Reproductive Health

Definition

A person's reproductive health is the maintenance of the health of his or her reproductive systems, which include respectively the penis and the testes, and the vagina, uterus, and breasts. The reproductive health spectrum also includes pregnancy and infertility.

Description

The reproductive systems

The female reproductive system comprises ovaries, fallopian tubes, uterus, vagina, breasts, and external genitalia. The ovaries hold the eggs and release them during ovulation. When an egg is fertilized, it travels through the fallopian tubes and is implanted in the uterus. The uterus, through the placenta and umbilical cord, nurtures the fetus for approximately 40 weeks, at which time the woman delivers.

The male reproductive system consists of the testes, epididymis, vas deferens, urethra, seminal vesicles, prostate, and penis. During intercourse, the penis—the copulating organ—becomes engorged with blood and becomes erect. Upon ejaculation, mature sperm cells are ejected into the vagina after moving through the vas deferens, passing the seminal vesicles and prostate gland. After the semen is deposited in the vagina, the sperm swim through the cervix, into the uterus, and up into the fallopian tubes. The egg is fertilized in the fallopian tubes, if indeed an egg is present.

Infertility

A person is infertile when he or she is unable to perform the function of reproduction. Infertility is considered a disease and affects more than six million men and women in the United States, according to the American Society for Reproductive Medicine (ASRM).

Infertility disorders in men include azoospermia, in which no sperm cells are produced; and oligospermia, in which few sperm cells are produced. Although the number of cases is rare, infertility can be caused by a genetic disorder. Typically, male infertility rests with the testes, responsible for the production of sperm. Disorders of the thyroid, adrenal and pituitary glands, liver, and kidneys—as well as infections and trauma to the testes—can contribute to male infertility.

Further, hazards in a man's workplace can affect his ability to have healthy children. These are called reproductive hazards, and include radiation, chemicals, drugs (legal and illegal), heat, and lead. Still, every man does not suffer the effects of workplace hazards; frequency, length, and method of exposure (inhalation, skin contact, ingestion) are a few of the factors that affect whether the man is exposed to any dangerous degree. These hazards, unfortunately, can arrest or slow the production of sperm. If there are fewer sperm to fertilize the egg, there will be fewer chances that the egg will be fertilized; if there are no sperm produced, the man is termed "sterile." If the workplace hazard has prevented sperm from being produced at all, the man is permanently sterile.

As of 2001, it is projected that reproductive issues will be the focus of greater attention in the United States in years to come. Reproductive issues are already included in the National Occupational Research Agenda (www.cdc.gov/niosh.com) coordinated by the National Institute of Occupational Safety and Health (NIOSH).

In women, infertility can be caused by an ovulation disorder, blocked fallopian tubes, pelvic inflammatory disease (PID), or endometriosis.

The vast majority of individuals suffering from infertility—85 to 90%—can be treated with medication or surgery. The remaining percentage of persons may turn to in vitro fertilization, in which conception takes place outside the body and the embryo is implanted in the uterus by a physician.

Viewpoints

Abortion

One of the most explosive and controversial aspects of reproductive health is abortion. Issues of morality, religion, and politics are often part of these discussions. Worldwide, it is estimated that nearly half of all human pregnancies are unplanned. Many result from incorrect use or failure of contraceptives. Women also may become pregnant because they do not have access to family planning alternatives or are pressured by a partner not to use contraceptives.

Abortion became legal in 1973 following the landmark U.S. Supreme Court decision in Roe vs. Wade. Since then, the Court has heard at least 20 major cases challenging the law. The Supreme Court, however, has upheld Roe vs. Wade as of 2006.

Most abortions are performed within the first trimester, or the first three months of pregnancy. Fewer than 9% of abortions are performed in the second trimester, and in only rare cases when there is serious health concern are abortions performed in the final trimester.

Contraception

The purpose of contraceptives is to avoid pregnancy by preventing the likelihood of fertilization or implantation of a fertilized egg. Women can use devices that fit into either the vagina or uterus; these are known as barrier methods. There are advantages and disadvantages to each method. Sometimes they can cause serious side effects, such as excessive menstrual bleeding. Barrier contraceptive devices, in addition to preventing pregnancy, also can help prevent sexually transmitted diseases (STDs) and the human immunodeficiency virus (HIV), the virus that causes acquired immune deficiency syndrome (AIDS ). Male barrier methods include latex condoms.

Female barrier methods include the diaphragm, female condom, cervical cap, sponge, and intrauterine device (IUD). These devices also can be used with a chemical combination known as a spermicide, which helps to kill sperm during intercourse.

A diaphragm is a dome-shaped flexible barrier with a rim that fits into the vagina and prevents sperm from reaching the cervix. Health professionals recommend that diaphragms be used with spermicide to achieve an 82-94% effectiveness rate against pregnancy. Instruction is required on how to insert and remove the diaphragm. This device, which can be inserted up to six hours before intercourse, must remain in the vagina for six hours after intercourse. There are two disadvantages to the diaphragm. The diaphragm may be dislodged during sex. There is also an increased risk of bladder and urinary tract infections.

