IMPOTENCE/ ERECTIL DYSFUNCTION

Impotence: - The physical inability of a person to perform sexual intercourse &

achieve gratification is impotence& the person is called impotent. Impotence in
male is a ground for divorce but sterility of female is not a ground for divorce,
because marriage is a contract between male & female which is consummated
through sexual contact.

Sexual potency: is the ability to carry out and consummate sexual intercourse,
usually referring to the male.

Erectile dysfunction:-Inability to develop & maintain a penile erection

sufficient for satisfactory sexual intercourse, ejaculation of semen is not a
ground for potency in an impotent male, because flaccid (Relaxed) penis is not
capable of performing sexual intercourse.

Quod:- (as regards) A male may be impotent with one particular female, but
not with another.

Frigidity:- (coldness)- absence of desire for sexual intercourse in female or

incapacity to achieve orgasm.

Etiology or causes of erectile dysfunction and sterility in males

a) Psychological:- earlier, psychogenic causes were supposed to be most

common cause of ED, but recently organic diseases are found to be most
common. Absence of desire for sexual inter cause may result from dislike
of partner, passion for a particular woman, fear of failure, anxiety or
mood disorder, guilt, aversion, childhood sexual abuse, post-traumatic
stress disorder.

b) AGE: before puberty, boys are usually impotent and sterile with certain
exceptions; poor physical development of penis is common cause of ED.
In advanced age libido diminished, but they are not impotent or sterile

c) Developmental (Congenital) & Acquired abnormalities--

Malformation & deformities of penis & testes. e.g. hypospadias,
epispadias, absence of testicles
d) Local Diseases- Stricture of urethra, inguinal hernia, hydrocele,
phimosis, Elephantiasis of scrotum or penis, Atrophy of testes, Disease of
testes & epididymis- tuberculosis, syphilis.
e) General diseases- Erectile dysfunction is common during acute illness,
severe debilitating illness, Brain & spinal cord diseases, neurological
condition- paraplegia, hemiplegia, endocrinal disorders- Diabetes
Mellitus, and hypothyroidism. And diseases like - Tuberculosis, nephritis
may cause ED and sterility. Malnutrition, vitamin C and zinc deficiency
may cause ED.

f) Chronic poisoning:- Prolong exposure of – lead ,arsenic, pesticides,

cocaine, chloral hydrate, ganja and chars may cause ED

g) Injuries: - spinal cord injury, Fracture of lower limb& penis may cause
ED.

h) Medications:- Antidepressants, antipsychotics, anti- hypertensive’s, anti

ulcer agents (cemetidine), cholesterol lowering agents may cause
impotence.

i) Behavioral factors: - Life style choices- chronic Alcoholism, smoking,

over weight and avoiding exercise are possible cause of ED.

j) Addiction:-Certain drugs, e.g.- morphine, heroin, opium, cannabis,

cocaine, tobacco smoking may cause impotence.
 STERILITY

Sterility: - It is absolute inability of either a male or a female to procreate.

In case of male- sterility is inability to make conceive or impregnate a female
& beget a child, and In case of female- sterility is inability to conceive a child.
Sterility occurs more in female because pregnancy is demonstrable only in
female.
Fertility:- Capacity to reproduce or the state of being fertile
Infertility:- Failure to conceive after 1 year of unprotected and regular
intercourse
Etiology or causes of erectile dysfunction and sterility in females
a) Age- Women are fertile from puberty to menopause, but may be pregnant
before menarche and after menopause. In old age narrowing the vagina.
And the infertility rises significantly as age increases. Commonly
Reproductive period is 14- 45 years.

b) Developmental (Congenital) & Acquired abnormalities:- Defective

Ovulation, Defect in genital organs-Vagina, uterus, ovary.

c) Diseases- pelvic inflammatory diseases, vaginitis, endometrites,

salpingitis, acidic discharge from genital canal, vaginal fistula, retro
verted uterus, obstruction of fallopian tube. Disease of ovaries, Tumors of
Labia & Vagina.

d) Chronic poisoning:- Prolong exposure of – lead ,arsenic, pesticides,

cocaine, chloral hydrate, ganja and chars may cause sterility.

e) Medications:- chemotherapy , cessation of oral contraceptives.

f) Psychological cause- Hysterical Fits, Fear, pain, apprehension for

intercourse.

