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REPRODUKSI
LABORATORIUM
Bagian Ilmu Patologi Klinik
Fakultas Kedokteran
UKRIDA
Mei 2014
Sanarko Lukman Halim

1. Fungsi Reproduksi

Fungsi reproduksi & kehamilan diatur oleh hormon-
hormon yang sangat kompleks:
Testis: Testosteron
Ovarium: Estradiol, Progesterone
Pituitary: Follicle Stimulating Hormone (FSH)
Luteinizing Hormone (LH)
Hypothalamus: Gonadotropin Releasing
Hormone (GnRH)
feed back
Placenta: Estrogens & Progesterone
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Pada pria kalau sperma normal tidak
perludiperiksa lebih lanjut hormonnya.
semen: cairan+spermatozoa.
Cairan ini pada pria harus alkalis karena
spermatozoa tidak bisa berenang pada suasana
asam.
Reproduksi diatur oleh hormon. Testosteron
pada pria dan wanita bermacam-macam
Klinefelter syndrome mungkin bisa punya
anak karena masih ada sel sperma

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Hormon ada feed back ke otak. Contohnya
thyroid hormon. Dia di stimulasi oleh thyroid
stimulating hormone. Kalau tyroxine sudah
cukup maka otak tidak memproduksi TSH
lagi. Begitupula sexhormone.
Hipotalamus ada GNRH(gonadotropin
releasing hormone.) pada hiposfise anterior
ada FSH(folicle stimulating hormone).
FSH dipakai juga oleh pria walau tidak ada
folikel
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Pada wanita menopause maka ovarium tidak
memprouksi estrogen karena mulai atrofi.
Estrogen disingkat E2.
E2 pada menopause<< sehingga FSH>>LH>>
Pada yabng mens nya tidak teratur diperiksa
FSH,LH dan E2 untuk tahu hormonnya.
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Plasenta ada juga estrogen dan
progesterone.
IgG bisa masuk pada plasenta. Sedangkan
IgM tidak dapat melalui plasenta.
Pada bayi baru lahir kemudian ada penyakit,
untuk tahu ini penyakit dr ibu atau anak maka
diperiksa IgM. Kalau ada IgM brt infeksi pada
bayi. Ini penting untuk pengobatan.
Pada bayi bila TSH tinggi maka T4 nya tidak
terproduksi. Begitu juga pada orang dewasa
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The Pituitary-Gonad Axis
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2. Evaluasi Laboratorium
Fungsi Reproduksi:
Pria: Analisa Sperma
Hasil normal pemeriksaan lanjut tidak perlu.
Bila hasil abnormal:
perlu evaluasi hormon: Testosteron, FSH, LH.

Indikasi disfungsi reproduksi wanita:
Haid menandakan ada ovulasi.
Amenore dan infertilitas
Evaluasi laboratorium:
hCG, prolactin, thyroid-stimulating-hormone (TSH),
free-thyroxine(fT4), FSH dan LH.
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Pada wanita tuba harus paten agar bisa
hamil. Jadi jika terjadi konsepsi, harus bisa ke
uterus. Jika tidak di uterus berkembangnya
maka ini dinamakan kehamilan ektopik. Ini
bisa berbahaya
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Kasus ujian adalah infertilitas.
SOAL:
Perut membesar apa ini hamil atau
keganasan?
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3. Disfungsi Reproduksi
Indikasi disfungsi reproduksi wanita:
amenore, infertilitas

Evaluasi laboratorium:
hCG, prolactin , thyroid stimulating hormone
(TSH), free thyroxine (fT4)
FSH, LH, androgen
Lab tidak diperiksa semuanya. Tergantung
pengalaman dokter


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4. Infertilitas primer
Definition: One year of unprotected intercourse
without pregnancy
1: No previous pregnancies
2: Previous pregnancy (not necessarily live birth)

Fecundability: Probability of achieving pregnancy
within a menstrual cycle
20-25% for normally fertile couples
90% of couples should conceive within one year
10-15% of couples experience infertility

