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INFERTILITAS PADA PELAYANAN

PRIMER

Dr. Yanasta Moendanoe, SpOG


SUBBAGIAN FERTILITAS ENDOKRINOLOGI REPRODUKSI
BAGIAN OBSTETRI & GINEKOLOGI
RS Dr.M.DJAMIL PADANG/FK UNAND
Nama : dr. Yanasta Moendanoe, Sp.OG
Ttl : Pekanbaru, 23 Januari 1981
Status : Menikah
Jabatan : Staf Pengajar Universitas Andalas
Divisi fertilitas dan Endokrinologi Reproduksi
Pendidikan : Fakultas Kedokteran
Universitas Andalas
Spesialis Obgyn Universitas Andalas
Fellow Minimal Invasif Surgery World Class
Laparascopy India
Member Of Indonesian Society Endoscopy
Surgery
Pelatihan Asia Pasific Gynecologist Endoscopy
Tim Penyusu Panduan Nasional Pelayanan
Kedokteran Infertilitas dan PUAI HIFERI Center
padang
PREFACE
One in six couples have an unwanted delay in
conception.
Roughly half of these couples will conceive either
spontaneously or with relatively simple advice or
treatment.
The other half remain subfertile and need more
complex treatment, such as in vitro fertilisation and
other assisted conception technique about half of
these will have primary infertility.
DEFINISI PASANGAN INFERTIL
Pasangan yang gagal mendapatkan kehamilan setelah
menikah 1 tahun atau lebih dengan
melakukan hubungan secara teratur dan tanpa
proteksi

1 thn hrs dimulai


investigasi Pemeriksaan
lebih Dini

Umur lebih 35 tahun


Riwayat Oligo / Amenorrhea
Diketahui/curiga ada kelainan tuba / endometriosis
Partner juga subfertil
Definisi
Primary infertilitya delay for a couple who
have had no previous pregnancies

Secondary infertilitya delay for a couple


who have conceived previously, although the
pregancy may not have been successful (for
example, miscarriage, ectopic pregnancy)

Sferof, Leon. Clinical Gynecologic Endocrinology & Infertility,


ClickNational
to add text
Collaborating Centre for
Womens and Childrens Health 2004
84% dari pasangan dalam populasi umum bisa hamil
dalam 1 tahun bila tidak memakai kontrasepsi dan
melakukan hubungan seksual secara teratur.

Dari pasangan ini yang tidak hamil dalam tahun pertama,


kira-kira setengahnya akan hamil dalam tahun kedua
Waktu yang dibutuhkan untuk konsepsi
PENYEBAB INFERTILITAS
Faktor Pasangan
Faktor Istri
5% faktor tuba atau
10%
pelvis
10% 10% faktor tuba atau
35% faktor laki-laki
15% 40% pelvis
gangguan ovulasi
gangguan ovulasi
35% 40%
unexplained unexplained

unusual unusual (miom,polip)


(miom,polip)
Factors affecting Fertility
Age
A strong association exists between infertility and
increasing female age.
The reduction in fertility is greatest in women in
their late 30s and early 40s.
For women aged 35-39 years the chance of
conceiving spontaneously is about half that of
women aged 19-26 years.
The natural cumulative conception rate in the 35-39
age group is around 60% at one year and 85% at two
years.
Age
Recent evidence shows that male fertility also
declines with age.
Genetic defects in sperm and oocytes that are likely
to contribute to impaired gamete function and
embryonic development increase with age.
The age related decline in female fecundity is caused
by a steadily reducing pool of competent oocytes in
the ovaries.
Timing of intercourse during
ovulatory cycle
The window of opportunity lasts six days, ending on
the day of ovulation
. A study by Dunson et al (2002) showed that the
probability of conception rose from six days before
ovulation, peaked two days before ovulation, then fell
markedly by the day of ovulation.
This is consistent with the progesterone induced
changes in cervical mucus that occur immediately
after ovulation and impede the penetration of sperm.
Weight
Pregnancy is less likely if the womans body mass
index (BMI) (weight (kg)/(height (m)2)) is > 30 or <
20.
Women with a BMI > 30 need advice about
modifying their diet and doing more exercise to lose
weight and they should aim for a BMI < 30.
Women with a BMI < 20 should be advised to gain
weight and reduce exercise if they are exercising
excessively.
Others factor
The chance of conception may be reduced by
smoking, caffeine, and use of recreational
drugs
Excess alcohol consumption in men can
contribute to impotence and difficulties with
ejaculation and may impair spermatogenesis
Investigations: who and when
infertility is defined as failure to conceive after one
year of unprotected regular sexual intercourse.

Although usually it would be reasonable to start


investigations after this time, earlier investigations
and referral may be justified where there are
important factors in either partners history
Ovulasi
Starting investigations in primary care
Does the woman ovulate and if not why not?
Initial investigations should be completed within three to
four months and should establish the following points.
Does the woman ovulate?
If not, then why not?
Is the semen quality normal?
Is there tubal damage or uterine abnormality?
Both partners must be investigated because an
appropriate plan of management cannot be formulated
without considering both male and female factors that
may occur concurrently. I
Starting Investigation
Important to know the mechanism and
characteristic of menstruation
Adequate physical examination included a
Initial Pelvic examination need to perform.
There is no urgent situation of infertile
condition
Preconception advice need to be done before
secondary care (gynecologist)
PEMERIKSAAN INFERTILITAS WANITA

