Impotence And Sterility

Preety Jha
Roll No: 172
OBJECTIVES
• DEFINITIONS
• CAUSES
• MEDICOLEGAL IMPORTANCE
• EXAMINATION
• STERILIZATION
• ARTIFICIAL INSEMINATION
DEFINITIONS
IMPOTENCE  : It is the inability of a person to perform the
sexual intercourse

STERILITY : It is the inability of the male to beget children

and in the female the inability to conceive children
FRIGIDITY:  Is the inability to initiate or maintain the
sexual arousal pattern in females

SEXUAL DYSFUNCTION : Is an impairment either in the

desire for sexual gratification or in the ability to achieve it 

QUOD:  A male may be impotent with one particular

female but not with another 
FERTILITY: Capacity to reproduce 

INFERTILITY: Failure to conceive after 1 year of

unprotected and regular intercourse 
CAUSES OF IMPOTENCE AND STERILITY IN MALES

PSYCHOLOGICAL CAUSES : Dislike of partner

                                                            Fear of failure
                                                            Anxiety or mood disorders
                                                            Guilt, aversion, low self esteem
                                                            Hypochondriacs
                                                           Dhat syndrome
                                                           Widower syndrome
                                                           PTSD
AGE : power of erection may be present at a much earlier age
hence while examining development of private parts must be taken
into consideration  
 MC CUNE ALBRIGHT SYNDROME 

DEVELOPMENTAL AND ACQUIRED ABNORMALITIES:

Absence of penis, intersexuality, malformations like
hypospadias ,epispadias, absence of testicle , cryptorchidism etc

LOCAL DISEASES : priapism , hydrocele , elephantiasis ,

phimosis, peyronic disease, adherant prepuce , mumps,  syphilis , TB
  
GENERAL DISEASES :
o              Neurological: tabes dorsalis, paraplegia , hemiplegia ,
syringomyelia, ventricular tumours etc.
o                 Endocrine: diabetes, hypothyroidism , hyperprolactinemia 
o                 CVS: Leriche syndrome
o                 Others: malnutrition ,vitamin C and zinc deficiency 
INJURIES :spinal injury at L4 And L5 Level ,spinal cord injury at
sacral segments ,lower limb fractures , fracture of penis
BEHAVIOURAL FACTORS: Smoking , alcoholism , obesity ,
drug addiction.
CAUSES OF
IMPOTENCE AND
STERILITY IN FEMALES

PSYCHOLOGICAL CAUSES :
                                Vaginismus: 1)
spasmodic contraction of the
vagina due to hyperaesthesia
                                         
2)Attempt of intercourse will
cause painful reflex spasm of the
levator ani ,perineal
muscles ,adductor muscles of the
thigh
AGE :
                   No effect on potency
as females are passive partners in
sexual intercourse
DEVELOPMENTAL DEFECTS AND ACQUIRED
ABNORMAILITIES : 
                                 1) Occlusion of vagina
                                           2) adhesion of labia 
                                           3) tough imperforate hymen 
                                           4) surgery to vagina leading to stricture
                                                   formation
                                           5)absence of uterus ,ovaries ,Fallopian tubes
LOCAL DISEASES: Do not cause impotence but may produce
sterility . These include gonorrhoea , prolapse of uterus , bladder ,
vulval or vaginal tumours ,retrovaginal fistula , leucorrhoea .
GENERAL DISEASES: Exposure to lead ,xrays etc 
• MEDICOLEGAL IMPORTANCE :

