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INFERTILITAS

Dr. Kusuma Andriana SpOG

12/08/21 1
DEFINISI

Setelah dua belas bulan


Infertilitas Gagalnya atau lebih usia
pasangan usia pernikahannya
reproduksi untuk
mendapatkan
kehamilan Dengan frekuensi
hubungan suami-istri
teratur (2 atau 3 kali
seminggu)

Tanpa perlindungan
kontrasepsi

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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

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WHO (2000) MEMPERKIRAKAN ASIA

80 juta pasangan  gangguan kesuburan

7 – 15 % di usia subur (15 – 40 th)

40 – 60% wanita (terbanyak)

15% datang di klinik “reproduksi”

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Amerika
AmerikaSerikat
Serikat Indonesia
Indonesia7%7%pasutri
pasutri
10-15%
10-15%pasutri
pasutri mengalami
mengalamimasalah
masalah
mengalami
mengalamimasalah
masalah dengan
denganfertilitasnya
fertilitasnya
dengan
denganfertilitasnya
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
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INSIDEN

10-20 % pasutri  Infertilitas


Penyebab infertilitas
1. Faktor istri  35%
2. Faktor suami  30%
3. Faktor kombinasi  20%
4. Tidak diketahui  15%
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DUA DASA WARSA TERAKHIR

PERUBAHAN PARADIGMA “MENIKAH”

* GLOBALISASI

* KEMAMPUAN EKONOMI MENINGKAT

* PENINGKATAN TINGKAT PENDIDIKAN

* KESEMPATAN KERJA
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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%

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Komponen Dasar Fertilitas pd
Perempuan
 Vagina  Imun respon 
 Mukus Cx normal normal
– Sperma
 Siklus ovulatoar
– Hsl konsepsi
 Patensi Cx – Ov
– Fetal survival
 Uterus  Status kes,gizi &
 Hormonal  biokimiawi adekuat
memelihara
kehamilan
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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
• 12/08/21
Villi / Cilia Baik 10
KANTUNG KENCING
RAHIM

RONGGA RAHIM

VAGINA
MULUT RAHIM

KANTUNG TELOR

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SALURAN TELOR
PINTU

DEPO MAKANAN

SARINGAN

MULUT RAHIM

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TEMPAT
TUMBUH
JANIN

RAHIM

RONGGA RAHIM

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MENANGKAP SEL TELUR
TRANSPORTASI SPERMA
DAN EMBRIO
RAHIM
PERTUMBUHAN DINI
EMBRIO

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SALURAN TELOR
Komponen Dasar Fertilitas pd Pria
 Sperma normal
– Motilitas, struktur biologi, fungsi & jumlah
 Analisa 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

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Komponen Dasar Fertilitas pd Pria
 Traktus reproduksi  tdk ada
obstruksi
 Sekresi normal
 Kemampuan ejakulasi dan deposit
sperma di Cx

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JUMLAH GERAK BENTUK

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Major Causes

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Etiologi Infertil pd Perempuan

Unexplained 10%
Cervical/mucus 2-3%
Endometrial/uterine 2-3%
Pelvic/peritoneal 5-10%
Tubal 30-50%
Central (CNS) 40%

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Etiologi lain
 PID
 Cx conization/cautery
 Smoking
 DES exposure
 IUD
 Endometriosis
 PCOF
 Usia  stl 30 th fecundity me ↓
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Etiologi Infertil (Tidak berovulasi)
 Tdp pd 40 % perempuan
 Primary of premature ovarian failure
 PCOS
 Hypotyroidism
 Tumor hipofise
 Laktasi
 Adesi periovarial
 Endometriosis
 Medisinalis
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Polycystic Ovarian Syndrome
 Oligomenorrhea/amenorrhea and
hyperandrogenism
 Prevalence: 5%.
 Clinical evidence: hirsutism, acne, obesity
 Lab evidence: elevated testosterone,
elevated DHEA-S.

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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.

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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.

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Etiologi Infertil
(Tubal/ Pelvic pathology)
 Congenital  May occur as
anomalies sequelae of
 Tubal occlusion – PID
 Evaluated by: – endometriosis
– hysterosalpingogram – abdominal/pelvic
surgery
– laparoscopy
– peritonitis
– hysteroscopy

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Etiologi Infertil (Mukus Cx)
 Cervisitis
 Respon imun thd sperma
 Pemakaian lubrikasi or vag douche

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Etiologi Infertil (Blokade)
 Cx  Tuba  Tuba or
– Polip motilitas abN
– Myoma – PID
– Adhesi – IUD
– Endometriosis – Neoplasma
– Adenomyosis – Salpingitis
– Endometritis – Ligasi tuba
– Cx stenosis – Endometriosis
– Anomali kongenital – KE
– Peritubal
adesion
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Etiologi Infertil cont
Obst Ov – Fimbrie
 PID
 Adesi  Faktor Endometrium
 Endometriosis  tdk siap
– Anovulasi
– Defek fase luteal
– IUD

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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 normal parameter semen  WHO 1992


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Penyebab infertilitas pria
OLIGOSPERMA
– Mumps
– Criptochismus
ABORMAL SPERMA
– Pakaian ketat
– X- rays
– Varicocele
– Perokok
– Alkohol
– Medisinalis

