45087443-kuliah-infertilitas
TRANSCRIPT
![Page 1: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/1.jpg)
04/08/23 1
INFERTILITASINFERTILITAS
Dr. Kusuma Andriana SpOG
![Page 2: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/2.jpg)
04/08/23 2
DEFINISI
Gagalnya pasangan usia
reproduksi untuk mendapatkan
kehamilan
Tanpa perlindungan kontrasepsi
Setelah dua belas bulan atau lebih usia pernikahannya
Dengan frekuensi hubungan suami-istri teratur (2 atau 3 kali
seminggu)
Infertilitas
![Page 3: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/3.jpg)
04/08/23 3
DEFINISIDEFINISI
Infertil primer– Istri belum berhasil hamil dg CO teratur
dan dihadapkan pd kemungkinan kehamilan selama 12 bln berturut-turut
Infertil sekunder– Istri pernah hamil …………idem
![Page 4: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/4.jpg)
04/08/23 4
WHO (2000) MEMPERKIRAKAN ASIAWHO (2000) MEMPERKIRAKAN ASIA 80 juta pasangan gangguan kesuburan 7 – 15 % di usia subur (15 – 40 th)
40 – 60% wanita (terbanyak)
15% datang di klinik “reproduksi”
![Page 5: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/5.jpg)
04/08/23 5
Amerika Serikat10-15% pasutri
mengalami masalah dengan fertilitasnya
Amerika Serikat10-15% pasutri
mengalami masalah dengan fertilitasnya
Indonesia 7% pasutri mengalami masalah dengan fertilitasnya
Indonesia 7% pasutri mengalami masalah dengan fertilitasnya
Jawa Barat tahun 2004 10-15% jumlah penduduk mengalami masalah dengan infertilitas
Kecenderungan peningkatan upaya untuk mendapatkan pelayanan yang terpadu di klinik reproduksi buatan klinik FIV
![Page 6: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/6.jpg)
04/08/23 6
INSIDENINSIDEN
10-20 % pasutri Infertilitas
Penyebab infertilitas
1. Faktor istri 35%
2. Faktor suami 30%
3. Faktor kombinasi 20%
4. Tidak diketahui 15%
![Page 7: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/7.jpg)
04/08/23 7
PERUBAHAN PARADIGMA “MENIKAH” PERUBAHAN PARADIGMA “MENIKAH”
* * GLOBALISASIGLOBALISASI * KEMAMPUAN EKONOMI MENINGKAT * KEMAMPUAN EKONOMI MENINGKAT * PENINGKATAN TINGKAT PENDIDIKAN * PENINGKATAN TINGKAT PENDIDIKAN * KESEMPATAN KERJA * KESEMPATAN KERJA
DUA DASA WARSA TERAKHIRDUA DASA WARSA TERAKHIR
![Page 8: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/8.jpg)
04/08/23 8
Fecundability (conception rate)Fecundability (conception rate)
Normal : 20-25% of couples will conceive/cycle
50% should conceive after 3-4mos95% should conceive after 1 yrBila usia 38 th + riw infertil 3 th 2%
![Page 9: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/9.jpg)
04/08/23 9
Komponen Dasar Fertilitas pd Komponen Dasar Fertilitas pd PerempuanPerempuan
Vagina Mukus Cx normal Siklus ovulatoar Patensi Cx – Ov Uterus Hormonal
memelihara kehamilan
Imun respon normal – Sperma– Hsl konsepsi– Fetal survival
Status kes,gizi & biokimiawi adekuat
![Page 10: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/10.jpg)
04/08/23 10
FISIOLOGI TUBA FALOPIIFISIOLOGI TUBA FALOPII
Ovum Picked - Up
Transport Gamet & Embrio
Tempat Fertilisasi
Tempat Pertumbuhan Dini Embrio
FISIOLOGIFISIOLOGI
SYARATSYARAT
• Fimbriae BaikFimbriae Baik• PatentPatent• Bebas PerlekatanBebas Perlekatan• Otot Tuba BaikOtot Tuba Baik• Villi / Cilia BaikVilli / Cilia Baik
![Page 11: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/11.jpg)
04/08/23 11
RAHIM
KANTUNG TELOR
VAGINA
KANTUNG KENCING
SALURAN TELOR
MULUT RAHIM
RONGGA RAHIM
![Page 12: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/12.jpg)
04/08/23 12
MULUT RAHIM
PINTU
DEPO MAKANAN
SARINGAN
![Page 13: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/13.jpg)
04/08/23 13
RAHIM
RONGGA RAHIM
TEMPAT
TUMBUH
JANIN
![Page 14: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/14.jpg)
04/08/23 14
RAHIM
MENANGKAP SEL TELUR
TRANSPORTASI SPERMA DAN EMBRIO
PERTUMBUHAN DINI EMBRIO
SALURAN TELOR
![Page 15: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/15.jpg)
