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PENANGANAN INFERTILITAS PADA PRIA

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Presentasi berjudul: "PENANGANAN INFERTILITAS PADA PRIA"— Transcript presentasi:

1 PENANGANAN INFERTILITAS PADA PRIA
DIAGNOSIS DAN PENANGANAN INFERTILITAS PADA PRIA ALVARINO SIE UROLOGI LAB ILMU BEDAH FK. Univ. ANDALAS

2 PENDAHULUAN 10 – 15% pasutri ,hub.seksual normal tanpa kontrasepsi,belum hamil  Infertiliti Primer. Faktor Infertiliti pasangan : Female 1/3 Male /3 Both /3

3 FISIOLOGI REPRODUKSI PRIA
HYPOTHALAMUS-PITUITARY-GONADAL AXIS ( HPG ) EMBRYO PHENOTYPE SEXUAL MATURATION ENDOCRINE TESTICULAR FUNCTION  testosterone EXOCRINE TESTICULAR FUNCTION  spermatogenesis

4 ORGAN REPRODUKSI PRIA

5 TESTIS ENDOCRINE EXOCRINE INHIBIN & ACTIVIN
LEYDIG CELL  TESTOSTERON, 2% (FREE) INCREASED LEVEL OF ESTROGEN & THYROID  DECREASED SHBG. ANDROGEN, GH, OBESITY  DECREASED SHBG & ACTIVE ANDROGEN FRACTION EXOCRINE SERTOLI CELL  GERM CELL GROWTH INHIBIN & ACTIVIN

6 SPERMATOGENESIS SPERMATOGONIA SPERMATOZOA 13 STAGES 74 DAYS

7 ETIOLOGI PRE TESTICULAR : HIPOTALAMUS TESTICULAR : POST TESTICULAR :
Endokrinopati Sexual dysfunction HIPOFISIS . Malignancy,radiation ,operation . Hiperprolaktinemia,hemokromatosis TESTICULAR : UDT CHROMOSOMAL ABNORMALITY INFECTION MEDICATION INJURY VARICOCELE 20-40% POST TESTICULAR : CONGENITAL OBSTRUCTION : CYSTIC FIBROSIS ACQUIRED OBSTRUCTION : VASECTOMY FUNCTIONAL OBSTRUCTION : NEUROGENIC IDIOPATHIC 40%

8 History of infertility Medical hystory Gonadotoxin
DURATION PRIOR PREGNANCIES PRESENT PARTNER PREVIOUS TREATMENT EVALUATION & TREATMENT OF WIFE Systemic Illness ( i.e, DM ) Multiple sclerosis Previous / current therapy Chemicals / pestisides Drugs (chemo, cimetidine Sulfasalazine, Nitrofurantoin, Smoking, Alcohol Marijuana, Androgen steroids Thermal exposure Radiation Sexual Hstory Surgical History Family history POTENCY LUBRICANTS TIMING FREQUENCY ORCHIECTOMY RETROPERITONEAL, PELVIC INJURY PELVIC, INGUINAL, SCROTAL SURGERY HERNIORRAPHY Y-V PLASTY, TUR-P CYSTIC FIBROSIS ANDROGEN RECEPTOR DEFICIENCY INFERTILE FIRST DEGREE RELATIVES Childhood & Development Infection Review of System UDT, ORCHIOPEXY Y-V PLASTY TESTICULAR TORSION TERSTICULAR TRAUMA ONSET OF PUBERTY VIRAL, FEBRILE MUMPS ORCHITIS VENEREAL DISEASE TUBERCULOSIS, SMALLPOX RESPIRATORY INFECTIONS ANOSMIA GALACTORRHEA IMPAIRMENT VISUAL FIELDS

9 PEMERIKSAAN FISIK Pemeriksaan genital eksterna : Testis, epididymis, Vas deferens, varicocele,genital kecil. Karakteristik seks sekunder ; penyebaran rambut ketiak,pubis dan badan tumbuh besar. abnormal ; gynecomastia, anosmia(Kallmann),galaktore, ggn lap.penglihatan.

