at the first sign for full treatment.

Beyond the textbook. For the exam: learn the list of three incurable STIs. In reality: the causative organisms explain the pattern. Gonorrhoea, syphilis and chlamydiasis are bacterial (Neisseria gonorrhoeae, Treponema pallidum, Chlamydia trachomatis) and trichomoniasis is caused by a protozoan (Trichomonas vaginalis), so antibiotics and antiprotozoal drugs can clear them. Genital herpes, hepatitis-B and HIV are viral, and the virus persists in the body. Genital warts are also viral (human papillomavirus), yet they are counted among the curable infections, so memorise the list rather than the rule.

Infertility and Assisted Reproductive Technologies

Infertility is the inability to produce children despite unprotected sexual cohabitation. The causes may be physical, congenital, diseases, drugs, immunological or psychological. In India the woman is often blamed, but the problem frequently lies with the male partner. Specialised clinics diagnose the cause and offer Assisted Reproductive Technologies (ART).

The central idea is simple: pick the step that is broken and bypass it.

Artificial insemination is used when the male cannot inseminate the female or has too low a sperm count. If none of these works, legal adoption is a good way to have a family.

Pause and predict: an IVF embryo has reached the 6 cell stage. Where is it transferred?

Check your answer: into the fallopian tube, as in ZIFT, because ZIFT covers embryos up to 8 blastomeres. Only embryos with more than 8 blastomeres go into the uterus (IUT).

Beyond the textbook. For the exam: IVF and ET is the "test tube baby" programme. In reality: the baby never grows in a tube. Only fertilisation and the first cell divisions happen outside the body, and the pregnancy then develops normally in the mother's uterus. The first IVF baby, Louise Brown, was born in England in 1978, and Robert Edwards, who pioneered the technique, received the Nobel Prize in 2010.

Exam traps

60-second revision

Where this chapter connects

• Previous: Human Reproduction gives the menstrual cycle, ovulation, fertilisation and implantation. Every contraceptive here blocks one of those steps.
• Next: Principles of Inheritance and Variation moves from how babies are made to how traits pass on.
• Class XII link: Human Health and Disease covers HIV and AIDS in full.