Kuliah Infertilitas [PDF]

Citation preview

INFERTILITAS Dr. Kusuma Andriana SpOG



12/11/10



1



DEFINISI Infertilitas



Gagalnya pasangan usia reproduksi untuk mendapatk an kehamilan



Setelah dua belas bulan atau lebih usia pernikahannya Dengan frekuensi hubungan suamiistri teratur (2 atau 3 kali seminggu)



Tanpa perlindungan kontrasepsi 12/11/10



2



DEFINISI  Infertil



primer



– Istri belum berhasil hamil dg CO teratur dan dihadapkan pd kemungkinan kehamilan selama 12 bln berturut-turut  Infertil



sekunder



– Istri pernah hamil …………idem



12/11/10



3



WHO (2000) MEMPERKIRAKAN ASIA 80 juta pasangan  gangguan kesuburan 7 – 15 %



di usia subur (15 – 40



40 – 60%



wanita (terbanyak)



th)



15% “reproduksi” 12/11/10



datang di klinik 4



Amerika Serikat 10-15% pasutri mengalami masalah dengan fertilitasnya



Indonesia 7% pasutri mengalami masalah dengan fertilitasnya



Jawa Barat tahun 2004  10-15% jumlah penduduk mengalami masalah dengan infertilitas Kecenderungan peningkatan upaya untuk mendapatkan pelayanan yang terpadu di klinik reproduksi buatan  klinik FIV 12/11/10



5



INSIDEN 10-20 % pasutri  Infertilitas Penyebab infertilitas 1. Faktor istri  35% 2. Faktor suami  30% 3. Faktor kombinasi  20% 4. Tidak diketahui  15% 12/11/10



6



DUA DASA WARSA TERAKHIR PERUBAHAN PARADIGMA “MENIKAH” * GLOBALISASI * KEMAMPUAN EKONOMI MENINGKAT * PENINGKATAN TINGKAT PENDIDIKAN 12/11/10



* KESEMPATAN KERJA



7



Fecundability (conception rate)  Normal



: 20-25% of couples will conceive/cycle  50% should conceive after 3-4mos  95% should conceive after 1 yr  Bila usia 38 th + riw infertil 3 th  2%



12/11/10



8



Komponen Dasar Fertilitas pd Perempuan  Vagina  Mukus



Cx normal  Siklus ovulatoar  Patensi Cx – Ov  Uterus  Hormonal  memelihara kehamilan 12/11/10



 Imun



respon  normal – Sperma – Hsl konsepsi – Fetal survival



 Status



kes,gizi & biokimiawi adekuat



9



FISIOLOGI TUBA FALOPII FISIOLOGI 



Ovum Picked - Up







Transport Gamet & Embrio







Tempat Fertilisasi







Tempat Pertumbuhan Dini Embrio



SYARAT



• Fimbriae Baik • Patent • Bebas Perlekatan • Otot Tuba Baik •12/11/10 Villi / Cilia Baik



10



KANTUNG KENCING



RAHIM



RONGGA RAHIM VAGINA



MULUT RAHIM



KANTUNG TELOR 12/11/10



11



SALURAN TELOR



PINTU



DEPO MAKANAN



SARINGAN



MULUT RAHIM



12/11/10



12



TEMPAT TUMBUH JANIN RAHIM



RONGGA RAHIM



12/11/10



13



MENANGKAP SEL TELUR TRANSPORTASI SPERMA DAN EMBRIO RAHIM PERTUMBUHAN DINI EMBRIO



12/11/10



14



SALURAN TELOR



Komponen Dasar Fertilitas pd Pria  Sperma



normal



– Motilitas, struktur biologi, fungsi & jumlah  Analisa



– – – – –



12/11/10



sperma normal :



Volume : 2 – 5 ml Jumlah sperma >20 juta/ml Motilitas pada 6-8 jam : >40 % Bentuk sperma yang abnormal : < 20 % Kandungan kadar fruktosa : 120 -450 mikrog/ml. 1



15



Komponen Dasar Fertilitas pd Pria  Traktus



reproduksi  tdk ada obstruksi  Sekresi normal  Kemampuan ejakulasi dan deposit sperma di Cx



12/11/10



16



JUMLAH



12/11/10



GERAK



BENTUK



17



Major Causes



12/11/10



18



Etiologi Infertil pd Perempuan Unexplained



10%



Cervical/mucus 2-3% Endometrial/uterine 2-3% Pelvic/peritoneal Tubal



30-50%



Central (CNS)



12/11/10



5-10%



40%



19



Etiologi lain  PID  Cx



conization/cautery  Smoking  DES exposure  IUD  Endometriosis  PCOF  Usia  stl 30 th fecundity me ↓ 12/11/10



20



Etiologi Infertil (Tidak berovulasi)  Tdp



pd 40 % perempuan  Primary of premature ovarian failure  PCOS  Hypotyroidism  Tumor hipofise  Laktasi  Adesi periovarial  Endometriosis  Medisinalis 12/11/10



21



Polycystic Ovarian Syndrome  Oligomenorrhea/amenorrhea



and



hyperandrogenism  Prevalence: 5%.  Clinical evidence: hirsutism, acne, obesity  Lab evidence: elevated testosterone, elevated DHEA-S.



