1. TinjauanPustaka Kimia Klinik PemeriksaanLaboratoriumpadaInfertilitasWanita DiahPuspitaRini/SidartiSoehita SFHS 1

2. I. PENDAHULUAN 2

3. Definisi Infertilitas: pasutritidakmampuhamilsetelahsatutahunmelakukanhubunganseksualteraturtanpakontrasepsi Infertilitassekunder: pernahhamil, tidakhamillagidalam 12 bulantanpakontrasepsi 3

5. Kelainanpada tuba3. Gabunganpriadanwanita 4. Unexplained infertility: penyebabinfertilitas yang pastitidakdiketahui 4

6. 5 II. AnatomidanFisiologi SistemReproduksiWanita

7. AnatomiFungsional Gambar 1. Organ reproduksiwanita 6

8. AksisHipotalamus-Pituitari-Ovarium 7 Gambar 2. Interaksiendokrinpadaaksis HPO danendometrium . E2, Estradiol; FSH, follicle-stimulating hormone; GnRH, gonadotropin-releasing hormone; InhA, inhibin-A; InhB,inhibin-B; LH, luteinizing hormone; P, progesteron.

9. SintesisHormonOvarium Ovariummensekresi : Estrogen Progesteron Androgen Folikel -> sumberproduksihormonovarium Folikelterdiridari : Seltheka->produksi androgen Selgranulosa -> produksi estrogen 3. Oosit primer 8 Gambar 3. Perubahanovariumselamamasasiklus

10. RegulasiHormonReproduksi Gambar 4. Siklusmenstruasi 9

12. hari 16-19 dgnstimulasigonadotropineksogenHilangnyasinkronisasiantaraendometriumdanembrio -> keguguranberulang 10

13. Gambar 5. Tahapanimplantasi, dimulaidenganovulasidandiikutifertilisasidanperpindahankeendometrium. 11

14. 12 III. Penyebabinfertilitaspada wanita

15. KelainanOvulasi Hiperprolaktinemia Gangguanfungsi tuba falopii Endometriosis 13

16. KelainanOvulasi Kegagalanhipotalamus-pituitari FSH & LH  -> Hipoestrogenemia Disfungsihipotalamuspituitari Estrogen normal, kelainangonadotropin Terbanyak : PCOS (Polycystic Ovary syndrome) Kriteria: oligo - danatauanovulasi hiperandrogenism yang dibuktikansecaraklinisataulaboratorium ovariumpolikistik, denganmenyingkirkanpenyebab lain Kegagalanovarium FSH, amenorea, hipogonadism, estrogen rendah 14

17. 2.Hiperprolaktinemia galaktorea, estrogen rendah, anovulasi, siklusmenstruasitidakteratur-> infertilitas 3. Gangguanpada tuba falopii dialami 25%pasangan perlekatanringansampaisumbatan total terapi: pembedahan 4. Endometriosis Kelenjarendometriumataustromadiluarkavitasendometriumdan uterus Patogenesis: belumjelas, mungkinadesi 15

18. 16 iv. Pemeriksaanlaboratorium

19. 1. Penilaiancadanganoosit Pemeriksaan FSH hari ke-3 siklus 17

20. 2. PenilaianOvulasi Membuktikanadanyaovulasi -> terpentingdalamevaluasifertilitas Mengetahuiovulasi: Sesudahovulasi Suhu basal tubuh USG: ukuranfolikel <, hilangnyadeveloped folikel Progesteron Sebelumovulasi : deteksilonjakan LH -> 12-36 jam ovulasi 18

23. Pemeriksaan LH urine Menggunakanstrip->perubahankadar LH Pemeriksaandimulai 2 harisebelumovulasi ♀ siklus 28 hari : ovulasi 13-15 ♀ siklus 27-34: ovulasi 13-20 -> tesdimulaihari 11 sampai 20/sampaiovulasiterjadi Ovulasi (-) 2 siklusberurutan -> masalahovulasi 20

