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SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR.

SOETOMO HOSPITAL SURABAYA 26


SANA .. KE DOKTER
BIAR SUBUR . . . .

SAMSULHADI
KLINIK FERTILITAS GRAHA AMERTA
DIVISI FERTILITAS & ENDOKRINOLOGI REPRODUKSI
DEPARTEMEN / SMF OBSTETRI & GINEKOLOGI
FK UNAIR, RSUD DR SOETOMO SURABAYA

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
KESUBURAN MENURUN

1 Tahun

PRIMER / Tahun ke . . . ?
Bulan Madu
SEKUNDER

AWAS : Umur Istri & Tanda Klinis ada Kelainan Fungsi


Reproduksi yang Jelas
SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
MENGAPA KESUBURAN 

UMUM ORGAN
REPRODUKSI

 UMUR  MULUT RAHIM


 LAMA KAWIN  RAHIM
 FREK. SANGGAMA  TELUR
 EMOSI  SALURAN TELUR
 GAYA HIDUP  SPERMA

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
UMUR - KESUBURAN
% Fertilitas maksimum ISTRI Angka Kejadian
Abortus (%)

% Fertilitas maksimum
50
SUAMI
100
Angka kejadian Abortus (%)

80 40

60 30
Istri

40 20

20 10

0 0
20-24 25-29 30-34 35-39 40-44

Kurun Reprod. Sehat


Bayer Steven R. Hand Book of Infertility, Ed
Frits marc A and Leon Speroff . Clinical Gynecologic Endocrinology IInd Infroma. , UK 2007
and Infertility. Ed. VIII TH. Lippincott Williams & Wilkins Philadelphia
(2011) p : 1137 - 1190
SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
UMUR ISTRI -
INFERTILITAS
HAMIL
SAAT LAHIR PUBERTAS MASA SUBUR MENOPAUSE
20 MG
6 – 7 JUTA 1 – 2 JUTA 500 RIBU
SEL TELUR SEL TELUR SEL TELUR “ HABIS “

1. CADANGAN OVARIUM  DENGAN TAMBAHNYA UMUR,


DIPERCEPAT OLEH PENYAKIT / OPERASI INDUNG TELUR
2. KEPEKAAN OVARIUM THD GONADOTROPIN  > 35 TH

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
FAKTOR INFERTILITAS – LAMA KAWIN
LAMA INFERTILITAS – KEHAMILAN KUMULATIF
Lama Perawatan ( bl.) 6 12 18 24
Lama Infertilitas (th) (%) (%) (%) (%)

1–2 20 50 60 > 60

2–3 10 > 20 60 -

3–5 - 10 20 40

>5 - 10 10 10

Cedars Marcele. Infertility : Practical Pathways in Obstetrics & Gynecology. Mc Graw Hill. San Fransisco, 2005. p : 305 - 320

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
INFERTILITAS – LAMA KAWIN
CUMULATIVE RATES OF CONCEPTION RELATED TO DURATION OF INFERTILITY
90
80
70
60
50
40
% of couples

30
20
10
0

6 12 18 24
Months after initial clinic v isit

1 – 2 years 2 – 3 years
3 – 5 years > 5 years
Duration of Infertility
Cedars Marcele. Infertility : Practical Pathways in Obstetrics & Gynecology. Mc Graw Hill. San Fransisco, 2005. p : 305 - 320

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
FREKUENSI SANGGAMA
1 BULAN
1 TELUR
1 HARI

OV
35
10 - 21
F 14

FREKUENSI SANGGAMA YANG DIANJURKAN


2 – 3 HARI DALAM 1 MINGGU

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
FREKUENSI SANGGAMA

Ov.

Bayer Steven R. Hand Book of Infertility, Ed IInd Infroma. , UK 2007


SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
EMOSI - KESUBURAN
1. PROD. SPERMA DAN TELUR 
2. KONTRAKSI SALURAN TELUR
TERGANGGU
3. “BOSAN”, FREK. SANGGAMA

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
GAYA HIDUP - KESUBURAN
MODERN

 Pola Makan / Gemuk


 Kopi
 Alkohol - Narkoba
 Rokok
 Lingkungan

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
GEMUK / OBESITAS

BB (Kg) LINGKAR
BMI :
TB ( m) 2 PERUT

25 – 30 Kg / m2 : GEMUK / OBES.
Berat • WANITA > 80 cm
> 30 Kg / m2 : • PRIA > 90 cm
Gemuk / Obes.

