3-Samsul Hadi Protect

11/21/2008
SAMSULHADI
FERTILITY CLINIC GRAHA AMERTA

DEP. OF OBSTETRIC & GYNECOLOGY,
FAC. OF MEDICINE AIRLANGGA UNIVERSITY.
DR. SOETOMO HOSPITAL SURABAYA
SAMSULHADI. DEP. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA FEB 2006
1
11/21/2008
Techniques that involve manipulation

of oocytes, sperm and
Conceptuses to improve fecundity or
enhance pregnancy outcome
Strauss Jerome F., Barbieri Robert L. Yen and Jaffe’s, Reproductive Endocrinology. Physiology.
Pathophysiology and Clinical Management. Ed Vth. Elsevier Saunders . Pennsylvania. (2004), P : 839 - 873
 I.U.I
 IVF – ET
- ICSI
- PESA
- TESE
2
11/21/2008
WHERE ARE
THEY ?
35 Years
IVF
Increasing Fecundability
hMG or
hMG--IUI
hMG
CC or
CC - IUI
Expectant
Management
Correct all
Fertility factors
Identify all
Fertility factors
Increasing intensiveness of resource utilization
Figure 20 – 16. Staircase approach to empirical infertility treatment/ For women over 35 years old, the first three steps
in the algorithm should be rapidly completed. In women less than 30 years old, more time can be spent on
the first three steps in the staircase
Barbieri Robert L. : Female Infertility

In Yen and Jaffe’s Reproductive Endocrinology. Ed V Th Elsevier Saunders. Philadelphia.2004. P : 633- 668
3
11/21/2008
INFERTILITY FACTORS
Sperm Ovulation Tube &

Peritoneum P
Factors : R
- Age Treatment :
E
INFERTILITY
- Emotional • Medical
- Environment
G
• Surgical
- Freq. / Time N
• Combination A
of Coitus
- Social Economic • ART N
Cervix Uterus
C
Y
4
11/21/2008
AGING AND REPRODUCTION IN WOMEN
% of maximum fertility Miscarriage rate (%)

% of maximum fertility 50
100
Miscarriage rate (%)
80 40
60 30
40 20
20 10
0 0
20-24 25-29 30-34 35-39 40-44
Leon Speroff and Frits marc A. Clinical Gynecologic Endocrinology and Infertility. Ed. VII TH. Lippincott
Williams & Wilknis Philadelphia (2005) p : 1013 - 1056
INFERTILITY
MANAGEMENT
DIAGNOSIS
TREATMENT
5
11/21/2008
DIAGNOSIS OF
INFERTILITY FACTORS
SPERM TUBE & OVUL.

FACTOR PERITONEUM DISORDERS
• Unknown • Hypothal
Infection • Pituitary
• Infection
• Immunology • H–P–O
• Hormonal Endometriosis • Ovary
• Others • Others
• Sperm Analysis • HSG / ISS • Menstrual Cycle

• Culture • Laparoscopy • BBT
• Immunology Test • BEM
• Others • TVS
• Hormonal
DIAGNOSIS TUBAL FACTORS
HSG
6
11/21/2008
HSG NY. LD
HSG
SEPTUM UTERUS
PRE OPERATION
POST OPERATION
7
11/21/2008
NORMAL
HSG LAP Dx
8
11/21/2008
SAMSULHADI.
SAMSULHADI.
DEP. OF
DEP.
OBSTETRIC
OF OBSTETRICAL
& GYNECOLOGY,
& GYNECOLOGY,
FAC. OF FAC.
MEDICINE
OF MEDICINE
AIRLANGGA
AIRLANGGA
UNIVERSITY.
UNIVERSITY.
DR. SOETOMO
DR. SOETOMO
HOSPITAL
HOSPITAL
SURABAYA
SURABAYA
FEB 2006
ADHESION
MILD SEVERE
9
11/21/2008
MILD ENDOMETRIOSIS
SEVERE ENDOMETRIOSIS
10
11/21/2008
Lumen
Anatomy Oth
ers
Type of TUBE Paten Adhes Ovar
Tubal abn Note
Eval. Uteru cy ion y
Mu Wall orm
s Fimbr
Blocked cos Tube ality
iae
a
 Simple
HSG + + + + - + - - - -
 Cheap
Laparo  Invasive
scopy
- - - ++ + + + + ++ +
 Expensive
 Chepeast
ISS ++ + - + - - - - ++ +
 Simple
11
11/21/2008
DIAGNOSIS OF
INFERTILITY FACTORS
SPERM TUBE & OVUL.

