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