Umur
Pekerjaan
Kista ovarium Keluhan saat ini
Operasi pelvis Galaktorea
Tuberkulosis Eating disorder
Appendektomi PAST Diabetes mellitus/hipertensi
Laparotomi PRESENT Obat NSAID, steroid
Seksio sesarea Rokok, alkohol
Konisasi serviks Riw.menstruasi, menars, nyeri
haid, amenorea
Riw.obstetri: abortus, sepsis
puerperalis
Riw.KB: IUD
Riw. Coitus: frek, lubrikan, vaginal
duse, loss of libido, disparenia
PEMERIKSAAN INFERTILITAS WANITA
UMUM: Genitalia:
Tanda vital Ukuran dan bentuk klitoris
Berat badan dan tinggi badan BMI Himen
Karakter sekunder Ukuran, lokasi, mobilitas uterus
Pertumbuhan rambut >>, akne
Massa adneksa
Akantosis nigrikan
Abnormal skin depigmentation (vitiligo) Vaginal discharge
Kelenjar tiroid Kekakuan
Mamae: Nodul di cavum Douglasi
evaluasi perkembangan, galaktorea endometrioisis/TBC
Dada :
jantung dan paru
Abdomen:
Massa
Asites
Striae di abdomen
Scar operasi
PEMERIKSAAN INFERTILITAS WANITA
FAKTOR SERVIKS:
Keadaan serviks normal :
mukus encer (watery) ok
pengaruh hormon estrogen
shg memudahkan sperma
masuk.
Lendir serviks di bawah
pengaruh hormon estrogen
bisa diregangkan di antara
2 jari atau di antara 2 slide
mikroskop > 10 cm(uji
spinnbarkeit)
PEMERIKSAAN INFERTILITAS WANITA
FAKTOR OVARIUM (OVULASI):
Sulit, pasti terjadi bila kehamilan
telah terjadi
Siklus haid teratur, variasi + 2
hari (95% ovulasi)
Kadar progesteron mid-luteal > 30
nmol/L (10-30 ng/ml)
Ultrasonografi (USG) serial :
folikel de Graaf > 1.6 cm pecah,
cairan di kavum Douglasi
Lonjakan LH (LH surge) pd urine
Suhu basal badan
Penipisan mukus serviks
Sitologi hormonal mungkinkah
Preconception advice
Areas for discussion should include things that may
improve the chances of conception or increase the
chance of a successful outcome to the pregnancy (by
minimising the risk of abnormality or of pregnancy
related complications for baby and mother)
Preconceptional conseling
Counselling and fertility treatment
Adequate preparation through counselling before
treatment can substantially decrease the roller
coaster effect to which many couples have likened
the experience of infertility treatment.
Expectations of reproductive technologies are often
too high and, where treatment is unsuccessful,
personal inadequacy and a sense of failure leave
many feeling emotionally exhausted and vulnerable.
Investigasi lanjut
PEMERIKSAAN INFERTILITAS WANITA
HISTEROSALPINGOGRAFI (HSG)
FAKTOR TUBA:
Patensi : sumbatan
Silia: rambut getar
Mobilitas: mendekap
ovarium
LAPAROSKOPI
FALLOPOSCOPY
PEMERIKSAAN INFERTILITAS WANITA

FAKTOR UTERUS:
Tebal endometrium
Polip
Mioma
PENATALAKSANAAN INFERTILITAS WANITA
FAKTOR SERVIKS:
Swab vagina + kultur Faktor tuba:
Estrogen H8-9 Kedua tuba tersumbat
Inseminasi intra uterin (non paten) : In vitro
suami fertilization + embrio
transfer (bayi tabung),
GANGGUAN OVULASI: adopsi
SOPK: induksi ovulasi, Satu tuba tersumbat :
metformin inseminasi intra uterin
Hiperprolaktinemia:
bromokriptin
Take Home message
1. Skrining masalah infertilitas seharusnya
sudah bisa dimulai dari tahap pelayanan
primer bagi sejawat GP
2. Pengetahuan tentang siklus
menstruasi,Ovulasi, kelainan ginekologi
dasar melalui anamnesa, pemeriksaan fisik,
dan ginekologi serta pemeriksaan penunjang
sederhana sangat diperlukan sebagai tahap
skrening awal infertilitas
3. Konseling terhadap faktor-faktor pendukung,
penghambat dan faktor yang mungkin
mempengaruhi fertilitas perlu dilakukan sedini
mungkin melalui layanan primer sehingga
dimungkinkan terapi yang lebih tepat dan
cepat pada layanan sekunder dan tersier
Lebih cepat, lebih tepat, lebih baik
UMUR WANITA DAN MASA REPRODUKSI
< 25 tahun, kesuburan wanita paling tinggi
Usia 30 tahun mulai menurun dan umur 35 tahun menurun tajam
Umur 40 tahun: kesuburan sangat rendah
% Fertilitas maksimum Tingkat Keguguran (%)

100 % Fertilitas maksimum 50


Tingkat keguguran (%)
80 40

60 30

40 20

20 10

0 0
20-24 25-29 30-34 35-39 40-44 BACK
Leon Speroff and Frits marc A. Clinical Gynecologic Endocrinology and Infertility.
Ed. VII TH. Lippincott Williams & Wilkins Philadelphia (2005) p : 1013 - 1056
Leon Speroff and Frits marc A. Clinical Gynecologic Endocrinology and Infertility.
Ed. VII TH. Lippincott Williams & Wilkins Philadelphia (2005) p : 1013 - 1056
Back
Riw. Peny.radang panggul

Riw. Operasi Kerusakan


tuba/KE Riw. Abortus
tuba >> sepsis

Riw. Ruptur appendiks