04/08/23 15
Komponen Dasar Fertilitas pd PriaKomponen Dasar Fertilitas pd Pria
Sperma normal– Motilitas, struktur biologi, fungsi & jumlah
Analisa sperma normal :– Volume : 2 – 5 ml– Jumlah sperma >20 juta/ml– Motilitas pada 6-8 jam : >40 %– Bentuk sperma yang abnormal : < 20 %– Kandungan kadar fruktosa : 120 -450 mikrog/ml. 1
![Page 16: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/16.jpg)
04/08/23 16
Komponen Dasar Fertilitas pd PriaKomponen Dasar Fertilitas pd Pria
Traktus reproduksi tdk ada obstruksi
Sekresi normalKemampuan ejakulasi dan deposit
sperma di Cx
![Page 17: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/17.jpg)
04/08/23 17
JUMLAH GERAK BENTUK
![Page 18: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/18.jpg)
04/08/23 18
Major CausesMajor Causes
![Page 19: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/19.jpg)
04/08/23 19
Etiologi Infertil pd Perempuan Etiologi Infertil pd Perempuan
Unexplained 10%
Cervical/mucus 2-3%
Endometrial/uterine 2-3%
Pelvic/peritoneal 5-10%
Tubal 30-50%
Central (CNS) 40%
![Page 20: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/20.jpg)
04/08/23 20
Etiologi lainEtiologi lain
PID Cx conization/cautery Smoking DES exposure IUD Endometriosis PCOF Usia stl 30 th fecundity me ↓
![Page 21: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/21.jpg)
04/08/23 21
Etiologi Infertil (Tidak berovulasi)Etiologi Infertil (Tidak berovulasi)
Tdp pd 40 % perempuan Primary of premature ovarian failure PCOS Hypotyroidism Tumor hipofise Laktasi Adesi periovarial Endometriosis Medisinalis
![Page 22: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/22.jpg)
04/08/23 22
Polycystic Ovarian SyndromePolycystic Ovarian Syndrome
Oligomenorrhea/amenorrhea and hyperandrogenism
Prevalence: 5%. Clinical evidence: hirsutism, acne, obesity Lab evidence: elevated testosterone,
elevated DHEA-S.
![Page 23: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/23.jpg)
04/08/23 23
Hypothalamic AnovulationHypothalamic Anovulation
Low levels of GnRH, low of normal levels of FSH/ LH, low levels of endogenous estrogen.
Associated factors: low BMI (< 20), high-intensity exercise, extreme diets, stress.
Treatment: lifestyle modification.
![Page 24: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/24.jpg)
04/08/23 24
HyperprolactinemiaHyperprolactinemia
Causes: pituitary adenoma, psych meds. Test for: pregnancy, thyroid disease. Imaging: MRI for macro vs microadenoma Treament: Bromocriptine (dopamine
agonist). After correction, 80% of women will ovulate, 80% will get pregnant.
Discontinue treatment once pregnancy established.
![Page 25: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/25.jpg)
04/08/23 25
Etiologi Infertil Etiologi Infertil (Tubal/ Pelvic pathology)(Tubal/ Pelvic pathology)
Congenital anomalies
Tubal occlusion Evaluated by:
– hysterosalpingogram– laparoscopy– hysteroscopy
May occur as sequelae of– PID– endometriosis– abdominal/pelvic
surgery– peritonitis
![Page 26: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/26.jpg)
04/08/23 26
Etiologi Infertil (Mukus Cx)Etiologi Infertil (Mukus Cx)
CervisitisRespon imun thd spermaPemakaian lubrikasi or vag douche
![Page 27: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/27.jpg)
04/08/23 27
Etiologi Infertil (Blokade)Etiologi Infertil (Blokade)
Cx Tuba– Polip– Myoma– Adhesi– Endometriosis– Adenomyosis– Endometritis– Cx stenosis– Anomali kongenital
Tuba or motilitas abN – PID– IUD– Neoplasma– Salpingitis– Ligasi tuba– Endometriosis– KE– Peritubal
adesion
![Page 28: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/28.jpg)
04/08/23 28
Etiologi Infertil Etiologi Infertil contcont
Obst Ov – Fimbrie PID Adesi Endometriosis
Faktor Endometrium tdk siap– Anovulasi– Defek fase luteal– IUD
![Page 29: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/29.jpg)
04/08/23 29