Laboratory examination: it will vary depending upon the history and clinical
findings. E.g.- Examination of semen in case of infertility. For systemic disease-
urine analysis, blood counts, blood sugar, lipid and thyroid profile, renal and
liver function tests- creatinine, serum bilirubin. Serum testosterone, LH and
serum prolactin.
Besides routine blood and urine analysis, hysterosalpingogram (HSG), pelvic
ultrasonography, hysterosonogram, and MRI required.
Medico legal importance:-

• Nullity of Marriage & Divorce.

• Disputed paternity cases.
• After passing child bearing age a woman claims Right over Money of her
Husband without any issue.
• Any Natural or Unnatural sexual offences

STERILISATION (Family Planning)

Definition: Sterilization is a process to cause a Male or Female person sterile

without affecting their potency or sexual function. (Making them unable to
beget or conceive child without interfering their potency)

Classification: sterilization can be classified according purpose or intention in

following way-
1. Compulsory: it is by an order of the state, carried out on mentally or
physically defective person or as punishment to sexual criminals, or for
the purpose of eugenics. It is not done in India.
2. Voluntary: it is carried on married persons with consent of both the
husband and wife. It can be:
i. Therapeutic: it is done to prevent danger to health or life of women
due to future pregnancy.
ii. Eugenic: it is carried out to prevent conception of the children who
are likely to be defective physically or mentally.
iii. Contraceptive: it is done as a family planning measure.
Contraception: The term contraception includes all measures designed to
prevent pregnancy due to coital act.
Methods:-
Temporary
❖ Natural contraception- rhythm method, coitus interruptus and
breastfeeding ( abstinence during fertile period of a cycle, un safe
period)
❖ Barrier contraceptive- ( spermicidal agent, diaphragm in female,
condom in male)
❖ Intrauterine devices-or hormone containing IUD ( copper T,
Multiload 250/375, Lippes loop and levonogestrel intrauterine
system, progestasert)
❖ Steroidal contraception:- e.g.-
• Oral pills:- progestins and estrogens.
• Injectable steroids:- Depomedroxy progesterone acetate
(DMPA.
• Implants:- Norplant (levonorgestrel)
Permanent method:
❖ In males: Vasectomy (dividing the vas deferens) in newer
techniques uses chemical sclerosing agents, like ethanol,
formaldehyde and silver nitrate that can eliminate the need of
surgery.
❖ In females: Tubectomy (Fallopian tubes are ligated), laprotomy or
minilapand laproscopy using clips.
 ARTIFICIAL INSEMINATION (AI)

Definition: It is the artificially process of introduction of semen from the

husband or a donor by instruments into the vagina or uterus of a female to bring
about pregnancy which in not attainable by sexual intercourse called (AI)
Artificial insemination.

Types:

I. In case of husband artificial insemination homologous/husband(AIH)

II. In case of donor (other male) artificial insemination donor (hetrologous)
(AID)
III. ‘Pooled’ (AIHD) in this process donor semen is added to husband semen.
There is a technical possibility of husband being father of the child
Procedure : semen is obtained by masturbation after a week’s abstinence and 1
ml is deposited by means of a sterile needleless syringe just above the
internal os, at the time of ovulation (14th day after menstruation). The
success rate of AI vary depending on the type of insemination used, but
typically the success rate varies between 5-30%, the success rate can be
affected by factors such as stress and quality of the egg and sperm. A
more efficient method of AI is to insert semen directly into the uterus by
means of a catheter. The semen to be implanted is ‘washed’ in a
laboratory to remove mucus and non-motile sperms in the semen and
concentrated in Hams F10 media without L-glutamine, warmed to 37oc.
Indication:-
• The husband is impotent /ED
• Husband unable to deposit semen in vagina due to urethral fistula
• A zoo- spermia or decreased sperm counts, motility.
• husband sterile, suffering from hereditary disease
• widow/ unmarried women desiring children
• Rh incompatibility
• Multiple failures of IVF.

