t1 repro pleno group e

8/10/2019 T1 Repro Pleno Group E

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TRIGGER 1 - GROUP E

Reproduction Module

Mrs. M, 28 years old, came to a hospital with

complaints of feel pain in the lower left of

abdomen often and leucorrhea. She has been

married for 3 years with Mr. P, who works as a

personal trainer (PT) at a gym. He was a cyclist

athlete. Until now, they still dont have any

children.


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Keywords Mrs. M, 28 years old

Lower left abdomen

pain Leucorrhea

Married for 3 years

HusbandPT and

cyclist

Dont have any children

Identification ofProblem

The couple has been

married for 3 years

without any child.


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Unpregnant

BackgroundF, 28 yo

Married for 3

years

Husband: PT and

cyclist

Other Complain

Leucorrhea

Lower left

abdominal painRisk Factors

Causes

Acquired Congenital

Supporting exam

Diagnosis

Treatment

M F M F

Semen analysis

Infertility


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HYPOTHESIS

The couple dont have any children due to infertility, influencedby many factors.

KNOWLEDGE NEEDED

1. Normal anatomy of female and male reproduction system

2. Histology of female and male reproduction system

3. Physiology: Spermatogenesis

Hypothalamic hypophysis gonad axis

Menstrual cycle

Normal sexual intercourse and fertilization process

4. Infertility (definition, etiology, symptomatology, risk factors)5. Supporting examination (genital exam, Sperm analysis,

Fertile period, HSG, Referral criteria)


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Anatomy of Female Reproductive

Organs

Brenda Angeline Tiffany

1206289142Group E


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Pelvis

Pelvis: the space within the pelvic girdle,

overlapped externally by the abdominal and

gluteal regions, perineum, and lower back.

The greater pelvis: pelvic by virtue of its bony

boundaries, but is abdominal in terms of its

contents.

The lesser pelvis provides the skeleton for the

pelvic cavity and deep perineum.


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Male vs Female Pelvis


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Pelvis


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Pelvic Artery

artery origin course distribution anastomoses

ovarian

crosses pelvic brim,

descends in suspensory

ligament of ovary

abdominal and/pr

pelvic ureter, ovary,

and ampullary end of

uterine tube

uterine artery via tubal

and ovarian branches

uterine

runs anteromedially in base

of broad ligament/superior

cardinal ligament, gives rise

to vaginal branch, then

crosses ureter superiorly to

reach lateral aspect ofuterine cervix

Uterus, ligaments of

uterus, medial parts of

uterine tube and ovary,

and superior vagina

Ovarian artery (via

tubal and ovarian

branches); vaginal

artery

vaginaluterine

artery

Divides into vaginal and

inferior vesical branches,

the former descending on

the vagina, the latter

passing to the urinarybladder

Vaginal branch: lower

vagina, vestibular bulb,

and adjacent rectum;

inferior vesical branch:

fundus of urinarybladder

Vaginal branch of

uterine artery, superior

vesical artery


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PelvicArtery


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Uterine & Vaginal Arteries


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Pelvic Vein


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Neurovascular Structures of Pelvis


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PelvicLymphNodes


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Pelvis

Vascularisation: Supplied by internal iliac artery and

vein

Innervations:

Sacral plexus

Coccygeal plexus

Pelvic splanchnic nerves

Lymphatic drainage into: Common iliac nodes

External iliac nodes

Internal iliac nodes 15


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Ovaries

almond-shaped and almond-sized female

gonads in which the oocytesdevelop

also endocrine glands that produce

reproductive hormones.


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Ovaries & Fallopian Tubes


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Fallopian Tubes

conduct the oocyte, discharged monthly from

an ovary during child-bearing years, from the

periovarian peritoneal cavity to the uterine

cavity

also provide the usual site of fertilization.


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Fallopian Tubes

From lateral to medial: Infundibulum:the funnel-shaped distal end of the tube

that opens into the peritoneal cavity through theabdominal ostium.The finger-like processes (fimbriae)

spread over the medial surface of the ovary. Ampulla:the widest and longest part of the tube,

which begins at the medial end of the infundibulum;fertilization of the oocyte usually occurs in the ampulla.

Isthmus:the thick-walled part of the tube, which

enters the uterine horn. Uterine part:the short intramural segment of the tube

that passes through the wall of the uterus and opensvia the uterine ostium into the uterine cavity at the

uterine horn.


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Arteries & Veins of Ovaries & Fallopian

Tubes

The ovarian arteriesarise from the abdominal aortaand descend along the posterior abdominal wallcross over the external iliac vessel at pelvic brim andenter the suspensory ligaments

Veins draining the ovary form a vine-like pampiniformplexus of veinsin the broad ligament near the ovaryand uterine tube.

The veins of the plexus usually merge to form asingular ovarian vein,which leaves the lesser pelvis

with the ovarian artery. The right ovarian vein ascends to enter the inferior

vena cava;the left ovarian vein drains into the leftrenal vein. The tubal veinsdrain into the uterovaginal

venous plexus


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Arteries & Veins of Ovaries & Fallopian

Tubes


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Innervation of Ovaries

The nerve supply derives partly from the ovarianplexus, descending with the ovarian vessels, and partlyfrom the uterine (pelvic) plexus.

Visceral afferent pain fibers ascend retrogradely with

the descending sympathetic fibers of the ovarianplexus and lumbar splanchnic nerves to cell bodies inthe T11-L1 spinal sensory ganglia.