Assisted Reproductive Technology
Laboratorium: Estradiol, Progesterone, hCG

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Pada pasangan infertil pertama periksa
sperma pria. Kalau normal periksa wanita.
Tapi jangan terburu buru karena 15%
pasangan normal belum punya anak pada
usia pernikahan 1 tahun
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5. Kehamilan
Indikasi waktu ovulasi ditentukan dengan tes
urin LH surge ->kemungkinan hamil>>
Awal kehamilan ditentukan dengan tes hCG serum,
yang meningkat sekali pada kelanjutan kehamilan.
Serum >cepat dari urin. Biasanya pada praktek bayi
tabung.
Untuk praktisnya urin -hCG periksa pd miss
menstrual period
hari pertama tidak haid.
Konsentrasi hCG yang sangat tinggi (pada
pengenceran urin 1: 200 positif) indikasi
adanya mola hidatidosa yg bisa jd coriocarsinoma
Eclampsia/preeclampsia: (keadaan gawat)
hipertensi,proteinuri tes protein urin
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Dulu untuk menentukan masa subur dengan
mengukur suhu basal. Jika ada peningkatan ini
disebut masa subur.
Sekarang ada LH surge. Kalau meningkat berarti
ada ovulasi
HCG bisa dipakai untuk tumor marker juga
hCG ga boleh pada urin suhu lemari es dan periksa
pada pagi karena konsentrasi paling tinggi.
Eklamsia dan preeklamsia kalau sudah melahirkan
gejala proteinuria hilang.

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Operasi caesar itu perlu tahu golongan darah,
hb dan faktor resusnya.
Eklamsia: ada gangguan pada ginjal karena
proteinuria.
Pada bayi kuning itu bilirubin indirek dan
pada urin bilirubin negatif

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6. Screening Birth Defect
Trimester pertama-kedua screening
birth defects: chromosomal aneuploidy,
neural tube defects(tulang belakang terbuka karena
kekurangan asam folat). Sindroma Down(kebanyakan
pada wanita usia >35 th. Tp usia muda juga bisa. Infant
stimulating progres-> jika diketahui beresikosyndrom
down akan di th/ agar ga jadi syndrome down.)
7. Monitor fetal-hemolyticdisease dengan tes
kadar bilirubin cairan amnion.(bs meninggal karena
ginjal dan hati belom max fungsinya. dan akan timbul
hemoglobinuria)
8. Fetal-lung-maturity: estimasi surfactant paru cairan
amnion: rasio lecithin/sphingomyelin
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Pada janin, jika sudah terjadi hemolitik, masih
bisa hidup karena ibu bisa mengeliminasi
bilirubin yang tinggi dari janin. Biasanya di cairan
amnion bilirubin akan meningkat. Pemeriksaan
ini dinamakan amniosentesis.
Respiratory distress syndrome: kekurangan
sufaktan pada waktu lahir sehingga susah nafas
sehingga bisa terjadi gagal nafas. Ini terlalu
spesialistik tetapi penting diketahui jika
diundang keluar negri bisa saja di tanya.

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9. Toxemia of
Pregnancy(eklamsia)
Hypertensi
Proteinuria tes protein dalam urin




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10. Preterm delivery risk
(melahirkan sebelum waktunya)
untuk mengetahuinya periksa->Fetal
fibronectin cervical secretions

Regulasi Reproduksi Pria
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Pada pria yang tidak mau punya anak bisa di
vasectomi sehingga sperma tidak dapat
keluar.
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Hormones
Follicle-stimulating hormone (FSH) stimulates
spermatogenesis

Interstitial Cell Stimulating Hormone (ICSH)
stimulates the production of testosterone

testosterone stimulates the development of male
secondary sex characteristics & spermatogenesis.
Testosterone dipakai untuk penilaian laki2 pada
praktek.
Terapi testosteron meningkatkan ca prostat
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Pengaturan Reproduksi Wanita
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Ovarium ada 2 kanan dan kiri.
Telur hanya bisa dibuahi oleh 1 sperma.
Haid merupakan masalah yang kompleks
karena nilai hormonnya berlainan sehingga
perlu diketahui pada hari keberapa setelah
haid atau sebelum haid. Karena nilai rujukan
tergantung pada hari keberapa.
LH tinggi->ovulasi.
Pada mau menopause lebih sulit karena haid
ga teratur maka nilai saja FSH LH dan E2 nya.
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Haid
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Kehamilan
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Endometriosis: nyebabkan kehamilan
terganggu.
Kehamilan extrauterine: sangat bahaya karena
perdarahan tidak baik sehingga bisa mati janin
nya.
Ini tergantung oleh endometriosis. Darah yang
keluar waktu haid di dalem pelvis. Kalau ada
jaringan ikat bisa mengganggu patensi tuba.
hCG awalnya ningkat lalu ada fase plateu. Kalau
terus meningkat ini mungkin molahidatidosa
atau koriokarsinoma.
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Plasenta
Interlocking fetal and
maternal tissues
Performs digestive,
respiratory, and
urinary functions for
the fetus
Materials exchanged
across membrane that
separates
bloodstreams

