DIAGNOSIS DAN PENANGANAN INFERTILITAS PADA PRIA ALVARINO SIE

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

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

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

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ORGAN REPRODUKSI PRIA 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

SPERMATOGENESIS SPERMATOGONIA SPERMATOZOA 13 STAGES 74 DAYS 7

ETIOLOGI • • PRE TESTICULAR : • TESTICULAR HIPOTALAMUS • Endokrinopati • Sexual dysfunction HIPOFISIS. Malignancy, radiation , operation. Hiperprolaktinemia, hemokromatosis • • UDT CHROMOSOMAL ABNORMALITY INFECTION MEDICATION INJURY VARICOCELE 20 -40% POST TESTICULAR : • • : CONGENITAL OBSTRUCTION : CYSTIC FIBROSIS ACQUIRED OBSTRUCTION : VASECTOMY FUNCTIONAL OBSTRUCTION : NEUROGENIC 8 IDIOPATHIC 40%

ETIOLOGI DISORDERS OF SPERM FUNCTION AND MOTILITY • Immotile Cilia Syndrome • Maturation defects • Immunologic infertility • Infection DISORDERS OF SPERM DELIVERY / COITUS • Erectile dysfunction • Hypospadia 9

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 HERNIORRAPHY 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 10

PEMERIKSAAN FISIK 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. n 11

PEMERIKSAAN AWAL Urinalysis Semen analyses n n Speciment were obtained correctly !!! Abstinence 3 -5 days, no delay before the analyses. Minimally 2 X, ( 2 weeks 3 months ) 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 12

KARAKTERISTIK SPERMA NORMAL n n n Volume 1, 5 - 5 ml Conc > 20 million/ml, total > 50 million Motile > 50% Motile grade >2 normal morphology >30 -50% Fructose + 13

HORMONE PROFILE CONDITION T FSH LH PRL NORMAL NL NL PRIMARYTESTIS FAILURE LO HG NL/HG NL Hypogonadotrophic-hypogonadism LO LO LO HYPERPROLACTINEMIA LO LO/NL LO HIGH ANDROGEN RESISTANCE HG HG NL 14

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 15

KLASIFIKASI INFERTILITI PRIA TREATABLE CAUSES POTENTIALLY TREATABLE UNTREATABLE Varicocele Obstruction Infection Ejaculatory Dysfunction Hypogonadotropic. Hypogonadism Immunologic Problem Erectilel Dysfunction Hyperprolactinemia Idiopathic Cryptorchidism Vasal Agenesis Bilateral Anorchia Germinal Cell-Aplasia Primary Testicular- Failure Chromosomal-Anomalies Immotile Cilia- Syndrome 16

PENATALAKSANAAN SEMEN ANALYSIS HISTORY HORMONES SURGICAL THERAPY NON SURGICAL TREATMENT PHYSICAL ADJUNCTIVE TEST ASSISTED REPRODUCTIVE TECHNIQUE 17

Non Surgical Treatment SPECIFIC THERAPY HYPOGONADOTROPHIC-HYPOGONADISM n n n n INCIDENCE ; LOW ACQUIRED / CONGENITAL (KALLMANNIS SYNDROME) DUE TO DECREASED PRODUCTION OF Gn. RH 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 : h. CG 1500 -3000 IU s. C 3 times weekly for 8 -12 weeks, then h. MG 37, 5 -150 IU s. C 2 -4 times weekly 18

Non Surgical Treatment SPECIFIC THERAPY HYPERPROLACTINEMIA n n n INCIDENCE ; LOW HYPERPROLACTINEMIA NEG FEEDBACK TO Gn. RH, 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 19

Non Surgical Treatment SPECIFIC THERAPY ISOLATED TESTOSTERON DEFICIENCY n n n 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 20

Non Surgical Treatment SPECIFIC THERAPY CONGENITAL ADRENAL HYPERPLASIA n n 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. 21

Non Surgical Treatment SPECIFIC THERAPY IMUNOLOGIC INFERTILITY n n n EVEN oral PREDNISON CAN DECREASED ASA, ITS RARELY SUCCESSFUL TREATMENT OF CHOICE ; ART ICSI 3 – 7% MALE INFERTIL 22

Non Surgical Treatment SPECIFIC THERAPY GENITAL TRACT INFECTION n n n 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 23

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 24

Non Surgical Treatment SPECIFIC THERAPY ANEJACULATION n n INCIDENCE : RARE 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 25

ERECTILE DYSFUNCTION ? ? ? n 26

Non Surgical Treatment EMPIRIC THERAPY n n INDICATION : IDIOPATHIC OLIGOSPERMIA DRUGS CATEGORY FOR EMPIRYC THERAPY: – CLOMIPHEN CITRATE – – – – – TAMOXIFEN ANDROGENS TESTOSTERON REBOUND AROMATASE INHIBITORS GONADOTROPINS Gn. RH KALLIKREINS PROSTAGLANDIN SYNTHETASE INHIBITORS BROMOCRIPTINE PENTOXIFYLLINE – ANTIOXIDANTS – CARNITINE. 27

Non Surgical Treatment CLOMIPHEN CITRATE EMPIRIC THERAPY n n n n SYNTHETIC, NONSTEROIDAL ANTI-ESTROGEN BINDS TO ESTROGEN RECEPTOR COMPETITIVELY IN THE HYPOTHALAMUS, AND HYPOPHISE BLOCKING FEDBACK AND INCREASING SECRETION OF Gn. RH, 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 ; 10 -15 mg/ TWICE d 28

