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Infertility
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Introduction

Definition: Inability to conceive after 1 year of

unprotected intercourse o reasonable frequency

Divided: Primary & secondary infertility

Fecundability: Ability to concieve

Incidence : 10-15%

Fecundability ~ age-related, significant decrease

beginning at 32 yo, more rapid decline after 37 yo

Women older than 35 yo need evaluation after only

6 mo
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Infertility is defined as failure to conceive after

frequent unprotected sexual intercourse for
12 months in couples in the reproductive age group
Evaluasi dan penanganan lebih awal, bila:
1. Umur > 35 tahun
2. Riwayat oligo / amenorea
3. Diketahui terdapat sumbatan tuba atau endometriosis
4. Masalah pada faktor sperma

The Practice Committee of ASRM. Fertil Steril, 2003

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Time Require for Conception
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75% pasangan hamil pada 6 bulan pertama

Siklus Jumlah Pasangan Laju

pasangan yang yang hamil kehamilan
ingin hamil per siklus
1 200 59 0.30
2 137 41 0.30
3 95 16 0.17
4 78 12 0.15
5 66 14 0.21
6 52 4 0.08
7 48 5 0.10
8 43 3 0.07
9 40 2 0.05
10 38 1 0.03
11 37 2 0.05
12 35 1 0.03

Broekmans et al. Hum Reprod Update, 2006

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Etiology
Successful pregnancy requires a complex sequence:
ovulation, ovum pick-up by a fallopian tube,
fertilization, transport of a fertilized ovum into the
uterus, and implantation into uterine cavity

In the male system: Sperm of adequate number &

quality near the time of ovulation

Infertility : 1/3 female, 1/3 male, 1/3 both partners

Chance of conception increased from 5 days preceding

ovulation through the day of ovulation. Daily intercouse
to maximize the chance of conception

Sperm concentrations will drop with increasing coital

frequency
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Etiology of Infertility
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Causes of Infertility
Unsual problems Tubal and pelvic pathology
Male problems Ovulatory dysfunction
Unexplained infertility

10%
5%

15%
35%

35%

Couples

Speroff L, Glass R, Kase N. Clinical gynecologic endocrinology and infertility, 7 th edition, 2005
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Causes of Infertility
Unsual problems Tubal and pelvic pathology
Ovulatory dysfunction Unexplained infertility

10% 10%

40% 40%

Women

Speroff L, Glass R, Kase N. Clinical gynecologic endocrinology and infertility, 7 th edition, 2005
+
No History Taking
1 Pregnancy outcome and associated complications
2 Duration of infertility
3 Menstruation history
4 Changes in hair growth, body weight,or breast
discharge
5 Methods of contraception, coital frequency,
lubricants
6 Gynecologic history (PID, fibroids, endometriosis)
Surgery (cervix, ovary, uterus, fallopian tube)
7 Pap smears
8 Current medication
9 Occupation and use of tobacco or alcohol
10 History of chemotherapy or radiation
The Practice Committee of ASRM. Fertil Steril, 2004
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No Physical Examination
1 Patients weight and body mass index
2 Thyroid enlargement, nodule, or tenderness
3 Breast secretions and their character
4 Signs of androgen excess
5 Pelvic or abdominal tenderness, organ
enlargement, or mass
6 Vaginal or cervical abnormality, secretions, or
discharge
7 Uterine size, shape, position, and mobility
8 Adnexal mass or tenderness
9 Cul-de-sac mass, tenderness, or nodularity

The Practice Committee of ASRM. Fertil Steril, 2004

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Initial Advice to Couples

People who are concerned about their fertility

should be informed that sexual intercourse every
2 to 3 days optimises the chance of pregnancy