Visceral afferent reflex fibers follow parasympatheticfibers retrogradely through the uterine (pelvic) and

inferior hypogastric plexuses and the pelvic splanchnicnerves to cell bodies in the S2-S4 spinal sensoryganglia.


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Nerve

Suppy

ofOvaries


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Lymphatic Drainage of Ovaries

Most of tubal lymphatic join the lymphatics

from ovary and drain into the lateral aortic

andpreaortic nodes.

The lymphatics from isthmus accompany the

round ligament of the uterus and drain into

the superficial inguinal nodes.


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Uterus

a thick-walled, pear-shaped, hollow muscular

organ where the embryo and fetus will

develop.

The cervix of the uterusis the cylindrical,

relatively narrow inferior third of the uterus,

approximately 2.5 cm long in an adult non-

pregnant woman.


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Layers of Uterus

Perimetrium: the outer serous coat (consists of peritoneumsupported by a thin layer of connective tissue)

Myometrium: the middle coat of smooth muscle (containmain branches of the blood vessels and nerves of theuterus )becomes greatly distended (more extensive but

much thinner) during pregnancy. During childbirth,contraction of the myometrium is hormonally stimulated todilate the cervical os and expel the fetus and placenta.During the menses, myometrial contractions may producecramping.

Endometrium: the inner mucous coat (firmly adhered tothe underlying myometrium). The endometrium is activelyinvolved in the menstrual cycle, differing in structure witheach stage of the cycle. If conception occurs, the blastocystbecomes implanted in this layer; if conception does not

occur, the inner surface of this coat is shed duringmenstruation.


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Excavatio

Vesicouterina

Excavatio

Rectouterina

(Douglas

Pouch)

Vascularisation of Uterus


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Vascularisation of Uterus


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Lymphatic Drainage Uterus

Fundus: aortic lymph nodes, external iliac

lymph nodes or superficial inguinal lymph

nodes

Corpus: external iliac lymph nodes

Cervix: internal iliac and sacral lymph nodes


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Ligament

The ligament of the ovaryattaches to the uterus

posteroinferior to the uterotubal junction.

The round ligament of the uterus(L. ligamentum

teres uteri) attaches anteroinferiorly touterotubal junction.

The broad ligament of the uterus(assists in

keeping the uterus in position) is a double layerof peritoneum that extends from the sides of the

uterus to the lateral walls and floor of the pelvis.


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Cervix

The cervix is the least mobile part of the uterusbecause of the passive support provided byattached condensations of endopelvic fascia(ligaments):

Cardinal (transverse cervical) ligamentsextendfrom the supravaginal cervix and lateral parts ofthe fornix of the vagina to the lateral walls of thepelvis.

Uterosacral ligamentspass superiorly and slightlyposteriorly from the sides of the cervix to themiddle of the sacrum; they are palpable during arectal examination.


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Innervation of Female Genitalia


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Female External Genitalia


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Female External Genitalia


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Lymphatic Drainage of Female External

Genitalia

The upper third portion will drain into the

external iliac nodes

The middle third portion will drain into the

internal iliac nodes

The lower third portion will drain into the

medial group of superficial inguinal nodes


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Nerve Supply to the Female External

Genitalia

The upper two-third part is non-sensitive to

pain.

- Sympathetic (L1,2) and parasympathetic (S2,3)

nerves derived as vaginal nerves from theinferior hypogastric and uterovaginal plexuses

The lower third part is sensitive to pain

sensitive-Pudendal nerve through the inferior rectal and

posterior labial branches of perineal nerve


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STRUCTURE OF PENIS

Penis is divided into three

region :

Glans penis

Corpus penis

Radix penis


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Root

Crus Penis

Bulbus PenisRadix Penis

Glans Penis

40

consists of three masses

of erectile tissue in the

urogenital

triangle

two crura andthe bulbattached to

the pubic arch and

perineal membrane


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Corpus

consists of three massesof erectile tissuethe

right and left corpora

cavernosa, and the

median corpus

spongiosum


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Artery of the Penis


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Lymphatic Drainage of Penis

Lymphatic from the

glans drain into the

deep inguinal nodes.

Rest of the lymphaticsdrain into superficial

inguinal lymph nodes.


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Testes

the primary reproductiveorgans or gonads in themale

responsible for sperm

production andtestosterone production.

The left testis usually lieslower than the right testis

Three coats

tunica vaginalis

tunica albuginea

tunica vasculosa


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Vessels

Testicular Artery arise

from abdominal aorta,

inferior of renal

arteries

It travels together withSpermatic Cord

Pampiniform Plexus

are the combination

of testicular andepididymal veins

http://www.endotext.org/male/mal

e1/figures1/figure3.gif 45


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Scrotum

Def:a cutaneous fibromuscular sac containingthe testes and lower parts of the spermaticcords and hangs below the pubic symphysis

between the anteromedial aspects of thethighs

Divided into right and left halvescutaneousraphecontinues ventrally to the inferior

penile surface and dorsally along the midlineof the perineum to the anus


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Layers of the scrotum

Skin

Tunica dartos

External spermatic fascia

Cremaster muscle/ fascia Internal spermatic fascia

Parietal layer of tunica

vaginalis

Visceral layer of tunicavaginalis

Tunica albuginea

V l S l d L h i


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Vascular Supply and Lymphatic

Drainage

Artery the external pudendal

branches of the femoralartery

the scrotal branches of theinternal pudendal artery

a cremasteric branch fromthe inferior epigastricartery

Veinaccompany thearteries and join the externalpudendal veins.

The lymphatic

vessels of the

scrotum drain into

the superficialinguinal nodes.


