15 reproductive system


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15 reproductive system

  1. 1. 15-1 THE REPRODUCTIVE ORGANS• How is a man’s body different from a wom-an’s body?• What is this sex all about?• How do babies happen?• How do we stop having babies ?All of us are very interested in sex and this mystery ofhaving children. Yet, this is one topic that is not spokenfreely about.We know about our sex organs compared to how muchwe know about our hands or legs, our nose, eyes or stom-ach .Yet we need to know because sex and reproduction is a veryimportant part of our lives. It is the cause of much happi-ness as well as of misery.Only when we correctly understand will we be able to givecorrect advice and help to others.
  2. 2. 15-2 Growing Up & Changes in the BodyGirls grow up to be women and boys grow up tobe men. How does this happen? Does it happenovernight? No, these changes do not happen over-night.Growing up is part of a chain of things whichhappen to the body at a certain period in life.This period when the body changes to makingboys and girls capable of having children iscalled “puberty” (pyoo-ber-ti). If not for thisvery troubled and confused period in a youngperson’s life, a little girl would have remaineda little and a little boy would have remained alittle boy. Are Puberty and Adolescence (a-dawl-e-sense) the Same? Puberty Puberty is that time of growth in adolescence when a boy and girl become capable of producing a baby. Although the age for puberty is becoming lesser and lesser over the years, it can vary between 9 and 14 in girls and between 10 and 15 in boys. Adolescence Often used in place of each other, adolescence is the period in the life of boys and girls where they are undergoing a transition to their adulthood. Puberty is just one part of this process. The development of gender characteristics made possible by the different hormones of the body are some others.
  3. 3. 15-3 Puberty Girls 1. “Menarche” – first monthly periods 2. Appearance of breast buds. 3. Elevation and enlargement of breasts. 4. Projection of area around nipples. 5. Adult breasts. Gender characteristics During Adolescence, boys and girls get certain features that mark them as male or as female. These are: Girls Boys1. Puberty like monthly periods and 1. Puberty in penis, testes, prostate, vesiclesbreasts, etc. 2. “Adam’s apple;” deep voice.2. Voice remains as earlier 3. Beard, moustache and face hair; hairline re-3. Less body/ face hair cedes4. Pubic hair like inverted triangle 4. Pubic hair in pyramid form5. Narrow shoulders, broad hips; 5. Shoulders broad, big musclesThighs converge, elbows diverge.6. Skin softer, less oily. 6. Skin thicker; more prone to pimples/acne7. Sensitive, softer attitude 7. Aggressive attitude Boys 1. Enlargement of testes. 2. Penis size increases 3. Growth of the front end of the penis 4. Adult genitalia
  4. 4. 15-4 Female Sex Organs By the end of puberty, the body of a girl becomes capable of bearing children. Her sex organs would have developed enough. In women, some of the organs for reproduction can be seen – they are external or outside— and some organs are hidden inside the body, that is, they are internal or inside organs. Organs Outside: External Sex Organs of WomenWhat can be seen just in front of the hole fromwhere the shit comes out, are the two outer andtwo inner ‘lips.’ At the top of the vulva is the clito-ris, which looks like a smaller version of the men’spenis, except that no urine comes out of it. Womenhave a separate opening for the urine, just above clitoristhe opening where the child comes out of the womb vaginal urine openingat the end of pregnancy. opening anus or shit holeOrgans Inside:To carry out the task of bearing chil-dren, each woman has: a. a uterus (womb), b. a vagina, c. two ovaries and d. their tubes. How do reproductive organs work? Once a girl reaches 11 to 13 years of age and starts her monthly periods, she can bear a child. The ovaries produce the eggs and every month one egg is released. When the time is right, the brain signals the ovaries to start its work. The ovaries then starts making the female hormone oestrogen (ees-trow-jen). This hormone acts like a chemical messenger from the brain getting dif- ferent parts of a woman’s body to start developing “womanly features”. The body suddenly becomes shapely, the hips enlarge, breasts get formed and most important of all, the menstrual cycle starts.