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Penyebab infertilitas pria
BLOKADE
– Infeksi
– Tumor
– Anomali kongenital DEPOSIT SPERMA
– Vasektomi – Prematur ejakulasi
– Retrograde – Hyospadia
ejakulation – Retrograde ejakulation
– Ggn eurologi (spine)

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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
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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

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 USG OVARIUM

18 mm

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Evaluasi untuk Perempuan  Ax
 Gynecologic history (PID,
endometriosis, fibroids, cervical
dysplasia)
 DES exposure
 Medical and surgical history
 Medications
 Previous tests and therapy
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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
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TES CADANGAN OVARIUM

Biofisik Biokimia
Ultrasound Kadar basal (folikuler awal):
2D atau 3D FSH, LH, E2
Volume ovarium Inhibin dan activin
Basal antral folikel (AFC) Antimullerian hormon (AMH)
Aliran darah stroma ovarium Tes stimulasi ovarium :
Dimensi uterus GnRH agonist stimulation test
Densitas folikel Human menopausal gonadotropin
(hMG test)
Clomiphene citrate challenge test
(CCCT)
FSH

Tabel 1. Tes yang dapat digunakan untuk menilai cadangan ovarium


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Bukman A, Heineman MJ. Ovarian reserve testing and the use of prognostic models in patients with subfertility. Hum Reprod. Update 2001;7(6):581-
OVARIAN RESERVE

BASAL FSH & E2 AGE

PATHOLOGICAL CASES
• Post pelvic surgery
• Immun or genetic F.
• Etc.

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CADANGAN OVARIUM

• PENURUNAN JUMLAH DAN KUALITAS OOSIT


 PENURUNAN CADANGAN OVARIUM

• PROGNOSTIK KEBERHASILAN STIMULASI,


STRATEGI STIMULASI OVARIUM

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16-20 minggu kehamilan : 6-7 juta

Jumlah oosit
Saat lahir : 1-2 juta
Usia

Pubertas : 300.000.

Saat reproduksi : + 1000/ siklus menstruasi.

Folikel antral adalah folikel kecil – kecil yang mempunyai ukuran 2-8 mm
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resting follicle 43
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MEMPRODUKSI

SEL TELUR

INDUNG TELOR

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INFERTILITY

FEMALE MALE

> 37 Years or  > 30 Years. < 30 Years. Normal Abnormal


Multiple Factors  Married > 3 Years.

Suspect Adhesion,
Infertility Endometriosis and
or mass TUBE & OVULATION
PERITONEUM Tx  Tx 
• Mens. Cycle
HSG / ISS • BBT
• Endom. Biopsy
• P Success Failed
Abnormal  Normal

LAPAROSCOPY • 6 Months Abnormal


Ovulation 
• Others F. “N”

Normal • COH Tx /
Abnormal Op.  Reconstructive 1,5 – 2 Y. • IUI Induction
Surgery (Tube F. N)
6 Months.
Op.  Failed

Pregnant  IVF -ET Pregnant  6 Cycles.


Gonadotropin
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35 Years

IVF
Increasing Fecundability

hMG or
hMG-IUI
CC or
CC - IUI
Expectant
Management
Correct all
Fertility factors
Identify all
Fertility factors

Increasing intensiveness of resource utilization

Figure 20 – 16. Staircase approach to empirical infertility treatment/ For women over 35 years old, the first three steps in the algorithm
should be rapidly completed. In women less than 30 years old, more time can be spent on the first three steps in the staircase

Barbieri Robert L. : Female Infertility


In Yen and Jaffe’s Reproductive Endocrinology. Ed V Th Elsevier Saunders. Philadelphia.2004. P : 633- 668
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PENANGANAN FAKTOR TUBA

INFEKSI MOW ENDOMETRIOSIS

OPERASI + OPERASI - REKANALISASI BEDAH / MEDIK

1 – 2 TH 1 – 2 TH 1 – 2 TH

HAMIL -

HAMIL -

BAYI TABUNG
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HIDROSALPING & INFERTILITAS *

BERAT SEDANG / RINGAN

SALPINGECTOMI • FIMBRIOPLASTY
• SALPHINGOSTOMI

FIV – ET 1,5 – 2 TH

HAMIL 

* Awas : umur istri


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INFEKSI

ANTISPERMA

KENTAL

POLIP

MULUT RAHIM

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SPERMA
OVUM

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RONGGA RAHIM

VAGINA
MULUT RAHIM

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INFEKSI

TUMOR

RAHIM
KETEBALAN
RAHIM TIPIS

RONGGA RAHIM

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INFEKSI
RAHIM
ENDOMETRIOSIS

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SALURAN TELOR
TUBOPLASTI

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Dx Tx

Ringan Sedang Berat


Laparoskopi
Ablasi Ablasi & Ablasi
Med. Mentosa
3 Bl. Med.
Mentosa
1,5 – 2 Th
Hamil  Operasi

FIV - ET 3 Bl. Med.


Mentosa
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TIDAK ADA
OVULASI

KISTE

INDUNG TELOR GANGGGUAN


HORMON

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ADOPSI AKU
AE . . .
MARI MBAK

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Terima Kasih

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