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Spermatic Cord

As the testis traverses the abdominal wall intothe scrotum during early life, it carries itsvessels, nerves and vas deferens with it

These meet at the deep inguinal ring to formthe spermatic cordsuspends the testis inthe scrotum and extends from the deepinguinal ring to the posterior aspect of the

testis The left cord is a little longer than the right.


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Structure in Spermatic Cord

vas deferens the testicular artery and veins

cremasteric artery (a branch of the inferiorepigastric artery) and artery to the vas deferens(from the superior vesical artery)

the genital branch of the genitofemoral nerve andcremasteric nerve

the sympathetic components of the testicularplexus

48 lymph vessels draining the testis


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Spermatic Cord


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Epidydimis

The epididymis lies posteriorly and slightly lateral tothe testis, and the vas deferens lies along its medialside

Functions in the maturation and storage of

spermatozoain the head and body and propulsion ofthe spermatozoa into the ductus deferens.

Arterysupplied by the testicular artery

Nerves:supplied by sympathetic nerves through thetesticular plexus deriving from T11-L1 segment of

spinal cord Veins: Pampiniform plexus

Lymphatics: Preaortic and Para-aortic Lymph Nodes


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Epidydimis

Part :

head or globus major

superiorly

Corpus

Tail (cauda or globus

minor).


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Vas Deferens

Def:Thick-walled tube that enters the pelvis at thedeep inguinal ring at the lateral side of the inferiorepigastric artery.

Crosses the medial side of the umbilical artery and

obturator nerve and vessels, passes superior to theureter near the wall of the bladder, and is dilated tobecome the ampullaat its terminal part.

Contains fructosenutritive to spermatozoa

Innervation primarily from sympathetic nerves of thehypogastric plexus and parasympathetic nerves of thepelvic plexus.


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Seminal Vesicle

convoluted pouchlike structures, about 5 cm (2 in.) inlength, lying posterior to the base of the urinarybladder and anterior to the rectum

Through seminal vesiclesecrete an alkaline, viscous

fluid that contains, prostaglandins, and clottingproteins

The arteries to the seminal vesicles are derived fromthe inferior vesical and middle rectal arteriesveinsand lymphatics accompany these arteries.

The innervation of the seminal vesicles andbulbourethral glands is derived from the pelvicplexuses.


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Prostate Gland

located at the base of the urinary bladder. Has five lobes:

anterior lobe (or isthmus),lies in front of the urethra and is devoid ofglandular substance

middle (median) lobe, which lies between the urethra and the ejaculatoryducts and is prone to benign hypertrophy obstructing the internal urethral

orifice; the posterior lobe, which lies behind the urethra and below the ejaculatory

ducts, contains glandular tissue, and is prone to carcinomatoustransformation

The right and left lateral lobes, which are situated on either side of theurethra and form the main mass of the gland.

Secretes fluid that produces the characteristic odor of sementhesecretion from the seminal vesicles and the bulbourethral glands, and thespermatozoa constitute the semen or seminal fluid.

Receives the ejaculatory duct, which opens into the urethra on theseminal colliculusjust lateral to the blind prostatic utricle.


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Bulbourethral Glands

Located inferior to the prostate on either side

of the membranous urethra within the deep

muscles of the perineum, and their ducts

open into the spongy urethra

Function: secrete an alkaline fluid into the

urethrathat protects the passing sperm by

neutralizing acids from urine in the urethra.


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Histology of Female

Reproductive SystemGryselda

Covered by: germinal


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(1) Ovaries Covered by: germinal

epithelium (simple cuboidalepithelium)

Under germinal E: tunicaalbuginea Poorly vascularized, dense

irregular collagenous CTcapsule

2 regions of ovary: Cortex (outer) = highly cellular

stroma and many ovarianfollicles)

Medulla (inner) = loose CT and

BV enter the organ throughhilum from mesenteriessuspending the arteries(ovarian arteries)

NO distinct border between

cortex and medulla

Ovarian Follicles


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Ovarian Follicles

Consists of an oocyte withepithelial cells surrounding

it Primary oocyte

surrounded by a single layerof flattened follicular cells

Basal laminasurrounds

follicular cellsclearboundary between follicleand vascularized stroma

Primordial ovarian follicles Surrounded by = surface

epithelium (mesotheliumwith cuboidal cells) Sometimes also called

germinal epithelium

Below germinal E = tunicaalbuginea

Follicular Growth


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Follicular Growth

Between oocyte and granulosa cells =zona pellucida Binds with sperm surface protein

Induce acrosomal activation Small spaces between granulosa layerfollicular liquid (liquor folliculi)accumulates>> cavityantrum(secondary / antral follicles)

PubertyFSH

released

Primordial

follicles grow

Simple cuboidal E

(unilaminar

primary follicle)

Stratified follicular E

(multilayered primary

follicle surrounded by

basement membrane)

granulosa cells

mitosis

proliferate

Antral formation some cells form small hillock =


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Antral folliclesAntral formationsome cells form small hillock =cumulus oophorus

Surround oocyte and protrude into the antrum

Granulosa cells linked to oocytecorona radiatago with oocyte when it leaves ovary

Follicle development is accompanied with stromal cellsdifferentiation = follicular theca

Theca interna

Well-vascularized endocrine tissue

Cells differentiate as steroid-producing cells:androstenedione

Androstenedione granulosa+ FSHaromatase enzyme (F: steroidestradiol)

Theca externa

More fibrous, contain smooth muscle andfibroblasts

No distinct border between theca interna and thecaexterna

No distinct border between theca externa and thestroma

Distinct border between theca interna and granulosalayerdistinct cells and presence of thick basementmembrane


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Follicular Atresia

Various form of ovarianfollicles undergo atresia &disposed by phagocytosis

Secondary oocytes

degenerate if not fertilizedafter 24 h of the release

Mostly seen from beforebirth until a few years aftermenopause

Most prominent just afterbirth, during puberty andduring pregnancy

Corpus Luteum Aft l ti


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Corpus Luteum After ovulationgranulosa cells andtheca interna ofovulated folliclecorpus luteumin theovarian cortex.