  5. 5. 15-51. The OvariesThe ovaries are closely surrounded by finger like projections that eagerly wait to catch the newegg. The finger-like projections send the egg down the attached tubes by a gentle squeezing mo-tion, towards the uterus. Here it waits for the sperm from the male to fertilise it and grow into achild.2. The Uterus 3. Cervix (ser-viks) & VaginaIt is thick and muscular and its wall changes In its lower part, the uterus has a longthickness every few days. Normally about 3 neck, also called its cervix. This is not asinches long, two inches wide and an inch deep, muscular as the top part of the uterus.the thickness changes with the monthly men-strual cycle every few days. The cervix opens into the vagina, another tube like organ, not very muscular, butThe lining is thinnest when the woman is lined with cells. The vagina receives thebleeding. It starts putting on some thickness penis during sex and this is also the open-towards the middle of the cycle and gets re- ing from where the child comes out intoally thick when the egg is sent down to it. A the world.thick wall would keep a fertilised egg prop-erly for a long period of nine months. The thick The opening of this vagina is just in frontupper part of the uterus is also required for of the anus and just behind the openingsqueezing the child out at the time of deliv- for the urine. Nerve endings from theery! clitoris and from the vagina carry signals to the brain. When rubbed or massagedIf the egg is not fertilised by any sperm, the during sexual intercourse (or during mas-uterus sheds its lining and the menstrual bleed- turbation), the woman gets a pleasurableing takes place. sensation.
  6. 6. 15-6Male Sex Organs Sex Organs of MalesLike women, even men have differentexternal and internal sex organs.External organs. Of the external organs,what can be seen hanging between thethighs are:1. a penis (pee-nis)2. a scrotum. (skro-tem) testes1. The Penis glansThe penis when limp has a thin foreskin penis scrotumextending in front. When the foreskin ispulled back, it cuffs around the neck ofthe penis. The bulbous end of the penis iscalled the glans. Common Opening For Sperms & Urine Penis EjaculationMen have a common opening from which When stimulated by repeatedly rubbingboth semen and urine come out. This slit like against the walls of the vagina (or duringopening is at the tip of the glans. The part masturbation), the penis pours out aboutconnecting the glans to the body is called the 2.5 to 3.5 ml (half a small tea spoon) se-shaft of the penis. As short as two to three men in a few spurts. Immediately after, itinches and soft when normal, the penis can again returns to its normal limp shape andincrease in length — to four to six inches – size. It will need an hour up to a few hoursand in width when erect in an excited or to be able to stiffen up once again by sexualsexually stimulated state. It also hardens up stimulation or masturbation.at such times, ready to enter the vagina.Position of the PenisThe normal penis is naturally inclined to one side, either the left or the right. This becomes promi-nent when the penis is erect and a curve may be seen in many shafts. In young age, many menmay feel anxious about the fact, and should be reassured that it is normal.2. The Scrotum Size of the Penis Does NotBelow the penis, is a sac like structure that all men Matterhave and it is known as the scrotum. This has themale counterpart of ovaries. It is called the testes. Although the size of a man’s penis is the focus of many a discussion, a woman’sSperms have to be produced at a temperature vagina is only four inches deep andmuch lesser than the body temperature. Hence, the hence, the smallest of men’s erect penisestestes are stored in a sack (the scrotum) that hangs is enough to penetrate fully.outside the body (unlike in a woman, where theovaries are inside the abdomen). This foreskin is cut off during the ritual of circumcision in Jews and in Muslims.Inside the scrotum are the testes (single=testis). Some men are unable to pull the fore-These are small oblong ball like structures found skin back and find a tight foreskin aninside the scrotum. The testes produces sperms obstruction during sex. They can get(seed cell from the man needed to join with an egg their foreskin removed by a surgeon.in the woman to make a new baby).