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Figure 44.13
Page 791
Latex Agglutination
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Home Pregnancy Test Kits:PERHATIKAN KONTROL. KALAU KONTROL ga ada
BERARTI HASIL TIDAK DIPERCAYA
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INTERPRETASI

Negative Result
HCG is not present at detectable
concentrations

Positive Result
Pregnancy


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False Positives
Drugs: Antiparkinsonian,
anticonvulsants, phenothiazines.
Medical Conditions: Tumors, Recent
completed pregnancy or miscarriage.
Kalau ada abortus hCG jg masih +.
False Negatives
too early, Urine not at room temp.
Medical Conditions: Tumors, Recent
completed pregnancy or miscarriage.
False Negatives
Testing too early,
Urine not at room temp.

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Hormones and male reproductive
function
FSH (Follicle stimulating hormone)
Targets sustentacular cells to promote
spermatogenesis
LH (leutinizing hormone)
Causes secretion of testosterone and other androgens
GnRH (Gonadotropin releasing hormone)

Testosterone
Most important androgen
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Definisi Infertilitas primer
Infertilitas adalah tidak adanya kehamilan
setelah hubungan suami-isteri selama satu
tahun dengan teratur tanpa mengunakan
kontrasepsi

Infertility affects 15-20% of couples, or 11
million reproductive age people in the U.S.





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Fungsi Utama Kelenjar Pria/
Major Functions of Male Glands
1. 1. Activating spermatozoa
2. 2. Providing nutrients spermatozoa need
for motility
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.3 3. Propelling spermatozoa and fluids
along reproductive tract:
mainly by peristaltic contractions
.4 4. Producing buffers:
to counteract acidity of urethral and
vaginal environments
Semen = Sperm + Secretions
Secretions from epididymis aid sperm
maturation
Seminal vesicle secretes fructose and
prostaglandins
Prostate-gland secretions buffer pH
in the acidic vagina
Bulbourethral gland secretes mucus
Servix ada yang memiliki antibodi terhadap
sperma.
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Pemeriksaan Dasar Analisa Sperma
The analysis must include:
Volume measurement:kalau vol dikit ga bisa
buat hamil.
Concentration determination
Motility assessment: kalau dia ga bisa maju
ga sampai-sampai
Morphology assessment:ada yang kepala
besar
Anti-sperm antibody screen
Identification of other cells:ada SDM,trichomonas,
leukosit
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Indikasi Analisa Sperma
1. Assessment of fertility (2-3 samples; 7
days to 3 months - best 2 weeks)
2. Forensic purposes (DNA): sekarang bisa
diperiksa DNA dari mukosa mulut jg.
3. Effectiveness of vasectomy
samples 1 month apart negative.

Setelah disambung ulang sperma positif
4. Suitability donor for artificial insemination(untuk
bayi tabung.)

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Persiapan sampel
By masturbation.
Requires a period of abstinence prior(3 d)ga boleh
ejakulasi selama 3 hari
Must be delivered warm to the
laboratory.sebaiknya di lab dikeluarkannya. Kalau
di negara dingin sperma dimasukin ke dalam jaket
agar tidak mati semua.
Can either be produced on site.
Or at home if able to be delivered.
2 samples usually needed.
Compared against the
WHO criteria.
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Pengambilan Sampel Sperma 1/2
Name
Period of abstinence - 2-7days
Time of collection + analysis recorded
Entire ejaculate and not coitus interruptus in a wide
mouth container
Delivered within 1 hour of collection
Avoid temperature extremes
Ejakulasi retrogard:karena kelainan otot, sperma
masuk vesika urinaria. Di urin terdapat sperma.
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Pengambilan Sampel Sperma 2/2
If results of 2-3 assessments differ greatly, additional
samples must be analyzed.
If a sperm function test is to be performed, the sperm
must be separated from fluid within 1 hour of
ejaculation.
For vasectomy evaluation, only the presence of sperm,
viable or nonviable is enough.
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Analisa Sperma meliputi pemeriksaan:
Makroskopik
Viscosity:dengan
jarum bisa dilihat
sampai berapa
tinggi ga putus
coagulation +
liquifaction
volume
pH
Mikroskopik
concentration/count
motility
morphology
viability

