Devi & Oming KUA

MALE INFERTILITY

➢ Andrologi
1. Infertility
2. Hypogonadism
3. Aging Male / Male Senescence /Andropause
4. Sexual Dysfunction : Premature Ejaculation &
Erectile Dysfunction
5. Male Family Planning/ Male Contraception

➢ Fertilitas
• Fertilitas : kemampuan u/ hamil / menginduksi kehamilan
• Fecundity : the probability of producing alive birth arising from a given menstrual cycle
• Infertilitas menurut WHO : kegagalan untuk mencapai kehamilan setelah 12 bulan atau lebih
berhubungan seksual tanpa pelindung secara teratur
• Sterilitas adalah ketidakmampuan permanen untuk hamil atau menginduksi kehamilan

➢ Fecundity
• Laju kelahiran per bulannya
• Fecundability : laju konsepsi per bulannya.
• Normalnya 20%

➢ Infertilitas
• Kegagalan kehamilan selama 1 th berhubungan seksual tanpa pelindung
• ±15% -20% pasangan itu infertile

➢ Penyebab Male Infertility

Kotak atas :
- Manajemen:
1. Operasi --- refer to urologist
Misal: abortus berulang ; kasus sperma < 10 jt ; varikokel grade
2,3
2. Treatment
Misal: varikokel grade 1 spermanya masih bagus
3. Menunggu ----- Kl mau bayi tabung tunggu dulu sampai
modal sperma membaik
➢ Basic Investigation Male Infertility
• Infertility : - Primary : blm pernah hamil sama sekali
- Secondary : sudah pernah hamil (entah keguguran dll yg penting pernah)
• Before 1 year,if :
* High risk of male infertility . eg : history of Crytorchidism
* Female partner’s risk factor eg : age over 35
* Request for male fertility potential

➢ Procedure of Investigation
1. History taking Ada sejawat yg langsung ke Sperm Analisis →
2. Physical examination diagnosisnya akan salah → ditreatment terus → gagal →
3. Sperm Analysis kondisi memburuk baru dirujuk andrologist. Ini salah kasian
4. Other laboratory investigations uang px nya abis
5. Additional Technical investigations

1. HISTORY TAKING
The patient medical history is used to identify risk factors and behavior pattern that could have a
significant impact on male infertility :
• Fertility History Previous -------------- tanya sudah pernah program kemana
• Investigation/treatment of infertility -------- pernah konsumsi obat penyubur ; sudah sampai tahap apa
(jgn2 pernah inseminasi)
• History of disease with possible adverse effect on fertility -------- tanya apa DM ; TB testis
(testisnya sangat besar shg granulomnya rusak) ; demam (spermanya bisa habis, maka ditunda 3 bulan
kemudian)

Px varicella harus ditunda inseminasi

krn ada demam (walau sebentar)
• Pathology possibly causing testicular damage
− Mumps, Orchitis
− Testicular injury ---------- kena tendang, kecelakaan
− Testicular Torsion -------------- ciri: nyeri hebat daerah testis ; sering salah penanganan GP malah
rujuk ke Spkk → tdk membaik → rujuk ke sanglah sudah nekrosis testis → testis yg nekrosis
diangkat, sisa 1 testis → tentu testis tetangganya akan terbentuk antisperma → tdk pnya anak
− History of varicocele
− Testicular maldescent

• Other Factors with Possible Adverse Effect on Fertility

− Environmental and/or occupational factors
o Heat ------- sopir truk ( testis bbq )
o Toxic factors (Pb)
o Others
− Excess consumption of alcohol
− Drug abuse
− Tobacco smoking

• Sexual Dysfunction
Average frequency of intercourse per month
1. Desire
2. Arousal
3. Erection
4. Ejaculation :
 An ejaculation
 Extreme ejaculation praecox
 Extra vaginal ejaculation
 Hypospadias
 Retrograde ejaculation

2. PHY EXAM
Cek BMI → px kegemukan ada gangguan enzim aromatase berlebihan
 Sperm analisis juga biasa digunakan oleh tim
forensic saat kasus pemerkosaan, setelah
kejadian torsio testis, sebelum dan setelah
varicocele (untuk investigai dan menilai
keberhasilan treatment).

Parameter yang baik itu dari WHO:

Volume: ejakulasi harus lebih dari 2mL kalok gak
aspermia→ biasanya disebabkan oleh
prostatektomi (ejakulasi malah ke kandung
kemih); Konsentrasi: bahkan bisa extreme-oligo
(kurang dr 5 juta); motilitas (gerakan); morfologi
Penyebab (bentuk)

Tambahan: laboratory investigations

HIV biasanya diikuti

dengan tes hepatitis B.