FACTOR PERITONEUM DISORDERS
• Unknown • Hypothal
• Infection Infection • Pituitary
• Immunology • H–P–O
• Hormonal Endometriosis • Ovary
• Others • Others
• Sperm Analysis • HSG / ISS • Menstrual Cycle

• Culture • Laparoscopy • BBT
• Immunology Test • BEM
• Others • TVS
• Hormonal
Hypothalamus Short F.B

Long F.B
Ultra Short FB
(Down Reg.)
GnRH
Pulsatile Secretion
In
“Critical Range”
Pituitary FSH & LH
Ovary
Steroidogenesis Foliculogenesis
&
oogenesis
E&P
Single
Menstruation Ovulation
SAMSULHADI.
SAMSULHADI.
DEP. OFDEP.
OBSTETRIC
OF OBSTETRIC
& GYNECOLOGY,
& GYNECOLOGY,
FAC. OFFAC.
MEDICINE
OF MEDICINE
AIRLANGGA
AIRLANGGA
UNIVERSITY.
UNIVERSITY.
DR. SOETOMO
DR. SOETOMO
HOSPITAL
HOSPITAL
SURABAYA
SURABAYA
FEB 2006
12
11/21/2008
Progesterone
17-OHP
Ng/mL PHISIOLOGY MENSTRUATION
10 LH
9
Progesterone
8 LH
FSH
7
FSH FSH
6 Estradiol
5
LH LH
4
2 Estradiol
1 Estradiol 17-OH Progesterone

17-OH Progesterone
Progesterone
Ov.
2 4 6 8 10 12 14 16 18 20 22 24 26 28
FSH LH  P 
• Gran. Cell Prolif.  OMI 
• Arom. Androg – E2 FSH & LH 
• FSH & E2  R / FSH in  Synth PG
Gran. Cells  Elevated P + : - plasminogen - Plasmin  LH Maintain
• Stim. Inhibin, Act. Prod. - FSH – Surge Corpus luteum
LH (Theca Cells) FSH Surge : - Proteolytic enzym activity  - Vascul
• Synth Androg. - FSH + E2  R/ LH in gran cells - Steroidogenesis
ABN. OF OVUL. ABN. OF MENS. INFERTIL. ART
TOOLS HIPOTAL IV
HIPOG-
HIPOG-
ABN.
HIPOG AMENORE
HORMON C (CENTRAL)
OF
•LIPID III OVUL.
•PROT. O HYPOFESA IUI
&
•AMINE M OVUL. DYSFUNC. & IVF - ET
TRANSPORT
M OTHER
•E  FSH D.U.B
(FREE, BOUND) U LH FACTORS
N
RECEPTOR I •E  FSH AMENORE
•MEMBRANE C
•INTRACEL A OVARY HIPER – HIPOG AMENORE
T ( PERIPHERY) II
COM.
SYSTEM I
O OOGENESIS
OVULATION
•ENDOCRIN
•PARACRIN N FOLICULOGEN.
•AUTOCRIN
•INTRACRIN STEROIDOGEN
AMENORHEA
UTERINE -ABN. OF DEVELOP
(ENDOMET) -INFECTION
MENS.
SAMSULHADI.
Prof. DEP. OFSpOG
Dr. H. Samsulhadi, OBSTETRIC & GYNECOLOGY,
(K). Seksi FAC. OF MEDICINE
Fertilitas Endokrinologi AIRLANGGA
Reproduksi, UNIVERSITY.
Bag / SMF ObstetriDR. SOETOMO HOSPITAL
& Ginekologi SURABAYA
RSU Dr. Soetomo FEB Surabaya
/ FK Unair 2006
13
11/21/2008
INFERTILITY
MANAGEMENT
DIAGNOSIS
TREATMENT
INFERTILITY TREATMENT
INFERTILITY
UNEXPLAINED MILD SEVERE /

MULTIPLE
OR / AND FACTORS
MEDICAL SURGERY
*
1 – 2 YEARS IVF – ET
(INCLUDED IUI ICSI
3 – 6 CYCLES)
*Micro surgery or laparoscopic surgery
14
11/21/2008
INFERTILITY FACTORS
Sperm Ovulation Tube &

Peritoneum P
Factors : R
- Age Treatment :
E
INFERTILITY
- Emotional • Medical
- Environment
G
• Surgical
- Freq. / Time N
• Combination A
of Coitus
- Social Economic • ART N
Cervix Uterus
C
Y
35 Years
IVF
Increasing Fecundability
hMG or
hMG--IUI
hMG
CC or
CC - IUI
Expectant
Management
Correct all
Fertility factors
Identify all
Fertility factors
Increasing intensiveness of resource utilization
Figure 20 – 16. Staircase approach to empirical infertility treatment/ For women over 35 years old, the first three steps
in the algorithm should be rapidly completed. In women less than 30 years old, more time can be spent on
the first three steps in the staircase
Barbieri Robert L. : Female Infertility