24. 3. Hormon Lain A. FSH Nilairujukan: Fasefolikular 1,68 – 15,0 IU/ml Faseovulasi 21,9 - 56,6 IU/ml Faseluteal 0,61 - 16,3 IU/ml Fase menopause 14,2 - 52,3 IU/ml Meningkat: hipogonadisme, pubertasprekoks, menopause dansidroma Turner Menurun : keadaaninsufisiensihipotalamus, disfungsi gonad, anovulasi, insufisiensihipofisis, dan tumor ovarium. 21

26. menilaiaksis gonad-pituitarijikaadakecurigaankekuranganestrogenisasi

27. amenoreasentralataufertilitas yang berkurangsetelahkemoterapikanker

28. diagnosis kegagalanovariumatau gonad usia <40 tahun22

30. akanmenjalaniinduksiovulasi

31. kemungkinanmengalamikegagalanovariumsebelumumur 40

32. pubertasprekoksNilairujukanPremenopause : 30 - 400 pg/mL Postmenopause : 0 - 30 pg/mL Interpretasi kadartinggi > 100 pg/mLdankadar FSH < 10 IU/L hari 2 sampai 4 siklusmenstruasi -> tandadisfungsiovulasidanresponterapiinfertilitas yang buruk 23

33. Nilairujukan : testosteron total 15-70 ng/mL Interpretasi Kadar testosteron >200 ng/ml ->tumor ovarium /adrenal PCOS <150 ng/ml Nilairujukanwanitatidakhamil 3-30 ng/mL Interpretasi Peningkatanprolaktinnyata (> 100 μg/L [normal< 25 μg/L]): hipogonadisme, galaktoreadanamenorea Peningkatanprolaktinmoderat (51–75 μg/L) : oligomenorea Peningkatanprolaktinsedang (31–50 μg/L) : faseluteal yang pendek, penurunan libido daninfertilitas 24 D. TESTOSTERON E.PROLAKTIN

35. Waktu: sedekatmungkindenganovulasi

36. Persiapanpasien: Tidakkoitusdalam 48 jam Koitus 2-8 jam sebelumke lab Tidakmenggunakan gel yang bersifatspermisidaataulubrikan - Pemeriksaan lab: 9-14 jam post coital 25

38. sampeldiambildiserviks & vagina

39. 3 obyekglas: “fern”, “endoserviks”, “vagina”

40. Fern: mukusserviksdiambildenganswab->obyekglas -> keringEndoserviks & Vagina : mukusdiambilmenggunakanspuittuberkulin->tutupdengancover glass 26

41. 1. EvaluasiMukusServiks Volume Viskositas Ferning Spinnbarkeit Selularitas pH 27 SKOR : 0,1,2,3 2. Evaluasi Spermatozoa

42. 28 Gambar 6. TehnikSpinnbarkeit Gambar 7. Bentukgambaranferning

43. 1. EvaluasiMukus 29

44. pH mukus : tidaktermasukdalamskor, determinanpentingdalaminteraksimukus-sperma asam -> immobilisasi spermatozoa alkali -> meningkatkanmotilitas pH optimum : 7 - 8,5 (pH mukus normal pertengahansiklus) Skormukusserviks > 10 -> kualitasmukusbagus, memudahkanpenetrasisperma 30

46. Konsentrasi spermatozoa dihitungdalamjumlah spermatozoa/μL

47. Motilitasnya : PR (progressive motility) : spermaaktif, gerakan linier/membentuklingkaranbesar NP (non-progressive motility): tidakmaju, lingkarankecil, hanyagerakanflagela IM (immotile spermatozoa): tidakadapergerakan 31

48. 32 Gambar 8. Contohformulirhasilpost coital test

49. Interpretasi Tesdianggapnegatifbilatidakditemukan spermatozoa Spermatozoa denganmotilitasprogresifmenyingkirkanfaktorserviksdanautoimunterhadapspermasebagaipenyebabinfertilitas Spermatozoa motilitas non progresif, fenomenashaking -> antibodidimukusataudi spermatozoa 33