TEST TUBE BABIES

In vitro fertilization:- Also known as IVF of ovum by the sperm of her
husband.
The embryo at the stage of blasto cyst is introduced in the uterus of the
woman from whom ovum was obtained (in case of infertile or sterile
husband donor sperm is utilized for IVF after the consent of the couple
 SURROGATE MOTHERS

Definition: Surrogate (Latin subrogare: to substitute) mother is a woman who

carries a child for a couple or a single person with the intention of giving up the
child, once it is born (also called surrogate pregnancy)

the surrogate mother may be the baby’s biological mother (traditional

surrogacy) or she may be implanted with someone else’s fertilized egg
(gestational surrogacy), She accepts pregnancy either by AI or by implantation
of in vitro fertilized ova at the blastocyst stage, till delivery for the woman who
in incapable to bear child. The most common reason for using a surrogate
mother is infertility. In IVF techniques the surrogate mother receive the embryo
of other couple in her uterus & after delivery she hand over the baby to
biological parents from whom ovum & sperm was obtained. It is a contract with
another woman.

▪ The surrogate mother should be below 45 years of age.

▪ No individual can be a surrogate mother more than thrice in a life time

 VIRGINITY & DEFLORATION

Virgin (Latin Virgo: intacta, untouched)

Defloration: the act of depriving a woman of her virginity.

Virginity means- A female who have not any sexual intercourse during her life
time& defloration means- loss of virginity who has intercourse during life time.

(The presence & absence of Hymen is not an absolute proof of virginity &
defloration.
In some cases Hymen remain intact even after sexual intercourse with elastic,
dilatable, fimbriated & fleshy hymen in character called false virgin)
Sign of virginity-

• Hymen- Intact, rigid & elastic

• Labia Majora & Minora- Firm, elastic& rounded labia Majora & adjacent
to each other, fully developed & closed to the vaginal orifice. Rose color
labia Minora lying hidden under the labia Majora & adjacent.
• Clitoris- Not Enlarged.
• Fourchitte- Intact.
• Vagina- Narrow & more folded with pinkish wall
• Perineum- Entire or intact
• Uterus- very small, not palpable, External OS Round slit like.

External sign-

• Breast- Hemispherical, firm & elastic.

• Nipple- small, pointed
• Areola- small& pink
• Abdomen- No sign of Enlargement & pregnancy (No striae gravidorum)
Sign of Defloration-

• Hymen- May be torn (Absent with opening allowing passage of two

Fingers easily)
• Labia Majora & Minora- Separate & vaginal orifice exposed.
• Labia Minora- Separate Not covered with Labia Majora, Brownish color
• Fourchitte - Ruptured.
• Vagina- Dilated, less folded, soft &length increase.
• Perineum- Entire or intact
• Uterus- May be palpable.
External sign-
• Breast- Flabby& globular with blunt nipple & brownish enlarge areola.
• Nipple- small, pointed
• Areola- small& pink
• Abdomen- Striae gravidorum may be present with other sign of pregnancy.

Differentiate Virgin & Deflorated Girl

Female Genitalia virgin Deflorated

Definition A girl who have not A girl who has
intercourse during her intercourse during her
life time life time
Hymen Intact,Rigid&Inelastic Torn or Absent

Labia Majora Adjacent to each other Separate

Labia Minora Adjacent to each other Separate

Fourchitte Intact Ruptured

(posterior part of vagina)
Vagina Narrow &More Folded Less Folded& Length
Increase
 PREGNENCY

Definition:- Pregnancy is a physiological condition which occurs in a female

after fertilization of ovum by sperm and carries a fertilized ovum within the
uterus.