In Yen and Jaffe’s Reproductive Endocrinology. Ed V Th Elsevier Saunders. Philadelphia.2004. P : 633- 668
15
11/21/2008
Infertility Monitoring Fertility

(Women)
Complicated
• Costly Age Related

• Takes Time
Standard Evaluation
Pregnant TIME
(“Marker”)
INFERTILITY
FEMALE MALE
> 37 Years or  > 30 Years. < 30 Years. Normal Abnormal

 Married > 3 Years.
Multiple Factors  Suspect Adhesion,
Infertility Endometriosis and
or mass TUBE & OVULATION
PERITONEUM Tx  Tx 
• Mens. Cycle
HSG / ISS • BBT
• Endom. Biopsy
• P Success Failed
Abnormal  Normal
LAPAROSCOPY • 6 Months Abnormal

Ovulation 
• Others F. “N”
Normal • COH Tx /
Abnormal Op.  Reconstructive 1,5 – 2 Y. • IUI Induction
Surgery (Tube F. N)
6 Months.
Op.  Failed
Pregnant  IVF -ET Pregnant  6 Cycles.

Gonadotropin
16
11/21/2008
WHEN A.R.T WILL BE DONE
 Indication
 Requirement
 Contra Indication
A.R.T
IUI IVF - ET
• Unexplained Inf. Indication • Severe Abnormality

• Ov. Factor • Failure of previous Treat.
• Mild Endometriosis • Multiple Factors
• Oligo zoopspermia • Unexplained Inf.
• Etc.
There is Requirement There is

• Sperm (Legal Couple) • Sperm
• Oocyte • Oocyte
• Uterus • Uterus
Normal Tube
- Poor ov. Reserve - Poor ov. Reserve

- > 40 yrs of old Contra
- > 40 yrs of old
- C.I. to be Pregn. Indication
- C.I. to be Pregn.
17
11/21/2008
OVARIAN RESERVE
BASAL FSH & E2 AGE
PATHOLOGICAL CASES
• Post pelvic surgery
• Immun or genetic F.
• Etc.
SAMSULHADI.
SAMSULHADI.
DEP. OFDEP.
OBSTETRIC
OF OBSTETRIC
& GYNECOLOGY,
& GYNECOLOGY,
FAC. OFFAC.
MEDICINE
OF MEDICINE
AIRLANGGA
AIRLANGGA
UNIVERSITY.
UNIVERSITY.
DR. SOETOMO
DR. SOETOMO
HOSPITAL
HOSPITAL
SURABAYA
SURABAYA
FEB 2006
REDUCED OVARIAN RESERVE

DIAGNOSIS
The diagnosis of reduced ovarian reserve is supported by :
1. Cycle day 3 : 2. Abnormal CCCT

- FSH > 10 mlU/ml or To perform :
• Cycle day 3 : FSH, estradiol levels
- Estradiol > 70 pg /ml • Clomiphene citrate 100 mg cycle
days 5 – 8
• Cycle day 10 : FSH level
if any of the FSH levels are > 10 mIU/ ml or the estradiol is > 70 pg/ml
The test is considered abnormal
Documented poor response to aggressive ovulation induction
18
11/21/2008
REDUCED OVARIAN RESERVE

DOCUMENTED POOR RESPONSE TO AGGRESSIVE OVULATION INDUCTION
TREATMENT OPTIONS
FSH 10 – 19 mIU / ml FSH > 20 mIU / ml
Aggressive ovulation
Induction with
Intrauterine
Inseminations
Adequate response Poor response Counsel on other options

 Egg donation
Try 3 cycles  Adoption
then IVF
Steven R. Bayer, Michael M. Alper, Alan S. penzias : The Boston IVF Handbook of Infertility, Practical guide for
practioners who care for infertile couples. The Parthenon publishing Group. Massachusetts. 2002. 67 - 74
SAMSULHADI.
SAMSULHADI.
DEP. OFDEP.
OBSTETRIC
OF OBSTETRIC
& GYNECOLOGY,
& GYNECOLOGY,
FAC. OFFAC.
MEDICINE
OF MEDICINE
AIRLANGGA
AIRLANGGA
UNIVERSITY.
UNIVERSITY.
DR. SOETOMO
DR. SOETOMO
HOSPITAL
HOSPITAL
SURABAYA
SURABAYA
FEB 2006
Hospital
Education Competence
Social -Economy Diagnosis

Infertility &
Treatment
Management
Culture
• Experties
• Equipment
Age Infertility • Trained skill
Factors
19
11/21/2008
INFERTILITY PROBLEM
COMPLICATED
COSTLY TAKES TIME
PATIENTS HEALTH  Multiple Factors

