P ENANGANAN I NFERTILITAS

Dr. Maria Loho, SpOG-K

Department of Obstetrics and Gynecology

Faculty of Medicine Sam Ratulangi University

Manado
Pendahuluan
FERTILITAS : kemampuan seorg istri untuk menjadi hamil dan
melahirkan anak hidup oleh suami yg mampu
Diagnosis menghamilkannya.

Infertilitas Primer : kalau istri belum pernah hamil walaupun

Penanganan bersanggama dan dihadapkan kepada kemungkinan kehamilan
selama 12 bulan

Infertilitas sekunder : kalau istri pernah hamil, akan tetapi

Kesimpulan
tidak terjadi kehamilan lagi walaupun bersenggama dan
dihadapkan kepada kemungkinan kehamilan selama 12
bulan
 Most pregnancies occur during the first six cycles of intercourse

Pendahuluan

Diagnosis

Penanganan

Kesimpulan

Zinaman et al. Fertil Steril 1996

Pendahuluan

Diagnosis Evaluasi Awal Infertilitas diindikasikan pada

1. Usia lebih dari 35 tahun

Penanganan 2. Riwayat oligomenorrhea/ amenorrhea
3. Menderita kelainan pada uterus/tuba atau
endometriosis
Kesimpulan 4. Pasangan telah diketahui subfertil

The Practice Committee of ASRM. Fertil Steril, 2003

 Natural female fertility declines with age

Pendahuluan

Diagnosis

Penanganan

Kesimpulan

Speroff L, Glass R, Kase N. Clinical gynecologic endocrinology and infertility, 7th edition, 2005
 PENYEBAB INFERTILITAS

Pendahuluan

Diagnosis

Penanganan

Kesimpulan

Couples

Speroff L, Glass R, Kase N. Clinical gynecologic endocrinology and infertility, 7th edition, 2005
 PENYEBAB INFERTILITAS

Pendahuluan

Diagnosis

Penanganan

Kesimpulan

Women

Speroff L, Glass R, Kase N. Clinical gynecologic endocrinology and infertility, 7th edition, 2005
Pendahuluan

Diagnosis

Pemeriksaan pada pasangan infertil meliputi :

Penanganan

Pemeriksaan fisik,
Kesimpulan
Riwayat menstruasi dan

Pemeriksaan penunjang
 No History
1 Pregnancy outcome and associated complications
Pendahuluan
2 Duration of infertility
3 Menstruation history
Diagnosis 4 Changes in hair growth, body weight, or breast discharge
5 Methods of contraception, coital frequency, lubricants
6 Gynecologic history (PID, fibroids, endometriosis)
Penanganan Surgery (cervix, ovary, uterus, fallopian tube)
7 Pap smears
8 Current medication
Kesimpulan 9 Occupation and use of tobacco or alcohol
10 History of chemotherapy or radiation

The Practice Committee of ASRM. Fertil Steril, 2004

Pendahuluan No Physical Examination
1 Patients weight and body mass index
2 Thyroid enlargement, nodule, or tenderness
Diagnosis
3 Breast secretions and their character
4 Signs of androgen excess
5 Pelvic or abdominal tenderness, organ enlargement, or mass
Penanganan
6 Vaginal or cervical abnormality, secretions, or discharge
7 Uterine size, shape, position, and mobility

Kesimpulan 8 Adnexal mass or tenderness

9 Cul-de-sac mass, tenderness, or nodularity

The Practice Committee of ASRM. Fertil Steril, 2004

 A NALISA S PERMA

No Kriteria Parameter
Pendahuluan
1 Volume > 2 ml
2 Waktu Likuifaksi 60 menit
3 pH > 7.2
Diagnosis
4 Konsentrasi > 20 juta spermatozoa /ml
5 Total sperma > 40 million spermatozoa per ejakulasi
6 Motalitas > 50% (grade a dan b atau >
Penanganan
25% dengan motilitas yang progresif (grade
a) pada 60 minutes dari ejakulasi
7 Morfologi 15% - 30%
Kesimpulan 8 Vitalitas > 75% yang hidup live
9 Leukosit < 1 juta /ml