A. Diagnosis of Pregnancy in the Living

1. presumptive sign/ symptoms

2. Probable sign of Pregnancy
3. Positive/conclusive sign of pregnancy

1. Presumptive sign/ symptoms Mnemonic for presumptive signs.

(ABCDEF) {Amenorrhea, breast Changes, Chadwick’s sign, Chloasma,
Diuresis, Emesis, Fatigue}

i. Amenorrhea: (Sudden & complete cessation of previously regular

menstrual flow in woman in child bearing age. This is the earliest and one
of the most important symptoms of pregnancy. Cessation of menstruation
may result from ill- health, fear of pregnancy after illicit inter course.
ii. Morning sickness: nausea, vomiting It is usually appears about the end of
the 1st month and disappears by end of 3rd month. Nausea and vomiting are
usually present in the morning, it is more prominent in primigravidas
iii. Changes in breasts- Breast become firm, tender, tense and enlarged. Nipples
become pigmented, erectile and areola becomes dark brown. Around the
nipple, the sebaceous glands (Montgomery’s tubercles) become large by the
end of 3rd month. Colostrum (thin, yellowish fluid) secreted at 12th week.
iv. Quickening- is a peculiar sensation of fetal movement felt by mother near
about 16th - 18th week which gradually increase in intensity.
v. Pigmentation of the skin: Axila, Abdomen become darker due to deposition
of pigment and a dark line extends from pubis to umbilicus which is called
Linea nigra seen by 20th week.
vi. Chloasma: Pigmentation over forehead and cheek and dark ring around eyes
may appear after 4th month.
vii. Chadwick’s sign: The mucous membrane of the vagina change from pink to
violet- blue as a result of venous obstruction at about 8th month of pregnancy
viii. Urinary disturbance: During 8-12 week of pregnancy of pregnancy, the
enlarging uterus exerts pressure on the bladder and produces frequent
micturition. This disappears gradually after 123th week as uterus straightens
up into the abdomen.
ix. Nervous symptom: Fainting attack in earlier months of pregnancy, irritable
temper & fatigueness, Pain in legs with cramps of muscle- due to pressure on
the nerve of limbo sacral cord, Pain in groin- due to stretching of round
ligament, Constipation, excessive salivation, perverted appetite.

2. Probable sign of Pregnancy

i. Enlargement of abdomen due to enlargement of uterus ( fundal

height): During pregnancy , abdomen gradually enlarges in size after the
12th week

ii. Changes in vagina, cervix& uterus. (In 2nd trimester of pregnancy)

Vagina- become moist

Cervix- - become soft
Uterus- become enlarged, palpable form at the end of 3rd month
onwards
At 3rd month above pubic bone
At 4th month above pubic symphysis
At 5th month between pubic symphysis &umbilicus
At 6th month at umbilicus
At8thmonthbetween xiphisternum & umbilicus
At 9 month at lower end of xiphisternum

iii. Hagar’s sign- the isthmus is felt as a soft compressible area between cervix
and elastic body of uterus by introducing two fingers in the vagina. it is
positive between6-10th week
iv. Goodell’s sign- Pregnant woman’s cervix become soft and feels like lips,
and in non pregnant woman’s like the tip of the nose.
v. Braxton-Hick’s contractions:-Intermitent, spasmodic, painless uterine
contraction is observed after 4th month. They are present even when the
fetus is dead.
vi. Uterine soufflé- Uterine blowing sound due to blood circulation through
enlarged uterine arteries.
vii. Ballottement- Movement of fetus in amniotic fluid felt by internal and
external ballottement.
• In internal ballottement fetus drops down on the finger after given
sudden upward motion (toss up like a ball).
• In external ballottement rebound sensation of the fetus felt by hand
after a sudden motion given to the abdominal wall covering the
uterus due to moving fetus in amniotic fluid usually after 6 month of
pregnancy.
Immunological tests- hCG appear in the maternal urine /serum about 1 week
after implantation or by 8-11 days after conception as the placenta begins to
develop and produce increasing amounts of hCG.
Advantages of this tests are-
• Convenient and sensitive
• Accuracy 98%
• No animal is required
• Results are quicker

Immunological Tests have replaced biological test for routine screening.