SERVICES (Long Work Up)
WORK UP  Varies Examination
• Human Resources
TREATMENT - Experties  Varies Treatment
• Medical - Technicians
• Surgical - Trained Paramedics
• ART
• Equipments
Referral System Needed

 Total
 Partial  Networking
 Guide Line
(Standardized)
Referral System in ART
Partial Total
Diagnosis Treatment
20
11/21/2008
 Indication
 Requirement
 Contra Indication
P
R
E
SCREENING SPERM INSEMI LUTEAL G
PREPARATION NATION SUPPORT N
A
N
Ovarian  CC & Gonadotr. Washing C
Reserve
 Gonadotropin Sperm Y
 Monitoring
 hCG
REFERRAL SYSTEM OF IUI

INFERTILITY - IUI
PATIENT
IUI
SELECTION
 Age
Ov. Reserve  Hormonal
Assay
 Strategies of
Superovulation
Indication Requirement Contra
 Monitoring
Indication
 Sperm
Unexpl. Infertility Preparation
 • Adequate sperm  Poor Ov. reserve
 Luteal Support
 Ovulation • Normal Oocyte  > 40 years of old
Factors • Normal Uterine women
 Endometriosis • Normal Tube  Contra indication
to be pregnant
 Male Factors • No Peritoneal
adhesion
 Etc.
21
11/21/2008
S P E R M
 Indication
AZOOSP OLIGO “N”
 Requirement
 Contra Indication PESA / TESE ICSI
Patient O F Embryo E Luteal P

Selection E T Supp. R
P R or blastocyst
E
U T Selection G
I N
Ovarian  GnRHa or GnRH L A
Reserve I PGD N
Antagonist Z
A C
 Gonadotropin Y
T
 Monitoring I
O
 hCG N
REFERRAL SYSTEM OF IVF - ET
PATIENT
SELECTION IIVF - ET
 Hormonal
Ov. Reserve Assay
 Strategies of
Superovulation
Indication Requirement Contra  Monitoring
Indication
 Getting Sperm
- Natural
 Severe / Multiple There are :  Contra indication - PESA
Factors to be pregnant - TESE
 Oocyte
 Failure Previous  Sperm  Poor Ov. reserve  Sperm Preparation
Management  Uterine  > 40 years of old  Fertilization
 Unexplained wife Natural or ICSI
Infertility  Luteal Support
22
11/21/2008
COMPLETELY AND INTEGRATED

FERTILITY CLINIC GRAHA AMERTA
DR. SOETOMO HOSPITAL / MEDICINE FACULTY UNIV. AIRLANGGA SURABAYA
Telp. 031 – 70906307 Fax. 031-

031-5501704 e-
e-mail:batabsby@yahoo.com
23

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11/21/2008

FERTILITY CLINIC GRAHA AMERTA

Techniques that involve manipulation

Increasing intensiveness of resource utilization

Barbieri Robert L. : Female Infertility

Sperm Ovulation Tube &

AGING AND REPRODUCTION IN WOMEN

% of maximum fertility Miscarriage rate (%)

SPERM TUBE & OVUL.

• Sperm Analysis • HSG / ISS • Menstrual Cycle

DIAGNOSIS TUBAL FACTORS

SPERM TUBE & OVUL.

• Sperm Analysis • HSG / ISS • Menstrual Cycle

Hypothalamus Short F.B

Pituitary FSH & LH

1 Estradiol 17-OH Progesterone

ABN. OF OVUL. ABN. OF MENS. INFERTIL. ART

UNEXPLAINED MILD SEVERE /

Sperm Ovulation Tube &

Increasing intensiveness of resource utilization

Barbieri Robert L. : Female Infertility

Infertility Monitoring Fertility

• Costly Age Related

> 37 Years or  > 30 Years. < 30 Years. Normal Abnormal

LAPAROSCOPY • 6 Months Abnormal

Pregnant  IVF -ET Pregnant  6 Cycles.

WHEN A.R.T WILL BE DONE

• Unexplained Inf. Indication • Severe Abnormality

There is Requirement There is

- Poor ov. Reserve - Poor ov. Reserve

BASAL FSH & E2 AGE

REDUCED OVARIAN RESERVE

1. Cycle day 3 : 2. Abnormal CCCT

REDUCED OVARIAN RESERVE

Adequate response Poor response Counsel on other options

Social -Economy Diagnosis

PATIENTS HEALTH  Multiple Factors

Referral System Needed

Referral System in ART

REFERRAL SYSTEM OF IUI

 Contra Indication PESA / TESE ICSI

Patient O F Embryo E Luteal P

REFERRAL SYSTEM OF IVF - ET

COMPLETELY AND INTEGRATED

Telp. 031 – 70906307 Fax. 031-

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