18. infertilitas wanita
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8/9/2019 18. Infertilitas wanita
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Dr. H. Undang Gani, SpOG.
Depart. of Obstetrics & GynecologyFaculty of Medicine, Jend. Ac!ad "ani Uni#ercity $
% M A H %
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InfertilityInfertility : one year of unprotected inter-: one year of unprotected inter- course without pregnancy course without pregnancy
Primary infertility : no previous pregnancy havePrimary infertility : no previous pregnancy have
occurred occurredSecondary infertility : a prior pregnancy, although notSecondary infertility : a prior pregnancy, although not
necessarily a live birth has occure necessarily a live birth has occure
FecundabilityFecundability : probability of achieving pregnancy: probability of achieving pregnancy
within single menstrual cycle within single menstrual cycleFecundityFecundity : probability of achieving a live birt: probability of achieving a live birt
within a single menstrual cycle within a single menstrual cycle
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Infertility is a problem of the couple
The presence of the male partner beginningwith the initial evaluation involves him in the
therapeutic process
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1!bnormalities in the semen "male factorinfertility#
$%vulatory disorders "ovulatory factors#&Tuba in'ury, bloc(age, paratubal adhesion orendometriosis "tubal)perotoneal factor#
*!bnormalities in cervical mucus-sperm interactio
"cervical factor#+arer condition uterine abnormalities, infection,
immunologic aberation
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The relative prevalence of the etiologies of infertility prevalence.ale factor $+-*/0oth 1/0Female fator */-++02ne3plained infertility 1/0
The appro3imate prevalence of the causes of infertility in thefemale
%vulatory dysfunction &/-*/0Tubal)peritoneal factor &/-*/02ne3plained infertility 1/-1+0.iscellaneous causes 1/-1+0
Table 1 4ause of infertility
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5isorders of ovulation account for appro3imately &/-*/0 of allcases of female infertility6ormal length of menstrual cycle : $+-&+ days
.ost women : $7-&1 days
.ethods to 5ocument %vulation
asal body temperature
ecord patient8s temperature each morning on a basal bodytemperature "T# chart
The characteristic biphasic pattern indicative of ovulation
.idluteal serum progesteron
9levation in serum levels of progesterone constitute indirectevidence of ovulation
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.ethods to 5ocument %vulation
uteini;ing hormone monitoring
5ocumentation of the < surge is a reproducible method ofpredicting ovulation
%vulation occurs &*-&= hours after onset the < surge andappro3imately 1/-1$ hours after < pea(
9ndometrial biopsy
Finding of secretory endometriumThe biopsy is performed $-& days before the e3pected onsetof menses
Invasive procedure
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.ethods to 5ocument %vulation
2ltrasound monitoring
.onitoring the development of the dominant follicle
%vulation : decrease in follicular si;e and appearanceof fluid in the cul-de-sac
Si;e of follicle : $1-$& m "17-$> mm#It is recommended to the monitoring of ovulationinduction in !T patients
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!ccount for &/-*/0 of cases of female infertilityTubal factors : 5amage or obstruction of fallopian tubes
Peritoneal factor : Peritubal and periovarian adhesions
4auses : endometriosis, pelvic)tubal surgery, PI5 eg,
subclinical chlamydial infections
<ysterosalpingography "<S?# : Initial test of tubal patencyPerformed cycle days =-11
aparoscopy is the @gold standardA for diagnosing
tubal)peritoneal factorsFalloposcopy : 5irect observation of the the lumen offallopian tube
T2! ) P9IT%69! F!4T%S
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.ore than +0 of cases
Post coital test "P4T# is to asses the Buality of
cervical mucus, the presence and number of motilesperm in the female reproductive tract after coitus,
and the interaction between cervical mucus and sperm
P4T should be performed 'ust before ovulation
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!bnormalities of the uterus
Fibroids
59S e3posure in utero : T shape endometrial cavity
!sherman8s syndrome : Intrauterine adhesions
9ndometrial polyps
<ysteroscopy should be used to further define and treatabnormalities detected by <S?
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!ntisperm antibodies "Ig? C Ig.# have been detected inhuman males and female
Ig? molecules may be found in serum as well as in
cervical mucus and semen
!gglutinating antibodies "Ig!# are typically found incervical mucus and seminal plasma
Ig. are found e3clusively in serumThe etiology of antisperm antibodies is not well definedand may be multifactorial
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!ntisperm antibodies may interfere withfertili;ation by :
5isrupting sperm transport
%bstructing gamete interaction
Promoting sperm phagocytosis
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Sperm !gglutinating test "Dibric(s8s or Fran(lin5u(es# and Sperm complement-dependentimmobili;ation test "Iso'ima8s# have been replaced
by the immunobead or mi3ed agglutination tests".! E mi3ed agglutination reaction#
The proper role of such testing is unclear
2se antibody testing in selected cases
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Infections
The relationship between subclinical infectionand fertility has received considerableattention
Two potential pathogen :4hlamydia trachomatous
.ycoplasma species
4hlamydia may produces an asymptomaticinfection silent tubal infection tubaldamage
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2ne3plained Infertility
easonable !pproach :1 ! semen analysis, <S? and documentation of
ovulation should be performed
$ 6ormal results laparoscopy
& 9tiology remains enigmatic endocrine evaluation"TS<, FS<, prolactin#
* 4ervical factor P4T and chlamydia cultures
+ 9valuation of sperm function hamster-egg test,9ndometrial maturation endometrial biopsy
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Summary of the evaluation of the infertile couple
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Treatment option
!bsolute infertility very few
.ost infertility therapy is directed towarddecreasing the time it would ta(e toconceive without intervention
Such therapy is often under ta(en in aneffort to achieve pregnancy before or
during the natural age-related decline infemale infertility
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Treatment option
.ale factor infertility :1 .edical therapy
$ Surgical therapy
& !rtificial insemination : Intrauterine insemination Intracervical insemination Fallopian tube sperm perfusion
5irect intraperitoneal insemination Intrafollicular insemination
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Treatment option
%vulatory factor ?reatest success rate
1 4lomiphene citrate
$ ?onadotropins
& Pulsatile ?n< therapy
* romocriptine and de3amethasone supplementation
+ Surgical therapy P4%
= uteal phase defect progesterone supplementatiand follicular phase clomiphene citrate use
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Treatment option
Tubal and peritoneal factor!s success rates continue to improve for !T theindications for surgical therapy for tubal factorinfertility may become increasingly limited
Pro3imal tubal occlusion
5istal tubal occlusion
Sterili;ation reversal
Peritoneal factor endometriosis
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4ervical factor infertility
Treatment directed for cervical stenosis or
poor mucus Buality!bnormalities not amenable to surgical therapymay bypassed by I2I, or by ovulation inductioncombined with IGF, ?IFT or HIFT
Treatment option
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Treatment option
2terine factor predominantly surgical
2ne3plained infertility : %vulation induction
I2I
!T ?IFT
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Treatment option
!ssisted eproductive Technologies "!T#
! typical protocol for standard IGF :1 ?n< agonist down regulation-prior ovulation inductio
$ Follicular maturation and ovulation are effected withh.?)h4? administration
& %ocyte retrieval is performed transvaginally by 2S?guidance
* !nalgesia for oocyte retrieval individuali;ed basis
+ 9mbryo transfer transcervical into the intrauterincavity
= uteal phase support