12/11/10



22



Hypothalamic Anovulation  Low



levels of GnRH, low of normal levels of FSH/ LH, low levels of endogenous estrogen.  Associated factors: low BMI (< 20), high-intensity exercise, extreme diets, stress.  Treatment: lifestyle modification. 12/11/10



23



Hyperprolactinemia  Causes:



pituitary adenoma, psych meds.  Test for: pregnancy, thyroid disease.  Imaging: MRI for macro vs microadenoma  Treament: Bromocriptine (dopamine agonist). After correction, 80% of women will ovulate, 80% will get pregnant.  Discontinue treatment once pregnancy established. 12/11/10



24



Etiologi Infertil (Tubal/ Pelvic pathology)  Congenital



anomalies  Tubal occlusion  Evaluated by: – hysterosalpingogram – laparoscopy – hysteroscopy



12/11/10



 May



occur as sequelae of – PID – endometriosis – abdominal/pelvic surgery – peritonitis



25



Etiologi Infertil (Mukus Cx)  Cervisitis  Respon



imun thd sperma  Pemakaian lubrikasi or vag douche



12/11/10



26



Etiologi Infertil (Blokade)  Cx



– – – – – – – – 12/11/10



 Tuba



Polip Myoma Adhesi Endometriosis Adenomyosis Endometritis Cx stenosis Anomali kongenital



 Tuba



or motilitas abN – – – – – – – –



PID IUD Neoplasma Salpingitis Ligasi tuba Endometriosis KE Peritubal adesion



27



Etiologi Infertil cont Obst Ov – Fimbrie  PID  Adesi  Endometriosis



 Faktor



Endometrium  tdk siap – Anovulasi – Defek fase luteal – IUD



12/11/10



28



Penyebab infertilitas pria 1. Gangguan produksi sperma 2. Gangguan fungsi sperma 3. Gangguan transportasi sperma 4. Idiopatik  Analisis



semen  Penilaian deskriptif parameter spermatozoa dan cairan seminal yang membantu menilai kualitas semen



 Nilai 12/11/10



normal parameter semen  WHO 1992 29



Penyebab infertilitas pria OLIGOSPERMA – – – –



12/11/10



Mumps Criptochismus Pakaian ketat Varicocele



ABORMAL SPERMA – – – –



X- rays Perokok Alkohol Medisinalis



30



Penyebab infertilitas pria BLOKADE – – – – –



12/11/10



Infeksi Tumor Anomali kongenital Vasektomi Retrograde ejakulation



DEPOSIT SPERMA – – – –



Prematur ejakulasi Hyospadia Retrograde ejakulation Ggn eurologi (spine)



31



Evaluasi untuk Perempuan  Ax  Infertility



duration  Detailed menstrual history  ovulasi  Prior pregnancies  Fertility in other relationships  IUD’s, OCP’s, Depo  Frequency of intercourse/sexual dysfunction 12/11/10



32



DETEKSI OVULASI  Riwayat



Haid  teratur  Biopsi endometrium  fase skeretorik  LH test  BBT  bifasik  Pemeriksaan hormonal : FSH , LH, P4 (hr XXI), TSH, prolaktin  TVS hr XIV  Folikel dominan Ø 18-22 mm 12/11/10



33



12/11/10



34



12/11/10



35



 USG



OVARIUM



18 mm



12/11/10



36



Evaluasi untuk Perempuan  Ax  Gynecologic



history (PID, endometriosis, fibroids, cervical dysplasia)



 DES



exposure



 Medical



and surgical history



 Medications  Previous



12/11/10



tests and therapy



37



Evaluasi unt Pria  Ax  Infertility



duration  Prior fertility in relationship(s)  Medical & surgical history  Meds (anabolic steroids, cancer chemotherapy, sulfasalazine, nitrofurantoin)  Alcohol, drugs, pot  Occupational exposures  Sexual dysfunction  Tight fitting underwear/pants  Previous testing



12/11/10



38



TES CADANGAN OVARIUM Biofisik Ultrasound 2D atau 3D Volume ovarium Basal antral folikel (AFC) Aliran darah stroma ovarium Dimensi uterus Densitas folikel