Corpus Albicans

Remnants from degenerationand regressionphagocytosed

by macrophagesa scar of

dense connective tissue = corpus

albicans

Stages of follicle maturation


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g

St f f lli l t ti


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Stages of follicle maturation

(2) Uterine Tubes


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(2) Uterine Tubes

(oviducts)

Each of the oviductsafunnel-shaped end(infundibulum)

fimbriae

Following is the order ofeach tube: Infundibulum

Ampulla the longest;fertilization usually

occured here Isthmus more narrow

region

Uterine/ intramuralpart

Mucosa of the


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Mucosa of the

uterine tube wall

(a) Cross-section of the uterine tube at the antrum shows the interwoven circular (C)and longitudinal (L) layers of smooth muscle in the muscularis and in the complex offolded mucosa, the lamina propria (LP) underlying a simple columnar epithelium(arrows

(b) The micrograph shows the epithelium (E) contains primarily two columnar celltypes, ciliated and nonciliated, with the latter showing darker staining apical pegsbulging into the lumen (L)

(c, d) Higher magnification of the epithelium shows the ciliated cells (CC) interspersedwith the secretory cells (SC), which produce the nutritive fluid covering the epithelium

(3) Uterus


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(3) UterusThe uterine wall has three important

layers:1. Perimetrium (outer CT layer)

2. Myometrium

Thickest tunic of the uterus

Composedbundles of smoothmuscle fibers separated by CT withmany blood vesselsform 4interwoven layers

The first and fourth layersparallelto the long axis of the organ, with the

Middle layerscircular and containlarger blood vessels

3. Endometrium


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Uterus Simple columnarE with ciliatedand secretory

cells Lamina propria /

stromal CT = typeIII collagen fibers,abundant

fibroblasts &ground substance

Has 2 zones: Basal layer = next

to themyometrium

Superficialfunctional layer =more spongyimportant duringmenstruation


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Menstrual Cycle

3 phase ofmenstrualcycle:

Proliferative phase

Secretoryphase

Menstrualphase

Also called follicular or


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Proliferative Phaseestrogenic phase After the last menstrual cycle,

the musosa of uterine will be

shedded until it became thin(approximately 0.5 mm)

At the end of this phase,endometrium become 2-3mm thick

Endometrial lining = simplecolumnar surface epithelium Uterine glands = relatively

straight tubules, narrow,nearly empty lumens

Spiral arteries lengthen Functional layer reestablished

and grows

Microvasculature forms

Secretory (Luteal)St t h


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Secretory (Luteal)

Phase Starts when corpus

luteum secretesprogesterone

Glands become highlycoiled

Superficialmicrovasculatureincludes thin-walled,blood-filled lacunae

Endometrium become5 mm thick due to

accumulation ofsecretions and edemain the stroma

Menstrual Phase Fertilization do not


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Menstrual Phaseoccur, corpus luteum

regresses

Shredding of the

surface epithelium,

most of each gland,

the stroma andblood-filled lacunae

At the end of the

phase, endometrium

is reduced until they

become a thin layer


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Menstrual Cycle


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Placenta

Placenta = the site in which nutrition, wate

products and essential gases are exchanged

between mother and fetus

Embryonic part = chroion

Maternal part = decidua basalis

Term Placenta


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Term Placenta

(A) arteries (V) vena (MB) maternal blood(Arrows) Smaller villus branches (CT)connective trissue (K) knots (S) sinusoids (C)capillaries

Uterine Cervix Endocervix = mucussecreting simple columnar

epithelium on thick lamina propria


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Uterine Cervixepithelium on thick lamina propria Region of the cervix where endocervical canal

opens into vaginaexternal oscovered byexocervical mucose w/ stratified squamous

epithelium Transformation zone = simple columnar

epithelium transitioned abruptly to stratifiedsquamous epithelium

Deeper, middle layer of the cervix = smoothmuscle and consists of dense CT

Endocervical mucose has numerous mucus-secreting cervical glands

Does not desquamate during menstruation

Ovulation = mucus secretions are maximal,watery and facilitate movement through theuterus by sperm

Luteal phase = mucous secretions are viscous andhinder the mobilization of sperm andmicroorganization

Pregnancy = mucous secretions abundant, highlyviscousplug in the endocervical canal

Transformation

Zone

Uterine Cervix

j


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Uterine Cervix (EC)endocervicalcanal(

SC)simplecolumnar

epitheliu

m(Arrows)cerv

icalglands(V)v

agina(J)

junction

(SS)stratifiedsq

uamousepithe

lium(M

)mucus

( ) i3 l h d h ll


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(4) Vagina 3 layers that made up the wallof vagina: a mucosa, a muscularlayer, and an adventitia

Mucosa of the structure consistof many sensory nerves and therange of tactile receptorsimportant for physiology of

sexual arousal Vagina mucosa = stratified

squamous epithelium Cells contain keratohyaline but no

keratinization Cells desquamatebacteria

metabolize glycogen to lactic acidlow pH of vagina

E l G i li


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External Genitalia

Inner surface of labia majora

(SD) sebaceous duct (SG)sebaceous gland (Ep) non-keratinized epithelium

Clitoris = 2 small erectile bodies(corpora carvenosa)