10 PEMERIKSAAN AWAL Urinalysis Semen analyses Hormonal evaluation
Speciment were obtained correctly !!! Abstinence 3-5 days, no delay before the analyses. Minimally 2X, ( 2 weeks  3 months ) Normal result, vary widely Hormonal evaluation (LH, FSH, Testosteron, Prolactine) less then 3% showed abnormalities Indications : < 10 million/ml, sugest endocrinopathy Azoospermia + (n) FSH  Vasography & biopsy

11 KARAKTERISTIK SPERMA NORMAL
Volume 1,5 - 5 ml Conc > 20 million/ml, total > 50 million Motile > 50% Motile grade >2 normal morphology >30-50% Fructose +

12 HORMONE PROFILE CONDITION T FSH LH PRL NORMAL NL NL NL NL
PRIMARYTESTIS FAILURE LO HG NL/HG NL Hypogonadotrophic-hypogonadism LO LO LO NL HYPERPROLACTINEMIA LO LO/NL LO HIGH ANDROGEN RESISTANCE HG HG HG NL

13 PEMERIKSAAN TAMBAHAN Semen leukocyte analysis Antisperm antibody test
Computerized assisted semen analyses (CASA) Hypoosmotic swelling test Sperm penetration assay Sperm-cervical Mucus interaction ROS (reactive oxygen species) GENETIC EVALUATION Chromosomal study Cystic fibrosis mutation testing Y chromosome microdeletion analysis Radiologis : usg, venography, TRUS, CT/MRI pelvic Biopsi Testis & Vasography FNA mapping of testis Semen culture

14 KLASIFIKASI INFERTILITI PRIA
TREATABLE CAUSES Varicocele Obstruction Infection Ejaculatory Dysfunction Hypogonadotropic- Hypogonadism Immunologic Problem Erectilel Dysfunction Hyperprolactinemia POTENTIALLY TREATABLE Idiopathic Cryptorchidism Vasal Agenesis UNTREATABLE Bilateral Anorchia Germinal Cell-Aplasia Primary Testicular- Failure Chromosomal-Anomalies Immotile Cilia- Syndrome

15 PENATALAKSANAAN SURGICAL THERAPY SEMEN ANALYSIS NON HISTORY SURGICAL
TREATMENT HISTORY HORMONES PHYSICAL ASSISTED REPRODUCTIVE TECHNIQUE ADJUNCTIVE TEST

16 Non Surgical Treatment SPECIFIC THERAPY
HYPOGONADOTROPHIC-HYPOGONADISM INCIDENCE ; LOW ACQUIRED / CONGENITAL (KALLMANNIS SYNDROME) DUE TO DECREASED PRODUCTION OF GnRH ASSOCIATED WITH OTHER CONG ANOMALY : ANOSMIA, DEAFNESS, CLEFT PALATE, RENAL ANOMALIES ACQUIRED : PITUITARY TUMOR/TRAUMA, ISOLATED GONADOTROPIN DEFICIENCY, ANABOLIC STEROID USE. DIAGNOSTIC TEST : CT / MRI  RULE OUT TUMOR THERAPY : hCG IU sC 3 times weekly for 8-12 weeks, then hMG 37,5-150 IU sC 2-4 times weekly

17 Non Surgical Treatment SPECIFIC THERAPY
HYPERPROLACTINEMIA INCIDENCE ; LOW HYPERPROLACTINEMIA  NEG FEEDBACK TO GnRH, INHIBITORY EFFECT on LH BINDING to LEYDIG INFERTILITY, ERECTILE DYSFUNCTION ETIOLOGY : HIPOPHYSEAL TUMOR, HYPOTHYROIDSM, LIVER DISEASE, DRUGS (Phenothiazine, Tricyclic Antidepresant, some antihypertensive) DIAGNOSTIC TEST : CT/MRI  RULE OUT TUMOR THERAPY : CAUSAL or BROMOCRIPTINE 2,5 -7,5 mg 2-4 TIMES DAILY