BMI IDEAL : 20 – 25 Kg / m2
SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
OBESITAS - KESUBURAN
 WANITA OBES 43 % LEBIH SULIT
UNTUK HAMIL
 PENURUNAN BB 10 % 
KESUBURAN NAIK 40 %

DIATASI

• POLA MAKAN
• OLAH RAGA *

* Olah raga berlebihan / dengan beban mental  menurunkan kesuburan


SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
KOPI, ALKOHOL , NARKOBA - KESUBURAN

KOPI, TEH, COKLAT & SOF DRINK ALKOHOL - KESUBURAN


– KESUBURAN (KONTROVERSI) PRIA,

• kopi / teh > 7 cangkir / • ukuran testis 


hari kesuburan .

• Ingin hamil : • Kwalitas semen


< 1 cangkir kopi / hari. (air mani) 

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
ROKOK - KESUBURAN *
• 60 % perokok wanita Infertil
• < 20 rokok / hari kesuburan tinggal 75%, > 20 / hari
tinggal 57 %
2. Rokok – Bayi Tabung
- Dosis Gonadotropin  * Risiko abortus & KET 
- Angka Kehmilan  * Cacat ( Syndronme Down) 
3. Kualitas Sperma 

* AWAS : Perokok Pasif

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
LINGKUNGAN - KESUBURAN
MEKANISMENYA ?
 Pestisida,
 Solvent (dipakai pada
industri dry cleaning)
 Thinner
 Logam berat (cadmium,
mercury)
 Gas anestesi
 Radiasi dosis besar
dalam jangka panjang
SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
OBAT-OBATAN - KESUBURAN
NSAIDs ( Obat sakit kepala, nyeri haid,
arthritis)  pada masa subur 
mengganggu ovulasi

Valproate (Obat anti epilepsi)


238 penderita epilepsi dengan valprote
didapatkan :
Gangguan haid 45 %
SOPK 43 %
Androgen  17 %
SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
MENGAPA KESUBURAN 

UMUM ORGAN
REPRODUKSI

 UMUR  MULUT RAHIM


 LAMA KAWIN  RAHIM
 FREK. SANGGAMA  TELUR
 EMOSI  SALURAN TELUR
 GAYA HIDUP  SPERMA

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
MENGAPA KESUBURAN 

Saluran Telur
Miometrium

Rahim

Endometrium
Indung Telur

Mulut
Rahim

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
TELUR 1 BULAN
1 BIJI
1 HARI
IMPLANTASI
6 – 7 Hari
PEMBUAHAN Pasca Ovulasi

Sperma : + 2 x 24 jam
di servik

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
FAKTOR (ORGAN) INFERTILITAS

F. Sal. Telur
(35%)

F. Telur
(15%)

Pasutri Istri

F. Sperma
Fritz Marc A and Speroff Leon. Clinical Gynecologic
Endocrinology and Infertility. Ed. VIII TH. Lippincott Williams & (40%)
Wilknis Philadelphia (2011)

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
HAID NORMAL

FSH LH FSH LH FSH LH

FSH LH

Primordial Maturation of Follicle Ovulation Corpus Luteum


Degenerating
E P Follicle
Corpus Luteum
P E
E

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
HAID TERATUR
FAKTOR
> 90%
OVULASI & HAID
OVULASI 
SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
NORMAL MENSTRUATION

INTERVAL (CYCLE) 24 – 35 Days

DURATION 3–7 Days

FLOW (VOLUME) 30 - 80 ml

3-7 OV S
28
14 14

OV
24
10 14

OV
35
21 14
SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
GANGGUAN SEL TELUR - SOPK
GEJALA KLINIK :
 Siklus Haid
 Pertumbuhan
rambut sex
 Jerawat
 Obesitas

PEMERIKSAAN
PENUNJANG :
- USG Pervaginam
- Hormon
- dsb.

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
Ultrasonograf

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
OV
35
21 14
F

SAAT telur keluar :


1. Pemeriksaan Hormon LH urine
2. Penampang kantong telur dgn USG pervaginam
3. Temperatur badan basal, dll.
atau
dianjurkan rutin hubungan suami istri 2-3
hari sekali dari haid ke haid
SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
ENDOMETRIUM & MENSTRUAL CYCLE

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
USG : MONITORING PERTUMBUHAN FOLIKEL
ENDOMETRIUM FOLIKEL MASAK SOPK

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
MONITORING FOLIKEL

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
FAKTOR (ORGAN) INFERTILITAS

F. Sal. Telur
(35%)

F. Telur
(15%)

Pasutri Istri

F. Sperma
Fritz Marc A and Speroff Leon. Clinical Gynecologic
Endocrinology and Infertility. Ed. VIII TH. Lippincott Williams & (40%)
Wilknis Philadelphia (2011)

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
SEBAB FAKTOR TUBA ?

