IMPOTENCE AND STERILITY

Impotence:
It is defined as inability to perform sexual intercourse.
Sterility:
It is defined as inability to beget children/ conceive children
Frigidity:
Impotence in females- inability to initiate / maintain sexual arousal pattern in females
Causes of impotency/sterility in males:
1. Age:
• Ability for erection and coitus present even before puberty but sperms are usually not
found before puberty
• Ability for erection and sperm count diminishes with age
2. Developmental defects and other acquired abnormalities:
• Absence or non - development of sexual organs
• Malformation of external genitalia - intersexuality, epispadiasis, hypospadiasis
• Loss of both testes
3. Local disease:
• Large hernias, large hydrocele, phimosis- mechanical obstruction to intercourse
• Diseases of testicles, epididymis or penis- cancer, sarcoma, syphilis- impotence/
sterility / both
4. General diseases:
• Acute illness,
• Pulmonary tuberculosis,
• Chronic nephritis,
• Endocrine diseases causing impotence,
• Disease of CNS causing hemiplegia, paraplegia,
• Syringomyelia,
• Erectile dysfunction caused due to smoking, alcohol etc.
5. Psychological causes:
• Emotional stress, fear, disgust of sexual act, dislike of partner
• Quoad hoc/ quoadhanc
Inability to perform sexual intercourse/ initiate sexual arousal against one particular
individual and normal with all other individual.
Causes of impotence/ sterility in females
1. Age:
• Age has no effect on potency of a female.
• Females are Fertile from puberty to menopause
2. Developmental defects and other acquired abnormalities:
• Malformed genitals in turner’s Syndrome, intersexuality
• Absence of uterus, ovaries or fallopian tubes
3. Local disease
• Hyperesthesia of vagina, vulval or vaginal tumours- impotence
• Disease of genital organs- gonorrhoea, syphilis, diseases of ovaries, obstruction of
fallopian tubes etc cause sterility
4. General diseases-
• Exposure to lead, x-rays/ drug dependence- sterility
5. Psychological causes-
• Vaginismus- spasmodic contraction of vagina
• Spasm of all perineal muscles, levatorani muscles & adductor muscles of thighs
with severe constriction of vaginal outlet
Legal issues:
Civil: Criminal:
1. Nullity of Marriage, 1. Adultery,
2. Divorce, 2. Rape,
3. Disputed Paternity, 3. Unnatural Sexual Offences
4. Claim for damages where sexual function
is lost due to assault/ accident
STERILIZATION
Procedure to make a male / female sterile without interfering with potency
Types:
• Compulsory – made mandatory by the government even without the
consent of the individual
• Voluntary –
• Therapeutic – as a treatment for any disease involving reproductive
organs
• Eugenic – to prevent birth of child with congenital deformities from an
individual with hereditary disease
• Contraceptive – as a family planning method
Methods:
• Permanent - Vasectomy in males
- Tubectomy in females
• Temporary - condoms, oral hormonal pills, spermicidal jellies
Artificial insemination:
Process of artificially introducing semen into vagina, cervix or uterus to produce
pregnancy
Indications:
1. Husband is impotent
2. Husband is unable to deposit semen in vagina due to epispadiasis/
hypospadiasis
3. Husband is sterile
4. Husband suffering from hereditary disease
Types:
1. Artificial insemination homologous:
When the husband is impotent but not sterile then the sperm of the husband is
collected and used.
2. Artificial insemination donor
When the husband is sterile then the sperm of a donor is used
3. Artificial insemination homologous donor - pooled semen
 When the husband is sterile but has minimum sperms the sperm of a donor
mixed with sperm of husband and used.
Guidelines:
1. Consent of donor and his wife is mandatory
2. Identity of donor remains secret
3. Donor should not know to whom semen is donated &result of insemination
4. Mentally and physically healthy donor with no familial / hereditary diseases
5. Donor should not be relative of either of spouse
6. Donor should have healthy children of his own
7. Donor should be of same blood group as that of the husband
8. Doctor’s best judgement in selecting donor
9. Written consent of recipient woman and her husband
10. Pooled semen is preferred
11. Doctor doing artificial insemination should not deliver the baby
Legal issues
1. Adultery (497 I.P.C)
A women begetting child through artificial insemination cannot be held with crime of
adultery. But if the women do it without the consent of her husband then he can claim
for divorce.
2. Legitimacy
Any child born out of artificial insemination is illegitimate until it is legally adopted as
a legitimate child.