The female condom is designed to line the inside of the vagina. Made from polyurethane, unlike male condoms (which are made from latex), and used without a spermicide, the female condom can be inserted up to eight hours before intercourse.

The cervical cap is a small dome, but is not as flexible as the diaphragm. It is placed tightly on the cervix one-half hour to 48 hours prior to intercourse, and is used with spermicide. When used alone, the cervical cap provides an 82-94% effectiveness rate. With spermicide, the cervical cap provides an even greater degree of confidence against unwanted pregnancy. There are several reasons that cervical caps are not widely used. Some women have difficulty with their insertion, which must be done at least one-half hour before intercourse. There is some discomfort when they are being inserted. Cervical caps can also be difficult to remove, and repeated intercourse dictates reapplication of the unit. There is some risk of irritation and allergic reaction. Last, because of the risks of toxic shock syndrome (TSS), women should not wear the cervical cap more for more than 48 hours after intercourse.

The contraceptive sponge also acts as a barrier and is used with a spermicide. The sponge is available without a prescription, and the woman does not need training to insert and remove it. However, the spermicide used with the sponge may be irritating and cause allergic reactions. The sponge should not be used more than once, and should be left in the vagina for six hours after intercourse. If left in for more than six hours, the woman is at risk for toxic shock syndrome.

The IUD, inserted by a health professional, blocks the fallopian tubes so that sperm have fewer chances of passing through the tubes to fertilize the woman's egg. In the event that sperm do pass through the tubes and an egg is fertilized, the IUD can prevent the fertilized egg from becoming implanted in the uterus. An IUD, however, can cause cramping and bleeding in women, and can be spontaneously expelled. This device has also been known to increase a woman's risk of developing PID, might increase her menstrual flow, and can cause cramping. The rate of effectiveness with the IUD is greater than 99%.

Birth control pills (also called "combined pills") are more than 99% effective against pregnancy. They do not offer any protection against sexually-transmitted diseases (STDs). While they have some other disadvantages for women, such as possible dizziness, nausea, menstruation changes, and weight and mood fluctuations, there are also advantages. These include continuous contraceptive protection, if taken as prescribed. They are reversible. When one stops taking them, the pills stop working, and another method of birth control must be used immediately. Birth control pills must be taken daily, and are contraindicated for smokers over 35 years of age. They also increase blood clot risk.

The minipill, which is progestin only, has a 95% estimated effectiveness rate. It can also cause irregular bleeding, breast tenderness, weight gain, and a slightly increased chance of ectopic pregnancy; it does provide some protection against PID. It is completely ineffective as a barrier to STDs.

With a greater than 99% rate effectiveness and continuous protection against pregnancy for up to five years, the woman who has had a subdermal implant does not need to be bothered remembering to take a pill. An in-office procedure is required, though, to surgically introduce the implant. The patient may suffer from side effects, which may include menstrual bleeding irregularities and weight change.

Another birth control method with a greater than 99% effectiveness rate is the contraceptive injection (depot medroxyprogesterone acetate). The patient has three months of protection, with no need to remember to do anything related to birth control on a daily basis. The woman requires quarterly injections at the doctor's office by the doctor or nurse. As with the implant, there may be side effects, which also include changes in menstrual bleeding and weight.

Tubal ligation, performed surgically by a physician, is a procedure that is irreversible. After a woman has undergone this procedure, she has a greater than 99% guarantee against becoming pregnant.

Men have far fewer choices in barrier contraceptives, but condoms are the most popular choice. They are easy to obtain and the best means of protection from STDs and HIV. Made from latex, condoms are placed over the penis before intercourse to prevent the ejaculation of sperm into the woman's vagina. They can be used with or without spermicides. Without a spermicide, condoms are 88-98% effective against pregnancy. With spermicide, condoms may provide even higher protection against pregnancy. The disadvantages of using a condom are possibly reduced feeling by the man. There may also be less sexual spontaneity—and, of course, condoms can break.

The man also has the option of having a vasectomy. A surgical procedure that is permanent, the vasectomy provides continuous contraceptive protection. It is over 99% effective, and has no side effects.

Spermicide may be used alone, but it must be inserted within one hour before intercourse, requires reapplication for repeated intercourse, must be left in place for six to eight hours afterward, and is often messy. It may give some protection against chlamydia and gonorrhea. Spermicide's effectiveness rate against pregnancy is 79-97% when properly used. It provides a greater measure of safety when used with a condom.

Lastly, there is periodic abstinence, which requires no equipment, foams, or gels. It does, however, necessitate extremely careful planning, motivation, and patience. When a couple is practicing abstinence, intercourse during half of the menstrual cycle is prohibited. If a woman has an irregular cycle, the couple cannot use this method, as fertile periods cannot be determined with any degree of confidence.