ENDOMETRIOSIS INFEKSI

Nyeri Tumor Kesuburan  • Nyeri Panggul


(Haid) Indung Telur • Keputihan Bau
(kista coklat) • Operasi Panggul
• Dll.

• Tuba Buntu
• Perlekatan
• Tuba / Ovarium rusak

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
PATOGENESIS - ENDOMETRIOSIS
(1690 Daniel Shroen)
• Pop. Umum : + 10%
• Infertilitas : + 50%

Asal Ektopik Endometrium

1920 Sampson Meyer HalBan Autotrans


Refluk Darah Metaplasia Sebaran via plantasi
Haid Coelomic P. Limphe / P. Darah

Tidak satupun Sempurna

Pertumbuhan Selanjutnya

dipacu oleh E
SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
ENDOMETRIOSIS BERAT - INFERTILITAS

1. DISTORSI ORGAN REPRODUKSI


2. DESTRUKSI ORGAN REPRODUKSI
3. KUANTITAS DAN KUALITAS OOSIT MENURUN

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
USG KISTA ENDOMETRIOSIS

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
SEBAB FAKTOR TUBA ?

ENDOMETRIOSIS INFEKSI

Nyeri Tumor Kesuburan  • Nyeri Panggul


(Haid) Indung Telur • Keputihan Bau
(kista coklat) • Operasi Panggul
• Dll.

• Tuba Buntu
• Perlekatan
• Tuba / Ovarium rusak

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
INFEKSI KANDUNGAN
- KESUBURAN
• Penjalaran infeksi organ
sekitar kandungan
• TBC
• PHS (Ganti –ganti partner)
AWAS !!!
CHLAMIDIA
Saluran Telur :
TRACHOMATIS
• Dinding Rusak
• Fimbriae / Ujung Sal. Telur rusak
• Buntu
• Perlekatan

FUNGSI TERGANGGU
SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
INFEKSI PANGGUL - INFERTILITAS
JUMLAH PAPARAN RISIKO FAKTOR
INF. PANGGUL SALURAN TELUR

Episode Rate of
of PID Tubal Infertility ( % )

I 12

II 23

III 54

Barbieri Robert L. : Female Infertility


In Yen and Jaffe’s Reproductive Endocrinology. Ed VI Th Elsevier Saunders. Philadelphia.2009. P : 517 - 546

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
BAGAIMANA MENGETAHUI FUNGSI SALURAN TELUR ?

SALURAN TELUR NORMAL :


 Lubang (Paten)

 Ujung baik (Fimbriae)

 Perlekatan 

 Dinding baik

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
BAGAIMANA MENGETAHUI FAKTOR SAL. TELUR ?
SYARAT FUNGSI SAL. TIUP FOTO TEROPONG /
TELUR HSG / SIS LAPAROSKOPI
Lubang / Patent + + +
Fimbria Baik - - +
Otot Tuba baik - ? +

Tidak ada - - +
perlekatan
Patologi Lain :
Endometriosis, - + +
Kista, Mioma, dll
Perbaikan - - +

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
SALURAN TELUR

DIAGNOSIS

HSG
SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
NORMAL

HSG LAP. DX

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
Video LAP Dx NORMAL

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
ENDOMETRIOSIS RINGAN

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
KISTA COKLAT
Video Lap Op. Kistektomi

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
PERLEKATAN
RINGAN BERAT

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
HIDROSALPING
LAP. DX HSG

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
PERAN LAPAROSKOPI – INFERTILITAS

1. DIAGNOSIS
2. KOREKSI KELAINAN
A. MELEPASKAN PERLEKATAN
B. KISTEKTOMI / MIOMEKTOMI
C. MEMPERBAIKI SALURAN TELUR
D. ABLASI ENDOMETRIOSIS
E. LAPARASCOPIC OVARIAN DRILLING

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
Ovarian Drilling

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
APAKAH HISTEROSKOPI ?