3. Nullity of marriage and divorce
If the reason for a woman to go for artificial insemination is impotency of her husband,
then she can claim nullity of marriage. But if the reason is sterility of her husband,
then she can’t claim for nullity of marriage as nullity is not a ground for divorce
4. Natural birth after A.I:
Any child born naturally after the birth of a child by Artificial insemination is a
legitimate child.
5. Incest
As the identity of the donor is not revealed the parents, there is a chance of a child
born out of artificial insemination latter getting married to child born to the donor.
SURROGACY:
• A surrogate mother is a woman who by contract agrees to bear child for someone else.
(womb leasing)
• Legal issues same as artificial insemination
VIRGINITY, PREGNANCY AND DELIVERY
• VIRGIN - A person who has not experienced sexual intercourse
• DEFLORATION -Loss of virginity
Types of hymen-
1. Semilunar
2. Annular
3. Infantile
4. Cribriform
 5. Vertical
6. Septate
7. Microperforate
8. Carunculaehymenales/ myrtiformes
 Hymen present as notches - symmetrical, anterior, does not extend to vaginal wall
and is covered by mucous membrane - mistaken for tear
Causes of rupture
1. Accident
2. Masturbation- objects/ foreign bodies
3. Surgical operations
4. Foreign body- sola pith
5. Ulcerations
6. Sanitary tampons
Medico legal significance
1. Divorce/ nullity of marriage
2. Rape
3. Defamation cases - Presence of un-ruptured hymen is a presumption and not
absolute proof of virginity
PREGNANCY
Condition of having a developing embryo or foetus in a female after an ovum is
fertilized by a spermatozoon.
• Signs of pregnancy
 PRESUMPTIVE SIGNS
1. Amenorrhea
2. Changes in the breasts- montgomery’s tubercle
3. Morning sickness- 1-3 months
4. Quickening- 16th-20th week
5. Pigmentation of skin-vulva/ axilla
6. Changes in vagina- Jackquemier’s/Chadwick’s sign
7. Urinary disturbance
8. Fatigue
 PROBABLE SIGNS
1. Enlargement of abdomen
2. Changes in uterus- haegar’s sign
3. Changes in cervix- goodell’s sign
4. Intermittent uterine contraction- braxton-hick’s sign
5. Ballottement
6. Uterine souffle
7. Immunological tests- presence of HCG - 12-15 days after implantation
 POSITIVE SIGNS
1. Foetal movement and parts- 36wks
2. Foetal heart sounds- 18-20wks
3. Placental souffle
4. Umbilical souffle
 5. Ultrasonography
Normal human gestation period- 10 months/ 40 weeks/ 280 days.
Viability of foetus- 210 days/ 7 months
The ability to foetus to live on its own after separation from mother owing to maturity
of the foetus.
Pseudocyesis(spurious/ phantom pregnancy)
 Patient presents with subjective signs of pregnancy when she is not actually pregnant
 Patient usually has an intense desire for begetting child
 Psychic or hormonal disorder
 Clinical examination with radiological confirmation
Superfecundation:
Fertilization of 2 ova which has been discharged from ovary at the same period by 2
different acts of coitus committed in short interval. Development parallel but not equal
Superfoetation:
• Fertilization of second ovum in a woman who is already pregnant
• Ovulation may occur in 1st trimester of pregnancy.
• Two foetuses may be born at the same time showing different stages of
development or two fully developed foetuses are born at different period
varying from 1-3months
Foetus compressus or foetus papyraceus:
One of the foetus can be compromised for the development of other foetus leading
to death of one foetus and it gets compressed and mummified.
LEGITIMACY
 Legal state of a child born in lawful marriage
Legitimate child:
 Born during continuance of a legal marriage or within 280 days of dissolution of
marriage or death of the husband
Medico legal significance
1. Inheritance of property
 A legitimate child only can inherit the property of his father
2. Affiliation cases
 A women may allege a particular man to be a father of her illegitimate child.
 May file a case in court for fixing paternity
 If paternity is fixed, he becomes responsible to support the child.
3. Supposititious child
 It means fictitious(fabricated) child
 A women may pretend pregnancy and delivery, later produce a living child as her
own child.
 She may substitute a male child for a female child born for her or for an abortion.
 This is done to obtain money or for the purpose of claiming property.
4. Posthumous child
 Child born after death of the father, the mother having conceived the child by the
said father.
  This child is considered as legitimate child.