50. Hasilawalnegatif, tesharusdiulang Tes yang negatifdapatdisebabkankarenawaktu yang tidaktepat Masaovulasitidakdapatdiprediksi, post coital test diulangbeberapa kali dalamsatusiklusmenstruasi Post coital test padawaktu yang optimal, hasilnegatifmenunjukkanfaktorservikssebagaikemungkinanpenyebabinfertilitas 34

51. 35 Terimakasih

52. Causes of Female Infertility 36

53. 37

54. Luteal Phase Defect Three causes of LPD include poor follicle production, premature demise of the corpus luteum, and failure of the uterine lining to respond to normal levels of progesterone. Once a diagnosis of LPD is suspected, a serum progesterone test will often be performed at about seven days past ovulation. A level less than 14 ng/ml indicates that progesterone production in the luteal phase is inadequate. Should progesterone levels prove to be low, the temptation is often to "treat the symptom" by giving the patient progesterone supplementation during the luteal phase. In the case of inadequate corpus luteum performance, progesterone support may indeed be the appropriate solution. However, inadequate follicle development may also be causing the low progesterone levels. Thus, it is important to measure midcycle follicle size (via ultrasound) and estradiol levels (via a blood test). 38

55. FERNING As ovulation nears, estrogen increases and causes the body's sodium levels to rise. Saliva is affected by the increased salinity. This is noticeable when allowing samples of saliva to dry. Near ovulation the higher salt content causes the dried saliva to form crystallization patterns. Both saliva and cervical mucus have shown these patterns. 39

56. in vitro sperm mucus penetration test This is performed simply by putting a drop of freshly removed mucus next to a drop of freshly ejaculated semen on a microscope slide. The interface between the two drops is examined for about a quarter of an hour, and it is then possible to see if the sperm are penetrating the mucus and swimming actively in it. If this does not occur, then it is likely that there is some form of immune response between the sperm and the mucus, and further tests should be conducted to examine this. Another simple test for antisperm antibodies in the mucus is called the sperm cervical mucus contact test (SCMC for short) where the sperm and mucus are mixed together. If, under the microscope, the sperm are seen to be shaking in a characteristic way, this means that there are anti-bodies present 40

57. Treatment on poor cervical mucus Cervical problems can be corrected depending upon what the cause is. For example, if the reason for the poor mucus is: lack of ovulation, then ovulation can be induced cervical infection, then this can be treated by cauterising or freezing the abnormal cervical tissue, so that this is destroyed, and is then replaced by healthy cervical glands thick or viscous mucus can occasionally be treated by cough medicines (expectorants, which contain guaifensin ( Robitussin) in a dose of 1-2 tsp per day, beginning three to four days prior to when you want to conceive.) Just like guaifensin helps to thin the thick phlegm if you have a cough, it also helps to thin the cervical mucus. scanty mucus, then mucus production can be enhanced by supplemental low-dose estrogens 41

58. Negative Post Coital Test The PCT was not done at the best time. For example, the PCT may have been done too early or too late in the cycle. Wrong timing is the commonest reason for a negative test and can even cause repeatedly negative tests. There was no ovulation the month of the test - perhaps because of the strain or stress of making love to order. The sperm count was poor. Obviously, men with persistently low sperm counts, or men with poor motile sperm, may be responsible for a negative PCT. There may be an abnormality of the cervix - for example, chronic infection in the cervix may prevent production of adequate mucus; and some women with a scarred cervix may not produce enough mucus.Patients who have had surgery on the cervix ( for example, cervical conisation, in which a cone of cervical tissue is removed to treat cervical dysplasia) often have this problem. The cervix is producing antibodies to the sperm. Medications such as clomiphene, tamoxifen, progesterones and danazol - all drugs used for infertility problems - can interfere with the production of good mucus. 42

59. Endocrine and paracrine products of the endometrium 43

60. 44

61. FSH (+) E2 (-) FSH=Follicle Stimulating Hormone E2=Estradiol Effects of Aging on the Ovary

62. 46

63. Sperm Count Fresh sample (to lab within 30 mins.) –most sperm in initial ejaculate Male should be abstinent for 48 to 72 hours sperm concentration > 20 million per ml total count > 60 million ejaculate volume > 1.5 ml total motile count > 30 million viable sperm > 50% normal shapes (morphology) > 60%