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
FAKTOR (ORGAN) INFERTILITAS

F. Sal. Telur
(35%)

F. Telur
(15%)

Pasutri Istri

F. Sperma
Fritz Marc A and Speroff Leon. Clinical Gynecologic
Endocrinology and Infertility. Ed. VIII TH. Lippincott Williams & (40%)
Wilknis Philadelphia (2011)

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
F. SPERMA - INFERTILITAS

NILAI NORMAL
PARAMETER
MAYOR Tradisi- WHO 2010 KETERANGAN
onal

OLIGO SPERMIA
• Konsentrasi > 20 > 15 jt./
jt./ ml ml
• Motilitas > 50 % > 40 % ASTHENOSPERMIA

(a + b)
Epidedemis
> 15 % > 4 % TERATOZOOSPERMIA
• Morfologi
Normal

Bila ketiga parameter mayor = 0  AZOOSPERMIA

* Fritz Marc A, Speroff leon,. Clinical Gynecology Endocrinology and Infertility , ed. VIIIth Lipincot William Wilkins,
Philladelphia, 2011,
SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
BAGAIMANA FERTILISASI
BILA ADA KELAINAN SPERMA BERAT ?
Depends on :
IUI or IVF
Female factors ?
20 50 15
Sperm recovery ?
IVF or IUI or ICSI IVF history ?
Female factor ?
10 25 10
Sperm recovery ?
ICSI or IVF IVF history ?
5 10 5
ICSI
Concentration Motility Morphology
(mill./ml) a + b (%) normal (%)
Hinting et al, 1997
SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
INFERTILITAS

Komplek
Sosial Medis
1. Arti Anak 1. Multi Disiplin
2. Dana – Waktu 2. SDM Terampil & Sarana
3. Pendidikan / Pengertian 3. Penyebaran Fasilitas

3. Lokasi (Daerah Luas) 4. Prioritas

SOLUSI
1.Penanganan Komprehensif, tergantung F. Penyebab
2.Terarah & terencana
3.Rujukan
4.PKB - KIE Pasutri 56

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
TAHAPAN PENANGANAN PASUTRI INFERTIL
Dipercepat 35 Tahun
Bayi
Tabung
Obat Penyubur
Peningkatan Kesuburan

Suntik / Inseminasi
Obat Penyubur
oral /
Pengobatan Inseminasi
Sederhana
Koreksi Faktor
Infertilitas
Identifikasi
Faktor Infertil

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

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
PENGERTIAN
INSEMINASI BAYI TABUNG

CUCI
SARING
CUCI
SARING

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
KAPAN DILAKUKAN ?
INSEMINASI BAYI TABUNG
INDIKASI :
INDIKASI :
1.Endometriosis ringan 1.Kelainan
2.Gangguan ovulasi - F. Infertilitas Berat/Ganda
- umur istri lanjut
3.Kel. Sperma ringan
4.Unexplained Infertility 2. Gagal Pengobatan
3. Unexplained Infertility.

SYARAT SYARAT ADA :


1.Telur dan sperma cukup 1.Telur, Uterus
2.Uterus Normal 2.Sperma (Masturbasi,
3.Kedua tuba normal PESA/TESE)

Kontra Indikasi :
1.Infeksi Kandungan
2.Penyakit ibu berat
SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
INSEMINASI
SELEKSI PROSES

INDIKASI STIMULASI SPERMA

FASE LUTEAL
PENUNJANG
INSEMINASI
OVARIUM
SYARAT MONITOR. CUCI /
SARING
KONTRA PEMASAK-
INDIKASI AN TELUR

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
INSEMINASI – STIMULASI OVARIUM
– MONITORING - PEMASAKAN TELUR
USG *

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

36
jam
Penunjang Fase Luteal
1. Obat Minum  > 18 mm

Inseminasi
(KS)
2. Minum + Suntik CUCI
Suntik (FSH) Masak SARING
3. Suntik (FSH) Telur
LH Urine
- 16
*
Maksimum 3 telur masak
SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
Bagaimana
hasil inseminasi Dook…..

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
ANGKA KEHAMILAN INSEMINASI

100
80

80
60

% Keberhasilan
60
Kehamilan (%)

40
40

20
20

0 1 2 3 4 5 6 7 8 9 10 11 12 Umur 21 - 30 31-35 > 35


Jumlah Siklus Jml. Pasien N = 67 N = 31 N =107
A B

Siebel Machelle M., Infertility : A Comprehensive Text, 2 nd Ed. Appleton & Lance.
Stamford. Connecticut 1997

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
KAPAN DILAKUKAN ?
INSEMINASI BAYI TABUNG
INDIKASI :
INDIKASI :
1.Endometriosis ringan 1.Kelainan
2.Gangguan ovulasi - F. Infertilitas Berat/Ganda
- umur istri lanjut
3.Kel. Sperma ringan
4.Unexplained Infertility 2. Gagal Pengobatan
3. Unexplained Infertility.