Non Surgical Treatment ANTIOXIDANT n n n EMPIRIC THERAPY RECENT STUDIES DEMONSTRATED AN INCREASED OF ROS in IDIOPATHIC SUBFERTILITY ROS INCLUDE ; HYDROXYL RADICAL (OH), SUPEROXIDE ANION (O 2), HYDROGEN PEROXIDE (H 2 O 2) ROS DAMAGE SPERM LIPID MEMBRANE VITAMIN E 400 -1200 iu /D IMPROVED CAPACITY FOR SPERM-OOCYTE FUSION IN-VITRO GLUTHATION 600 mg/d 29

PEMBEDAHAN Varicocelectomy n Vasovasostomy, Epididymovasostomy, TUR of Ejaculatory duct n Ablation of Pituitary Adenoma n 30

PROPILAKSIS PEMBEDAHAN Orchydopexy n Operation for Testicular Torsion n Electroejaculation n 31

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 32

INTRAUTERINE INSEMINATION 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 n 33

IVF & ICSI EXCELLENT TECH, BY PASS MODERATE TO SEVERE FORMS OF MALE INFERTILITY n IVF ; 500. 000 -5. 000 MOTILE SPERMA AND EGGS ARE FERTILIZED IN PETRI DISHED n ICSI ; 1 VIABLE SPERM INJECTED INTO CYTOPLASMIC AREA n 34

ICSI 35

MALE CONTRACEPTIVE 36

METHODE n n ESTABLISHED – – CONDOM PERCUTANEOUS VAS OCCLUSION TRADITIONAL VASECTOMY NON-SCALPEL VASECTOMY – – Hormonal : PILL’S, INJECTABLE Non-hormonal Vaccine Imunologic RESEARCH 37

VASECTOMY MINOR SURGICAL PROCEDURE n CUTTING / OCCLUSSION OF VAS DEFERENS n MINOR COMPLICCATION n NO CHANGES IN SEXUAL FUNCTION n 38

Syarat Operasional Vasektomi 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 n 39

Harapan Suatu KLinik Memberikan rasa aman n Memberikan penjelasan n Melaksanakan persiapan n Mengatasi penyulit n Melakukan pengawasan lanjutan n Merujuk bila perlu n 40

Pelaksana pelayanan Vasektomi n Dokter yang telah mengikuti pendidikan dan latihan tindak bedah vasektomi 41

Peranan dokter 1. Menseleksi calon akseptor n 2. Melakukan pembedahan n 3. Pelayanan paska bedah n 4. Mengkoordinasi semua kegiatan n 42

Peranan paramedik 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 n 43

Syarat Akseptor 1. Sukarela n 2. Bahagia n 3. Kesehatan n 44

Informasi sebelum tindakan 1. Terangkan macam kontrasepsi keuntungan dan kekurangan masing 2 nya. n 2. Terangkan bahwa vasektomi adalah suatu pembehan n 3. Terangkan bahwa vasektomi ini dianggap permanen. n 4. Beri kesempatan akseptor untuk berfikir. n 45

Pemeriksaan prabedah 1. Anamnesa n 2. Pemeriksaan fisik n 3. Pemeriksaan laboratorium sederhana n 46

VASECTOMY 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 n 47

Pramedikasi dan anestesi 1. Evaluasi keadaan pasien n 2. Infiltrasi dengan anestesi lokal ( xylocain, lidokain, procain dll 0, 5 -1%) 1 cc n 3. Lakukan insisi setelah 2 -3 menit n 48

Alat emergensi 1. Oksigen n 2. Alat resusitasi sederhana n 3. Obat 2 an n 4. Infus set n 5. Spuit 5 dan 10 cc n 49

Komplikasi premedikasi 1. Intoksikasi Hentikan obat n 2. Kejang 2 -- Valium 5 -10 mg IV n 3. Alergi ----- Dexamethason 5 mg. IV n 50

Teknik Vasektomi 1. Celana dibuka dan pasien berbaring n 2. Bersihkan daerah operasi n 3. Tutup dengan kain steril berlobang n 51

4. Anestesi lokal 53

5. Insisi kulit skrotum 54

6. Cari dan pegang vas deferen 55

7. Ikat dan potong vas deferen 56

Cara mengikat vas deferen 57

8. Rawat perdarahan 58

9. Lakukan prosedur yang sama pada vas deferen sebelahnya 59

PROCEDURE 60

KOMPLIKASI HAEMATOM n PERDARAHAN n ANTI BODI SPERMA n GRANULOMA SPERMA n INFEKSI n REKANALISASI n 61

KEGAGALAN VASEKTOMI 1. Spermatozoa ditemukan setelah 3 bulan atau setelah 10 -12 kali ejakulasi n 2. Ditemukan spermatozoa setelah sebelumnya azoosperma n 3. Pasangannya hamil setelah berhubungan dg akseptor 3 bulan paska vasektomi n 62

Perawatan paska vasektomi 1. Berbaring kira 2 15 menit, amati. n 2. Rasa nyeri atau perdarahan n 3. KU dan lokal baik, pulangkan n 63

Nasehat Perawatan luka yang baik n Ada komplikasi kembali ke RS n Obat 2 an n Jangan kerja berat/naik sepeda dulu n Boleh berhubungan suami istri, sebaiknya pakai alat pencegah kehamilan dulu selama masih ada sisa sperma n 64

n Sebaiknya periksa sperma suami kelaboratorium untuk memastikan tidak ada sperma lagi, barulah melakukan hubungan suami istri tanpa alat pencegah kehamilan apapun. 65

Catatan medik 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. n 66