64. Sperm Terms Normozoospermia Normal ejaculate Asthenozoospermia Teratozoospermia Azoospermia Aspermia Normal ejaculate Sperm concentration <20 × 106 /ml <50% spermatozoa with forward progression <30% spermatozoa with normal morphology No spermatozoa in the ejaculate No ejaculate

65. Hook Effect 49 The prozone or (high-dose) hook effect, documented to cause false-negative assay results 50 years ago , still remains a problem in one-step immunometric assays , immunoturbidimetricassays , and immunonephelometricassays for immunoglobulins. To detect the prozone effect, samples are often tested undiluted and after dilution . If the result on dilution is higher than or the undiluted sample, then the undiluted sample most likely exhibited the prozone effect.

66. Diagnostic studies to confirm Ovulation Basal body temperature Inexpensive Accurate Endometrial biopsy Expensive Static information Serum progesterone After ovulation rises Can be measured Urinary ovulation-detection kits Measures changes in urinary LH Predicts ovulation but does not confirm it

67. Basal Body Temperature Excellent screening tool for ovulation Biphasic shift occurs in 90% of ovulating women Temperature drops at the time of menses rises two days after the lutenizing hormone (LH) surge Ovum released one day prior to the first rise Temperature elevation of more than 16 days suggests pregnancy

69. Alteration in sex steroid metabolism-> attenuated release of gonadotropin-> anovulation SHBG->free testosteron high normal Increased visceral fat -> hiperinsulinemia->independent effect on ovulation 53 OBESITY and INFERTILITY

70. Hypothyroid bioactive estrogen : decreased metabolism of estrogen in the liver (seen with both hypothyroidism and hyperthyroidism) decreased levels of the protein that binds estrogen in the circulation. Persistent elevations of bioactive estrogen can interfere with follicular growth and can disrupt the midcyclepreovulatory LH and FSH surges that are required for normal ovulation.  TRH can "crosstalk" within the pituitary gland to release other pituitary hormones such as prolactin. Elevated prolactin levels are known to interfere with ovulation . 54

71. Hyperthyroid The mechanism for the ovulatory dysfunction associated with hyperthyroidism is not entirely clear. There may be elevated bioactive estrogen concentrations either due to decreased liver metabolism of estrogens or due to an increase in the activity of the enzyme that forms estrogens (called aromatase). Persistent elevations of estrogen interfere with follicular growth and can disrupt the midcycle LH and FSH surges. 55

72. Hyperprolactinemia prolactin released from the pituitary gland ->brain's dopamine ->inhibit GnRH release from the hypothalamus -> FSH and LH secretion. A decrease in FSH may be the basis for most prolactin associated ovulatory problems. There are prolactin receptors on the adrenal glands. The adrenal glands may respond to increased prolactin by increasing their own androgenic hormones. The adrenal androgenic hormones are known to interfere with ovulation. Prolactin->progesterone production by granulosa cells. If there is a direct effect of prolactin on granulosa cell progesterone production in vivo (in a woman's ovaries) then this could also lead to an ovulatory dysfunction, called a luteal phase defect. 56

74. 59 PCOS

76. Egg retrieval

77. Sperm retrieval-wash sperm

78. Fertilization

79. Embryo transfer

81. Anti Sperm Antibody ASA in men are assumed to occur mainly as a consequence of trauma to the blood testis barrier, epididymis, or vas deferens (Gubin et al, 1998). The immunogenicity of the sperm antigens is indicated by the high incidence of ASA in the sera and accessory gland fluids of vasectomized men (Aitken et al, 1988). ASA may impair sperm function at various stages of reproduction, such as during the transport of spermatozoa in the female genital tract (Bronson et al, 1984), capacitation, acrosome reaction (Lansford et al, 1988; Wolf, 1989), and binding with zona or fusion with egg (Bronson et al, 1982; Alexander, 1984). 62

82. 63