DIAGNOSIS DAN PENANGANAN INFERTILITAS PADA PRIA

ALVARINO
SIE UROLOGI LAB ILMU BEDAH FK. Univ. ANDALAS
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PENDAHULUAN

10 15% pasutri ,hub.seksual normal tanpa kontrasepsi,belum hamil Infertiliti Primer.

Faktor Infertiliti pasangan :

Female Male Both

1/3 1/3 1/3

FISIOLOGI REPRODUKSI PRIA

HYPOTHALAMUS-PITUITARY-GONADAL AXIS ( HPG )

EMBRYO PHENOTYPE SEXUAL MATURATION ENDOCRINE TESTICULAR FUNCTION testosterone EXOCRINE TESTICULAR FUNCTION spermatogenesis

ORGAN REPRODUKSI PRIA

TESTIS

ENDOCRINE
LEYDIG CELL TESTOSTERON, 2% (FREE) INCREASED LEVEL OF ESTROGEN & THYROID DECREASED SHBG. ANDROGEN, GH, OBESITY DECREASED SHBG & ACTIVE ANDROGEN FRACTION

EXOCRINE
SERTOLI CELL GERM CELL GROWTH

INHIBIN & ACTIVIN

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SPERMATOGENESIS
SPERMATOGONIA SPERMATOZOA 13 STAGES 74 DAYS

ETIOLOGI
PRE TESTICULAR :
HIPOTALAMUS Endokrinopati Sexual dysfunction HIPOFISIS . Malignancy,radiation ,operation . Hiperprolaktinemia,hemokromatosis

TESTICULAR

UDT CHROMOSOMAL ABNORMALITY INFECTION MEDICATION INJURY VARICOCELE 20-40% CONGENITAL OBSTRUCTION : CYSTIC FIBROSIS ACQUIRED OBSTRUCTION : VASECTOMY FUNCTIONAL OBSTRUCTION : NEUROGENIC 7

POST TESTICULAR :

IDIOPATHIC 40%

History of infertility
DURATION PRIOR PREGNANCIES PRESENT PARTNER PREVIOUS TREATMENT EVALUATION & TREATMENT OF WIFE

Medical hystory
Systemic Illness ( i.e, DM ) Multiple sclerosis Previous / current therapy

Gonadotoxin
Chemicals / pestisides Drugs (chemo, cimetidine Sulfasalazine, Nitrofurantoin, Smoking, Alcohol Marijuana, Androgen steroids Thermal exposure Radiation

Sexual Hstory
POTENCY LUBRICANTS TIMING FREQUENCY

Surgical History
ORCHIECTOMY RETROPERITONEAL, PELVIC INJURY PELVIC, INGUINAL, SCROTAL SURGERY HERNIORRAPHY Y-V PLASTY, TUR-P

Family history
CYSTIC FIBROSIS ANDROGEN RECEPTOR DEFICIENCY INFERTILE FIRST DEGREE RELATIVES

Childhood & Development

UDT, ORCHIOPEXY HERNIORRAPHY Y-V PLASTY TESTICULAR TORSION TERSTICULAR TRAUMA ONSET OF PUBERTY

Infection
VIRAL, FEBRILE MUMPS ORCHITIS VENEREAL DISEASE TUBERCULOSIS, SMALLPOX

Review of System
RESPIRATORY INFECTIONS ANOSMIA GALACTORRHEA IMPAIRMENT VISUAL FIELDS 8

PEMERIKSAAN FISIK
Pemeriksaan genital eksterna : Testis, epididymis, Vas deferens, varicocele,genital kecil. Karakteristik seks sekunder ; penyebaran rambut ketiak,pubis dan badan tumbuh besar. abnormal ; gynecomastia, anosmia(Kallmann),galaktore, ggn lap.penglihatan.

