42

DIAGNOSIS DAN
PENANGANAN
INFERTILITAS
PADA PRIA
ALVARINO

SIE UROLOGI
LAB ILMU BEDAH
FK. Univ. ANDALAS

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-PITUITARYGONADAL AXIS ( HPG )
EMBRYO PHENOTYPE
SEXUAL MATURATION
ENDOCRINE TESTICULAR
FUNCTION
testosterone
EXOCRINE TESTICULAR FUNCTION
spermatogenesis
3

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

PRE TESTICULAR :

TESTICULAR

HIPOTALAMUS

Endokrinopati

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

UDT
CHROMOSOMAL ABNORMALITY
INFECTION
MEDICATION
INJURY
VARICOCELE 20-40%

POST TESTICULAR :

ETIOLO
GI

CONGENITAL OBSTRUCTION : CYSTIC FIBROSIS

ACQUIRED OBSTRUCTION : VASECTOMY
FUNCTIONAL OBSTRUCTION : NEUROGENIC

IDIOPATHIC 40%
7

ETIOLO
GI

DISORDERS OF SPERM FUNCTION AND MOTILITY

Immotile Cilia Syndrome
Maturation defects
Immunologic infertility
Infection
DISORDERS OF SPERM DELIVERY / COITUS
Erectile dysfunction
Hypospadia

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

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.
10

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

11

KARAKTERISTIK SPERMA
NORMAL
Volume 1,5 - 5 ml
Conc > 20 million/ml, total
> 50 million
Motile > 50%
Motile grade >2
normal morphology >3050%
Fructose +
12

HORMONE PROFILE
CONDITION

FSH

LH

PRL

NORMAL

NL

NL

NL

NL

PRIMARYTESTIS FAILURE

LO

HG

NL/HG

Hypogonadotrophic-hypogonadism

LO

LO

LO

HYPERPROLACTINEMIA

LO

LO/NL LO

HIGH

ANDROGEN RESISTANCE

HG

HG

NL

NL

NL

HG

13

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

14

KLASIFIKASI
INFERTILITI PRIA

TREATABLE CAUSES

Varicocele
Obstruction
Infection
Ejaculatory
Dysfunction
HypogonadotropicHypogonadism
Immunologic
Problem
Erectilel Dysfunction
Hyperprolactinemia

UNTREATABLE

POTENTIALLY
TREATABLE
Idiopathic
Cryptorchidism
Vasal Agenesis

Bilateral Anorchia
Germinal CellAplasia
Primary TesticularFailure
ChromosomalAnomalies
Immotile CiliaSyndrome
15

PENATALAKSAN
AAN
SEMEN ANALYSIS

HISTORY

HORMONES

SURGICAL
THERAPY

NON
SURGICAL
TREATMENT

PHYSICAL
ADJUNCTIVE
TEST

ASSISTED
REPRODUCTIVE
TECHNIQUE

16

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
17

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

18

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

19

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. 20

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

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

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.

24

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
25
DOSES ; 10-15 mg/ TWICE d

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
26

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

PROPILAKSIS
PEMBEDAHAN
Orchydopexy
Operation for Testicular Torsion
Electroejaculation

27

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

28

INTRAUTERINE
INSEMINATION

PLACEMENT OF WASH PELLET

EJACULATE WITHIN UTERUS
INDICATION ;

BY PASS CERVICAL FACTORS

IMUNOLOGIC INFERTILITY
LOW SPERM QUALITY
MECHANICAL PROBLEM OF SPERM DELIVERY

29

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

30

ICSI

31

MALE
CONTRACEPTIVE
METHODE

ESTABLISHED

CONDOM
PERCUTANEOUS VAS OCCLUSION
TRADITIONAL VASECTOMY
NON-SCALPEL VASECTOMY

RESEARCH

Hormonal : PILLS, INJECTABLE

Non-hormonal
Vaccine
imunologic

32

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

33

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

34

PROCEDURE

35

COMPLICATION

HAEMATOME
RECANALIZATION
ASA
SPERM GRANULOMA

36