The first voided urine in the morning contains highest level of hCG and it is
preferable for testing.
Immunoassays without radioisotopes: indirect agglutination inhibition test
(Gravindex test) A simple rapid test using latex particles coated with a purified
preparation of Hcg as the antigen and an antiserum to hCG

Limitations: It will give positive test with- ectopic pregnancy, Hydatidiform

mole,
And breast or ovarine tumors, Choriocarcinoma, after abortion, 1st week of
puerperum.

4. Positive/conclusive sign of pregnancy: Mnemonic for positive signs

of pregnancy: RUFFF (Radiological, Ultrasound, Fetal heart sound, Fetal
movements, Fetal cell in mother blood.

i. Fetal movements and parts: Fetal movements and fetal parts can be
identified distinctly by 20th- 22nd week on abdomen.
ii. Heart sound of fetus- Definite sign of pregnancy. They are heard
between 18-20th week with an stethoscope. The sounds like ticking of a
watch placed under the pillow, it is heard 2 inch above upper border of
pubis (symphysis) The rate is usually 160 /minute at 5th month and
140/min at 9th month (normal range 110- 160 beat/ min)
iii. Ultrasonic Doppler test- confirmed after 2nd month (8th week) of
pregnancy
iv. Doppler fetal heart sound heard after 3 month of pregnancy
v. by foetoscope audible at the end of 5 month
vi. Fetal cells in mother’s blood:- some fetal cells also make their way into
the maternal blood streams. These cells can be detected in the mother’s
peripheral blood by 5th week of pregnancy. Even the sex of the fetus can
be determined by karyotyping these cells.
vii. Radiological sign: Skeleton (mandible) become detectable after 16 week
(4 month) X-Ray examination avoided–Repeated x-ray Harmful to
gonads & fetus Produces microcephalice fetus& death.

Maximum and minimum period of Gestation

❖ The usually accepted average is 280 days from the first day of the
last menstrual period, so that the actual period of gestation is about 9
months (266 days) or less.
❖ The woman may over carry the fetus to post maturity up to a period
of 320 days.
❖ Expulsion of fetus may occur at any period before full term.
Medically, for a fetus to be viable, it should be 28 weeks (7 months)
of gestation.
❖ 7 month (210 days) infant is legally accepted viable child.
❖ Although 6 month (180 day) child may be viable capable of
continuing independent existence if proper care is taken.
B. Diagnosis of pregnancy in the dead

External physical changes should be noted. In the internal examination, the

following should be looked for:
 i. Presence of embryo, fetus, placental tissue or membranes- positive
proof of pregnancy.
ii. Enlarged end thickened uterus
iii. Corpus luteum in ovary- corroborative evidence.
PSEUDO CYESIS (SPURIOUS /FALSE/ PHANTOM PREGNANCY)

Definition: -it is a psychological disorder where the woman has a false but firm
belief that she is pregnant, although no pregnancy exists &there may be some
presumptive probable sign without pregnancy but absent of positive sign of
pregnancy.

❖ It is generally observed in infertile females or women nearing

menopause, who desire a child intensely.

❖ Most of these women suffer from some form of psychic or

hormonal disorder.

❖ Such patients may present with all the subjective symptoms of

pregnancy due to pathological condition, like ovarine tumor, or
ascites.