PEMERIKSAAN AWAL
Urinalysis Semen analyses

Speciment were obtained correctly !!! Abstinence 3-5 days, no delay before the analyses. Minimally 2X, ( 2 weeks 3 months ) Normal result, vary widely

Hormonal evaluation (LH, FSH, Testosteron, Prolactine) less then 3% showed abnormalities Indications : < 10 million/ml, sugest endocrinopathy Azoospermia + (n) FSH Vasography & biopsy
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KARAKTERISTIK SPERMA NORMAL

Volume 1,5 - 5 ml Conc > 20 million/ml, total > 50 million Motile > 50% Motile grade >2 normal morphology >30-50% Fructose +
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HORMONE PROFILE
CONDITION
NORMAL
PRIMARYTESTIS FAILURE

T
NL LO LO LO HG

FSH
NL HG LO

LH
NL

PRL
NL

NL/HG NL LO NL HIGH NL

Hypogonadotrophic-hypogonadism

HYPERPROLACTINEMIA ANDROGEN RESISTANCE

LO/NL LO HG HG

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PEMERIKSAAN TAMBAHAN
Semen leukocyte analysis Antisperm antibody test Computerized assisted semen analyses (CASA) Hypoosmotic swelling test Sperm penetration assay Sperm-cervical Mucus interaction ROS (reactive oxygen species) GENETIC EVALUATION
Chromosomal study Cystic fibrosis mutation testing Y chromosome microdeletion analysis

Radiologis : usg, venography, TRUS, CT/MRI pelvic Biopsi Testis & Vasography FNA mapping of testis Semen culture
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KLASIFIKASI INFERTILITI PRIA

TREATABLE CAUSES POTENTIALLY TREATABLE
Idiopathic Cryptorchidism Vasal Agenesis

UNTREATABLE

Varicocele Obstruction Infection Ejaculatory Dysfunction HypogonadotropicHypogonadism Immunologic Problem Erectilel Dysfunction Hyperprolactinemia

Bilateral Anorchia Germinal Cell-Aplasia Primary Testicular- Failure Chromosomal-Anomalies Immotile Cilia- Syndrome

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PENATALAKSANAAN
SURGICAL THERAPY SEMEN ANALYSIS HISTORY NON SURGICAL TREATMENT

HORMONES
PHYSICAL

ADJUNCTIVE TEST

ASSISTED REPRODUCTIVE TECHNIQUE

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Non Surgical Treatment SPECIFIC THERAPY

HYPOGONADOTROPHIC-HYPOGONADISM

INCIDENCE ; LOW ACQUIRED / CONGENITAL (KALLMANNIS SYNDROME) DUE TO DECREASED PRODUCTION OF GnRH ASSOCIATED WITH OTHER CONG ANOMALY : ANOSMIA, DEAFNESS, CLEFT PALATE, RENAL ANOMALIES ACQUIRED : PITUITARY TUMOR/TRAUMA, ISOLATED GONADOTROPIN DEFICIENCY, ANABOLIC STEROID USE. DIAGNOSTIC TEST : CT / MRI RULE OUT TUMOR THERAPY : hCG 1500-3000 IU sC 3 times weekly for 8-12 weeks, then hMG 37,5-150 IU sC 2-4 times weekly
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Non Surgical Treatment SPECIFIC THERAPY

HYPERPROLACTINEMIA

INCIDENCE ; LOW HYPERPROLACTINEMIA NEG FEEDBACK TO GnRH, INHIBITORY EFFECT on LH BINDING to LEYDIG INFERTILITY, ERECTILE DYSFUNCTION ETIOLOGY : HIPOPHYSEAL TUMOR, HYPOTHYROIDSM, LIVER DISEASE, DRUGS (Phenothiazine, Tricyclic Antidepresant, some antihypertensive) DIAGNOSTIC TEST : CT/MRI RULE OUT TUMOR THERAPY :
CAUSAL or BROMOCRIPTINE 2,5 -7,5 mg 2-4 TIMES DAILY
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Non Surgical Treatment SPECIFIC THERAPY

