Infertilitas

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Infertility Problem

Gunawan Dwi Prayitno



Introduction
Definition :
Infertility is Failure to conceive after
regular unprotected sexual intercourse for
2 years in the absence of known
reproductive pathology
Clasification :
- Primary
- Secondary


Infertility Causes
In RSPAD-Gatot Soebroto Jakarta

FAKTOR PENYEBAB INFERTILITAS
PENYEBAB FAKTOR ISTRI
TUBA

OVARIUM

FAKTOR ISTRI UTERUS &
49 51 SERVIKS
FAKTOR SUAMI
HORMONAL

ENDOMETRIO
SIS
IMUNOL/INFE
KSI



Requisite for Succesful
pregnancy
 Oosit : ovulation ?, Oosit
Quality(≈ age)
 Sperm : Concentration,
motility, morphology
 Sperm & oosit transport,
fertilization, and
implantation. :
Psychology, organic, and
immunologic compatible.
 Endometrial reseptivity



Anamnesis

• Age
• History of Thyroid
- Hypothyroid
- Hyperthyroid
- Family / Diabetes mellitus history
→ Resistensi insulin
PCOS
• Complain : Dismenorhea ? PID, Endometriosis
• Intercourse Frequency : 2-3 x/w
• Intercourse Problem : Impotensi / Frigyd
• Smoking, alcohol, drug abuse



Anamnesis
-Menstrual Cycle

28 d + 3d
Eumenorhea

Polimenorhea
oligomenorhea

25 31


Physical Examination



The Level of Evidence
Level Evidence
1a Systematic review and meta-analysis of randomised
controlled trials
1b At least one randomised controlled study without
randomisation
2a At least one well-designed controlled study without
randomisation
2b At least one other type of well-designed quasi-
experimental study
3 Well-designed non-experimental descriptive studies,
such as comparative studies, correlation studies or
case studies
4 Expert committee report or opinions and/ or clinical
experienceof respected authoritis



The Grade of Evidence
Recommendation
Grade Strenght of evidence
A Directly based on level 1
evidence
B Directly based on level 2
evidence or extrapolated
recommendation from level 1
evidence
C Directly based on level 3 evidence or extrapolated
recommendation from either level 1 or 2 evidence
D Directly based on level 4 evidence or extrapolated
recommendation from either level 1, 2 or 3 evidence
Good practice The view of the Guideline Development Group
Poin (GPP)
NICE Technology Recommendation taken from a NICE Technology
Appraisal
Appraisal



Semen Analysis



ASA, Abnormal semen analysis



Definition Relating to Sperm
Quality
Term Definition

Normozoospermia Normal ejaculate ~ WHO reference values

Oligozoospermia Sperm concentration less than WHO reference
values
Asthenozoospermia Sperm motility less than WHO reference
values
Teratozoospermia Sperm morphology less than WHO reference
values
Oligoasthenoteratozoospe Signifies disturbance of all 3 or 2 variables
rmia
Azoospermia No spermatozoa in the ejaculate

Aspermia No ejaculate

Cryptozoospermia Few spermatozoa recovered after
centrifugation
RCOG 2004


Tubal Patency (HSG,
Hysterosalpingo-contrast-USG,
Laparaskopy-kromotubation)



Screening Clamydial and Antibiotic Profilactic
before Uterine instrumentation



The Thyroid function

- There is no value in women with a
regular menstrual Cycle RCOG B 200
• Hypothyroid : High TSH
→ Oligomenorhea
- amenorhea



Basal FSH & Estradiol (Day 2 – 3)

- Patients Ages ≥ 35 years
- Ovarian Reserve : ( decreased
negative feed back from
ovaries )



Ovarian Reserve
FSH > 10 m IU/mL Decreased ovarian reserve
> 15 m IU/mL Diminished ovarian reserve
E-2 > 70 pg/mL (High FSH  Premature
follicel developed)



Ovulation detection

- Mid Luteal Progesteron
- USG monitoring



Treatment



Frequency and Timing of Sexual
Intercourse



Stop Smoking



Obesity and Weight loss



Scrotal Temperatur



Folic Acid
Supplementation



Male Factor Management

Medical Management
(Hypogonadotrophic hypogonadism, idiopatic, ASA,
Leucocytes in semen)



Obstuctive azoospermia

Varicocele



Ovulation Induction

1. Antiestrogen : CC or Tamoxifen



2. Insulin Sensitizer : Metformin



3. Gonadotrophin : FSH, hMG,
CC+IUI



Hyperprolaktinemia :
Bromokriptin



Management of Endometriosis
Ovarian Suppresion

Surgical Ablation



Non Paten Tubes : Microsurgery
and Laparascopic tubal surgery



Intra Uterine Insemination



Take home baby : IVF



Summary

 Sperm transport, egg transport,
physiology fertilisation, and physiology
of implantation  important to
pregnancy outcome



Thank You


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