Penyebab infertilitas priaPenyebab infertilitas pria
1. Gangguan produksi sperma2. Gangguan fungsi sperma3. Gangguan transportasi sperma4. Idiopatik
Analisis semen Penilaian deskriptif parameter spermatozoa dan cairan seminal yang membantu menilai kualitas semen
Nilai normal parameter semen WHO 1992
![Page 30: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/30.jpg)
04/08/23 30
Penyebab infertilitas priaPenyebab infertilitas pria
OLIGOSPERMA– Mumps– Criptochismus– Pakaian ketat– Varicocele
ABORMAL SPERMA– X- rays– Perokok– Alkohol– Medisinalis
![Page 31: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/31.jpg)
04/08/23 31
Penyebab infertilitas priaPenyebab infertilitas pria
BLOKADE– Infeksi– Tumor– Anomali kongenital– Vasektomi– Retrograde
ejakulation
DEPOSIT SPERMA– Prematur ejakulasi– Hyospadia– Retrograde ejakulation– Ggn eurologi (spine)
![Page 32: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/32.jpg)
04/08/23 32
Evaluasi untuk Perempuan Evaluasi untuk Perempuan AxAx
Infertility durationDetailed menstrual history ovulasiPrior pregnanciesFertility in other relationshipsIUD’s, OCP’s, DepoFrequency of intercourse/sexual
dysfunction
![Page 33: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/33.jpg)
04/08/23 33
DETEKSI OVULASIDETEKSI OVULASI
Riwayat Haid teratur Biopsi endometrium fase skeretorik LH test BBT bifasik Pemeriksaan hormonal : FSH , LH, P4 (hr
XXI), TSH, prolaktin TVS hr XIV Folikel dominan Ø 18-22 mm
![Page 34: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/34.jpg)
04/08/23 34
![Page 35: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/35.jpg)
04/08/23 35
![Page 36: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/36.jpg)
04/08/23 36
USG OVARIUM
18 mm
![Page 37: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/37.jpg)
04/08/23 37
Evaluasi untuk Perempuan Evaluasi untuk Perempuan AxAx
Gynecologic history (PID, endometriosis, fibroids, cervical dysplasia)
DES exposureMedical and surgical history Medications Previous tests and therapy
![Page 38: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/38.jpg)
04/08/23 38
Evaluasi unt Pria Evaluasi unt Pria Ax Ax Infertility duration Prior fertility in relationship(s) Medical & surgical history Meds (anabolic steroids, cancer
chemotherapy, sulfasalazine, nitrofurantoin)
Alcohol, drugs, pot Occupational exposures Sexual dysfunction Tight fitting underwear/pants Previous testing
![Page 39: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/39.jpg)
04/08/23 39
Tabel 1. Tes yang dapat digunakan untuk menilai cadangan ovarium
Biofisik Biokimia
Ultrasound 2D atau 3D Volume ovarium Basal antral folikel (AFC) Aliran darah stroma ovarium Dimensi uterus Densitas folikel
Kadar basal (folikuler awal): FSH, LH, E2
Inhibin dan activin Antimullerian hormon (AMH)Tes stimulasi ovarium : GnRH agonist stimulation test Human menopausal gonadotropin (hMG test) Clomiphene citrate challenge test (CCCT) FSH
Bukman A, Heineman MJ. Ovarian reserve testing and the use of prognostic models in patients with subfertility. Hum Reprod. Update 2001;7(6):581-90.
TES CADANGAN OVARIUMTES CADANGAN OVARIUM
![Page 40: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/40.jpg)
04/08/23 40
OVARIAN RESERVEOVARIAN RESERVE
BASAL FSH & EBASAL FSH & E22 AGEAGE
PATHOLOGICAL CASESPATHOLOGICAL CASES• Post pelvic surgeryPost pelvic surgery• Immun or genetic F.Immun or genetic F.• Etc.Etc.
![Page 41: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/41.jpg)
04/08/23 42
CADANGAN OVARIUMCADANGAN OVARIUM
• PENURUNAN JUMLAH DAN KUALITAS OOSIT PENURUNAN CADANGAN OVARIUM
• PROGNOSTIK KEBERHASILAN STIMULASI, STRATEGI STIMULASI OVARIUM
![Page 42: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/42.jpg)
04/08/23 43
Jumlah oosit
16-20 minggu kehamilan : 6-7 juta
Saat lahir : 1-2 juta
Pubertas : 300.000.
Saat reproduksi : + 1000/ siklus menstruasi.