ISOLATED TESTOSTERON DEFICIENCY

PRIMARY HYPOGONADISM ( LEYDIG CELL FAILURE ) DECREASED LEVEL OF TESTOSTERON DECREASED LIBIDO & SEXUAL FUNCTION ( ERECTILE DYSFUNCTION, etc) INCIDENCE ; RARE THERAPY :
TESTOSTERON ENANTHATE / PROPIONATE im Hcg 1500 iu t.i.w

ISOLATED LH DEFICIENCY / FERTILE EUNUCH SYNDROME

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Non Surgical Treatment SPECIFIC THERAPY

CONGENITAL ADRENAL HYPERPLASIA

INCIDENCE : RARE DEFICIENCY OF ADRENAL HYDROXYLASE DECREASED CORTISOL SECRETION INCREASED ACTH INCREASED ADRENAL ANDROGEN PRODUCTION DECREASED Gnrh SUPPRESSES SPERMATOGENESIS. DIAGNOSTIC TEST : Urinary 17-KETOSTEROID or DEHYDROEPIANDROSTERON (DHEA) THERAPY : GLUCOCORTICOID REPLACEMENT.

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Non Surgical Treatment SPECIFIC THERAPY

IMUNOLOGIC INFERTILITY

EVEN oral PREDNISON CAN DECREASED ASA, ITS RARELY SUCCESSFUL TREATMENT OF CHOICE ; ART ICSI 3 7% MALE INFERTIL

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Non Surgical Treatment SPECIFIC THERAPY

GENITAL TRACT INFECTION

EFECT of GTI ABNORMAL SEMEN QUALITY < 2% Severe (Enterobacteriaceae, Chlamydia, Gonorrhoeae) TESTIS ATROPHY / EPIDIDYMAL DUCT OBSTRUCTION generate ROS harm sperms ability to fertilize Therapy ; Antibiotics Persistent Obstruction Surgery

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Non Surgical Treatment SPECIFIC THERAPY

RETROGRADE EJACULATION

ETIOLOGY :
ANATOMIC, : BLDDER NECK SURGERY NEUROGENIC, : SPINAL CORD INJURY, RETROPERTONEAL SURGERY, DIABETES MELITUS PHARMACOLOGIC : NEUROLEPTICS, TRICYCLIC ANTIDEPRESSANT, ALPHA BLOCKERS, ANTIHYPERTENSIVE IDIOPATHIC

DIAGNOSTIC TEST : POST EJACULATE URINE THERAPY :

ALPHA ADRENERGICS AGONIST (EPHEDRINE, PSEUDOEPHEDRINE, IMIPRAMINE, PHENYLPROPANOLAMINE ART INTRAUTERINE INSEMINATION
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Non Surgical Treatment SPECIFIC THERAPY

ANEJACULATION

INCIDENCE : RARE ETIOLOGY :

NEUROGENIC, : SPINAL CORD INJURY, RETROPERTONEAL SURGERY, DIABETES MELITUS, TRANSVERSE MYELITIS, MULTIPLE SCLEROSIS PSYCHOGENIC / IDIOPATHIC

DIAGNOSTIC TEST : POST EJACULATE URINE THERAPY :

RECTAL PROBE EJACULATION PENILE VIBRATORY STIMULATION
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ERECTILE DYSFUNCTION

???
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Non Surgical Treatment

EMPIRIC THERAPY

INDICATION : IDIOPATHIC OLIGOSPERMIA DRUGS CATEGORY FOR EMPIRYC THERAPY:

CLOMIPHEN CITRATE
TAMOXIFEN ANDROGENS TESTOSTERON REBOUND AROMATASE INHIBITORS GONADOTROPINS GnRH KALLIKREINS PROSTAGLANDIN SYNTHETASE INHIBITORS BROMOCRIPTINE PENTOXIFYLLINE

ANTIOXIDANTS
CARNITINE.