Nice Guidelines, 2004

Pendahuluan

Diagnosis
Kriteria WHO pada kualitas analisa sperma
berdasarkan pada populasi pria yang fertil dan
digambarkan sebagai nilai referensi lebih dari normal
Penanganan

Basic semen analysis using the WHO criteria is a sensitive test

(sensitivity of 89.6%), but it has poor specificity
Kesimpulan

Nice Guidelines, 2004

 Analisa Sperma
Pendahuluan
No Recommendations
1 Screening for antisperm antibodies should not be
Diagnosis offered because there is no evidence of effective
treatment to improve fertility
2 If the result of the first semen analysis is abnormal,
a repeat confirmatory test should be offered
Penanganan
3 Repeat confirmatory tests should ideally be undertaken
3 months after the initial analysis to allow time for the
cycle of spermatozoa formation to be completed
Kesimpulan

Nice Guidelines, 2004

 MORFOLOGI SPERMA NORMAL

Pendahuluan

Diagnosis

Penanganan

Kesimpulan
 MORFOLOGI SPERMA ABNORMAL

Pendahuluan

Diagnosis

Penanganan

Kesimpulan
 P ENILAIAN O VULASI
No Recommendations
Pendahuluan 1 Women with regular monthly menstrual cycles should be informed
that they are likely to be ovulating
2 Women with regular menstrual cycles and more than 2 years
Diagnosis infertility can be offered a blood test to measure serum
progesterone in the midluteal phase

3 The use of basal body temperature charts to confirm ovulation does

not reliably predict ovulation and is not recommended
Penanganan

4 Women with irregular menstrual cycles should be offered a blood

test to measure serum gonadotrophins
Kesimpulan
5 Prolactin test should only be offered to women who have an
ovulatory disorder, galactorrhoea or a pituitary tumour

Nice Guidelines, 2004

 ANOVULATION
Hypothalamus
1 Central amenorrhea
Kallman Syndrome
Pendahuluan

Pituitary
Central amenorrhea
Diagnosis 2 - Anorexia
- Stress exercise

Penanganan 3 Hyperprolactinemia

Ovaries
Kesimpulan 4 - PCOS
- Turner SYNDROME

Dhont M. Int Cong Ser, 2005

 Penilaian Kerusakan Tuba
No Recommendations
Pendahuluan
1 Prophylactic antibiotics should be considered before uterine
instrumentation if screening has not been carried out

Diagnosis
2 Women who are not known to have comorbidities (such as pelvic
inflammatory disease, previous ectopic pregnancy or
endometriosis) should be offered
Penanganan hysterosalpingography (HSG) to screen for tubal occlusion

Kesimpulan 3 Women who are thought to have comorbidities should be offered

laparoscopy and dye so that tubal and other pelvic pathology can
be assessed at the same time

Nice Guidelines, 2004

Pendahuluan

Diagnosis

HSG Patent Non Patent

Penanganan
Patent 94%
Non patent 38%
Kesimpulan
 UTERUS NORMAL
Pendahuluan

Diagnosis

Penanganan

Kesimpulan
 Penilaian Uterus Abnormal

Pendahuluan

Diagnosis

Penanganan

Kesimpulan
 PENANGANAN INFERTILITAS :

Pendahuluan
1. Faktor Laki-laki
2. Anovulasi
Diagnosis

3. Faktor tuba
Penanganan 4. Faktor Uterus
5. Unexplained Infertility Endometriosis
Kesimpulan
 FAKTOR LAKI-LAKI
Pendahuluan
BEBERAPA KONDISI DAPAT DIKONSUL Urologist.

Diagnosis KONDISI YG PERLU TERAPI MEDIKAMENTOSA :

a. Hypothyroidisme.
Penanganan b. Hypogonadotropic-Hypogonad.

c. Kongenital Adrenal Hiperplasia.

Kesimpulan d. Hyperprolaktinemia.

e. Sperma Abnormal.

f. Retrograde ejaculation
 FAKTOR LAKI-LAKI
1. Thyroxin Replacement.
Pendahuluan
2. HCG & HMG.

