Define impotence and sterility. Describe their causes and medicolegal importance. Add a note on artificial insemination.

Definitions

Causes

• Impotence in the male — psychological causes account for the majority: anxiety, depression, fear of failure, guilt and relationship difficulty, characteristically with preserved nocturnal and early-morning erections, which is the key distinguishing feature; organic: diabetes (much the commonest organic cause, through neuropathy and vascular disease), vascular disease and hypertension, neurological disease including spinal cord injury and multiple sclerosis, endocrine disorders (hypogonadism, hyperprolactinaemia, hypothyroidism), and local disease such as Peyronie disease, hypospadias and phimosis; drugs: alcohol (both acutely and chronically), antihypertensives (particularly beta-blockers and thiazides), antipsychotics, antidepressants, opioids, and cimetidine; and age
• Impotence in the female — vaginismus; an imperforate or rigid hymen; congenital absence or atresia of the vagina; a vaginal septum; scarring and stenosis after infection, surgery or female genital mutilation; painful local conditions; and psychological causes including a history of sexual abuse
• Sterility in the male — azoospermia or oligospermia from undescended testes, mumps orchitis, varicocele, obstruction, vasectomy, radiation, cytotoxic drugs, heat and Klinefelter syndrome
• Sterility in the female — tubal blockage (commonly following pelvic inflammatory disease and genital tuberculosis, which remains a significant cause in India), anovulation including polycystic ovary syndrome, uterine causes including Asherman syndrome, endometriosis, and cervical factors

Medicolegal Importance

• Nullity of marriage — impotence, not sterility, is a ground for annulment on the basis of non-consummation under the Hindu Marriage Act and other personal laws. Sterility is not a ground for nullity, though it may found a claim of concealment. Impotence quoad hanc (or quoad hunc) — impotence with one particular partner only — is recognised and is sufficient
• Divorce — on grounds including non-consummation and cruelty
• Disputed paternity and legitimacy — where a husband alleges he could not have fathered the child; here sterility is the question, and DNA testing has largely replaced inference
• Defence in a charge of rape — an accused may plead impotence. The plea is weak, since impotence may be quoad hanc, may be intermittent, and since penetration between the labia suffices and does not require a full erection. The examination cannot prove potency, only that no evident bar exists
• Nullity and legitimacy claims after artificial insemination
• Compensation for loss of sexual function after injury, and sterilisation performed without valid consent or negligently

Artificial Insemination and Applied Aspects

• AIH (artificial insemination by husband) — using the husband's semen. Raises few legal problems: the child is legitimate, and the consent of both spouses is taken
• Aid (artificial insemination by donor) — using donor semen. Historically raised difficult questions of legitimacy, adultery and inheritance. The settled position is that with the husband's consent the child is legitimate, and that aid does not constitute adultery, since there is no sexual intercourse. Written consent of both spouses is essential, and the donor is anonymous, screened, and has no rights or duties toward the child
• The ART (Regulation) Act 2021 and the Surrogacy (Regulation) Act 2021 now govern the field — registration of clinics and banks, a national registry, standards for donation and storage, and the prohibition of commercial surrogacy, only altruistic surrogacy being permitted for defined categories
• Ethical issues — the status and disposal of surplus embryos; multiple pregnancy and selective reduction; donor anonymity against the child's interest in knowing their origins; exploitation of poor women as donors and surrogates; and affordability
• Do not confuse impotence with sterility in a report; establish which question is being asked, since nullity turns on the first and paternity on the second
• Ask about nocturnal and early-morning erections; their preservation points strongly to a psychological cause, which is treatable, and this single question directs the whole assessment
• Examine for diabetes, alcohol and drugs in every case of male impotence; these are the common and reversible organic causes
• The doctor cannot certify potency, and should say so; the opinion is that there is or is not any evident physical bar to intercourse
• Impotence is inability to perform; sterility is inability to procreate, and a person may be one without the other — the distinction decides which relief is available
• Impotence is a ground for nullity and sterility generally is not, because non-consummation goes to the validity of the marriage itself
• Quoad hanc and quoad hunc — impotence toward one particular partner only — is recognised, and is usually psychological
• Most impotence is psychogenic, and the nocturnal penile tumescence study distinguishes it from organic causes
• Never certify impotence on a single examination; the opinion should rest on repeated assessment, specialist opinion and investigation, and a wrong certificate ends a marriage
• Sterility in the male is established by semen analysis, repeated after an interval, since a single abnormal sample proves little
• Artificial insemination raises questions of consent and legitimacy — AIH by the husband, and aid by a donor, which requires the written consent of both spouses and is now regulated by the ART Act 2021
• Frigidity is the female counterpart of psychogenic impotence, and is a recognised ground where it prevents consummation
• Vaginismus and an imperforate hymen are physical causes of non-consummation that are correctable, which the report should state
• Do not confuse sterility with impotence in a report; the two attract different reliefs and the confusion is common
• A child born of aid with consent is legitimate; without the husband consent, questions of legitimacy and of adultery have been raised
• Advancing age reduces fertility in both sexes, and an opinion on sterility must take the age and the duration of cohabitation into account
• Examine both partners before opining on sterility; attributing it to one without examining the other is indefensible and common
• Impotence may be temporary — from drugs, alcohol, illness or psychological state — and a certificate should say so
• Sterilisation requires the person own consent alone, and a spouse consent is neither required nor sufficient
• Record the examination in detail; these opinions decide marriages and inheritance, and are revisited years later
• Avoid the older terminology in reports; write what was found and what it means functionally rather than applying a label
• Erectile failure with preserved nocturnal tumescence is psychogenic, and the distinction determines both treatment and the legal outcome
• Azoospermia after vasectomy must be confirmed by semen analysis before sterility is certified; early failures occur
• Consummation requires penetration, not ejaculation, and a marriage is not unconsummated merely because conception has not occurred
• Impotence quoad hanc is a recognised plea, and its psychological basis should be stated rather than left implied
• The examination is intimate and needs consent and a chaperone, and these opinions are frequently sought in bitterly contested proceedings
• Sterility may be primary or secondary, and the distinction directs the investigation and bears on any allegation of concealment
• A eunuch is impotent and sterile, whereas a vasectomised man is sterile and fully potent — the classical illustration of the difference
• Hormonal and genetic causes must be excluded — Klinefelter syndrome, hypogonadism and androgen insensitivity — before a functional label
• Report the findings and their functional meaning, and leave the question of nullity or divorce entirely to the court
• Take a full drug history; antihypertensives, antidepressants, antipsychotics and alcohol are common and reversible causes of impotence