Timing intercourse to coincide with ovulation

causes stress and is not recommended
1 KUNJUNGAN PERTAMA

siapa pasangan suami istri

kapan hari ke-2 atau ke-3 siklus haid

tujuan anamnesis dan pemeriksaan (spekulum)

evaluasi uterus dan adneksa
evaluasi folikel antral basal

jadwalkan
analisis sperma dan IFD
pap smear (bila perlu)
office hysteroscopy (bila perlu)
analisis hormon dan AMH (bila perlu)
HSG
profilaksis Chlamydia
penanganan suplementasi asam folat
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PENILAIAN CADANGAN OVARIUM

FOLIKEL ANTRAL BASAL

UKURAN 2-6 mm
Hari ke-2 atau ke-3 siklus haid

Rosen et al. Fertil Steril, 2010

+ Semen Analysis
No Criteria Parameter
1 Volume 2.0 ml or more
2 Liquefaction time Within 60 minutes
3 pH 7.2 or more
4 Sperm 20 million spermatozoa per millilitre
concentration or more
5 Total sperm 40 million spermatozoa per ejaculate
number or more
6 Motility 50% or more motile (grades a and b
or
25% or more with progressive
motility (grade a) within 60 minutes
of ejaculation
7 Morphology 15% or 30%
8 Vitality 75% or more live
9 White blood cells fewer than 1 million per milli litre
Nice Guidelines, 2004
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Semen Analysis
No Recommendations Grade
1 Screening for antisperm antibodies should GPP
not be offered because there is no
evidence of effective treatment to
improve fertility
2 If the result of the first semen analysis is B
abnormal, a repeat confirmatory test
should be offered
3 Repeat confirmatory tests should ideally GPP
be undertaken 3 months after the initial
analysis to allow time for the cycle of
spermatozoa formation to be completed

Nice Guidelines, 2004

 KAPAN PERIKSA HORMON

Siklus haid tidak Konfirmasi Cadangan

teratur ovulasi ovarium
> 35 hari atau < 26 menurun
hari umur > 35 tahun
FSH Progesteron endometriosis
LH fase luteal
(bilateral)
Estradiol madya
Prolaktin (LH + 7) kistektomi bilateral

hari ke-2-5 siklus haid FAB

AMH
hari ke-2-5 siklus haid

Imperial, 2012
2 KUNJUNGAN KEDUA

siapa pasangan suami istri

kapan hari ke-9 atau ke-10 siklus haid

tujuan kerjakan
analisis sperma dan IFD
office hysteroscopy (bila perlu)
HSG atau sono-HSG
penangana see and treat
n bila dijumpai kelainan di kavum uteri
polip endometrium
septum
3 KUNJUNGAN KETIGA (bila perlu)

siapa pasangan suami istri

kapan fase luteal madya (7 hari sebelum haid)

tujuan diskusi hasil dan diagnosis

konseling tahap penanganan
konfirmasi ovulasi (bila perlu)
penangana jadwalkan pertemuan
n selanjutnya
penanganan definitif
hari ke-2 atau ke-3 siklus haid
berikutnya
 1 3

UNJUNGAN PERTAMA KUNJUNGAN KETIGA

Riw haid, perkawinan, pekerjaan, gaya hidup, hub seksual Konfirmasi ovulasi (bila
IMT, evaluasi uterus dan adneksa perlu)
Jadwalkan pemeriksaan Diskusi hasil dan diagnosis
Profilaksis Chlamydia Jelaskan rencana
penanganan definitif

2 3 9 10 21

KUNJUNGAN KEDUA
HSG / Sono-HSG
Analisis sperma dan IFD
Office hysteroscopy (bila perlu)
Pap smear (bila perlu)

2
RENCANA DEFINITIF

Gaya hidup Asam folat

Konseling awal
Hubungan seksual Profilaksis Chlamydia
Pekerjaan Umur

Pemeriksaan dan penanganan

IDIOPATIK SPERMA ANOVULASI ENDOMETRIOSI TUBA

S
UTERUS
Obat pemicu Bedah
ovulasi
3 6 siklus

Inseminasi intra uterin

4 kali

FERTILISASI IN VITRO
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Assessing Ovulation

