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INFERTILITY

DEFINITIONS

INFERTILITY
WHO: INABILITY TO CONCEIVE AFTER ONE YEAR OF
REGULAR UNPROTECTED INTERCOURSE.
AFS : INABILITY TO CONCEIVE AFTER ONE YEAR
OF REGULAR UNPROTECTED INTERCOURSE, (AGE 35 > 6
MONTH)

FECUNDITY
ABILITY WOMEN TO PREGNANT
STATISTICS
80-85% OF COUPLES WILL CONCEIVE WITHIN 1 YEAR OF
UNPROTECTED INTERCOURSE
90% WILL CONCEIVE WITHIN 2 YEARS OF UNPROTECTED
INTERCOURSE
ORIGIN:

causa percentase%
Faktor tuba , pelvik 35
Faktor laki-laki 35
Disfungsi ovulasi 15
idiopatik 10
lain-lain 5
INFERTILITY MANAGEMENT

COUPLE MANAGEMENT

FEMALE MALE

GYNECOLOGY ANDROLOGY
INSIDENCE

COUNTRY - DEVELOPED :+5-8%


- DEVELOPING : + 30 %
WHO : + 8 - 10 % (+ 50 - 80 MILLION)
COUPLES IN THE WORLD
INDONESIA : + 12 % (+ 3 MILLIONS)
REFERENCES : + 15 % ( 1 OUT OF 7 COUPLES)
CLASSIFICATION
PRIMARY INFERTILITY: NEVER PREGNANT

SECUNDARY INFERTILITY: HAD PREVIOUS PREGNANCIES

IDIOPATIC/UNEXPLAIN INFERTILITY
Tube and Pertoneal Factor

Ovulation Factor
Uterine Factor

Cervical Factor

ETIOLOGY OF Sperm Factor


INFERTILITY
ETIOLOGIES

SPERM FACTOR 25-30%


OVULATION FACTOR 15-20%
TUBAL/PERITONEAL FACTOR 25-40%
UTERINE FACTOR 5-10%
CERVICAL FACTOR 2-5%
UNEXPLAINED 10-15%
INFERTILITY FACTORS

Sperm Ovulation Tube &


Peritoneum
P
Factors : R
- Age Treatment : E
G
- Emotional Medical
N
INFERTILITY

- Environment Surgical A
- Freq. / Time Combination N
of Coitus ART C
Y
- Social
Economic Cervix Uterus
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

COMPLICATED

MULTIPLE FACTORS IN BOTH MALE AND FEMALE


MORE THAN 1 FACTORS IN EITHER MALE OR FEMALE
TUBAL FACTORS 25 - 40 %
The most frequent causes:
P.I.D. / S.T.D
SepticAbortion
IUD
Previous pelvic / tube operation
Apendicitis with perforation

OVULATION FACTORS 15 - 20 %
Genetic disorders
Hiperprolaktinemia
Tiroid disease
Stress
Weight Changes
Polycystic Ovary
SERVICAL FACTORS 2 - 5%

Anatomic disorders
Infection

UTERUS FACTORS 5 - 10 %
Anatomic disorders :
Congenital
Intrauterine adhesion
Myoma uteri

Endometrial polip
Hyperplasia of endometrium
EXAMINATION

HISTORY
PHYSICAL EXAMINATION
SPERM ANALYSIS
DETECTION OF OVULATION
POST COITAL TEST
USG
HSG
LAPAROSCOPY
BOTH COUPLES SHOULD BE PRESENT
AGE
PREVIOUS PREGNANCIES BY EACH PARTNER

HISTORY-GENERAL LENGTH OF TIME WITHOUT PREGNANCY


SEXUAL HISTORY
FREQUENCY AND TIMING OF INTERCOURSE
USE OF LUBRICANTS
IMPOTENCE, ANORGASMIA, DYSPAREUNIA
CONTRACEPTIVE HISTORY

HISTORY OF PELVIC INFECTION


RADIATION, TOXIC EXPOSURES (INCLUDE DRUGS)
HISTORY-MALE TESTICULAR SURGERY/INJURY
HISTORY-FEMALE

PREVIOUS FEMALE PELVIC SURGERY


PID
APPENDICITIS
IUD USE
ECTOPIC PREGNANCY HISTORY
ENDOMETRIOSIS
DETAILED MENSTRUAL HISTORY
STRESS
WEIGHT CHANGES
EXERCISE
CERVICAL AND UTERINE SURGERY
SIZE OF TESTICLES

PHYSICAL EXAM-MALE TESTICULAR DESCENT

VARICOCOELE

PELVIC MASSES
ABDOMINOPELVIC TENDERNESS
THYROID EXAM
PHYSICAL EXAM-FEMALE
CERVICAL AND UTERINE ABNORMALITIES
PHYSICAL EXAMINATION

Bodyweight, BMI
Thyroid Enlargment
Breast Secretions
Sign of Androgen Excess
Pelvic tenderness
Vaginal discharge
Uterine size, adnexal mass,
NORMAL SEMEN ANALYSIS
OVULATORY FACTORS

Ovulatory dysfunction commonly results


in gross menstrual disturbances :
- Oligo / Amenorrhea
- Dysfunctional Uterine Bleeding

The Underlying cause should


always be sought :
Thyroid Disease
Hyperandrogenism
Extreme of weight loss
Hyperprolactinemia
Obesity
Etc
METHODS FOR INVESTIGATION

Menstrual history
Basal body temperature :
- Simple and in expensive method
- Biphasis patterns
Serum Progesterone
Urinary luteinizing hormone
Endometrial Biopsy

Serial Transvagianl Ultrasound ( DOMINANT FOLLICLE 18-24 mm)


Other Evaluation - FSH
- Clomiphen Citrate Challenge test
UTERINE FACTORS

Abnormalities of Uterine Anatomi Relatively uncommon


Function Causes of infertility
Methods for Investigation
HSG : Defines the size and shape of the uterine cavity and
will reveal developmental anomalies
( unicornuate, Septate, bicornuate uteri polyps,
submucous myoma )
Ultrasound
Sonohysterography
(High sensitive method for diagnosis of polys,
subsemucous myoma)
Hysteroscopy
(Definitive method for evaluation of uterine cavity)
INFERTILITY MANAGEMENT:
MEDICATION
RECONSTRUCTIVE SURGERY
ASSISTED REPRODUCTIVE TECHNOLOGY (ART)
INFERTILITY FACTORS
AGE
Patient
(Wife)
Wishes
Management &
Treatment Program

SOCIAL
ECONOMIC

HEALTH SERVICE
FACILITIES
MEDICATION
USING OVARIAN STIMULATION DRUGS (OVULATION INDUCTION):

CLOMIPHENE CITRATE (CC)


HUMAN MENOPAUSAL GONADOTROPHINE (HMG)
ART
INTRA UTERINE INSEMINATION
(IUI)

INVITRO FERTILIZATION (IVF)

INTRA CYTOPLASMIC SPERM


INJECTION (ICSI)