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Motility &Viability must be
performed
within 1 - 2 hrs of
collection.koleksi ga boleh pake
kondom
Pemeriksaan Makroskopik
Volume: in graduated cylinder to the nearest
0.1 ml or centrifuge tube free of
contamination.
Viscosity: 5ml pipette or plastic pipette
normal, more viscous, very viscous
pH: important parameter of motility and
viability 7.2-8.0; measured by
pH paper.
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Lihat Petunjuk Pemeriksaan Praktikum
Pemeriksaan Makroskopik
Semen is viscous, yellow grayish.
Forms gel-like clot immediately.
Liquefies completely in 5-60 minutes; this must be
complete before further testing (mix before further
testing).
Appearance: homogenous white-gray opalescence.
Brown/red in hematospermia
less opaque if low sperm concentration
Dense white turbid if inflammation and high WBC
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Pemeriksaan mikroskopik
Wet mount:
approximate count
sperm agglutination pattern
viability
motility
morphology
Preparation:
mix
drop on glass slide and apply coverslip
Important: volume (10ul) of semen and the
dimensions of the coverslip (22x22) be standard
so that we have fixed depth (20um).
Observe 10-20 using 40x-60x
If number vary from field to field; not mixed
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Sel yang Terlihat
Normally seen:
Mature cells make up the greatest percentage of cells
Epithelial cells of genital tract: many in urethritis
Immature germ cells
WBC
Abnormally seen:
Gross bacteria
Trichomonas
Candida
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Motilitas
While estimating count
No stain
Count 200 total sperm and then the motile
Calculate the percentage
>50% motile
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Aglutinasi
Reported when motile sperm stick to each
other in a definite pattern.
Head-head
Tail-tail
Head-tail
Immunological cause of infertility
Done on several HPF
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`
Spermatozoon Structure
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Figure 19-4

DNA
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Jumlah Sperma
Decreased:
vasectomy (should be 0 after 3-6 months)
Varicocele(testis terjadi varises->suhu>>-
>sperma mati)
primary testicular failure (Klinefelters:maka
disuntuk testosteron.)
secondary testicular failure
congenital vas obstruction
retrograde ejaculation
endocrine causes (prolactinemia, low
testosterone)
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Common Descriptive Labels
Oligozoospermia
(poor count)

Asthenozoospermia
(poor motility)

Teratozoospermia
(abnormal morphology)

Azoospermia

Sperm concentration
<20 x 10
6
/ml

Fewer than 50% sperm cells with
forward progression

High number of abnormal forms



No sperm cells in the ejaculate
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Ringkasan tentang infertilitas
From the above data, it seems that serum
progesterone for detection of ovulation,

hysterography for tubal patency and

semen analysis are the basic essential tests for
diagnosis of infertility.
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Penyebab Infertilitas
Tubal pathology 35%
Male factor 35%
Ovulatory dysfunction 15%
Unexplained 10%
Cervical/other 5%
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Sabar
In normal young couples:
25% conceive after one month
70% conceive after six months
90% conceive by one year

Only an additional 5% will conceive in an
additional 6-12 months
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Faktor Pria

Male partner should be evaluated simultaneously
with female
Causes of male infertility:
reversible conditions (varicocele, obstructive azoospermia)
not reversible, but viable sperm available (ejaculatory
dysfunction, inoperative obstructive azoospermia)
not reversible, no viable sperm (hypogonadism)
genetic abnormalities
testicular or pituitary cancer
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Sperm Count
Decreased:
vasectomy (should be 0 after 3-6 months)
varicocele
primary testicular failure (Klinefelters)
secondary testicular failure
congenital vas obstruction
retrograde ejaculation
endocrine causes
(prolactinemia, low testosterone)
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Limitations of the procedure :
Delayed examination of the specimen
Collection in improper container
Exposure of the specimen to temperature
extremes during transport
Abnormally low sperm count allowing for
evaluation of less than 200 spermatozoa
Use of dirty or contaminated supplies
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Nilai Rujukan/Reference Ranges
Volume 2.0-6.0 ml
pH 7.2-8.0 **
Count >20 million/ml
Total count > 40 million
Morphology > 30% normal form
Viability > 75%(50% in other)
WBC< 1million/ml
RBC none
**sperm cannot swim in acidic environments

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Common Descriptive Labels
harus faham
Oligozoospermia
(poor count)

Asthenozoospermia
(poor motility)

Teratozoospermia
(abnormal morphology)