CIVIL: 1) Nullity of marriage 

                  2) divorce
                  3) disputed paternity and legitamacy
                  4)suits of adoption
                  5)claim for damages where loss of sexual function is      
claimed as a result of an assault or accident 
CRIMINAL : 1)Adultery
                                 2)rape 
                                 3)unnatural offences 
EXAMINATION
• DONE on request from court police personal
• INFORMED CONSENT Should be taken  in all cases 
IF PERSON IS ARRESTED EXAMINATION CAN BE DONE
WITHOUT CONSENT (U/S 53CrPC)
MALE EXAMINATION 
• MEDICAL HISTORY
• SURGICAL HISTORY
• SEXUAL HISTORY
• PSYCHOLOGICAL EVALUATION
• PHYSICAL EXAMINATION
• SPECIAL INVESTIGATIONS
MEDICAL HISTORY: diabetes , hypertension , atherosclerosis etc
SURGICAL HISTORY: Radical pelvic surgery.
PSYCHOLOGICAL: Anxieties, fear , phobia etc
SEXUAL HISTORY : rapidity of onset of dysfunction , duration of dysfunction ,
severity of the problem 
SPECIAL INVESTIGATIONS :
  MALE:  1)BLOOD : serum testosterone ,sex hormone binding globulin  ,HBA1c
                2)nocturnal penile tumescence 
                 3)duplex ultrasonography
                  4)cavernosometry
                  5)penile arteriography
                  6)spongiosography
• FEMALE: 1) genital blood flow: vaginal photoplethysmography
{volume , pressure compliance of blood flow are measured }
•                  2)lubrication: PH , filter papers
•                     3)muscular: pelvic floor electromyogram
•                     4) neural: sensory testing
•                      5)coital imaging studies : MRI ,ultrasound
CERTIFICATE OF POTENCY 
• Registered medical practitioner in government service can issue a
potency certificate 
• If he finds that a male is physically normal in all respects and if all the
causes of impotence ennumerated above are excluded , he is justified
in opinion that there is nothing to suggest that the person examined
is incapable of participating in sexual intercourse
                            STERILISATION
• Sterilization Is a procedure to make a male or female person
sterile without any interference with potency.
• Types:
            1.Compulsory: done on mental detectives or as a
punishment for                                                   sexual criminals.
            2.Voluntary:performed on married persons with consent of
both husband and wife.
                         (a)Therapeutic :performed to prevent danger to
health or life of a women due to any future pregnancy.
                         (b)Eugenic: performed to prevent conception of
children who are likely to be defective both physically or mentally.
                         (c)Contraceptive: performed to limit the size of
family. 
Guiding principles:
• In order to avoid any future legal complications some precautions
should be taken. They are:
1) Consent of both wife and husband should be obtained for
contraceptive sterilization.
2) It is not unlawful if performed on therapeutic or eugenic grounds
provided there was true and valid consent.
3) The person should be advised to abstain from sexual intercourse for
about 3 months or until the seminal examination shows absence of
spermatozoa on two successive occasions.
 ARTIFICIAL INSEMINATION
• The artificial introduction of semen into vagina cervix or uterus to
produce pregnancy is called artificial insemination.
• Types:
1.A.I.H: If the semen of woman’s husband is used
it is called as “artificial insemination homologous”
2.A.I.D: If the semen of some person other than
husband is used it is known as “artificial insemination donor”
3.A.I.H.D: If the pooled donor semen (containing donor semen to
which husband semen is added) is used then it is called “artificial
insemination husband donor”.
• Biological aspects:
Semen is obtained by masturbation and one ml is deposited by means of
syringe in or near the cervix.
The timing of insemination is important.
The time of maximum fertility coincides with ovulation.
Due to the problems related to timing ,Insemination on several
successive days in the month increases the chances of pregnancy.
Success rate is 30-40% pregnancies within 3-4 months.
The use of frozen semen for A.I.D is becoming increasingly common.
• Indications:
When the husband is impotent.
When the husband is unable to deposit the semen in vagina due to
hypospadiasis,epispadiasis etc..
When the husband is sterile.
When there is Rh compatibility between the husband and wife.
When the husband is suffering from hereditary disease.
• Precautions:
1. Consent of the donor and his wife is essential.
2. The identity of the donor must remain secret.
3. The donor should not know to whom the semen is donated and result
of insemination.
4. The donor must be mentally and physically healthy and should not be
suffering from any hereditary or familial disease.
5. The donor must not be a relative of either spouse,he should be potent
and his age should not exceed 40 and should have had children of his
own.
6. The race and characterstics of donor should resemble those of husband
of the women as closely as possible.
7.The donor should be of the blood group as that of husband.
8.There should not be any Rh incompatibility between the donor and
recipient.
9.The woman to be inseminated and her husband must give consent in
writing that an unknown donor should be used.
10.The couple should be psychologically fit and emotionally stable.
11.A witness must be present when insemination is done.
12.It is usually wise to use pooled semen .When husband’s semen is mixed
with that of a donor there is always the technical possibility that the
husband may, in fact be the father of child.
• Delhi artificial insemination (human) act,1995:
The main proposes of this legislation are:
To allow the issueless couples to have a child through A.I and give it a
legal status.
To control spread of HIV through A.I.D.
To regulate the donation,sale or supply of human semen/ovum for A.I.
To make obligatory on part of medical practitioners:
-not to indulge in segregating the XX or XY chromosomes.
-not to disclose the identity of donor/recipient.
-to prohibit to carry on semen bank without registration.
• Legal Problems:
Adultery
Legitimacy
Nullity of marriage and divorce: A.I is not a ground for nullity of marriage
or divorce, because sterility is not a ground for it. But if A.I was due to
impotence, it is a ground.
Natural birth
Unmarried woman or widow
Incest
• Complications:
The husband may feel humiliation of his deficiency from the presence of
child of someone else and may develop psychiatric symptoms.
If the child is mentally retarded or physically deformed ,the father may
develop bitter feelings, for he may be held responsible for this deformity by
other persons.
A neurosis may develop in the mother based on the fact that the child
belongs to her alone.
She may also develop an obsession to know the donor, and having a
second child from the same donor.
The child may suffer mental trauma of he learns his past history.