Transcript MALE INFERTILITY - Universitas Andalas

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.
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Faktor Infertiliti pasangan :
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Female
Male
Both
1/3
1/3
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
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ENDOCRINE
– LEYDIG CELL  TESTOSTERON, 2% (FREE)
– INCREASED LEVEL OF ESTROGEN &
THYROID  DECREASED SHBG.
– ANDROGEN, GH, OBESITY
–  DECREASED SHBG & ACTIVE ANDROGEN
FRACTION
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EXOCRINE
– SERTOLI CELL  GERM CELL GROWTH
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INHIBIN & ACTIVIN
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SPERMATOGENESIS
SPERMATOGONIA
SPERMATOZOA
13 STAGES
74 DAYS
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ETIOLOGI
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PRE TESTICULAR :
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TESTICULAR
HIPOTALAMUS
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Endokrinopati
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Sexual dysfunction
HIPOFISIS
. Malignancy,radiation ,operation
. Hiperprolaktinemia,hemokromatosis
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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
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IDIOPATHIC 40%
History of infertility
Medical hystory
Gonadotoxin
DURATION
PRIOR PREGNANCIES
PRESENT PARTNER
PREVIOUS TREATMENT
EVALUATION & TREATMENT OF
WIFE
Systemic Illness ( i.e, DM )
Multiple sclerosis
Previous / current therapy
Chemicals / pestisides
Drugs (chemo, cimetidine
Sulfasalazine,
Nitrofurantoin,
Smoking, Alcohol
Marijuana, Androgen
steroids
Thermal exposure
Radiation
Sexual Hstory
Surgical History
Family history
POTENCY
LUBRICANTS
TIMING
FREQUENCY
ORCHIECTOMY
RETROPERITONEAL, PELVIC
INJURY
PELVIC, INGUINAL, SCROTAL
SURGERY
HERNIORRAPHY
Y-V PLASTY, TUR-P
CYSTIC FIBROSIS
ANDROGEN RECEPTOR
DEFICIENCY
INFERTILE FIRST DEGREE
RELATIVES
Childhood & Development
Infection
Review of System
UDT, ORCHIOPEXY
HERNIORRAPHY
Y-V PLASTY
TESTICULAR TORSION
TERSTICULAR TRAUMA
ONSET OF PUBERTY
VIRAL, FEBRILE
MUMPS ORCHITIS
VENEREAL DISEASE
TUBERCULOSIS, SMALLPOX
RESPIRATORY INFECTIONS
ANOSMIA
GALACTORRHEA
IMPAIRMENT VISUAL FIELDS
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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
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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
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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
T
FSH
LH
PRL
NORMAL
NL
NL
NL
NL
PRIMARYTESTIS FAILURE
LO
HG
NL/HG NL
Hypogonadotrophic-hypogonadism
LO
LO
LO
HYPERPROLACTINEMIA
LO
LO/NL LO
HIGH
ANDROGEN RESISTANCE
HG
HG
NL
HG
NL
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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
UNTREATABLE
Varicocele
Obstruction
Infection
Ejaculatory Dysfunction
HypogonadotropicHypogonadism
Immunologic Problem
Erectilel Dysfunction
Hyperprolactinemia
Idiopathic
Cryptorchidism
Vasal Agenesis
Bilateral Anorchia
Germinal Cell-Aplasia
Primary Testicular- Failure
Chromosomal-Anomalies
Immotile Cilia- Syndrome
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PENATALAKSANAAN
SURGICAL
THERAPY
SEMEN ANALYSIS
HISTORY
HORMONES
NON
SURGICAL
TREATMENT
PHYSICAL
ADJUNCTIVE
TEST
ASSISTED
REPRODUCTIVE
TECHNIQUE
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Non Surgical Treatment
SPECIFIC THERAPY
HYPOGONADOTROPHIC-HYPOGONADISM
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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
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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
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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
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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
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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
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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
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ETIOLOGY :
– ANATOMIC,
: BLDDER NECK SURGERY
– NEUROGENIC,
: SPINAL CORD INJURY, RETROPERTONEAL
SURGERY, DIABETES MELITUS
– PHARMACOLOGIC
: NEUROLEPTICS, TRICYCLIC
ANTIDEPRESSANT, ALPHA BLOCKERS, ANTIHYPERTENSIVE
– IDIOPATHIC
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DIAGNOSTIC TEST : POST EJACULATE URINE
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THERAPY :
– ALPHA ADRENERGICS AGONIST (EPHEDRINE,
PSEUDOEPHEDRINE, IMIPRAMINE, PHENYLPROPANOLAMINE
– ART  INTRAUTERINE INSEMINATION
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Non Surgical Treatment
SPECIFIC THERAPY
ANEJACULATION
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INCIDENCE : RARE
ETIOLOGY :
– NEUROGENIC,
: SPINAL CORD INJURY, RETROPERTONEAL
SURGERY, DIABETES MELITUS, TRANSVERSE MYELITIS, MULTIPLE
SCLEROSIS
– PSYCHOGENIC / IDIOPATHIC
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DIAGNOSTIC TEST : POST EJACULATE URINE
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THERAPY :
– RECTAL PROBE EJACULATION
– PENILE VIBRATORY STIMULATION
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ERECTILE DYSFUNCTION
???
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Non Surgical Treatment
EMPIRIC THERAPY
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INDICATION : IDIOPATHIC OLIGOSPERMIA
DRUGS CATEGORY FOR EMPIRYC THERAPY:
– CLOMIPHEN CITRATE
–
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TAMOXIFEN
ANDROGENS
TESTOSTERON REBOUND
AROMATASE INHIBITORS
GONADOTROPINS
GnRH
KALLIKREINS
PROSTAGLANDIN SYNTHETASE INHIBITORS
BROMOCRIPTINE
PENTOXIFYLLINE
– ANTIOXIDANTS
– CARNITINE.
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Non Surgical Treatment
CLOMIPHEN CITRATE EMPIRIC THERAPY
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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
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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 :
Husband or Others
Technique of sperm extraction :
Ejaculate
MESA
TESE
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INTRAUTERINE INSEMINATION
PLACEMENT OF WASH PELLET
EJACULATE WITHIN UTERUS
 INDICATION ;
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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
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ESTABLISHED
–
–
–
–
CONDOM
PERCUTANEOUS VAS OCCLUSION
TRADITIONAL VASECTOMY
NON-SCALPEL VASECTOMY
–
–
–
–
Hormonal : PILL’S, INJECTABLE
Non-hormonal
Vaccine
Imunologic
RESEARCH
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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.
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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
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Dokter yang telah mengikuti pendidikan
dan latihan tindak bedah vasektomi
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Peranan dokter
1.
 2.
 3.
 4.
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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.
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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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