  7. 7. 15-7 Internal Parts of the Internal Parts of the Male Reproductive System Male Reproductive ureter System - brings urine from kidneys1. The Testes: urinary bladderThe testes of males has two - stores urinemain functions: vas deferens rectuma. Makes Male Hormone: - - carries spermsThe male hormone ,testesterone is responsible for prostrate anusthe different “male character- - adds fluid to the - shit holeistics” - Like hair on face, semendeeper voice, “Adam’s apple” testesa rough skin, front and side penis - sperms arebalding of males, a muscular - carries sperms made herebody and for the erection and outside the body scrotumsexual stimulation as well. - sac where testes is locatedb. Makes Sperms : The sperms are produced in plenty by the testes. Only one sperm is required to fertilise orjoin the ovum for a baby. But normally every ml of the semen brought out during ejaculation hasabout ten crores of sperms! If this count is less than two crores per ml, the chances of producing achild are almost nil!3. Vas Deferens 4. Prostrate GlandsThe sperms along with some fluid (combined is what is The prostate is a round or-semen) are sent from the two testes through the vas defer- gan at the junction betweenens on each side to two worm like seminal vesicles. Here, the base of the penis andsemen is stored and sqeeszed out at the time of stimula- the urinary bladder above.tion It surrounds the urethra for a short while. It produces much of the nourishingVasectomy : Cutting The Vas Deferens fluid that the sperms re-The two vas deferens are cut on either side and the cut- quire for their travel to theends are tied in the operation for permanent birth control, woman’s tubes.called vasectomy. This small and easy operation, unlikethe tubectomy of the woman prevents the sperms from Enlargement of Prostratereaching the semen. The prostate may enlarge after the age of fifty and be-But as the testes are not touched, the blood can continue yond. This creates problemto take the male hormone for male like characteristics. As in men by making it diffi-the prostate and seminal vesicles continue their connec- cult to pass urine. The moretion with the urethra in the penis, there is practically no the person tries, the worsedecrease in quantity of semen as well. it gets. Only if the person relaxes, is he able to passIn other words, the manliness of men – of voice, hair, skin, urine. An operation to re-muscle and muscle power, erection and ejaculation remains move or decrease the size ofintact after Vasectomy. Once done, men can have sex nor- prostate is now much sim-mally without fear of causing pregnancy. pler and safer than the ear- lier days.
  8. 8. 15-8 Know the Answers THE REPRODUCTIVE ORGANSPlease in the blanks:1. Puberty refers to changes in _______________ while adolescence means changes in __________________, _____________________ and ____________________2. Egg from a woman’s ______________________ goes to the ______________ where it may meet the _____________ from the man. The two together may start developing into a baby that stays in the _____________ for 9 months.3. Men have _________________ sperms in every ml of their _________________. They are made in the _____________ and are taken to their ______________ vesicles through a tube called ________________.4. __________________ in women and _______________ in men can help us stop having babies permanently.5. An erect penis can be _____ to ______ inches long, while a woman’s vagina is _______ inches long.Please mark if “right” or “wrong”:1. Menarche means the first monthly period in girls.2. The cervix helps to push the baby down during delivery.3. Masturbation means stimulating onself for sex and is not good for health.4. Men produce one sperm per month in their testes and this sperm goes to meet the egg from a woman to produce a child.
  9. 9. 15-9 Diseases ofTHE REPRODUCTIVE ORGANS
  10. 10. 15-10 Diseases of Reproductive SystemMany diseases can be transmitted while two people have sex with each other. There area range of Sexually Transmitted Diseases (STDs): simple ones that affect only the skin,like Lice and Scabies (which spreads when people come into physical contact with eachother) to those that can affect the entire body if not treated, like Syphilis and AIDS.Types Of STDsSome STDs are common and can be treated by the health worker. Others are fairly serious andmaybe untreatable. They also constitute a risk to the person’s family & society and will also bediscussed. Serious STDs Include: Simple STDs Include: 1. Gonorrhoea 1. Hepatitis B and C 2. Syphilis (see Phase I Manual in diseases of 3. LGV digestive system) 4. GI 2. Scabies, 5. HIV/AIDS 3. Lice, (skin diseases) etc 6. Herpes SimplexDischarges and SoresUsually, genital problems appear in males and Discharge from Genital Organsfemales as discharges or sores in an aroundthe genital areas. Rashes, warts or swollenglands are other ways in which it is seen.You can find out most types of STDs byknowing what kind of discharge it is or whatkind of sore is found in which part of thegenital area. Take Note It is recommended that all people de- tected to have STDs should be ad- Vaginal Discharge Discharge from Penis vised to get their Blood checked for HIV. Sores in the Genital Ar- Men with STD are usually found to eas have more than one sexual partner and women with STDs are likely to have husbands with more than one sexual partner (commercial sex workers would have multiple part- ners themselves also). All categories are at higher risk of getting the HIV infection and hence AIDS too. Genital sore (ulcer) Genital sore in a woman in man