18 Non Surgical Treatment SPECIFIC THERAPY
ISOLATED TESTOSTERON DEFICIENCY PRIMARY HYPOGONADISM ( LEYDIG CELL FAILURE )  DECREASED LEVEL OF TESTOSTERON  DECREASED LIBIDO & SEXUAL FUNCTION ( ERECTILE DYSFUNCTION, etc) INCIDENCE ; RARE THERAPY : TESTOSTERON ENANTHATE / PROPIONATE im Hcg 1500 iu t.i.w ISOLATED LH DEFICIENCY / FERTILE –EUNUCH SYNDROME

19 Non Surgical Treatment SPECIFIC THERAPY
CONGENITAL ADRENAL HYPERPLASIA INCIDENCE : RARE DEFICIENCY OF ADRENAL HYDROXYLASE  DECREASED CORTISOL SECRETION  INCREASED ACTH  INCREASED ADRENAL ANDROGEN PRODUCTION  DECREASED Gnrh  SUPPRESSES SPERMATOGENESIS. DIAGNOSTIC TEST : Urinary 17-KETOSTEROID or DEHYDROEPIANDROSTERON (DHEA) THERAPY : GLUCOCORTICOID REPLACEMENT.

20 Non Surgical Treatment SPECIFIC THERAPY
IMUNOLOGIC INFERTILITY EVEN oral PREDNISON CAN DECREASED ASA,  ITS RARELY SUCCESSFUL TREATMENT OF CHOICE ; ART  ICSI 3 – 7% MALE INFERTIL

21 Non Surgical Treatment SPECIFIC THERAPY
GENITAL TRACT INFECTION EFECT of GTI  ABNORMAL SEMEN QUALITY < 2% Severe (Enterobacteriaceae, Chlamydia, Gonorrhoeae)  TESTIS ATROPHY / EPIDIDYMAL DUCT OBSTRUCTION  generate ROS  harm sperm’s ability to fertilize Therapy ; Antibiotics Persistent Obstruction  Surgery

22 Non Surgical Treatment SPECIFIC THERAPY
RETROGRADE EJACULATION ETIOLOGY : ANATOMIC, : BLDDER NECK SURGERY NEUROGENIC, : SPINAL CORD INJURY, RETROPERTONEAL SURGERY, DIABETES MELITUS PHARMACOLOGIC : NEUROLEPTICS, TRICYCLIC ANTIDEPRESSANT, ALPHA BLOCKERS, ANTIHYPERTENSIVE IDIOPATHIC DIAGNOSTIC TEST : POST EJACULATE URINE THERAPY : ALPHA ADRENERGICS AGONIST (EPHEDRINE, PSEUDOEPHEDRINE, IMIPRAMINE, PHENYLPROPANOLAMINE ART  INTRAUTERINE INSEMINATION

23 Non Surgical Treatment SPECIFIC THERAPY
ANEJACULATION INCIDENCE : RARE ETIOLOGY : NEUROGENIC, : SPINAL CORD INJURY, RETROPERTONEAL SURGERY, DIABETES MELITUS, TRANSVERSE MYELITIS, MULTIPLE SCLEROSIS PSYCHOGENIC / IDIOPATHIC DIAGNOSTIC TEST : POST EJACULATE URINE THERAPY : RECTAL PROBE EJACULATION PENILE VIBRATORY STIMULATION

24 ERECTILE DYSFUNCTION ???

25 Non Surgical Treatment EMPIRIC THERAPY
INDICATION : IDIOPATHIC OLIGOSPERMIA DRUGS CATEGORY FOR EMPIRYC THERAPY: CLOMIPHEN CITRATE TAMOXIFEN ANDROGENS TESTOSTERON REBOUND AROMATASE INHIBITORS GONADOTROPINS GnRH KALLIKREINS PROSTAGLANDIN SYNTHETASE INHIBITORS BROMOCRIPTINE PENTOXIFYLLINE ANTIOXIDANTS CARNITINE.