Vestibule = stratified squamousepithelium, >> small mucousglands


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Histology of Male Reproductive

System

T


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Testes

A pair of ovoidorgans within

the scrotum

Function:production of

sperm and male

sex hormones

The tubule is lined by seminiferous

epitheli m


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epithelium:

Characteristics:

-Complex, specialized stratified

epithelium resting on basal lamina-Composed of proliferative

spermatogenic cells (SG, PS) and

supporting sertoli cells (SC)

External to basal lamina of SE is

tunia propria or peritubular tissue

Characteristics:

- A multilayered fibrous connective

tissueLayers of fibroblasts (F)

The innermost layer is the site of

flattened, smooth muscle-like myoid

(M) cells and collagen fibrils

Interstitial cells (IC)

scattered in the connective

tissue (CT) between the

seminiferous tubules

S t li ll


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Sertoli cell

They are columnar orpyramidal cells non-replicating cells thatadhere to basal lamina ofseminiferous epithelium

Functions: Support, protection and

nourishment ofspermatogenic cells

Exocrine and endocrine

secretioninhibin andantimullerian hormone

Phagocytosis

Structure: Abundant smooth ER,

some rough ER, well-developed Golgicomplexes, as well asnumerous mitochondriaand lysosomes

Cell nucleus is euchromatic

Tight occluding junctionsbetween the basolateralmembranes of adjacentSertoli cells form a blood-testis barrier

Blood-testis barrier:


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It prevents autoimmuneattacks against the

spermatogenic cellsIt divides the tubule into

basal & adluminalcompartment

Spermatogonia and earlyprimary spermatocytes arerestricted to the basalcompartment

More maturespermatocytes andspermatids are restricted tothe luminal side

-Spermatogonia (SG) reside in the basement

membranesmall cells which divide mitotically,Spermatogenic


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then proceed to meiosis

-The meiotic cells grow and undergo

chromosomal synapsisprimary spermatocytes(PS)

- Largest spermatogenic cells, abundant at all

levels between the basement membrane and the

lumen

-Each primary spermatocyte will divide to form

two secondary spermatocytes

-Newly formed round spermatids (RS)

differentiate and lose volume become late

spermatids (LS)- Motile, highly specialized sperm cells.

- All stages of spermatogenesis and

spermiogenesis occur with the cells associate with

the surfaces of adjacent Sertoli cells (SC)

cells

I t titi l (L di ) ll


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Interstitial (Leydig) cells

The site of androgenproductionproducetestosterone

During puberty:

Rounded or polygonalwith central nuclei

Eosinophilic cytoplasm,rich in small lipid

droplets The cytoplasm contains

an abundance of sER

Intratesticular Ducts


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Intratesticular Ducts

It consists of: tubuli recti, the rete testis, and the

efferent ductules

Tubuli recti(T) and Retetestis (R)are lined bysimple cuboidalepithelium

The efferentductules (E) arelined by anunusualepithelium with

groups ofnonciliatedcuboidal cellsalternating withgroups of tallerciliated cells

A thin circularlayer of smoothmuscle outsidebasal lamina ofepithelium

Genital


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The epididymal duct is lined with

pseudostratified columnar epithelium

(arrows)

It is composed of rounded basal cells (B)

and columnar cells with long, branched,

irregular microvilli called stereocilia

Stereocilia: reabsorbing testicular fluid

and for transferring nutrients and

secretions to the sperm stored in the

lumen

They are supported on a basal lamina

surrounded by smooth muscle (SM) cells

Genital

Excurrent

Duct:Epididymys

Genital Excurrent


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Duct: Vas deferens

1. Mucosa (M)

2. A thick muscularis with inner and outer

layers of longitudinal smooth muscle (L-

SM) and an intervening layer of circular

smooth muscle (C-SM)

3. An external adventitia (A).

The epithelium is pseudostratified

with basal cells and many columnar

cells with some stereocilia

Accessory SexO S i l


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Organs: Seminal

vesicles

-The seminal vesicles are exocrine glands that

secrete most seminal fluidconsist of highly

tortuous tubes

-The folds include smooth muscle (SM)

covered by a thin lamina propria (LP) and an

epithelium.- The epithelial cells are simple or

pseudostratified columnar, varying with

activity and location in the gland, and contain

lipid droplets, secretory granules, and also

commonly lipofuscin

Accessory Sex Organ: Prostate


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Accessory Sex Organ: Prostate

The prostate is a collection of branchedtubuloalveolar glands, surrounded by a densefibromuscular stroma covered by a capsule.

The glands are arranged in concentric layersaround the urethra:

the inner layer of mucosal glands

an intermediate layer of submucosal glands

a peripheral layer with the prostate's main glands Ducts from individual glands may converge but all

empty directly into the prostatic urethra


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The prostate has a dense fibromuscular stroma

(S) in which are embedded a large number of

small tubuloalveolar glands (G)

a corpus amylaceum (CA) concretion,

shows a secretory simple or

pseudostratified columnar epithelium

(E) surrounded by lamina propria (LP),

which is in turn surrounded by smooth

muscle

Accessory Sex Organ: Bulbourethral


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glands

The glands are compoundtubuloalveolar glands

The ducts are lined bysimple columnar

epitheliumvariesconsiderably in heightdepending on thefunctional state of thegland

They secrete mucus thatcontains galactose andgalactosamine,galacturonic acid, sialicacid, and methylpentose

External genitalia: Penis


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External genitalia: Penis

3 cylindrical masses of erectile tissue: Two corpora cavernosaplaced dorsally

It is surrounded by tunica albuginea

Corpus spongiosumplaced ventrally

It surrounds the penile urethra, which is lined bypseudostratified columnar epithelium Small mucus-secreting urethra glands (glands of Littre) are

found along the length of the penile urethra

At its end, the corpus spongiosum expandsglans

penis The penile urethra is now lined by stratified squamous

epithelium

The corpus spongiosum (CS) surrounds theurethra (U).