  11. 11. 15-111. GonorrhoeaIt is a disease that is caused by very strong bacteria, Gonorrhoea affects both men and women, butdirectly causes problems in men.* Women & GonorrhoeaWhen a doctor internally examines women with Gonorrhoea, Types of Sores inmany wounds on the inside of her vagina may be found. De- Vagina of Womenspite the wounds in the vagina women usually do not haveany complaints, although a long time infection may result intheir being unable to bear children.* Can infect childBut if a woman has gonorrhoea, she can pass this infection tothe child at birth. This affects the child’s eyes. The eyes getvery red and pus comes out. It may even lead to blindness.* Men & GonorrhoeaMen on the other hand, have serious problems. Within a fewdays of getting the infection, they may get serious difficulty inpassing urine, almost like a block, and one can easily see pusdribbling out. Asked to press the shaft of the penis results inpus being squeezed out. Fever may also be present. Treatment for Gonorrhoea EARLY TREATMENT IS A MUST. If possible, refer to a doctor. If likely to take time to visit to a doctor, this is the treatment to be advised:Adult : · Capsule Doxycycline 200 mg (two capsules of 100 mg each) initially followed by 100 mg (one cap- sule) with /after food to eat every 12 hours for 7 days.Pregnant Women & Breastfeeding Women · As Doxycycline cannot be given to pregnant or breast feeding women (a woman may stop breast feeding for the duration of treatment until three days after the treatment)), Capsule Amoxycillin 3.0 gm (six 500 mg capsules) may be given by mouth altogether at one time unless there is history of problems with Penicillin / Amoxycillin. A single dose of Cotrimoxazole DS 4 tablets may also be given instead.Children · For children, Amoxycillin at 50mg per kilo body weight in a single dose must be given, but should not cross more that 3 gm at a single time. · For a newborn child having gonorrhoea in the eyes, Amoxycillin as above along with any antibiotic eye drops every two hours for three days can be given.
  12. 12. 15-122. SyphilisSyphilis is a disease that usually goes through three stages in a patient if not treated.I Stage: The first stage presents usually as a single, hard but painless, roundor oval ulcer that has a red margin — called chancre (shan-ker) — and is seenmore commonly on the tip or shaft of penis. Other places are on the vulva,vagina, breasts, lips and anus – all places that may come on contact with theinfecting partner’s syphilis. Appearing within two to three weeks (usually) ofthe exposure to infection, the syphilis ulcer gets well by itself within a few Chancre in syphilisweeks. II Stage : About a quarter (25%) of those who had the chan- II Stage cre goes into the II stage. This usually happens within a month Syphilis or two of the healing of the chancre. In this stage, the person gets non-irritating rashes – only faintly visible when seen from the side - on both sides of the body in various parts of the body, especially on the chest and arms, but specially on the palms and soles. Secondary Syphilis may also be seen as greyish white circular or irregular ulcers inside the mouth. In some, warts may be seen around the anus and in other moist parts. All the Secondary Syphilis ulcers are teeming with germs and even touching them can give a risk of contracting the germs. Rash in body, The person in this stage can also get headaches at night, joint hands & soles of pains and fever. Although the rash goes away, in 25% of them, feet it keeps coming back every now and then unless treated. III Stage: Some of these patients may go into the third stage. In this, punched out ulcers may be seen on the skin and inside the mouth and nose that are surrounded by hardness. Healing starts from the centre of the ulcer but gets covered only with a papery thin scar. The bones of the legs may also get thick- ened and irregular, while those of the nose may collapse giving a saddle nose appearance. This last stage of Syphilis may affect the heart and the big vessels that may burst to cause death or else it may affect the brain to cause confusion, difficulty in walking, pain and imbalance of the limbs and body paralysis and insanity as well. Women after the first stage may get repeated abortions.Treatment for Syphilis There are cheap and good Blood tests that can check Syphilis, like VDRL. However they may turn negative in many cases after the first year or so. Other tests are available now that can confirm Syphilis. Syphilis can be treated well at village level, but a great deal of motivation is required. A Capsule of Doxycycline twice day for 10 to 14 days is considered sufficient. The sex partner should be asked and checked for symptoms of Syphilis and if need be, treated all the same. As said earlier, people with Syphilis are more prone to HIV/AIDS and should be tested for HIV/AIDS.
