Transcript MALE INFERTILITY - C A R D I O | Community of
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 1/3 1/3
Both 1/3
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FISIOLOGI REPRODUKSI PRIA
HYPOTHALAMUS-PITUITARY-GONADAL AXIS ( HPG ) EMBRYO PHENOTYPE SEXUAL MATURATION ENDOCRINE TESTICULAR FUNCTION
testosterone EXOCRINE TESTICULAR FUNCTION
spermatogenesis
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ORGAN REPRODUKSI PRIA
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TESTIS
ENDOCRINE
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LEYDIG CELL
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TESTOSTERON, 2% (FREE) INCREASED LEVEL OF ESTROGEN & THYROID
DECREASED SHBG.
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ANDROGEN, GH, OBESITY
DECREASED SHBG & ACTIVE ANDROGEN FRACTION EXOCRINE
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SERTOLI CELL
INHIBIN & ACTIVIN
GERM CELL GROWTH
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SPERMATOGENESIS
SPERMATOGONIA
SPERMATOZOA
13 STAGES
74 DAYS
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ETIOLOGI
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PRE TESTICULAR : HIPOTALAMUS
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Endokrinopati Sexual dysfunction HIPOFISIS . Malignancy,radiation ,operation . Hiperprolaktinemia,hemokromatosis TESTICULAR
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UDT : CHROMOSOMAL ABNORMALITY INFECTION MEDICATION INJURY VARICOCELE 20-40% POST TESTICULAR
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: CONGENITAL OBSTRUCTION : CYSTIC FIBROSIS ACQUIRED OBSTRUCTION : VASECTOMY FUNCTIONAL OBSTRUCTION : NEUROGENIC IDIOPATHIC 40%
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ETIOLOGI
DISORDERS OF SPERM FUNCTION AND MOTILITY
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Immotile Cilia Syndrome
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Maturation defects
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Immunologic infertility
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Infection DISORDERS OF SPERM DELIVERY / COITUS
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Erectile dysfunction
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Hypospadia
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History of infertility DURATION PRIOR PREGNANCIES PRESENT PARTNER PREVIOUS TREATMENT EVALUATION & TREATMENT OF WIFE Sexual Hstory POTENCY LUBRICANTS TIMING FREQUENCY Childhood & Development UDT, ORCHIOPEXY HERNIORRAPHY Y-V PLASTY TESTICULAR TORSION TERSTICULAR TRAUMA ONSET OF PUBERTY Medical hystory Systemic Illness ( i.e, DM ) Multiple sclerosis Previous / current therapy Surgical History ORCHIECTOMY RETROPERITONEAL, PELVIC INJURY PELVIC, INGUINAL, SCROTAL SURGERY HERNIORRAPHY Y-V PLASTY, TUR-P Infection
VIRAL, FEBRILE MUMPS ORCHITIS VENEREAL DISEASE TUBERCULOSIS, SMALLPOX
Gonadotoxin Chemicals / pestisides Drugs (chemo, cimetidine Sulfasalazine, Nitrofurantoin, Smoking, Alcohol Marijuana, Androgen steroids Thermal exposure Radiation Family history CYSTIC FIBROSIS ANDROGEN RECEPTOR DEFICIENCY INFERTILE FIRST DEGREE RELATIVES Review of System
RESPIRATORY INFECTIONS ANOSMIA GALACTORRHEA IMPAIRMENT VISUAL FIELDS 10
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.
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PEMERIKSAAN AWAL
Urinalysis Semen analyses
Speciment were obtained correctly !!!
Abstinence 3-5 days, no delay before the analyses.
Minimally 2X, ( 2 weeks Normal result, vary widely 3 months )
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 + 13
HORMONE PROFILE
CONDITION
NORMAL
PRIMARYTESTIS FAILURE Hypogonadotrophic-hypogonadism T
NL LO LO
FSH
NL HG LO
LH
LO
PRL
NL NL NL/HG NL NL HYPERPROLACTINEMIA ANDROGEN RESISTANCE LO HG LO/NL LO HG HG HIGH NL 14
PEMERIKSAAN TAMBAHAN
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Semen leukocyte analysis
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Antisperm antibody test
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Computerized assisted semen analyses (CASA)
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Hypoosmotic swelling test
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Sperm penetration assay
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Sperm-cervical Mucus interaction
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ROS (reactive oxygen species)
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GENETIC EVALUATION
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Chromosomal study
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Cystic fibrosis mutation testing Y chromosome microdeletion analysis
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Radiologis : usg, venography, TRUS, CT/MRI pelvic
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Biopsi Testis & Vasography
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FNA mapping of testis
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Semen culture
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KLASIFIKASI INFERTILITI PRIA TREATABLE CAUSES Varicocele Obstruction
Infection Ejaculatory Dysfunction Hypogonadotropic Hypogonadism Immunologic Problem Erectilel Dysfunction Hyperprolactinemia
POTENTIALLY TREATABLE Idiopathic Cryptorchidism Vasal Agenesis UNTREATABLE
Bilateral Anorchia Germinal Cell-Aplasia Primary Testicular- Failure Chromosomal-Anomalies Immotile Cilia- Syndrome 16
PENATALAKSANAAN
HISTORY SEMEN ANALYSIS HORMONES SURGICAL THERAPY NON SURGICAL TREATMENT 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 18
HYPERPROLACTINEMIA Non Surgical Treatment SPECIFIC THERAPY
INCIDENCE ; LOW HYPERPROLACTINEMIA INHIBITORY EFFECT on LH BINDING to LEYDIG NEG FEEDBACK TO GnRH, 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 CORTISOL SECRETION INCREASED ACTH ADRENAL ANDROGEN PRODUCTION SUPPRESSES SPERMATOGENESIS.