All three bodies of erectile tissue are covered


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All three bodies of erectile tissue are covered

by dense, fibrous tunica albuginea (TA).

Along the dorsal side run the major blood

vessels (V) and deep in each mass of erectile

tissue are smaller blood vessels (V)Externally the penis is covered by skin (S)

attached to the tunica albuginea

-The corpus spongiosum (CS) is surrounding

the penile urethra (PU) with its longitudinallyfolded wall.

- Near the penile urethra are small urethral

glands (UG) with short ducts for the release of

a mucus-like secretion into the urethra during

erection.

Spermatogenesis


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p g

Seminiferous tubules: contains sertoli cells,spermatogonia, developing sperm cells

Layers of germ cells in progression of spermdevelopmentleast differentiated in the outer layermoving inward through various stages of divisionto the lumenhighly differentiated spermexitfrom testis

Takes 64 days from a spermatogonium to a

mature sperm Different seminiferous tubules are in different

stages of differentiation at any given timeupto several hundred million sperm mature daily


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Sherwood, L. Human physiology.

7thedition. Belmont: Brooks/Cole;

2010. Chapter 20; p.749-57

Sertoli Cells


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Sertoli Cells

Functions of Sertoli Cells


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Tight junction between adjacent sertoli cells

blood-testes barrieronly selectedmolecules can pass through tubule, preventsantibody

Provide nutrition for developing sperm cellsmetabolize glucose to lactate as energysource

Phagocytic functionengulf cytoplasmfrom spermatids during remodeling, destroydefect germ cells



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Secrete seminiferous tubule fluid

flushes the released sperm into

epididymis, contain androgen-binding

proteinmaintain a very high level oftestosterone within tubule to sustain

sperm production

Has receptors for FSH and testosterone

Release hormone inhibinnegative

feedback to regulate FSH secretion


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Sherwood, L. Human physiology. 7th

edition. Belmont: Brooks/Cole; 2010.

Chapter 20; p.749-57


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HORMONAL PROFILES DURING THE MENSTRUAL

CYCLE


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CYCLE


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Normal Sexual Intercourse and

Fertilization ProcessAntonia Christa Paramitha

1206289256

Phase of Sexual Response


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Phase of Sexual Response

1. Excitement Phase: erection and increase sexualawareness

2. Plateau Phase: response intensification andother general body responses (elevating heartrate, BP, RR, muscle tension)

3. Orgasmic Phase: ejaculation and otherresponses that reach peak of sexual excitement

strong physical pleasure4. Resolution Phase: body system and genital

return to prearousal condition.

Erection


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Erection

Ejaculation


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Emission

Sympathetic impulsecontraction of prostate, reproductiveduct, seminal vesiclesdelivery of semen to urethra.

Sphincter at neck of bladder tighten.

Expulsion

Semen in urethra triggers nerve impulseactivated skeletalmuscle at base of penisrhythmic contractionssemen is

expelled to the exterior.

Occurs when the stimuli that generate erection

intensifies and reaches the critical peak.

j

Fertilityvolume and quality of sperm.

Average volume2.75 ml with 66 million/ml sperm.

Physiology of Sexual Response in


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Female

Similar with male.

Stimulusvasodilation of arterioles throughoutvagina and clitorisincrease blood flowswelling of labia and erection of clitoris.

Clitorismany erectile tissueslarge and mostpart is located inside.

Function of clitoris erection:

Squeeze urethra closed Support vaginal wall

Strengthen pleasure signaling

Fertilization


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Fertilization

Follicle ruptureegg is releasedenter fallopiantube.

Sperms accumulated in vaginaundergo finalmaturation (capacitation)able to swim rapidly andfertilize egg.

Eggcan be fertilized for 1224 hours afterovulation

Spermlife span: 46 days

Egg has 2 barriers: Corona radiata (outer layer) consist of

loosely connected granulose cells

Zona pellucida glycoprotein coat


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IMPLANTATION


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IMPLANTATION

Zygote remains in ampulaconstriction of canalundergo mitotic cell divisionsmorula.

After ovulationnewly developing corpusprogesteronerelease glycogen as energy fordeveloping embryo and relax oviduct constrictionoviductal peristaltic contraction and ciliaryactivity.

67 days post ovulation

uterus is inprogestational phaseincrease glycogenstorage and vascularizationprepare forimplantation.