Biokimia Kadar basal (folikuler awal): FSH, LH, E2 Inhibin dan activin Antimullerian hormon (AMH) Tes stimulasi ovarium : GnRH agonist stimulation test Human menopausal gonadotropin (hMG test) Clomiphene citrate challenge test (CCCT) FSH



abel 1. Tes yang dapat digunakan untuk menilai cadangan ovar 12/11/10 Bukman A, Heineman MJ. Ovarian reserve testing and the use of prognostic models in patients with



39



OVARIAN RESERVE



BASAL FSH & E2



AGE



PATHOLOGICAL CASES • Post pelvic surgery • Immun or genetic F. • Etc. 12/11/10



40



RESPON DAN RESERVE OVARIUM



 Respon



kemampuan ovarium menghasilkan folikel  Reserve



kemampuan ovarium menghasilkan folikel dalam jumlah dan kualitas dengan rangsangan 12/11/10



41



CADANGAN OVARIUM



•



PENURUNAN JUMLAH DAN KUALITAS OOSIT  PENURUNAN CADANGAN OVARIUM



•



PROGNOSTIK KEBERHASILAN STIMULASI, STRATEGI STIMULASI OVARIUM



12/11/10



42



Usia



Saat lahir : 1-2 juta Pubertas : 300.000.



Jumlah oosit



16-20 minggu kehamilan : 6-7 juta



Saat reproduksi : + 1000/ siklus menstruasi.



Folikel antral adalah folikel kecil – kecil yang mempunyai ukuran 2-8 mm resting follicle 12/11/10



43



12/11/10



44



12/11/10



45



12/11/10



46



12/11/10



47



MEMPRODUKSI



SEL TELUR



INDUNG TELOR 12/11/10



48



12/11/10



49



12/11/10



50



INFERTILITY FEMALE



> 30 Years. > 37 Years or  Married > 3 Years. Multiple Factors  Suspect Adhesion, nfertility Endometriosis and or mass



MALE



< 30 Years.



TUBE & PERITONEUM HSG / ISS



Abnormal ⊕



Abnormal 6 Months. Pregnant  12/11/10



Abnormal



OVULATION • Mens. Cycle • BBT • Endom. Biopsy • P



Tx ⊕



Success



Tx 



Failed



Normal • 6 Months Ovulation ⊕ • Others F. “N”



LAPAROSCOPY Normal



Normal



•COH •IUI Op. ⊕ Reconstructive 1,5 – 2 Y. (Tube F. N) Surgery



Abnormal Tx / Induct ion Failed



Op.  IVF -ET



Pregnant 



6 Cycles.



Gonadotropin 51



35 Years



Increasing Fecundability



IVF hMG or hMG-IUI CC or CC - IUI Expectant Management



Correct all Fertility factors Identify all Fertility factors Increasing intensiveness of resource utilization



taircase approach to empirical infertility treatment/ For women over 35 years old, the first three steps e rapidly completed. In women less than 30 years old, more time can be spent on the first three steps



bieri Robert L. : Female Infertility en and Jaffe’s Reproductive Endocrinology. Ed V Th Elsevier Saunders. Philadelphia.2004. P : 633- 668 12/11/10 52



PENANGANAN FAKTOR TUBA



MOW



INFEKSI



OPERASI +



1 – 2 TH



OPERASI -



ENDOMETRIOSIS



BEDAH / MEDIK



REKANALISASI



1 – 2 TH



1 – 2 TH HAMIL -



HAMIL -



BAYI TABUNG 12/11/10



53



HIDROSALPING & INFERTILITAS * BERAT



SEDANG / RINGAN



SALPINGECTOMI



• FIMBRIOPLASTY • SALPHINGOSTOMI



FIV – ET



1,5 – 2 TH HAMIL 



*Awas : umur istri 12/11/10



54



INFEKSI



ANTISPERMA



KENTAL



POLIP



MULUT RAHIM



12/11/10



55



SPERMA OVUM



12/11/10



56



RONGGA RAHIM



VAGINA



12/11/10



MULUT RAHIM



57



INFEKSI



TUMOR RAHIM



KETEBALAN RAHIM TIPIS



RONGGA RAHIM



12/11/10



58



INFEKSI RAHIM ENDOMETRIOSIS



12/11/10



59



SALURAN TELOR



TUBOPLASTI



12/11/10



60



12/11/10



61



12/11/10



62



12/11/10



63



12/11/10



64



Dx Laparoskopi



Tx Ringan Ablasi



1,5 – 2 Th Hamil  FIV - ET 12/11/10



Sedang



Berat



Ablasi & Med. Mentosa



Ablasi 3 Bl. Med. Mentosa



Operasi 3 Bl. Med. Mentosa 65



12/11/10



66



TIDAK ADA OVULASI



KISTE INDUNG TELOR 12/11/10



GANGGGUAN HORMON 67



12/11/10



68



12/11/10



69



ADOPSI AKU AE . . . MARI MBAK



12/11/10



70



Terima Kasih



12/11/10



71