Methods of determining paternity
1. Parental likeness:
 A child may resemble the father in feature, in gesture and also in other personal
peculiarities.
 They are considered only as corroborative evidence.
 Atavism-
 A child resembles not its parents but resembles its grandparents.
 Its due to chance of recombination of genes.
 Any mental or physical characteristic feature or disease of ancestor may
be inherited. eg: achondroplasia, haemophilia
2. Developmental defects:
 Disease or deformity of parents may be inherited to children
3. Blood grouping test:
 Blood group of a child are inherited from parents.
4. DNA fingerprinting
DELIVERY
 Expulsion or extraction of child at birth
Signs of recent delivery:
1. General indisposition-
 For first two or three days, the women looks pale & exhausted
 Increase in pulse and slight fever
2. Breast changes:
 Enlarged nodular breasts.
 Colostrum or milk may be expressed
 Dark areola
 Enlarged nipples with superficial prominent veins & Montgomery’s tubercles
3. Abdomen:
 Pendulous, wrinkled with Linea Albicantes over flanks
4. Perineum:
 Lacerated, age of tear may be useful
5. Labia:
 Tender, swollen, bruised or lacerated
6. Vagina:
 Relaxed, capacious , tear heal by 7 days, rugae reappear by 3rd week
7. Uterus:
 Immediately after delivery contracts and retracts lies 3cm above umbilicus.
 Involution at the rate of 1 and half cm per day
8). Cervix:
 Soft, dilated and edges torn transversely
9). Lochia:
 Discharge from uterus which lasts 2-3 weeks after delivery
 First 4-5 days- bright red colour- lochia rubra
 Next 4 days- serous and paler- lochia serosa
 9th day- yellowish grey or turbid- lochia alba
Signs of remote delivery:
1. Abdomen: lax, lineaalbicantes
2. Breasts: lax, pendulous, wrinkled, enlarged nipples, dark areola, montgomery tubercles
present
3. Vulva: labia does not completely close, vagina partially open, scars of old tear in
perineum, vaginal rugae absent and walls relaxed.
4. Uterus: enlarged, twice length of cervix, wall concave from inside forming rounded
cavity, cervix irregular with scars on the edges.
ABORTION
DEFINITION
 Expulsion of foetus before 20 weeks of gestation (medical)
 Premature expulsion of foetus from the mother’s womb at any time of pregnancy
before full term is completed (legal)
CLASSIFICATION
1). Natural
Spontaneous
Accidental
2). Artificial
Therapeutic
Criminal
Natural abortion- 10-15% of pregnancy common in 2nd/ 3rd month
Causes:
 Chromosomal defects
 Developmental anomalies in foetus
 Low implantation
 Disease of placenta
 Rh incompatibility
 Hormonal deficiency
Therapeutic abortion:
 Done in good faith to save life of mother
 Considered under Medical Termination of Pregnancy Act 1971
 To prevent the fatalities due to criminal abortions
Criteria to be met legally before conducting an abortion:
1. Reasons under which termination of pregnancy can be done
a) THERAPEUTIC:
If the continuation of pregnancy endangers the mother’s life or cause serious injury to
her physical or mental health
b) EUGENIC:
If there is risk of child being born with physical or mental abnormalities
c) HUMANITARIAN:
If the pregnancy caused by rape
d) SOCIAL:
If the pregnancy due to failure of contraceptive methods
2. Doctor who can perform Medical termination of pregnancy
Qualified registered medical practitioner with prescribed experience as below
 a) Upto 12 weeks gestation
 Registered medical practitioner who has assisted in 25 MTPs, 5 of which are
conducted independently in an hospital established/ maintained/ training institute
approved for this purpose by government.
b) 12-20wks of gestation
 Registered medical practitioner with experience in practice of obstetrics and
gynaecology for not less than 3 years
 Registered medical practitioner who has completed 6 months’ house surgency in
obstetrics and gynaecology / has experience in recognised hospital for not less than
1 year in practice of obstetrics and gynaecology
 Registered medical practitioner with post graduate degree or diploma in obstetrics
and gynaecology
3. The place where Medical termination of pregnancy can be performed
 Government hospitals or hospitals and institutes recognised by government for this
purpose
 Licence to conduct MTP has to be obtained from chief medical officer of the
district and has to be displayed prominently
 Licence has to be renewed every 5 years
4. Gestational age up to which Medical termination of pregnancy can be performed
 Period of pregnancy less than 12 wks- can be terminated on opinion of a single
doctor
 Period of pregnancy between 12-20 weeks- 2 doctors must agree there is an
indication and termination can be done by any 1 doctor.