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Endometrial tissue undergo

alteration to support embryo

deciduasecretesprostaglandinincrease

vascularization and nutrient

storage


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Etiology


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Etiology

Male 2

Semen

Testicles

Absence of sperm

Sterilisation

Ejaculationdisorder

Hypogonadism

Medicine anddrugs

Acohol

Female

Ovulatorydysfunction1

PelvicInflammatorydisease 1

Uretrineabnormalities1

Endometriosis1

Other

Both

Weight

STI

Smoking

Stress

Risk Factors Male3


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Risk Factors Male

History of Prostatitis,genital infection, or STD

Exposure to radiation,radioactivity, welding,

and chemical (lead,ethylene dibromine, andvinyl chloride)

Cigarette or marijuanaconsumption

Heavy alcoholconsumption

Exposure of the genitalsto high temperatures

Hernia repair

Undescended testicles

Prescription drugs forulcers or psoriasis

Risk Factors Female3


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Risk Factors Female

Age

Endometrosis

Chronis diseasediabetes, lupus, arthritis,

hypertension, or asthma) Hormonal imbalance

Environmental factorsCigarrettes smoking,

alcohol consumption Excessive or very low

body fat

Abnormal pap smear thathave been treated withcryosurgery or conebiopsy

DES taken by motherduring pregnancy

STD

Fallopian tube defect

Multiple miscarrieges


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Examinations to diagnose

infertilityBy Maria Nathania

1206220346

Anamnesis: medical history andinformation from couple


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information from couple Copy of pervious medical records

Completed medical historyquestionnaire

History of previous infertilityevaluation or treatment

Female menstrual history, frequencyand pattern since menarche

History of weight changes, hirsutism,frontal balding and acne

Male medical history: Previous semen analysis results,

history of impotence, prematureejaculation, change in libido, history oftesticular trauma, previous

relationships, history of any previouspregnancyin or offspringfromprevious female partners

Fertility Tests for Women [Internet]. 2014 [Cited 15 October 2014]. Available from: http://www.webmd.com/infertility-and-

reproduction/guide/fertility-tests-for-wome

History of STD

Surgical contraception (e.g.vasectomy, tubal ligation)

Lifestyle, alcohol consumption,tobacco and recreational drugs(amount and frequency

Occupation

Physical activities

Current medical treatment ifany, reason and history ofallergies

Complete review to identify

endocrinologic or immunologicabnormalities that may beassociated with infertility

Physical Examination


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Routine records of blood pressure, pulse rate andtemperature

Height and weight to calculate BMI

Head and neck assessment Presence of exophthalmosassociated with hyperthyroidism

Presence of epicanthus, lower implantation of ears and hairline,

and webbed neck

associated with chromosomalabnormalities

Exclude thyroid gland enlargement or nodulesindicatesthyroid dysfunction

Breast evaluation: assess breast development, seek forabnormal mass or secretions

Abdominal evaluation: assess abnormal mass athypogastrium level

Puscheck E. Infertility [Internet]. 2013 [Updated 2013 Jun 10; Cited 2014 Oct 14]. Available from:

http://emedicine.medscape.com/article/274143-overview

Webbed neck


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Exophthalmos Epicanthus

Physical Examination


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y Gynecologic evaluation: assess hair distribution, clitoris

size, Bartholin glands, labia majora/minora, anycondylomata acuminatum or other lesions that indicateSTD

Speculum examination: Papanicolau test and cultures for gonorrhea, chlamydia,

ureaplasma urealyticum, Mycoplasma hominis Assess cervical stenosis

Bimanual examination: Direction of cervix, size or position of uterusexclude

presence of uterine fibroids,

Adnexal masses, tenderness or pelvic nodulesindicatesinfection or endometriosis

Assess defects (e.g. absence of vagina and uterus, vaginalseptums



Table 1. Laboratory, imaging and/or

surgical evaluation of female fertility

Table 2. Laboratory, imaging and/or

surgical evaluation of male fertility


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g y

Cervical Sims-Huhner test (post-coital

test)

Uterine Hysterosalpingogram

Pelvic USG

Saline infusion sonograms

Pelvic MRI

Hysteroscopy

Endometrial biopsy

Tubal and

peritoneal

Laparoscopy

Hysterosalpingogram

Ovarian Progesterone levels and/or

serial ultrasonography FSH and estradiol levels

Clomiphene citrate challenge

test



g y

Semen

analysis

Volume

pH level

Concentration

Motility

Morphology

WBC count

Sperm

function

tests

The acrosome reaction test

with fluorescent lectins or

antibodies

Computer assessment of

sperm head

Computer motility

assessment

Hemizona-binding assay

Hamster penetration test

Human sperm-zona

penetration assay

Huhner testE l t tibilit f d i l


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Evaluates compatibility of sperm and cervical mucus

Procedure: Carried out 4 to 8 hours after intercourse near ovulation time;

mucus sample is collected from the cervix and examined

Microscopic exam of mucushow many sperms are present?(1 drop = 12 or more sperms) swim with a strong forwardmotion? Presence of other cells (immune and yeast cells)?

Presence of yeast cells

infection affecting sperms survival andmotility

Cervical cells secrete mucus which changes in consistencydepending on phases of menstrual cycle

Near ovulationgreater amount of mucus is secreted

The quality of mucus also changes as ovulation approaches pH: 7 to 8,5, and certain degree of viscosity and stretchto

facilitate sperm migration

Lloyd E, Harris B. What is Huhner Test? [Internet]. 2014 [Updated 2014 Sep 29; Cited 2014 Oct 14]

Available from: http://www.wisegeek.com/what-is-a-huhner-test.htm

Pelvic Ultrasound

h h f d


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Uses high frequency sound wavescaptured by a transducer to create

images of the organs andstructures in the pelvic area

What is observed: the bladder,ovaries, uterus, cervix andfallopian tubes

It can be done in 3 ways:transabdominal (used to look foruterine fibroids), transrectal (formales) and transvaginal (to lookfor fertility problems)

Purpose: examine size and shapeof uterus, thickness ofendometrium, size and shape ofovaries and to check for uterinefibroids