Usia
Folikel antral adalah folikel kecil – kecil yang mempunyai ukuran 2-8 mm resting follicle
![Page 43: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/43.jpg)
04/08/23 44
![Page 44: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/44.jpg)
04/08/23 45
![Page 45: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/45.jpg)
04/08/23 46
![Page 46: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/46.jpg)
04/08/23 47
![Page 47: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/47.jpg)
04/08/23 48
INDUNG TELOR
MEMPRODUKSI
SEL TELUR
![Page 48: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/48.jpg)
04/08/23 49
![Page 49: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/49.jpg)
04/08/23 50
![Page 50: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/50.jpg)
04/08/23 51
• Mens. Cycle• BBT• Endom. Biopsy• P
INFERTILITY
FEMALE MALE
> 30 Years. Married > 3 Years. Suspect Adhesion, Endometriosis and or mass
LAPAROSCOPY
TUBE &PERITONEUM
OVULATION
< 30 Years.
NormalAbnormal
HSG / ISS
• 6 Months• Others F. “N”
NormalAbnormal
Op.
Op. ReconstructiveSurgery
1,5 – 2 Y.
Pregnant Pregnant
6 Months.
IVF -ET
Ovulation Abnormal
Tx / Induction
Failed
• COH• IUI(Tube F. N)
6 Cycles. Gonadotropin
Normal Abnormal
Tx Tx
Success Failed
> 37 Years orMultiple Factors Infertility
![Page 51: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/51.jpg)
04/08/23 52
Barbieri Robert L. : Female InfertilityIn Yen and Jaffe’s Reproductive Endocrinology. Ed V Th Elsevier Saunders. Philadelphia.2004. P : 633- 668
Identify allIdentify allFertility factorsFertility factors
ExpectantExpectantManagementManagement
CC or CC or CC - IUICC - IUI
hMG orhMG orhMG-IUIhMG-IUI
IVFIVF
Correct allCorrect allFertility factorsFertility factors
Increasing intensiveness of resource utilization
Incr
easi
ng
Fec
un
dab
ilit
y
Figure 20 – 16. Staircase approach to empirical infertility treatment/ For women over 35 years old, the first three steps in the algorithm should be rapidly completed. In women less than 30 years old, more time can be spent on the first three steps in the staircase
35 Years
![Page 52: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/52.jpg)
04/08/23 53BAYI TABUNG
PENANGANAN FAKTOR TUBA
INFEKSI MOW ENDOMETRIOSIS
OPERASI + OPERASI - REKANALISASI BEDAH / MEDIK
1 – 2 TH
HAMIL -
1 – 2 TH 1 – 2 TH
HAMIL -
![Page 53: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/53.jpg)
04/08/23 54
HIDROSALPING & INFERTILITAS*
* Awas : umur istri
BERAT
SALPINGECTOMI
FIV – ET
HAMIL
1,5 – 2 TH
• FIMBRIOPLASTY• SALPHINGOSTOMI
SEDANG / RINGAN
![Page 54: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/54.jpg)
04/08/23 55
MULUT RAHIM
INFEKSI
ANTISPERMA
KENTAL
POLIP
![Page 55: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/55.jpg)
04/08/23 56
SPERMAOVUM
![Page 56: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/56.jpg)
04/08/23 57
VAGINA
RONGGA RAHIM
MULUT RAHIM
![Page 57: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/57.jpg)
04/08/23 58
RAHIM
RONGGA RAHIM
INFEKSI
TUMOR
KETEBALAN RAHIM TIPIS
![Page 58: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/58.jpg)
04/08/23 59
RAHIM
INFEKSI
ENDOMETRIOSIS
SALURAN TELOR
![Page 59: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/59.jpg)
04/08/23 60
TUBOPLASTITUBOPLASTI
![Page 60: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/60.jpg)
04/08/23 61
![Page 61: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/61.jpg)
04/08/23 62
![Page 62: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/62.jpg)
04/08/23 63
![Page 63: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/63.jpg)
04/08/23 64
![Page 64: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/64.jpg)
04/08/23 65
Dx Tx
LaparoskopiRingan Sedang Berat
Ablasi Ablasi &Med. Mentosa
Ablasi
3 Bl. Med. Mentosa
Operasi
3 Bl. Med. Mentosa
1,5 – 2 ThHamil
FIV - ET
![Page 65: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/65.jpg)
04/08/23 66
![Page 66: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/66.jpg)
04/08/23 67
INDUNG TELOR
TIDAK ADA OVULASI
KISTE
GANGGGUAN HORMON
![Page 67: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/67.jpg)
04/08/23 68
![Page 68: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/68.jpg)
04/08/23 69
![Page 69: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/69.jpg)
04/08/23 70
ADOPSI AKU AE . . . MARI MBAK
![Page 70: 45087443-KULIAH-INFERTILITAS](https://reader033.vdocuments.site/reader033/viewer/2022061114/54617730b1af9f86228b490c/html5/thumbnails/70.jpg)
04/08/23 71
Terima KasihTerima Kasih