CONSENT
 Consent of woman to be taken before procedure
 Consent of the guardian if woman is a minor or mentally ill
 Consent of husband not necessary
 Cannot be performed at the request of the husband if the woman is not willing
OTHER PROVISIONS
 Woman need not produce proof of her age
 Police complaint in case of alleged rape case not required
 Admission register for MTP is maintained as confidential document
 In an emergency pregnancy can be terminated by a single doctor even without
required training even after 20 weeks without consulting a second doctor in a
private hospital which is not recognised but done in good faith and exercised proper
care and skill.
METHODS USED IN MTP
1st trimester
Medical method:
 Mifepristone used for induction and after 36-48 hours’ misoprostol is given which
causes contraction of uterine muscles and softening of cervix
Surgical method:
 Vacuum aspiration: cannula with 0.4-0.6kg/sq.cm
 Dilatation and curettage
2nd trimester
 Medical method:
 Amniotic fluid replacement therapy: amniotic fluid is removed and replaced with
equal volume of 20% saline or 50% glucose- abortion after 24-48 hrs of injection
 Intra amniotic injection of prostaglandin F2
Surgical method:
 Dilatation and evacuation
 Hysterectomy: done when sterilization has to be done along with MTP/ failure of
induction.
CRIMINAL ABORTION
 Any abortion done outside the purview of MTP act
METHODS
Upto end of 1st month:
 Violent exercises cycling, jumping from height, lifting heavy weights, running up
and down the stairs.
 Very hot and cold hip baths alternately
 Severe pressure on abdomen by kneading, blows, kicks
 Use of purgatives
 usually successful in people who have natural irritability of uterus and are prone for
abortion
Upto end of 2nd month:
Abortifacient drugs:
I. ECBOLICS
Action: Increase uterine contraction but do not dilate the cervix
a. Ergot: commonly used
Toxic side effect: arterial spasm and gangrene of extremities
b. Hydrastiscanadensis( golden seal plant): action similar to ergot but less intense.
c. Quinine: direct action upon uterus and uterine nerves
d. Lead: pills made from lead oleate. Causes tonic contraction of uterus and also toxic
effect on cells of developing ovum. Symptoms of lead poisoning may be seen
e. Pituitary extracts: oxytocic effect on uterine muscles
f. Decoctions of cotton root bark, nitrobenzol, picrotoxin and strychnine
II. EMMENAGOGUES
 Action: Produce or increase menstrual flow
 Act as abortifacient when given in large, repeated doses
 Savin, borax, apiol, rue, laburnum, oestrogen, sanguinarin, senecio, caulophyllin,
hellebore, etc.
I. IRRITANTS OF GENITO-URINARY TRACTS

 Action: reflex uterine contraction

 Eg: oil of pennyroyal, oil of tansy, oil of turpentine, canthrides, potassium
permanganate etc.
II. IRRITANTS OF GASTROINTESTINAL TRACT
 Action: substance causing irritation of colon -> hyperaemia and contraction of
uterus
  Eg: cathartics such magnesium sulphate or purgatives such as aloes, calomel,
phenolphthalein, rhubarb etc
III. DRUGS WITH POISONOUS EFFECT ON BODY
 Inorganic irritants: lead, copper, mercury, antimony
 Organic irritants: canthrides, unripe fruit of papaya, unripe fruit of pineapple, carrot
seeds, juice of calotropisetc
After 3rd month:
 Mechanical interference either by woman or some other person
1). Syringing: irritant fluid syringed at high pressure into uterine cavity. Air embolism,
chemical peritonitis, general toxemia through absorption, vagal inhibition
2). Cupping: negative pressure of over turned mug cause separation of membranes and
abortion
3). Rupturing the membranes: uterine sound, catheter, stick, pencil, umbrella rib, glass
rod. Infection, perforation of vaginal or uterine wall
Syringe aspiration: syringe attached to catheter to produce suction within uterus sufficient
to rupture chorionic sac and precipitate abortion
4). Dilation of cervix: foreign bodies left in cervical canal like laminaria tent or slippery
elm bark swell due to moisture and dilate the cervix, irritate uterine mucosa and cause
uterine contraction and expulsion of foetus
5). Abortion stick: 12-18cm long wood or bamboo stick used. One end covered with
cloth soaked irritant juice of calotropis/ SemecarpusAnacardium and introduced to uterine
cavity.