SYARAT SYARAT ADA :


1.Telur dan sperma cukup 1.Telur, Uterus
2.Uterus Normal 2.Sperma (Masturbasi,
3.Kedua tuba normal PESA/TESE)

Kontra Indikasi :
1.Infeksi Kandungan
2.Penyakit ibu berat
SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
BAYI TABUNG
SELEKSI PROSES

INDIKASI STIMULASI Panen

TANAM EMBRIO
PEMBUAHAN

FASE LUTEAL
PENUNJANG
OVARIUM Telur
SYARAT MONITOR. Cuci
Sperma
KONTRA PEMASAK-
INDIKASI AN TELUR

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
GnRHa / GnRH antag
BAYI TABUNG
Gonadotropin
Masturbasi hCG / P

Endogen
& Cuci sperma
USG
Penunjang Fase Luteal

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

36
jam

Transfer Embrio

Transfer Embrio
1. Obat Minum • > 3 Fol.

Panen Telur
(KS)   > 18 mm

2. Minum +
Suntik (FSH) Suntik AZOOSPERMI
Masak
3. Suntik (FSH)
Telur

Pembuahan 1 hr. 2 hr.


PESA
ICSI
TESE
Oligozoospermia
SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
BAYI TABUNG GAGAL ?
Masturbasi
& Cuci sperma
USG
Penunjang Fase Luteal

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
V
36
jam

Transfer Embrio

Transfer Embrio
1. Obat Minum • > 3 Fol.
I
Panen Telur
(KS)   > 18 mm

2. Minum +
Suntik (FSH) II
Suntik
Masak
3. Suntik (FSH)
Telur
IV
ICSI III Pembuahan 1 hr. 2 hr.

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
Kehamilan terjadi pada “ Kesempatan”
yang sangat “ kebetulan”
(Karena Kehendak Allah semata)

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
APAKAH BAYI TABUNG
PASTI BERHASIL DOK … ?

SAYA PUNYA
DUIT
BUANYUUUAAK …. ?

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
KEBERHASILAN MENDAPATKAN
BUAH HATI DIPERLUKAN…

KOMUNIKASI

• RENCANA PENGOBATAN
• PENYULUHAN
• KERJASAMA

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
BAGAIMANA MENILAI
KESUBURAN PASANGAN
BERDASARKAN
FAKTOR RISIKO / GEJALA KILINIK
YANG ADA

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
SKOR INFERTILITAS
SKOR 1 2 3
Umur Istri * < 30 30 - 35 > 35
Lama Kawin / Lama Infertilitas 1-2 >2 > 3

Siklus Haid Teratur Oligo / PUD Amenore


Nyeri (Panggul) ** 1 jenis > 2 jenis Nyeri
Neg
Nyeri / Massa Pelvik
Riwayat Kejadian Infeksi ***
- 1 kali / AKDR > 2 kali
/ Operasi Panggul
Analisa Sperma
Konsentrasi : 20 jt / ml Nilai 1 Kelainan > 2 Kelainan
Motilitas ( a + b) : 50 % Normal Parameter Mayor Parameter Mayor
Morfologi : 30 %

Total Skor Total


Apabila salah satu dari masing-masing faktor risiko infertilitas berada pada skor 3
maka seluruh skor total menjadi > 12 (daerah merah).
Skor 6
* Tahun *** • IUD
** - Dismenore • PHS Skor 7 - 12
- Dispareunia • Operasi Panggul
- Nyeri panggul Spontan Skor > 12
SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
TOTAL SKOR - INFERLITIAS

PROGRESIF TIDAK
STATIS
(ADA FAKTOR WAKTU)

MENGHINDARI RUJUKAN
TERLAMBAT
78

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
SAN INFERTILITAS
K A
N G KELAINAN ORGAN
RI UMUM
• Umur Istri *
• Lama Infert. * TELUR SAL. TELUR SPERMA
• Frek. Koitus
• Emosi ** ANALISA SP.
• Gaya hidup HAID Foto HSG / SIS LAPAROSKOPI