  13. 13. 15-13 3. Lymphogranuloma Venereum (LGV)Caused by a germ that is passed through sex, LGV also What to do in LGV?starts with a small, painless ulcer or boil like eruption on A capsule of DOXY-the penis or vaginal lips, but usually goes unnoticed. CYCLINE given two times a day for two to The second stage of LGV is highly vis- three weeks is consid- II Stage LGV ered good for treat- ible. Lymph nodes on the groin – usu- ally only on one side – swell up with ment. The partner should be the skin stretched tightly over it. The treated at the same time to avoid swelling is highly painful and the per- the infection from coming back. son may get fever with shivering also. In women, usually the lymph nodes In pregnant mothers who cannot near the buttocks are involved. Very be given Doxycycline, one CO- Bubos (swollen often the swollen lymph nodes called TRIMOXAZOLE DS tablet twice lymph nodes) bubos burst and the ulcers formed a day for two to three weeks refuse to heal for months. may be given.4. Granuloma inguinale (GI) GI starts with a small boil like swelling on the penis or vulva. It starts after a few weeks of exposure. In GI we can see the ulcer breaking down and then continuously increasing in size. This ulcer is red, slightly raised, a little painful and bleeds on touch. The ulcer keeps growing and involves nearby tissues, later occupying large parts of the body, especially the groins, etc. COTRIMOXAZOLE DS one tablet twice a day for ten days is the treatment Boil like swelling in penis that must be given early, once the diagnosis is made.5. Herpes SimplexMost of us must have had a small sore on the lips or the corner of the mouthwhen we had high fever. A virus called Herpes causes this Cold sore . It goesoff by itself. But if it reaches the sex organs, it gets changed into anotherform. It causes some tiny red boil like eruptions on the penis or the vagina(sometimes on the buttocks and legs too). This heals by itself but it may carryon to the child during delivery. In some of the children, Herpes may cause Sores insevere problems with the brain, like fits and death. Although there is a treat- Herpes Simplexment now available, the patient should be referred to the doctor.
  14. 14. 15-14 6. White discharge / Leucorrhoea Women’s white discharge or a. Normal Discharge Leucorrhoea is a common During pregnancy, during complaint. Every woman of a sexual excitement, around the village would have experi- middle of the cycle and before enced this problem. Yet, it the periods, many women maybe important to differen- have a heavy discharge and tiate a normal discharge from Vaginal discharge in women all the woman needs is to be an abnormal one. told that she is normal.b. Abnormal Discharges (called White Discharge / Leucorrhoea)Usually there are only three types of germs that create leucorrhoea.1.Candidiasis: This is one of the main Treating Candidiasisreasons for white discharge in our vil- Treatment needslages. Thick white discharge, often de- MICONAZOLE cream to bescribed as curd like or cheesy, that also applied inside the vagina formakes the woman very itchy is indica- three to seven days. Even painting thetive of Candidiasis. Candida is the fun- vagina with Gentian Violet helps a lot,gus responsible for it. though women do not prefer it nowa- days2. Trichomoniasis: This is also com- Treating Trichomoniasismon. Trichomoniasis is due to a small METRONIDAZOLE 200 mggerm Trichomonas and is spread thrice a day for seven daysthrough sex. An easy way to diagnose needs to be given to both, theis by asking if she had yellow or wife as well as the husband. Or else, fivegreenish discharge and some amount tablets of 400 mg each can be taken atof itching. If bubbles can be seen in the one go, which has some higher chancesdischarge, the diagnosis is almost of getting nausea or vomiting.certain.3. Bacterial Vaginal Infection: In this Treating Bacterial Vaginalcase too, the patient gets thick and clear Infectionand white to grey discharge with little The person can be given sevenor no other problem. A classic problem days of COTRIMOXAZOLEhowever is that a bad smell comes out DS twice a day every day, for sevenwhenever the woman has sex without a days. Treating the husband is not con-condom – it tells us about bacterial in- sidered essential.fection of the vagina.