Azoospermia

Sperm concentration
<20 x 10
6
/ml

Fewer than 50% sperm
cells with forward
progression
High number of abnormal
forms

No sperm cells in
the ejaculate
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Evaluasi fungsi Reproduksi
Wanita
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Menopos: FSH & LH E2

Tes hormon wanita perhatikan fase
haid


ADAM Syndrome
Androgen Deficiency in the Aging Man
analog dengan Andropause

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Uji Tapis Sindroma Down
Screening sebelum usia kehamilan 20 mg

Trimester pertama antara mg 12-13:diperiksa
-subunit hCG &
plasma associated plasma protein (PAPP-A)

fetal chromosomal abnormalities.
Ambil darah bisa dari umbilikus sekarang.
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Clinical Features
Central hair whorl (cowlick)
Flat occiput (back of the
head)
Upslanting eyes
Epicanthal folds (folds
around the corner of the
eye)
White spots in the iris of
the eye (Brushfield spots)
Upturned nose

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Uji Tapis NTD
Neural Tube Defects
Malformasi kongenital yg sering terlihat
USA 1 per 1000 kehamilan

NTD kegagalan menutupnya neural tube pd hari ke
27 selelah konsepsi

Di USA pada trimester kedua diperiksa
Serum -fetoprotein (MSAFP)
Diperiksa pada trimester 2



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Example of Closed Unrepaired
NTD
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Erythroblastolis Fetalis
Hemolisa darah fetus : anemi normoblastic
hyperplasia normoblastik (erythroblastosis) kurang
oksigen->gagal jantung-hydrops intrauterine death

Hemoglobin unconjugated bilirubin
cairan amnion spectral analysis 450 nm

Hydrops bisa terjadi pada thalasemia juga.
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BIL>26uG akan merusak otak. Normal pada
hari ketiga ada peningkatan tp kl lebih dari
rujukan dinamakan kern ikteris
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Gestational Diabetes
Intoleransi glukosa pada ibu hamil .
( Lihat kuliah tentang Diabetes)
Diagnosa dan terapi segera utk
mencegahkomplikasi pada ibu dan janin
seperti eclampsia, fetal congenital
malformation, fetal makrosomia .
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Fetal Lung Maturity
Fetal Lung maturity produksi surface active
phospholipid compound yg disebut surfactant.
Effective gas exchange
Prevent alveolar collaps
Defisien Respiratory Distress Sydr(RDS)

Lecithin/sphingomyelin ratio ( L/S test)
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Preeklampsia/Toxemia of Pregnancy
Preeclampsia adalah sindrome dengan
hipertensi (Sist >140 mm Hg, atau Diast > .90
mm Hg) dgn proteinuria > 0.3 g/l urin 24 jam
pada kehamilan > 20 minggu.
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Infeksi pada Kehamilan
Infeksi viral, bakterial dan parasit berpengaruh
pada kesehatan ibu dan janin. (Lihat kuliah
mirobiologi, penyakit
Kulit Kelamin, parasitologi).
HIV, virus hepatitis (A, B,C), virus rubela, virus
varisela, virus sitomegalo, klamidia trakhomatis,
group B streptococcus, Neisseria gonorrhoeae,
sifilis, tuberculosis, toksoplasmosis dan malaria .

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Kelainan
Hematologi/Koagulasi
Kelainan hematologi dapat berpengaruh
buruk pada ibu dan janin.

Ibu anemi: nutrisional, hemoglobinopati
(talasemia), trombositopenia, trombotik
trombositopenia,

Koagulopati ibu (DIC, penyakit von
Willebrand)
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Causes of female infertility
Pelvic factors
50%
Immunologic
factors
5%
Other
15%
Ovulatory
disorders
30%
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Thyroid disease and
infertility
Hypothyroidism
Pre-pubertal Delayed
sexual maturation, or rarely, precocious puberty
Post-pubertal
TSH may have leuteotropic effect

Hyperthyroidism
Amenorrhea
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Endometriosis
Appearance of endometrial tissue in the pelvic
cavity.

