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

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Presentasi berjudul: "1 DIAGNOSIS DAN PENANGANAN INFERTILITAS PADA PRIA ALVARINO SIE UROLOGI LAB ILMU BEDAH FK. Univ. ANDALAS."— Transcript presentasi:

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

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

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

4 4 ORGAN REPRODUKSI PRIA ORGAN REPRODUKSI PRIA

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

6 6 SPERMATOGENESIS SPERMATOGONIA  SPERMATOZOA  13 STAGES  74 DAYS

7 7 PRE TESTICULAR : HIPOTALAMUS 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% ETIOLOGI

8 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 POTENCYLUBRICANTSTIMINGFREQUENCYORCHIECTOMY 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 UDT, ORCHIOPEXYHERNIORRAPHY Y-V PLASTY TESTICULAR TORSION TERSTICULAR TRAUMA ONSET OF PUBERTY VIRAL, FEBRILE MUMPS ORCHITIS VENEREAL DISEASE TUBERCULOSIS, SMALLPOX RESPIRATORY INFECTIONS ANOSMIAGALACTORRHEA IMPAIRMENT VISUAL FIELDS

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

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

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

12 12 HORMONE PROFILE CONDITIONTFSHLHPRL NORMALNLNLNLNL PRIMARYTESTIS FAILURE LOHGNL/HGNL Hypogonadotrophic-hypogonadism LOLOLONL HYPERPROLACTINEMIALOLO/NLLOHIGH ANDROGEN RESISTANCEHGHGHGNL

13 13 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 PEMERIKSAAN TAMBAHAN

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

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

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

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

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

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

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

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

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

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

24 24 ERECTILE DYSFUNCTION n ???

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

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

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

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

29 29 PROPILAKSIS PEMBEDAHAN PROPILAKSIS PEMBEDAHAN n Orchydopexy n Operation for Testicular Torsion n Electroejaculation

30 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 : EjaculateMESATESE

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

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

33 33 ICSI

34 34 MALE CONTRACEPTIVE

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

50

51 4. Anestesi lokal 51

52 5. Insisi kulit skrotum 52

53 6.Cari dan pegang vas deferen 53

54 7.Ikat dan potong vas deferen 54

55 Cara mengikat vas deferen 55

56 8.Rawat perdarahan 56

57 9.Lakukan prosedur yang sama pada vas deferen sebelahnya 57

58 58 PROCEDURE

59 59 KOMPLIKASI n HAEMATOM n PERDARAHAN n ANTI BODI SPERMA n GRANULOMA SPERMA n INFEKSI n REKANALISASI

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

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

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

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

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


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