Pelvic Ultrasound [Internet]. 2014 [Updated 2014 Mar 12; Cited 2014 Oct 14]. Available from: http://www.webmd.com/women/pelvic-ultrasound

Saline Infusion Sonogram Done during transvaginal ultrasound


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Done during transvaginal ultrasound

Procedure: small volume of saline is

inserted to the uterus To allow lining of uterus to be more

visible on ultrasound

Purpose: to assess any thickening ofendometrium, presence of polyps

(small growth on the endometrium)

Pahuja M. Saline Infusion Sonohysterography (SIS) [Internet]. 2009 [Updated 2009 May 1; Cited 2014 Oct 14]. Available from:

http://www.insideradiology.com.au/pages/view.php?T_id=71#.VD4WrymvaFd

Hysteroscopy


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Uses a thin viewing tool called a hysteroscope

The tip is inserted into the vagina and gently movedthrough the cervix and into the uterus

Its hooked with a light and cameraendometriumcan be seen on a video feed

A sample biopsy may be taken during the procedure

and looked at under a microscope (if indicated) Function: assess shape or size of uterus, scar tissue in

uterus, uterine openings to the fallopian tubes (ifblockedmay be able to be opened using a tool

inserted to the hysteroscope), find and remove smallfibroids or polyps Laparoscopy may be done at the same time if infertility is

found to be the problem

Hysteroscopy [Internet]. 2014 [Updated 2014 Mar 12; Cited 2014 Oct 14]. Available from:

http://www.webmd.com/infertility-and-reproduction/guide/hysteroscopy-infertility

Hysteroscopy


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Hysteroscopy [Internet]. 2014 [Updated 2014 Mar 12; Cited 2014 Oct 14]. Available from:

http://www.webmd.com/infertility-and-reproduction/guide/hysteroscopy-infertility

Acrosome reaction test


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Artificially cause the sperm to

release their acrosome caps Fresh sperm sample from a fertile

man is needed as a normal control

Uses follicular fluid from eggretrievals to stimulate the cap

release Examined using a fluorescence

microscopesperm with dark tiphave undergone acrosomereaction and bright green ones

does not reactcalculatepercentage of sperm thatartificially react in the essay



Basic Components of the genital

examination (M)


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examination (M)

Checking the cremaster reflex Inspecting the pubis

Inspecting the penis

Inspecting the scrotum Palpating the scrotal contents

Palpating for inguinal hernia

Inspecting the perineum and anal orifice Examining the prostate gland

Interpreting Laboratory Test Results

(Male)


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(Male)

Part of the male genital examination involves laboratorytest results that help to make a differential diagnosis anddetermine the appropriate treatment

Urine Test. When present in urine;

Ketonesinsulin deficiency

Nitritesbacterial infection in the UT, kidneys, bladder

Leukocyte esteraseWBC & probable bacterial infectionin the genitourinary system

Prostate Secretions Test Normally few WBCs are present in prostatic secretions;

many WBCs indicates prostatitis

Genital Examination (Female)


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Abdominal Inspection and Examination

External Genital Examination

Vaginal Examination

Speculum Examinationroutine examination andinspection of cervix

Bimanual Genital Examination

Examination of Cervix

Palpation the uterus

Examination of the adnexa


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Semen Analysis Result


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The normal volume varies from 1.5 to 5.0 milliliter perejaculation.

The sperm count varies from 20 to 150 million spermper milliliter.

At least 60% of the sperm should have a normal shapeand show normal forward movement (motility)

Normal value ranges may vary slightly among differentlaboratories

It is not completely clear how these values and other

results from a semen analysis should be interpreted An abnormal result does not always mean there is a

problem with a man's ability to have children.

Abnormal Result


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May suggest a male infertility problem

if the sperm count is very low orvery high, a man may be less fertile

The acidity of the semen and the

presence of white blood cells

(suggesting infection) may affect

fertility

Testing may reveal abnormal

shapes or abnormal movements of

the sperm

However, there are many unknowns in

male infertilityfurther testing may be

needed if abnormalities are found.

Many of these problems are treatable

Things that may affect

a man's fertility:

Alcohol

Many recreationaland prescription

drugs

Tobacco

HSG


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Check for a blocked fallopian tube an infection may cause severe scarring of the fallopian tubes

and block the tubes, preventing pregnancy.

occasionally the dye used during a hysterosalpingogram will

push through and open a blocked tube.

Find problems in the uterus

such as an abnormal shape or structure, an injury, polyps,

fibroids, adhesions, or a foreign object in the uterusmay

cause painful menstrual periods / repeated miscarriages

Check whether surgery to reverse a tubal ligation has been

successful

How HSG is done


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The cervix may be held in place with a clamp

called a tenaculum

The cervix is washed with a special soap and a

stiff tube (cannula) or a flexible tube (catheter)

is put through the cervix into the uterus

The X-ray dye is put through the tube

If the fallopian tubes are open, the dye will

flow through them and spill into the belly

where it will be absorbed naturally by the body

If a fallopian tube is blocked, the dye will not

pass through. The X-ray pictures are shown on

a TV monitor during the test If another view is needed, the examination

table may be tilted or you may be asked to

change position.

After the test, the cannula or catheter

and speculum are removed

This test usually takes 15 to 30 minutes.

HSG Result

What affect the test?


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If your fallopian tube

has a spasm --fallopian tube look

blocked.

If the doctor can't

put a catheter in the

uterus.

This test is not done

on women who are

having their period,

are pregnant, orhave a pelvic

infection


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t1 repro pleno group e

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