❖ Obstetrical examination along with ultrasonography and

immunological tests for pregnancy will clear the patient of her
imagination.

❖ 7 month (210 days) infant is legally accepted viable child.

❖ Although 6 month (180 day) child may be viable capable of

continuing independent existence.
 DELIVERY

Definition: Delivery is defined as- Expulsion or extraction of the Child) from

mother’s womb at birth.

A. Sign and symptoms of recent delivery in living:

Symptoms

❖ Indisposition and fatigue

❖ Diuresis: 2-5 days
❖ Loss of weight
❖ Intermittent contraction of uterus
❖ Rise in temperature
❖ Transient depression- puerperal psychosis

A. Extra genital sign-

Outlook:-First 2-3days women will be pale color, exhausted & ill looking.
Sunken eyes temperature and pulse increased.
Breast:- Full enlarged prominent & tender. Colostrums and milk comes out
from nipple (Colostrums- Protein with Gama globulin).
Abdomen:- Abdominal wall relaxed and pendular with striae gravidorum line
occur due to fetal movements and linea nigra.
B. Genital sign-

Uterus:- just after delivery uterus reduce & become hard ,contracted, relaxes
& felt as flabby mass up to umbilicus.Retroverted position after 14- 21
days.

• Diameter of uterus after recent delivery- length-20-25 cm externally &

15- 18 cm internally, weight- about- 1 kg.
• Size decreases 1.5 c.m. per day after delivery & attains normal size after
6weeks.
• Fundus at the level of symphysis pubis: 10thy day.
• Descends within true pelvis: 2 weeks
 • Retunes to normal size: 5-6 weeks
(normal size & wt of uterus- 9 cm length, 6.5 cm width, 2.5 cm thick, 80-120
gm wt.)
 Cervix: -soft, edges of external os lacerated or torn transversely internal os
begins to close within 24 hrs & external as closes after 2 weeks.
Vagina: - smooth, relaxed & dilated with recent tears& inflammation sign.

Labia Majora & Minora: -tender, swollen & congested

Fourchitte & perineum: - may show tears & laceration &episiotomy with
stitching is seen in primary gravid

Lochia: - discharge from uterus after delivery which last for 2-3 weeks.

• Lochia rubra: 1st 3-4 days bright red discharge of large clotted blood

• Lochia serosa: Next 4 days it is serous & paler

• Lochia Alba: At 9thday it become yellow or greenish & disappear 2-3

weeks.

Biological tests-

If test are positive means pregnancy recently delivered presence of gonadotrophic

hormone (HCG) in urine (Gravindex test positive)1st week of puerperum

HCG test

HCG test (human chorionic gonadotrophic test)

It gives positive result in

• true pregnancy,
• ectopic gestation,
• Hydatidiform mole,
• chorionic epethelioma,
• after abortion,
• 1st week of puerperum.
B. signs of recent Delivery in Dead

All the local signs mentioned above may be present

Post mortem signs- in addition to the finding are mention in living subject.

❖ Uterus: - seen enlarged & flabby & cut surface of uterus shown dark
colour placental site seen as irregular elevated area. 12-15 cm in diameter
& covered with clotted blood.
• After 2-3 days 17 cm long, 10 cm width, weight 500 gm
• After 1 week 12-13 cm long, width 8 cm, weight 350 gm
• 10-12 days after delivery uterus may become Retroverted in position.
❖ Ovary & fallopian tube found congested & corpus luteum found in
ovaries.

Medico-legal aspect of pregnancy and delivery

Questions of pregnancy and delivery may arise in the following cases:

• Execution of judicial death sentence

• Deferring trial of case
• Criminal breach of trust/ rapes
• Blackmail
• Disputed chastity
• Homicide or suicide
• Concealment of birth
• Criminal abortion and infanticide
• Nullity of marriage and divorce
• Maternity/ paternity leave
• Legitimacy

Written informed consent needs to be taken before examination after

explaining reasons and possible consequences.