Diagnosis 3. Terapi glukokortikoid.

4. Bromokriptin.

Penanganan
- Jika Volume Semen atau :

- Washing Sperma
Kesimpulan
- Concentration INSEMINASI
INTRAUTERIN
- Extraction
 INSEMINASI INTRAUTERIN

Pendahuluan

Diagnosis

Penanganan

Kesimpulan
 FAKTOR LAKI-LAKI
Penderita dg Asthenospermia / motilitas
Pendahuluan
- Periksa Antisperma antibodies
Terapi steroid.
Diagnosis
Washing Sperma & IUI

Penanganan Retrograde Ejaculation :

Alpha Sympatomimetic.
Varicocele Operasi.
Kesimpulan

Jika ditemukan ggn faktor laki2 yg berat disertai Ggn Motilitas

ICSI = Intra cytoplasmic sperm injection
 ANOVULASI
Pendahuluan PENGOBATAN ANOVULASI tgt Penyebab.

- FSH Kegagalan ovarium

Diagnosis Resistensi ovarium.

- FSH dan prolaktin Normal

Penanganan Induksi Ovulasi diperlukan jika terjadi kronik anovulasi.

Klomifen Sitrat diberikan selama 5 hari mulai hari ke

5 haid.
Kesimpulan
Jika tjd ovulasi dan tdk tjd kehamilan perlu evaluasi
regimen
 ANOVULASI
Pendahuluan Penggunaan hMG (human Menopausal Gonadotropin)
Induksi Ovulasi

Diagnosis Penggunaan Gonadotropin dapat menyebabkan hiperstimulasi

ovarium 1-3% siklus.

Penanganan
kadar prolaktin ggn ovulasi terutama pd fase luteal atau
amenorea.

perlu pemeriksaan TSH

Kesimpulan

Hypotyrodisme menyebabkan prolaktin.

Terapi pemberian bromokriptin

 ANOVULASI
Ovarian Disorder
Pendahuluan
a. Premature Ovarian Failure :
- Ggn biasanya bersifat irreversible.
Diagnosis - Bbp laporan bisa tjd ovulasi spontan
ART = assisted reproductive technique

Penanganan IVF = in vitro fertilization

b. Decreased Ovarian Reserved :
- Bisa tjd pd usia
Kesimpulan
Kualitas ovum kurang baik
Kejadian Abortus
ART / IVF
 ANOVULASI
c. Polikistik Ovarium.
Pendahuluan
- Dilakukan induksi Ovulasi

Diagnosis 1. Metformin.

2. Klomifen citrat

Penanganan 3. Kombinasi metformin & klomifen

4. Gonadotropin & Inseminasi intrauterin

Kesimpulan 5. Laparoskopi

- Ovarian drilling.

- Diagnostik dan terapi

 FAKTOR UTERUS
Pendahuluan
a. Fibroid Submukosa.

Diagnosis b. Polip endometrium.

c. Anomali kongenital.

Penanganan d. Scar Intra uterin

Kesimpulan Hysteroscopic Resection

 FAKTOR TUBA
Pendahuluan
- Jika tidak tdp faktor umur/reserved ovarian
Laparoskopi :
Diagnosis
- Tubal lavage.
- Bebaskan perlekatan.
Penanganan
- Fimbrioplasty.
- Terapi endometriosis.
Kesimpulan
 UNEXPLAINED INFERTILITY ENDOMETRIOSIS
Pendahuluan

Diagnosis Induksi Ovulasi.

Klomifen Citrat 3 siklus
Penanganan

Kesimpulan
KESIMPULAN Gaya Hidup Asam Folat
Hubungan sex
Penilaian Awal Pencegahan Infeksi
Pekerjaan Umur dan fertilitas

Penemuan klinis dan strategi penanganan

Unexplained Faktor Pria Disfungsi Ovulasi Endometriosis Faktor Tuba

Induksi Ovulasi
Bedah
Stimulasi Ovarium

Intra uterine insemination = IUI

3-6 kali

IN VITRO FERTILIZATION