No Recommendations Grade
1 Women with regular monthly menstrual cycles B
should be informed that they are likely to be
ovulating
2 Women with regular menstrual cycles and more than B
2 years infertility can be offered a blood test to
measure serum progesterone in the midluteal phase
3 The use of basal body temperature charts to confirm B
ovulation does not reliably predict ovulation and is
not recommended
4 Women with irregular menstrual cycles should be GPP
offered a blood test to measure serum
gonadotrophins
5 Prolactin test should only be offered to women who C
have an ovulatory disorder, galactorrhoea or a
pituitary tumour

Nice Guidelines, 2004

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ANOVULATION
Hypothalamus
1 Central
amenorrhea
Kallman Syndrome

Pituitary
Central
2 amenorrhea
- Anorexia
- Stress exercise
3 Hyperprolactinem
ia

Ovaries
- PCOS
4
- Turner SYNDROME
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Assessing Tubal Damage
No Recommendations Grade
1 Prophylactic antibiotics should be considered GPP
before uterine instrumentation if screening has
not been carried out

2 Women who are not known to have B

comorbidities (such as pelvic inflammatory
disease, previous ectopic pregnancy or
endometriosis) should be offered
hysterosalpingography (HSG) to screen for tubal
occlusion
3 Women who are thought to have comorbidities B
should be offered laparoscopy and dye so that
tubal and other pelvic pathology can be
assessed at the same time

Nice Guidelines, 2004

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Assessing Tubal Damage
Tubal factors account for 14% of the causes of
subfertility in women
Proximal (uterotubal) obstruction occurs in 1025%
of women with tubal
Tubal disease includes tubal obstruction and pelvic
adhesions due to infection, endometriosis and
previous surgery

Nice Guidelines, 2004

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Tubal Disease
No Recommendations Grade
1 For women with mild tubal disease tubal surgery may B
be more effective than no treatment

In centres where appropriate expertise is available it

may be considered as a treatment option
2 For women with proximal tubal obstruction selective B
salpingography plus tubal catheterisation, or
hysteroscopic tubal cannulation, may be treatment
options because these treatments improve the chance
of pregnancy
3 Women with hydrosalpinges should be offered B
salpingectomy, preferably by laparoscopy, before in
vitro fertilisation treatment because this improves the
chance
of a live birth
Nice Guidelines, 2004
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TUBAL SURGERY
contraindications
The management of infertility in secondary care. RCOG, 1998

Aged > 35 years

Decreased ovarian reserve
Hydrosalpinx > 3 cm
Tubal length < 3 cm after
reconstruction
Male factor infertility
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Assessing Uterine Abnormalities
Uterine abnormalities such as adhesions, polyps,

submucous leiomyomas and septae have been

found in 10% to 15% of women seeking treatment

for fertility problems

Nice Guidelines, 2004

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Uterine
Abnormalities
No Recommendations Grade
1 Women with amenorrhoea who are found B
to have intrauterine adhesions should be
offered hysteroscopic adhesiolysis
because this is likely to restore
menstruation and improve the chance of
pregnancy
Nice Guidelines, 2004
ngapa Endometriosis Menyebabkan Infertilitas

4
3

1 5
2

Stiley et al.Cell Tissue Res, 2012

Algorithm for management of infertility associated with endometriosis
IVF=in-vitro fertilisation. ART=assisted reproductive technologies.
GnRH=gonadotropin-releasing hormone. ICSI=intracytoplasmic sperm
injection.

Endometriosis and infertility: pathophysiology and management

de Ziegler, Dominique, Prof, Lancet, The, Volume 376, Issue 9742, 730-738
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Intra Uterine
Insemination Nice Guidelines, 2004

No Recommendations Grade
1 Couples with mild male factor fertility B
problems, unexplained fertility problems or
minimal to mild endometriosis should be
offered up to six cycles of intrauterine
insemination because this increases the
chance of pregnancy
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Thank You