Family planning

Couples trying to control their number and rate of pregnancies can do so through family planning. Women may want to increase their chances of getting pregnant or determine the most infertile times to have intercourse so that they can prevent pregnancy. Women may choose to use barrier methods or oral contraceptives to prevent pregnancy, and men may use condoms.

In "natural family planning," women chart their menstruation and ovulation to determine fertile and infertile periods—but without actually having to use artificial contraception. Typically, women ovulate on the 14th day of their monthly cycle, which is the best time to become pregnant—although a woman is fertile over a range of days because sperm can remain viable inside the genital tract for up to 48 hours. Basal body temperatures and the texture of cervical mucus should be recorded. These data will aid in the determination of the woman's fertile days.

In 1970, President Richard Nixon signed into law Title X of the Public Health Service Act, referred to as "America's family planning program." The program provides funding for low-income women who need contraceptives to prevent pregnancy. The program set a minimum standard of care that requires women to have options among contraceptive methods, and prohibits coercion of women to choose one method over another. Individuals are charged fees for service based on their income and ability to pay. Title X monies do not fund abortions. The program provides for pelvic exams, Pap tests, breast examinations, safesex counseling, infertility screening, and referrals to specialized health care when needed.

Professional implications

There is a variety of health disciplines that serves the needs of individuals seeking reproductive health services. Gynecologists treat women seeking services that include Pap exams, breast exams, and pelvic exams; obstetricians provide medical care for women who are pregnant and planning to carry their babies to term. These professionals can refer women to specialists for further care as necessary—such as radiologists (who perform mammograms and a variety of ultrasound procedures) and oncologists (in cases of possible or confirmed diagnoses of gynecological cancers). In lieu of an obstetrician, a pregnant woman may consult a midwife. Women may also consult their primary care doctors for basic reproductive health questions. Primary care physicians typically can perform routine Pap and pelvic exams and give advice on contraception.

Similarly, men can consult their primary care doctors for reproductive health care. For further problems and follow-up, however, urologists should be consulted.

For other issues related to reproductive health—particularly those of an emotional nature—licensed social workers, psychologists, psychiatrists, and sex therapists may be helpful.

KEY TERMS

Azoospermia— In infertile men, it refers to the lack of sperm being produced.

Cervix— The lowest part of the uterus that connects the vagina to the uterus.

Contraceptives— Devices or medications designed to prevent pregnancy by suppressing ovulation, preventing sperm from passing through the cervix to fertilize an egg, or preventing implantation of a fertilized egg.

Diaphragm— A barrier form of contraception that is a flexible, dome-shaped device with a rim that blocks sperm from passing through the cervix.

Endometriosis— The presence and growth of functioning endometrial tissue in places other than the uterus that often results in severe pain and infertility.

Epididymis— Elongated cordlike structure along the posterior border of testes.

Fallopian tubes— Tubes that are part of a woman's reproductive system that extend from the uterus to the ovaries and carry a fertilized egg to the uterus for implantation.

Infertility— When a person is unable to perform the function of reproduction because of a physical, mental, or hormonal problem.

In vitro fertilization— When an egg is fertilized by sperm outside of the body.

Oligospermia— Low sperm count in men.

Ovulation— The discharge of a mature ovum, or egg, from the ovary.

Prostate— A gland made up of muscular and glandular tissue that surrounds the urethra at the bladder in men.

Testes— Male gonads; the paired egg-shaped glands normally located in the scrotum where sperm develop.

Urethra— Membranous canal through which urine is released from the bladder to the outside of the body.

Vas deferens— The tube cut in a vasectomy.

Resources

BOOKS

Knobil, Ernst, and Jimmy D. Neill, eds. Encyclopedia of Reproduction, Volumes 1-3. San Diego: Academic Press, 1998.

ORGANIZATIONS

Alan Guttmacher Institute. 120 Wall Street, New York, NY 10005. (212) 248-1111. 〈http://www.agi-usa.org〉.

American Society for Reproductive Medicine. 1209 Montgomery Highway, Birmingham, AL 35216-2809. (205) 978-5000. 〈http://www.asrm.org〉.

Effects of Workplace Hazards on Male Reproductive Health. National Institute of Occupational Safety and Health (NIOSH). (800) 356-4674. 〈http://www.cdc.gov/niosh/malrepro.html〉. Accessed June 21, 2001.

Food and Drug Administration. "Birth Control Guide." U.S. Food and Drug Administration. 〈http://fda.gov/fdac/features/1997/babytabl.html〉.

Harvard/Pilgrim Health Plan. "Women's Health Information/Reproduction and Sexually STDs/Birth Control." 〈http://www.bih.harvard.edu/obgyn/reproduction_birth.asp〉.

National Women's Health Information Center. United States Department of Health and Human Services (DHHS). The Office of Women's Health. 〈http://www.4woman.gov/faq.Easyread/birth-etr.htm〉. Accessed June 26, 2001.

Planned Parenthood Federation of America. 810 Seventh Ave., New York, NY 10019. (212) 541-7800. 〈http://www.plannedparenthood.org〉.