EVIDENCE OF CRIMINAL ABORTION
IN LIVING
 Signs of injury to abdomen
 Signs of recent abortion similar to signs of recent delivery but may vary depending
on length of pregnancy
st
1 2-3 months:
 Haemorrhage, slight softening of cervical os and vaginal wall, slight enlargement
of uterus
 Breast changes more prominent in primipara
th th
4 -5 month:
 Haemorrhage more marked, internal os admits 1 finger, genital organs softened,
vaginal canal shows erosions and lacerations, cervix show marks of valsellum
forceps indicating use of an instrument
 In case of suspected sepsis following criminal abortion fluid from vagina, uterine
cavity and blood collected for chemical and bacteriological examination
IN DEAD:

Suspected when:
 Deceased is pregnant and deeply cyanosed
 Instruments to procure abortion or abortifacient drugs are found at scene of death
 Underclothing appear to be disturbed after death
 Fluid, soapy or blood stained fluid coming out of vagina
Evidence of criminal abortion:
  Deceased’s medical history and her whereabouts prior to death
 Clinical or autopsy examination
 Examination of the aborted material if available
AT THE SCENE
 Condition of bed linen and the under clothing
 Scenes of recent interference of pregnancy
 Discarded linen, dressing, cotton wool, swabs
 Presence of known abortifacient drugs
AT AUTOPSY
 To get a bloodless field, all organs are removed prior to removal of pelvic organs
 Uterus is opened along long axis and any fluid obtained is collected
 If chorionic sac is still present then its integrity and attachment to decidua is noted
 Look for products of conception and state of placental bed noted
 Cervical canal, vaginal canal examined for injuries, inflammation or foreign
materials
Abortion by drugs:
 GI tract for signs of irritant poisoning
 Whole tract with contents along with other organs sent for chemical analysis
 Urinary tract examined for signs of inflammation
 Vagina and cervix examined for erosions and inflammation due to application of
local irritants
 Necrotic pseudo membrane formed in vagina due to irritants send for analysis
Instrumental abortion:
 Signs of injury to abdomen
 Abdomen is opened and peritoneum, pelvic floor and pelvic organs are examined
for punctures, ruptures, haemorrhage and inflammation
 Presence of air in large veins - in case of embolism
 Uterus crepitant and bubbles seen under serosal surface or parietal peritoneum
 Gas bubbles seen in the wall of placental bed
 If evacuation done by curetting, endometrium will have evidence of scooping
 In Dilation of cervical canal, Groove like parallel notches on cervical canal around
external orifice- holding with valsellum forceps
 Perforation of vagina and uterus may be of varying form and size
 Multiple perforations may be present
 Small/ large intestine may also be perforated segments of intestine, omentum or
mesentry may enter uterine cavity
 Foreign body found in genital tract to be preserved
Abortion by syringing:
 Fluid in vagina
 Cervical mucous plug displaced/ disintegrated
 Corrosion/ tissue damage due to use of antiseptics
 Cervical canal dilated and injured
 Foamy dark red fluid found between uterine wall and foetal membranes with partial
detachment of placenta
 Bubbles of gas in the venous system from uterus to right heart
  Right side of heart, SVC and IVC contain foamy blood and are ballooned out with
elastic feel
 Fatal venous air embolism- beaded appearance of IVC, uterine and pelvic veins due
to air bubbles
In case of sepsis following abortion:
 In uterine infection- uterus is spongy, swollen and discoloured
 Serosal surface brownish, endometrium ragged , foul smelling or purulent
 General signs of septicemia - enlarged soft spleen, prominent lymph nodes
 Kidney- bilateral cortical necrosis
 Skin - bronzed with mottled/ rain drop appearance- clostridial infection
Examination of expelled material:
 Material alleged to be expelled from uterus examined for products of conception
 Wash with water to dissolve the blood
 Histopathological examination- blood clot/ foetus/ polyp/fibroid
 If blood clot- grouping and precipitin test
 If foetus- determine the age
Causes of Death:
1. Immediate:
Vagal inhibition, air embolism, haemorrhage, fat embolism, amniotic fluid
embolism
2. Delayed:Within 48-72 hrs- septicemia, pyaemia, peritonitis, tetanus
3. Remote:Hepato-renal failure, bacterial endocarditis, pulmonary embolism