26 Non Surgical Treatment EMPIRIC THERAPY
CLOMIPHEN CITRATE SYNTHETIC, NONSTEROIDAL ANTI-ESTROGEN BINDS TO ESTROGEN RECEPTOR COMPETITIVELY IN THE HYPOTHALAMUS, AND HYPOPHISE  BLOCKING FEDBACK  AND INCREASING SECRETION OF GnRH, FSH, LH DOSES ; 12,5-50 mg/d, CONTINUOUSLY FOR 25 d, WITH 5-d REST PERIOD each MONTH, FOR 6 MONTHS FOLLOW-UP : TESTOSTERON LEVEL MUS BE IN NORMAL LIMIT. FREQUENT SEMEN ANALYSES. SIDE EFFECT : GYNECOMASTIA, NAUSEA, DIZZINESS, VISUAL COMPLAINT, ALLERGIC DERMATITIS RESULT : 3-9 MONTHS, PREGNACY RATE 22-58% TAMOXIFEN : WORK IN MANNER AS CLOMIPHEN, BUT WITH LESS ESTROGENIC EFFECT DOSES ; mg/ TWICE d

27 Non Surgical Treatment EMPIRIC THERAPY
ANTIOXIDANT RECENT STUDIES DEMONSTRATED AN INCREASED OF ROS in IDIOPATHIC SUBFERTILITY ROS INCLUDE ; HYDROXYL RADICAL (OH), SUPEROXIDE ANION (O2), HYDROGEN PEROXIDE (H2O2) ROS  DAMAGE SPERM LIPID MEMBRANE VITAMIN E iu /D IMPROVED CAPACITY FOR SPERM-OOCYTE FUSION IN-VITRO GLUTHATION 600 mg/d

28 PEMBEDAHAN Varicocelectomy
Vasovasostomy, Epididymovasostomy, TUR of Ejaculatory duct Ablation of Pituitary Adenoma

29 PROPILAKSIS PEMBEDAHAN
Orchydopexy Operation for Testicular Torsion Electroejaculation

30 ASSISTED REPRODUCTIVE TECHNIQUES
If neither Surgery nor medical therapy is apropriate  A logical treatment, technique atempt to overcome the problems of reduced sperm motility and number is ART Sperm Donation : Husband or Others Technique of sperm extraction : Ejaculate MESA TESE

31 INTRAUTERINE INSEMINATION
PLACEMENT OF WASH PELLET EJACULATE WITHIN UTERUS INDICATION ; BY PASS CERVICAL FACTORS IMUNOLOGIC INFERTILITY LOW SPERM QUALITY MECHANICAL PROBLEM OF SPERM DELIVERY

32 IVF & ICSI EXCELLENT TECH, BY PASS MODERATE TO SEVERE FORMS OF MALE INFERTILITY IVF ; MOTILE SPERMA AND EGGS ARE FERTILIZED IN PETRI DISHED ICSI ; 1 VIABLE SPERM INJECTED INTO CYTOPLASMIC AREA

33 ICSI

34 MALE CONTRACEPTIVE

35 METHODE ESTABLISHED RESEARCH CONDOM PERCUTANEOUS VAS OCCLUSION
TRADITIONAL VASECTOMY NON-SCALPEL VASECTOMY RESEARCH Hormonal : PILL’S, INJECTABLE Non-hormonal Vaccine Imunologic

36 VASECTOMY MINOR SURGICAL PROCEDURE
CUTTING / OCCLUSSION OF VAS DEFERENS MINOR COMPLICCATION NO CHANGES IN SEXUAL FUNCTION

37 Syarat Operasional Vasektomi
1. Ruang tunggu 2. Ruang pendaftaran 3. Ruang periksa 4. Ruang ganti pakaian 5. Ruang bedah 6. Ruang rawatan paska bedah 7. Laboratorium sederhana 8. Ruang peralatan dan pencucian alat

38 Harapan Suatu KLinik Memberikan rasa aman Memberikan penjelasan
Melaksanakan persiapan Mengatasi penyulit Melakukan pengawasan lanjutan Merujuk bila perlu

