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
The Pituitary-Gonad Axis
 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:

Amenore dan infertilitas
Evaluasi laboratorium:
hCG, prolactin, thyroid-stimulating-hormone
(TSH), free-thyroxine(fT4), FSH dan LH.
 3. Disfungsi Reproduksi
Indikasi disfungsi reproduksi wanita:
amenore, infertilitas

Evaluasi laboratorium:
hCG, prolactin , thyroid stimulating
hormone (TSH), free thyroxine (fT4)
FSH, LH, androgen
 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
 5. Kehamilan
Indikasi waktu ovulasi ditentukan dengan tes
urin LH surge
Awal kehamilan ditentukan dengan tes hCG
serum, yang meningkat sekali pada kelanjutan
kehamilan.
Untuk praktisnya urin -hCG periksa pd mmp
hari pertama tidak haid.
Konsentrasi hCG yang sangat tinggi (pada
pengenceran urin 1: 200 positif) indikasi
adanya mola hidatidosa
Eclampsia/preeclampsia:
hipertensi,proteinuri tes protein urin
 6. Screening Birth Defect
Trimester pertama-kedua screening
birth defects: chromosomal aneuploidy,
neural tube defects. Sindroma Down

7. Monitor fetal-hemolyticdisease dengan tes

kadar bilirubin cairan amnion.

8. Fetal-lung-maturity: estimasi surfactant paru

cairan amnion: rasio lecithin/sphingomyelin
 9. Toxemia of Pregnancy

Hypertensi
Proteinuria tes protein dalam urin

10. Preterm delivery risk

Fetal fibronectin cervical secretions

Regulasi Reproduksi Pria
 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.
Pengaturan Reproduksi Wanita
Haid
Kehamilan
 Plasenta
Interlocking fetal and
maternal tissues
Performs digestive,
respiratory, and
urinary functions for
the fetus
Materials exchanged
across membrane that
separates
bloodstreams
Figure 44.13
Page 791
Latex Agglutination

17
Home Pregnancy Test Kits

18
 INTERPRETASI

Negative Result
HCG is not present at detectable
concentrations

Positive Result
Pregnancy
False Positives
Drugs: Antiparkinsonian,
anticonvulsants, phenothiazines.
Medical Conditions: Tumors, Recent
completed pregnancy or miscarriage.
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.
 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
 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.
 Fungsi Utama Kelenjar Pria/
Major Functions of Male Glands
1. Activating spermatozoa .1
2. Providing nutrients spermatozoa .2
need for motility
3. Propelling spermatozoa and fluids .3
along reproductive tract:
mainly by peristaltic contractions
4. Producing buffers: .4
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
 Pemeriksaan Dasar Analisa Sperma
The analysis must include:
Volume measurement
Concentration determination
Motility assessment
Morphology assessment
Anti-sperm antibody screen
Identification of other cells
 Indikasi Analisa Sperma
1. Assessment of fertility (2-3 samples;
7 days to 3 months - best 2 weeks)

2. Forensic purposes (DNA)

3. Effectiveness of vasectomy
samples 1 month apart negative.

Setelah disambung ulang sperma positif

4. Suitability donor for artificial insemination

 Persiapan sampel
By masturbation.
Requires a period of abstinence prior(3 d)
Must be delivered warm to the laboratory.
Can either be produced on site.
Or at home if able to be delivered.
2 samples usually needed.
Compared against the
WHO criteria.
 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
 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.
Analisa Sperma meliputi pemeriksaan:
Makroskopik Mikroskopik
viscosity concentration/count
coagulation + motility
liquifaction morphology
volume viability
pH

Motility &Viability must be performed

within 1 - 2 hrs of collection
 Pemeriksaan Makroskopik
Lihat Petunjuk Pemeriksaan Praktikum

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
7.2-8.0; measured by viability
pH paper.
 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
 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
 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
 Motilitas
While estimating count
No stain
Count 200 total sperm and then the motile
Calculate the percentage
>50% motile
 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
Spermatozoon Structure

DNA

Figure 19-4
 Jumlah Sperma
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)
 Common Descriptive Labels
Oligozoospermia Sperm concentration

(poor count) <20 x 106/ml

Asthenozoospermia Fewer than 50% sperm cells

(poor motility) with forward progression

Teratozoospermia High number of abnormal forms

(abnormal
morphology)

Azoospermia No sperm cells in the ejaculate

 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.
 Penyebab Infertilitas
35% Tubal pathology
35% Male factor
15% Ovulatory dysfunction
10% Unexplained
5% Cervical/other
 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
 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
 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)
 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
 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
 Common Descriptive Labels
harus faham
Oligozoospermia Sperm concentration
(poor count) <20 x 106/ml

Asthenozoospermia Fewer than 50% sperm

(poor motility) cells with forward
progression
Teratozoospermia High number of
(abnormal morphology) abnormal forms

Azoospermia No sperm cells in

the ejaculate
48
Evaluasi fungsi Reproduksi
Wanita
Menopos: FSH & LH E2

Tes hormon wanita perhatikan

fase haid

ADAM Syndrome
Androgen Deficiency in the Aging Man
Andropause
 Uji Tapis Sindroma Down
Screening sebelum usia kehamilan 20 mg

Trimester pertama antara mg 12-13:

-subunit hCG &
plasma associated plasma protein (PAPP-A)

fetal chromosomal abnormalities

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

Hemoglobin unconjugated bilirubin

cairan amnion spectral analysis 450 nm
 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 .
 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)

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.
 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
 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)
Causes of female infertility
Other
Ovulatory
Immunologic 15%
disorders
factors 30%
5%

Pelvic factors
50%
 Thyroid disease and infertility
Hypothyroidism
Pre-pubertal
Delayed sexual maturation, or rarely,
precocious puberty
Post-pubertal
TSH may have leuteotropic effect

Hyperthyroidism
Amenorrhea
 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

 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
 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
 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
 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
Desirable characteristics of tumor
markers

Easy to measure
Specific for tumor
Always present with tumor
 Test performance
The sensitivity is 98.0%
The specificity is 85%
Liver cancer has an
incidence of 1.5:100,000
 Use of tumor markers
Screen for disease???
Diagnosis of symptomatic patients
Staging
Prognostic indicators
Detect recurrence of disease
Monitoring response to therapy
Radioimmunolocalization
 Prostate cancer
Prostate-specific antigen
2nd most common cancer (19%), and 2nd
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
 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
 Use of hCG
Early Pregnancy

Elevated with virtually all trophoblastic tumors

C/P Hyatidiform mole

Choriocarcinoma

Elevated in 70% of nonseminomatous

testicular tumors
 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

 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
 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
 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
 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%.
 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

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PENDAPAT & SARAN

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