‘N’ ‘TN’ ‘N’ ‘TN’ ‘N’ ‘TN’ ‘N’ TN

• Obat 6 bln Hamil R/S B


• LOD F.Lain “N”  R/S B
‘N’
 Ovul  Koreksi /
Terapi
Terapi
Konvensional
6 bl - 1 th.
Inseminasi 3 – 6 x Hamil  Bayi Tabung
* Umur istri > 35 th.. Lama Infertilitas > 3 th.  Lebih Radikal
** Usia muda dan tidak ada faktor risiko salura telur
SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
ALGORITMA PENATALAKSANAAN PASANGAN INFERTIL
(PUSAT PELAYANAN KESEHATAN PRIMER)
Pasangan Infertil

Suami Iihat faktor lain Istri

B A
Riwayat Analisa Sperma Umur < 30 Th. atau Umur > 30 Th.
Disfungsi Seksual (2- 3 x dan Atau dan
pemeriksaan) Lama Infertilitas / Lama Infertilitas /
Kawin 1 - 2 Tahun Kawin > 2 Tahun
Normal
Ada Kelainan
C
Siklus Haid Tidak Teratur Siklus Haid Teratur dan
Dan atau Risiko Faktor Tuba &
Terdapat risiko Peritoneum 
Faktor Tuba & Peritoneum

Perbaiki Gaya Hidup


Hindari :
Rujuk - Obesitas, - Rokok
- Alkohol - Narkoba
Dianjurkan :
Total Skor Total Skor - Sanggama terjadwal pada Masa
7 - 12 Subur
> 12 - Sanggama 2-3 x / 16 minggu
bulan
Pusat Pel. Keseh. Pusat Pel. Tidak Hamil
Sekunder Keseh.
Tersier
SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
INFERTILITAS PENCEGAHAN
• Gizi • Pola Makan • Pendidikan
• Polusi • Polusi Kespro – KB
• Pem. Hamil • Gaya Hidup • Kenali gejala dini Faktor
- Keseh. / Peny. - Seks bebas (PHS – AIDS) Infertilitas
Ibu Anak - Rokok – Alkohol - Narkoba • Hindari Penanganan
- PHS – AIDS – • Pendidikan terlambat – Skor
Hepatitis - Kespro / Seks (kenali gejala dini) Infertilitas
- Agama

• Pola beri makan – minum • Waspada


• Pendidikan - Kawin muda
- Disiplin - Hamil “ unwanted”
- Seks • Pendidikan
- Agama - Kespro – KB
Persalinan - Agama
Konseling Pra - Nikah
Bersih • Gaya Hidup / Pola Makan
SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
KURUN REPRODUKSI HINDARI 4 TERLALU
SEHAT
I. Terlalu Muda
I. Hamil umur 20 – 25 th.
II. Terlalu Tua
II. Anak < 3 orang
III. Terlalu rapat
III. Jarak > 2 th
IV. Terlalu banyak

1. KESPRO REMAJA
2. KIE
3. KB
Hindari UNWANTED Pregnancy
SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
KAMI SIAP MEMBANTU MELENGKAPI
KEBAHAGIAAN ANDA

KLINIK FERTILITAS GRAHA AMERTA


KlINIK FERTILITAS RS PUTERI
SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
Alhamdulillah . . .
diberi kepercayaan Allah

SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26
ART IN INFERTILITY
MANAGEMENT INFERTILITY MANAGEMENT
FEMALE MALE
 Age > 37 Years
Sperm An.
and or OVULATORY FACTOR TUBAL FACTORS
 Multiple Factors Normal Abnormal
of Infertility
• Age > 30 yrs • Age < 30 yrs
Irregular Cycles Regular
(WHO) cycles • Infertility • Infertility
duration > 3 yrs duration < 3 yrs Tx  Tx 

• There are Risk • No Risk Factors


I II III IV Factors of PID / of PID /
Endometriosis Endometriosis Succeed Failed
Gona • CC / Bromo
dotro • CC + ISA HRT criptin HSG / SIS Normal
LAPAROSCOPY
pin
• Ov. Abnormal
Drilling • CC • 6 Months
Abnormal Normal • “N”
• Gonadotro • Gonado No Pregn.
tropin Others F.
pin
In-ope Operable
6 months 6 months
rable
? - 1 years * 2 years - 1 years
Included Included
Included IUI 3 – 6 x
* IUI 3 – 6 No Pregnancy
IUI 3 – 6 x

* “N” Tubalx & Perit. F.


IVF –ET /
ICSI
SAMSULHADI. DEPT. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA 26