39 Pelaksana pelayanan Vasektomi
Dokter yang telah mengikuti pendidikan dan latihan tindak bedah vasektomi

40 Peranan dokter 1. Menseleksi calon akseptor 2. Melakukan pembedahan
3. Pelayanan paska bedah 4. Mengkoordinasi semua kegiatan

41 Peranan paramedik 1. Menerima dan mencatat akseptor
2. Mempersiapkan calon 3. Memantau keadaan akseptor selama dan setelah operasi 4. Mempertsiapkan segala sesuatu kebutuhan dokter sebelum dan saat tindakan

42 Syarat Akseptor 1. Sukarela 2. Bahagia 3. Kesehatan

43 Informasi sebelum tindakan
1. Terangkan macam kontrasepsi keuntungan dan kekurangan masing2nya. 2.Terangkan bahwa vasektomi adalah suatu pembehan 3. Terangkan bahwa vasektomi ini dianggap permanen. 4. Beri kesempatan akseptor untuk berfikir.

44 Pemeriksaan prabedah 1. Anamnesa 2. Pemeriksaan fisik
3. Pemeriksaan laboratorium sederhana

45 VASECTOMY PREPARATION : SHAVE AND WASH THE SCROTUM
BRING A PAIR OF TIGHT FITTING UNDERWEAR OR ATHLETIC SUPPORT AVOID ANTI INFLAMATORY DRUGS ( IBUPROFEN, ASPIRIN BEFORE SURGERY

46 Pramedikasi dan anestesi
1. Evaluasi keadaan pasien 2. Infiltrasi dengan anestesi lokal ( xylocain,lidokain,procain dll 0,5-1%) 1cc 3. Lakukan insisi setelah 2-3 menit

47 Alat emergensi 1. Oksigen 2. Alat resusitasi sederhana 3. Obat2an
4. Infus set 5. Spuit 5 dan 10cc

48 Komplikasi premedikasi
1. Intoksikasi  Hentikan obat 2. Kejang2 -- Valium 5-10mg IV 3. Alergi  Dexamethason 5 mgIV

49 Teknik Vasektomi 1.Celana dibuka dan pasien berbaring
2.Bersihkan daerah operasi 3.Tutup dengan kain steril berlobang

50

51 4. Anestesi lokal

52 5. Insisi kulit skrotum

53 6.Cari dan pegang vas deferen

54 7.Ikat dan potong vas deferen

55 Cara mengikat vas deferen

56 8.Rawat perdarahan

57 9.Lakukan prosedur yang sama pada vas deferen sebelahnya

58 PROCEDURE

59 KOMPLIKASI HAEMATOM PERDARAHAN ANTI BODI SPERMA GRANULOMA SPERMA
INFEKSI REKANALISASI

60 KEGAGALAN VASEKTOMI 1.Spermatozoa ditemukan setelah 3 bulan atau setelah kali ejakulasi 2. Ditemukan spermatozoa setelah sebelumnya azoosperma 3. Pasangannya hamil setelah berhubungan dg akseptor 3 bulan paska vasektomi

61 Perawatan paska vasektomi
1. Berbaring kira2 15 menit,amati. 2. Rasa nyeri atau perdarahan 3. KU dan lokal baik,pulangkan

62 Nasehat Perawatan luka yang baik Ada komplikasi kembali ke RS Obat2an
Jangan kerja berat/naik sepeda dulu Boleh berhubungan suami istri,sebaiknya pakai alat pencegah kehamilan dulu selama masih ada sisa sperma

63 Sebaiknya periksa sperma suami kelaboratorium untuk memastikan tidak ada sperma lagi,barulah melakukan hubungan suami istri tanpa alat pencegah kehamilan apapun.

64 Catatan medik 1.Identitas peserta dan istri 2.Pemeriksaan pra bedah
3.Laporan pembedahan 4.Data paska bedah 5.Data kunjungan ulang 6.Laporan komplikasi dan kematian 7.Laporan tertulis permohonan dan persetujuan kontrasepsi mantap.


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