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INFERTILITAS

Dr. Kusuma Andriana SpOG

12/11/10 1
DEFINISI
Gagalnya
pasangan Setelah dua belas
Infertilitas usia bulan atau lebih
reproduksi usia
untuk pernikahannya
mendapatk
Dengan frekuensi
an
hubungan suami-
kehamilan
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 Serikat Indonesia 7%
10-15% pasutri pasutri
mengalami mengalami
masalah dengan masalah dengan
fertilitasnya 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
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* KESEMPATAN KERJA
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
 Siklus ovulatoar – Sperma
– 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
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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  Mayoccur 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 ejakulation
– Hyospadia
– 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
 Infertilityduration
 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 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

abel 1. Tes yang dapat digunakan untuk menilai cadangan ovar


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Bukman A, Heineman MJ. Ovarian reserve testing and the use of prognostic models in patients with
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

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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 resting follicle
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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


 Married > 3 Years.
Multiple Factors
 Suspect Adhesion,
nfertility Endometriosis and
or mass TUBE & OVULATION
PERITONEUM Tx ⊕ Tx 
• Mens. Cycle
HSG / ISS • BBT
• Endom. Biopsy
• P Success Failed
Abnormal ⊕ Normal

LAPAROSCOPY • 6 Months
Ovulation ⊕ Abnormal
• Others F. “N”

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

Pregnant  IVF -ET Pregnant  6 Cycles.


Gonadotropin
12/11/10 51
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

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
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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
12/11/10 53
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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