DIAGNOSIS DAN

PENANGANAN INFERTILITAS
PADA PRIA

ALVARINO
SIE UROLOGI
LAB ILMU BEDAH
FK. Univ. ANDALAS
1

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

5

SPERMATOGENESIS
SPERMATOGONIA
SPERMATOZOA
13 STAGES
74 DAYS

ETIOLOGI

PRE TESTICULAR :

TESTICULAR

HIPOTALAMUS

Endokrinopati

Sexual dysfunction
HIPOFISIS
. Malignancy,radiation ,operation
. Hiperprolaktinemia,hemokromatosis

UDT
CHROMOSOMAL ABNORMALITY
INFECTION
MEDICATION
INJURY
VARICOCELE 20-40%

POST TESTICULAR :

CONGENITAL OBSTRUCTION : CYSTIC FIBROSIS

ACQUIRED OBSTRUCTION : VASECTOMY
FUNCTIONAL OBSTRUCTION : NEUROGENIC
7

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
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
10

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 +
11

HORMONE PROFILE
CONDITION

FSH

LH

PRL

NORMAL

NL

NL

NL

NL

PRIMARYTESTIS FAILURE

LO

HG

NL/HG NL

Hypogonadotrophic-hypogonadism

LO

LO

LO

LO

LO/NL LO

HG

HG

HYPERPROLACTINEMIA
HIGH
ANDROGEN RESISTANCE

HG

NL

NL
12

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
13

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 TesticularFailure
ChromosomalAnomalies
Immotile CiliaSyndrome

14

PENATALAKSANAAN

SEMEN ANALYSIS
HISTORY
HORMONES

SURGICAL
THERAPY

NON
SURGICAL
TREATMENT

PHYSICAL
ADJUNCTIVE
TEST

ASSISTED
REPRODUCTIVE
TECHNIQUE
15

Non Surgical Treatment

SPECIFIC THERAPY

HYPOGONADOTROPHICHYPOGONADISM

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
16

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
17

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
18

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.

19

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

20

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

21

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
22

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
23

ERECTILE DYSFUNCTION

???
24

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.

25

Non Surgical Treatment

CLOMIPHEN CITRATE 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
26

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

27

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

28

PROPILAKSIS
PEMBEDAHAN
Orchydopexy
Operation for Testicular Torsion
Electroejaculation

29

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

30

INTRAUTERINE INSEMINATION
PLACEMENT OF WASH PELLET
EJACULATE WITHIN UTERUS
INDICATION ;

BY PASS CERVICAL FACTORS

IMUNOLOGIC INFERTILITY
LOW SPERM QUALITY
MECHANICAL PROBLEM OF SPERM
DELIVERY

31

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

32

ICSI

33

MALE
CONTRACEPTIVE

34

METHODE

ESTABLISHED

CONDOM
PERCUTANEOUS VAS OCCLUSION
TRADITIONAL VASECTOMY
NON-SCALPEL VASECTOMY

RESEARCH

Hormonal : PILLS, INJECTABLE

Non-hormonal
Vaccine
Imunologic
35

VASECTOMY
MINOR SURGICAL PROCEDURE
CUTTING / OCCLUSSION OF VAS
DEFERENS
MINOR COMPLICCATION
NO CHANGES IN SEXUAL
FUNCTION

36

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

37

Harapan Suatu KLinik

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

38

Pelaksana pelayanan
Vasektomi

Dokter yang telah mengikuti

pendidikan dan latihan tindak
bedah vasektomi

39

Peranan dokter
1. Menseleksi calon akseptor
2. Melakukan pembedahan
3. Pelayanan paska bedah
4. Mengkoordinasi semua kegiatan

40

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

41

Syarat Akseptor
1. Sukarela
2. Bahagia
3. Kesehatan

42

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.

43

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

44

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

45

Pramedikasi dan anestesi

1. Evaluasi keadaan pasien
2. Infiltrasi dengan anestesi lokal
( xylocain,lidokain,procain dll 0,51%) 1cc
3. Lakukan insisi setelah 2-3 menit

46

Alat emergensi
1. Oksigen
2. Alat resusitasi sederhana
3. Obat2an
4. Infus set
5. Spuit 5 dan 10cc

47

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

48

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

49

4. Anestesi lokal

51

5. Insisi kulit skrotum

52

6.Cari dan pegang vas

deferen

53

7.Ikat dan potong vas

deferen

54

Cara mengikat vas

deferen

55

8.Rawat perdarahan

56

9.Lakukan prosedur yang

sama pada vas deferen
sebelahnya

57

PROCEDURE

58

KOMPLIKASI
HAEMATOM
PERDARAHAN
ANTI BODI SPERMA
GRANULOMA SPERMA
INFEKSI
REKANALISASI

59

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

60

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

61

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

62

Sebaiknya periksa sperma suami

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

63

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.

64