  15. 15. 15-15 6. PID or Pelvic Inflammatory Disease.Another common ailment of Treating PIDswomen, PID has the following • The woman must be encouraged to clean her vagina.symptoms: • A hot water bottle on the Pain in the lower ab- lower abdomen and back re- domen duces the pain. Pain in the lower back • A course of Pain in the genital or- DOXYCYCLINE gans for ten days may be Pain starting from the good to prevent relapses. Starting with two back and coming in capsules, the patient needs to give one capsule e v e r y front to the abdomen, 12 hours for each of the children. like labour pains. • Alternatively, COTRIMOXAZOLE or Some bleeding on AMOXYCILLIN for ten days may help. Many special- having sex ists may like to give METRONIDAZOLE along with White discharge Doxycycline for ten days. 7. HIV/AIDSAIDS (acquired immune deficiency syndrome) is caused AIDS has no cureby the human immunodeficiency virus HIV). HIV AIDS is a disease that has nodestroys the body’s immune system, which makes it cure as of now. We have noimpossible to fight off disease or even minor illnesses. vaccines to prevent AIDS. There are some medicines that can con- trol (not cure) the disease but even these are very costly. These medicines can be very harmful and cost more than a lakh of ru- pees to extend each year of life. Signs of HIV infection Many people who have HIV never come to know about their infection. However, one can sus- pect HIV infection if : o they get fever for more than 1 month o weight loss more than 10% of their original weight o diarrhoea for more than 1 month As the body loses more of its capacity to fight germs, skin infections, TB and many other infections of the lungs may also be found.
  16. 16. 15-16 Who is at greatest risk of getting AIDS?a. Many sex partners : Chances of spreading the HIV virus are higher in people who havemany sex partners. Commercial sex workers (earlier called prostitutes) are at great risk ofgetting HIV. Many of them when tested are found to have it in their blood. Men having sexwith them are also at risk of HIV and they pass it on to their innocent wives. Peopleshould try to restrict their sex relationship only with one partner. At other times - if at all- a condom must be used to prevent direct contact.b. Drug Addicts: Drug addicts who inject heroin or otherdrugs are found to have HIV. They often use old sy-ringes and share their syringe with their friends. Thisquickly helps to spread HIV. They are usually youngand are also sexually active – and hence can also passthe virus to their sex partners. Reduce the risk of needle sharing c. Those needing blood exchange : The risk of spreading HIV through sharing Those people who need to take of needles and syringes is very high – blood repeatedly are also at very Manipur and now Nagaland have shown high risk of getting HIV. A single how high the risk is. It is advised that any bottle of blood from a HIV posi- needle and syringe must be boiled for at tive person can ruin a person’s life. least 20 minutes before using it on another Now, according to Indian law, no person to allow the viruses to be killed. Ad- blood transfusion centre can exist dicts who never have the time and space to without a HIV testing facility. Fur- boil the syringe must learn to flush the sy- ther, no blood can be given to an- ringe and needle with Liquid Bleach three other person without testing the times before using. blood for HIV.Blood tests to check HIV infectionThere are blood tests to diagnose HIV infection. ELISA test is a cheap test that is good for findingout HIV. But one cannot confirm only with ELISA. If an ELISA test is positive i.e. it show HIV), asurer test called Western Blot is carried out. Only if this is positive that a person can be called HIVpositive. Counselling is needed Treat people before HIV testing with HIV with loveAs the tests are not so straightforward, it is People, relatives, friends andIMPORTANT and compulsory to have coun- even doctors and medicalselling before and after a test is carried out. personnel SHOULD NOT treat people with HIV withCounsellors need to be trained. They need to shame, hate and discrimina-help the person getting a HIV test to look at tion. We need to rememberlife positively, whatever the result maybe. that many of them have gotCounsellors need to help remove anxiety, re- the infection for no fault ofduce chances of the husband or wife getting theirs and they deserve ourthe infection, and to help the person in early fullest sympathies, coopera-treatment or prevention of a complication. tion and love.
  17. 17. 15-17
  18. 18. 15-18 Know the Answers Diseases of the Reproductive Systema. Please mark whether “right” or “wrong”:1. AIDS can be passed by hugging & kissing.2. Syphilis can be treated easily with DOXYCYCLINE.3. In initial Syphilis, we can see a small painless ulcer two to three weeks after getting the infection.4. In the second stage of syphilis, heart and brain may be affected.5. P.I.D is common in women and can be treated.b. Please fill in the blanks:1. P.I.D can be treated by: a. _____________________________________ b. _____________________________________ c. _____________________________________ d. _____________________________________2. HIV can be spread only by: a. _____________________________________ b. _____________________________________ c. _____________________________________3. Ulcers on the penis or vagina can be because of : a.______________________ b. _____________________ c. _____________________ d. _____________________ e. _____________________