Hormonal Assays-ujian
Indikasi :
- Konsentrasi sperma <5 juta/mL
- Gangguan fungsi seksual (g mau
ereksi) → hormone sgt
mempengaruhi, misal prolactin
tinggi→ berikan bromocriptin
- Sugesttive specific endocrinopathy:
gendut; wajah kyk cewek
Hormon Assay utamanya menilai yg tebel:
1. FSH : Azoospermia/oligozoospermia
2. Testosteron : Hypoandrogenism &
sexual dysfunction
3. Prolactin : sexual dysfuction
4. LH: not routine
5. Estradiol : Gynaecomastia → untuk
orang gendut (curiga aromatase
tinggi)
Genetic Analysis
Indication : (JARANG/MAHAL)
1. Azoospermia : Non-obstructif azoospermia (NOA) & CBAVD
2. Severe Oligozoospermia (Extreme Oligozoospermia) : dikasi hormone g mempan, g ada varicocele
jek langsung → IVF-bayi tabung (ICSI) with genetic counseling

Genetic Testing
- Y Chromosom (microdeletion/RBM) AZFa, AZFb, AZFc(550 bp), DAZ(400 bp) → PCR
- Chromosom karyotype Sex chromosom and autosom
- Cystic fibrosis gene mutations: CFTR gene → ♂ CBAVD & ♀
ADDITIONAL TECHNICAL INVESTIGATION

• Scrotal thermography → Subclinical Varicocele

• Doppler thermography→ Subclinical Varicocele
• USG
* Trans Rectal USG (TRUS) → masukin alat lewat dubur
Azoospermia : ejaculatory duct obstructive CBAVD
* Scrotal USG → Scrotal examination difficult testiscular mass
• Imaging Hypothalamo-Pituitary region
* Hyperprolactinemia → tumor
* Gonadotrophin deficiency → FSH ↓↓
• Testicular Biopsi
Indication : tumor or Ca In Situ (CIS)
FLOW CHART OF MALE INFERTILITY

1. Procedure of investigation (anamnesis, pem.fisik, dll)

2. Diagnosis category
↓
▫ Irreversible conditions (perlu diobati?)
▫ Potential Correctable conditions
▫ Life or health treatening condition
▫ Genetic abnormalities→ offspring
↓
3. Styrategy of treatment
Some examples of medical history, physical examination, semen analysis data, and
possible underlying pathology
 ALGORITMA PERBEDAAN DIAGNOSIS DARI MALE FERTILITY DISORDERS INDICATING
THE IMPORTANCE OF FSH, ALONG WITH SEMEN ANALYSIS

Jika pasien azoospermia (<5jt) → cek hormone dulu → FSH

Kalau hormone tinggi tapi testis kecil: klinefelter

Kalau hormone normal, sperma jelek → varicocele

Management of Male Infertility

• Conventional Management :
- Medical
- Surgical
- Psychological → sering diabadikan
- ART (Assisted Reproductive Technology) → reproduksi berbantu
1. Conventional management (Medical)
A. Causal (base on pathophisiology) :
1. Sexual & ejaculatory dysfunction : Treatment Erectile Dysfunction and underlying disease
2. Endocrine cause : Hormon FSH (hMG)), HCG (LH analog), GnRH
3. Systemic cause → infeksi (prostatitis kronis: lama pengobatan 10-14 hari)
4. MAGI : Antibiotic 10-14 days
5. (Immunological cause)
 B. Empirical (base on hypothetical) :
1. Stimulation of spermatogenesis.
2. Improvement of epididymal function.
3. Improvement of sperm transport.
4. Stimulation of sperm metabolism : Antioksidant → jangan sembarangan, harus sesuai
cause. Tapi biasanya dikasik antibiotic dosis tinggi jika ingin bayi tabung tp bapaknya g mau
operasi gangguannya, tapi setelah program bayi tabung harus tetep operasi).
5. Co Enzym Q.
2. Conventional management (Surgical)
• Microsurgical reconstruction of the vas/epididymis
TURED in case of ejaculatory/ duct obstruction
• Varicocelectomy : Varicocele with abnormal semen parameters
• Vasovasostomy : vasectomy

3. Conventional management (psychological)

• Lifestyle (utama)
• Obesity (utama)
• Time of coitus → harus sama2 punya waktu berdua
• Environment (polutan)
• Underwear
• Female Factor

4. Assisted Reproductive Technology (ART)

All treatment or procedures that include the in vitro handling of human oocytes and sperm or
embryos for the purpose establishing pregnancy. Jadi oositnya dipindah pindahin.

A. Intra-corporeal
- Intra Uterine Insemination (IUI)
- Gamete Intra Fallopian Transfer (GIFT)
B. Extra-corporeal
- In-vitro Fertilization (IVF) = conventional → tidak dilakukan
- Intra-cytoplasmic Sperm Injection (ICSI)