Origin is uncertain

One of the most common diseases of
menstruating women

Involved in 20-50% of infertility cases

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Anti-sperm autoantibodies
1955: Rumke and Hellinga demonstrate association
between humoral autoantibodies to sperm and
unexplained infertility

Results were controversial, and hampered by inadequate
analytical techniques

Humoral antibodies do not effect fertility unless they
exist in the reproductive tract

Antibodies must be demonstrated on the sperm
surface
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Effect of sperm
autoantibodies
Spontantous agglutination
Motility/penetration
Binding to tail
Disruption
IgG mediated complement fixation (tail)
Seminal fluid contains complement inhibitors, so
membrane attack occurs in the female
reproductive tract
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Anti-sperm antibodies in the
female
Clinically significant only in high titers (in serum)
Anti-sperm antibodies may exist in vaginal secretions
or cervical mucus even when humoral antibodies are
not detected
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Diagnosis of immune-related
infertility
Post-coital test
Evaluates sperm viability in the cervical mucus
Humoral antibodies
Not diagnostic
Demonstration of antibodies on the sperm
surface
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Desirable characteristics of
tumor markers
Easy to measure
Specific for tumor
Always present with tumor
Tapi tidak spesifik dan tidak dianjurkan pada
pasien tanpa gejala
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Test performance
The sensitivity is 98.0%
The specificity is 85%
Liver cancer has an
incidence of 1.5:100,000
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Use of tumor markers
Screen for disease???
Diagnosis of symptomatic patients
Staging
Prognostic indicators
Detect recurrence of disease
Monitoring response to therapy
Radioimmunolocalization
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Prostate cancer
2
nd
most common cancer (19%), and 2
nd

leading cause of cancer death, in men
Sensitivity of PSA (at 4.0 g/L) is 78%;
specificity is approximately 33%.
PSA concentration correlates with clinical
stage of cancer
PSA is used to monitor therapy
Meningkat juga pada BPH. Makanya klinis berperan.
Kalau cancer meningkat tinggi sekali bisa 500-1000
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Prostate-specific antigen
hCG
Awal kehamilan

Glycoprotein secreted by the
syncytiotropoblastic cells of the placenta
subunit is shared with LH, FSH, TSH
subunit is specific to hCG

Assays can measure intact (sandwich) or both
intact and subunit
Cancer patients produce both intact hCG and
subunit
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Use of hCG
Early Pregnancy

Elevated with virtually all trophoblastic tumors
C/P Hyatidiform mole

Choriocarcinoma

Elevated in 70% of nonseminomatous testicular
tumors
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Alpha-Fetoprotein
Major fetal protein (70 kd glycoprotein)
Synthesized in the yolk sac, fetal liver, GI tract, kidney
Structurally related to albumin

Used as a marker for neural tube defects

Moderate elevations in liver disease
(hepatitis/cirrhosis)

Concentrations >1000 g/L are associated with
hepatocellular carcinoma

Lower cutoff is used for screening
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Carcinoembryonic antigen
Family of up to 36 large, cell-surface
glycoproteins
Elevated in . . .
70% of colorectal cancers
45% of lung cancers
50% of gastric cancers
40% of breast cancers
55% of pancreatic cancers
25% of ovarian cancers
40% of uterine cancers
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Use of CEA
Elevated in non-malignant conditions:
Cirrhosis, emphysema, rectal polyps, benign breast
disease, ulcerative colitis

Most useful in staging and
monitoring recurrence of
disease
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Breast cancer
Most common malignancy in U.S. women (7%
of women develop breast cancer by age 70)
Episialin is expressed by mammary epithelium

CA 15-3, CA 549, and CA 27.29 are
three distinct epitopes on episialin
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CA 125
High MW glycoprotein recognized Isolated
from a serous ovarian tumor

Elevated in 50% of stage I ovarian cancer
Elevated in 90%+ of stage II, III, and IV

Overall, sensitivity 95%; specificity 82%; PPV
78%; NPV 91%.
Pada Ca ovarium bisa untuk prognosis dari
keganasan jika sudah di terapi. Jika timbul lagi
maka berarti ada kekambuhan.
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93
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Kepustakaan

Buku wajib
McPherson RA., Pincus MR., Editors. Henrys Clinical Diagnosis and Management by
LaboratorMethods 22nd edition, ISBN:978-1-4377-0974-2 Saunders Elsevier 2011

Kepustakaan lain yang dianjurkan:
Gaw A, Clinical Biochemistry, ISBN 0-443-04481-3 Churchill Living Stone New York 1995,
92-93
Churchill Living Stone New York
ISBN 0-443-04481-3
Abraham P. editor, Physiology, ISBN-13: 978-1-905704-64-4, Amber Books London 2007
66-73
Federman DD., The Biology pf Human Sex Differences. N Engl J Med 2006; 354:1507-14
Interpretive Handbook. Mayo Medical Laboratories. Minnesota 2005



PENDAPAT & SARAN
CCH