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CLOMIPHEN CITRATE EMPIRIC THERAPY

Non Surgical Treatment

SYNTHETIC, NONSTEROIDAL ANTI-ESTROGEN BINDS TO ESTROGEN RECEPTOR COMPETITIVELY IN THE HYPOTHALAMUS, AND HYPOPHISE BLOCKING FEDBACK AND INCREASING SECRETION OF GnRH, FSH, LH DOSES ; 12,5-50 mg/d, CONTINUOUSLY FOR 25 d, WITH 5d REST PERIOD each MONTH, FOR 6 MONTHS FOLLOW-UP : TESTOSTERON LEVEL MUS BE IN NORMAL LIMIT. FREQUENT SEMEN ANALYSES. SIDE EFFECT : GYNECOMASTIA, NAUSEA, DIZZINESS, VISUAL COMPLAINT, ALLERGIC DERMATITIS RESULT : 3-9 MONTHS, PREGNACY RATE 22-58% TAMOXIFEN : WORK IN MANNER AS CLOMIPHEN, BUT WITH LESS ESTROGENIC EFFECT DOSES ; 10-15 mg/ TWICE d
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Non Surgical Treatment

ANTIOXIDANT

EMPIRIC THERAPY

RECENT STUDIES DEMONSTRATED AN INCREASED OF ROS in IDIOPATHIC SUBFERTILITY ROS INCLUDE ; HYDROXYL RADICAL (OH), SUPEROXIDE ANION (O2), HYDROGEN PEROXIDE (H2O2) ROS DAMAGE SPERM LIPID MEMBRANE VITAMIN E 400-1200 iu /D IMPROVED CAPACITY FOR SPERM-OOCYTE FUSION IN-VITRO GLUTHATION 600 mg/d

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PEMBEDAHAN
Varicocelectomy Vasovasostomy, Epididymovasostomy, TUR of Ejaculatory duct Ablation of Pituitary Adenoma

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PROPILAKSIS PEMBEDAHAN
Orchydopexy Operation for Testicular Torsion Electroejaculation

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ASSISTED REPRODUCTIVE TECHNIQUES

If neither Surgery nor medical therapy is apropriate A logical treatment, technique atempt to overcome the problems of reduced sperm motility and number is ART Sperm Donation : Technique of sperm extraction :
Ejaculate MESA TESE

Husband or Others

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INTRAUTERINE INSEMINATION
PLACEMENT OF WASH PELLET EJACULATE WITHIN UTERUS INDICATION ;

BY PASS CERVICAL FACTORS IMUNOLOGIC INFERTILITY LOW SPERM QUALITY MECHANICAL PROBLEM OF SPERM DELIVERY

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IVF & ICSI

EXCELLENT TECH, BY PASS MODERATE TO SEVERE FORMS OF MALE INFERTILITY IVF ; 500.000-5.000.000 MOTILE SPERMA AND EGGS ARE FERTILIZED IN PETRI DISHED ICSI ; 1 VIABLE SPERM INJECTED INTO CYTOPLASMIC AREA

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ICSI

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MALE CONTRACEPTIVE

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METHODE

ESTABLISHED

RESEARCH

CONDOM PERCUTANEOUS VAS OCCLUSION TRADITIONAL VASECTOMY NON-SCALPEL VASECTOMY Hormonal : PILLS, INJECTABLE Non-hormonal Vaccine Imunologic
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VASECTOMY
MINOR SURGICAL PROCEDURE CUTTING / OCCLUSSION OF VAS DEFERENS MINOR COMPLICCATION NO CHANGES IN SEXUAL FUNCTION

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Syarat Operasional Vasektomi

1. 2. 3. 4. 5. 6. 7. 8.

Ruang tunggu Ruang pendaftaran Ruang periksa Ruang ganti pakaian Ruang bedah Ruang rawatan paska bedah Laboratorium sederhana Ruang peralatan dan pencucian alat
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Harapan Suatu KLinik

Memberikan rasa aman Memberikan penjelasan Melaksanakan persiapan Mengatasi penyulit Melakukan pengawasan lanjutan Merujuk bila perlu

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Pelaksana pelayanan Vasektomi

Dokter yang telah mengikuti pendidikan dan latihan tindak bedah vasektomi

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Peranan dokter
1. 2. 3. 4.