DECREASED INCREASED DECREASED Gnrh 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 SUCCESSFUL CAN DECREASED ASA, TREATMENT OF CHOICE ; ART
3 – 7% MALE INFERTIL ICSI
ITS RARELY 22
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 sperm’s 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 24
Non Surgical Treatment SPECIFIC THERAPY ANEJACULATION
INCIDENCE : RARE ETIOLOGY : – –
NEUROGENIC
SURGERY, DIABETES MELITUS, TRANSVERSE MYELITIS, MULTIPLE SCLEROSIS , : SPINAL CORD INJURY, RETROPERTONEAL
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:
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CLOMIPHEN CITRATE TAMOXIFEN ANDROGENS TESTOSTERON REBOUND AROMATASE INHIBITORS GONADOTROPINS GnRH KALLIKREINS PROSTAGLANDIN SYNTHETASE INHIBITORS BROMOCRIPTINE PENTOXIFYLLINE ANTIOXIDANTS CARNITINE.
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CLOMIPHEN CITRATE Non Surgical Treatment EMPIRIC THERAPY
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 5 d 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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ANTIOXIDANT Non Surgical Treatment 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 31
ASSISTED REPRODUCTIVE TECHNIQUES
If neither Surgery nor medical therapy is sperm motility and number is
ART Sperm Donation :
Husband or Others
Technique of sperm extraction :
Ejaculate MESA TESE 32
INTRAUTERINE INSEMINATION
PLACEMENT OF WASH PELLET EJACULATE WITHIN UTERUS INDICATION ; BY PASS CERVICAL FACTORS IMUNOLOGIC INFERTILITY LOW SPERM QUALITY MECHANICAL PROBLEM OF SPERM DELIVERY 33
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 34
ICSI
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MALE CONTRACEPTIVE
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METHODE
ESTABLISHED – CONDOM – – – PERCUTANEOUS VAS OCCLUSION TRADITIONAL VASECTOMY NON-SCALPEL VASECTOMY RESEARCH – Hormonal : PILL’S, INJECTABLE – – – Non-hormonal Vaccine Imunologic 37
VASECTOMY
MINOR SURGICAL PROCEDURE CUTTING / OCCLUSSION OF VAS DEFERENS MINOR COMPLICCATION NO CHANGES IN SEXUAL FUNCTION 38
Syarat Operasional Vasektomi
1. Ruang tunggu 2. Ruang pendaftaran 3. Ruang periksa 4. Ruang ganti pakaian 5. Ruang bedah 6. Ruang rawatan paska bedah 7. Laboratorium sederhana 8. Ruang peralatan dan pencucian alat 39
Harapan Suatu KLinik
Memberikan rasa aman Memberikan penjelasan Melaksanakan persiapan Mengatasi penyulit Melakukan pengawasan lanjutan Merujuk bila perlu 40
Pelaksana pelayanan Vasektomi
Dokter yang telah mengikuti pendidikan dan latihan tindak bedah vasektomi 41
Peranan dokter
1. Menseleksi calon akseptor 2. Melakukan pembedahan 3. Pelayanan paska bedah 4. Mengkoordinasi semua kegiatan 42
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 43
Syarat Akseptor
1. Sukarela 2. Bahagia 3. Kesehatan 44
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. 45
Pemeriksaan prabedah
1. Anamnesa 2. Pemeriksaan fisik 3. Pemeriksaan laboratorium sederhana 46
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 47
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 48
Alat emergensi
1. Oksigen 2. Alat resusitasi sederhana 3. Obat2an 4. Infus set 5. Spuit 5 dan 10cc 49
Komplikasi premedikasi
1. Intoksikasi 2. Kejang2 - 3. Alergi ---- Hentikan obat Valium 5-10mg IV Dexamethason 5 mgIV 50
Teknik Vasektomi
1.Celana dibuka dan pasien berbaring 2.Bersihkan daerah operasi 3.Tutup dengan kain steril berlobang 51
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 61
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 62
Perawatan paska vasektomi
1. Berbaring kira2 15 menit,amati.
2. Rasa nyeri atau perdarahan 3. KU dan lokal baik,pulangkan 63
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 64
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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