Menseleksi calon akseptor Melakukan pembedahan Pelayanan paska bedah Mengkoordinasi semua kegiatan

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Peranan paramedik
1. Menerima dan mencatat akseptor 2. Mempersiapkan calon 3. Memantau keadaan akseptor selama dan setelah operasi 4. Mempertsiapkan segala sesuatu kebutuhan dokter sebelum dan saat tindakan

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Syarat Akseptor
1. Sukarela 2. Bahagia 3. Kesehatan

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Informasi sebelum tindakan

1. Terangkan macam kontrasepsi keuntungan dan kekurangan masing2nya. 2.Terangkan bahwa vasektomi adalah suatu pembehan 3. Terangkan bahwa vasektomi ini dianggap permanen. 4. Beri kesempatan akseptor untuk berfikir.

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Pemeriksaan prabedah
1. Anamnesa 2. Pemeriksaan fisik 3. Pemeriksaan laboratorium sederhana

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VASECTOMY
PREPARATION : SHAVE AND WASH THE SCROTUM BRING A PAIR OF TIGHT FITTING UNDERWEAR OR ATHLETIC SUPPORT AVOID ANTI INFLAMATORY DRUGS ( IBUPROFEN, ASPIRIN BEFORE SURGERY

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Pramedikasi dan anestesi

1. Evaluasi keadaan pasien 2. Infiltrasi dengan anestesi lokal ( xylocain,lidokain,procain dll 0,5-1%) 1cc 3. Lakukan insisi setelah 2-3 menit

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Alat emergensi
1. 2. 3. 4. 5.

Oksigen Alat resusitasi sederhana Obat2an Infus set Spuit 5 dan 10cc

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Komplikasi premedikasi
1. Intoksikasi Hentikan obat 2. Kejang2 -- Valium 5-10mg IV 3. Alergi ----- Dexamethason 5 mgIV

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Teknik Vasektomi
1.Celana dibuka dan pasien berbaring 2.Bersihkan daerah operasi 3.Tutup dengan kain steril berlobang

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4. Anestesi lokal

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5. Insisi kulit skrotum

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6.Cari dan pegang vas deferen

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7.Ikat dan potong vas deferen

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Cara mengikat vas deferen

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8.Rawat perdarahan

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9.Lakukan prosedur yang sama pada vas deferen sebelahnya

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PROCEDURE

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KOMPLIKASI
HAEMATOM PERDARAHAN ANTI BODI SPERMA GRANULOMA SPERMA INFEKSI REKANALISASI

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KEGAGALAN VASEKTOMI
1.Spermatozoa ditemukan setelah 3 bulan atau setelah 10-12 kali ejakulasi 2. Ditemukan spermatozoa setelah sebelumnya azoosperma 3. Pasangannya hamil setelah berhubungan dg akseptor 3 bulan paska vasektomi

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Perawatan paska vasektomi

1. Berbaring kira2 15 menit,amati. 2. Rasa nyeri atau perdarahan 3. KU dan lokal baik,pulangkan

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Nasehat
Perawatan luka yang baik Ada komplikasi kembali ke RS Obat2an Jangan kerja berat/naik sepeda dulu Boleh berhubungan suami istri,sebaiknya pakai alat pencegah kehamilan dulu selama masih ada sisa sperma

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Sebaiknya periksa sperma suami kelaboratorium untuk memastikan tidak ada sperma lagi,barulah melakukan hubungan suami istri tanpa alat pencegah kehamilan apapun.

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Catatan medik
1.Identitas peserta dan istri 2.Pemeriksaan pra bedah 3.Laporan pembedahan 4.Data paska bedah 5.Data kunjungan ulang 6.Laporan komplikasi dan kematian 7.Laporan tertulis permohonan dan persetujuan kontrasepsi mantap.

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