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DIAGNOSIS DAN PENANGANAN INFERTILITAS PADA PRIA

DIAGNOSIS DAN PENANGANAN INFERTILITAS PADA PRIA. ALVARINO SIE UROLOGI LAB ILMU BEDAH FK. Univ. ANDALAS. PENDAHULUAN. 10 – 15% pasutri , hub.seksual normal tanpa kontrasepsi,belum hamil  Infertiliti Primer. Faktor Infertiliti pasangan : Female 1/3 Male 1/3

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DIAGNOSIS DAN PENANGANAN INFERTILITAS PADA PRIA

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

  2. PENDAHULUAN • 10 – 15% pasutri ,hub.seksual normal tanpakontrasepsi,belumhamil Infertiliti Primer. • FaktorInfertilitipasangan : • Female 1/3 • Male 1/3 • Both 1/3

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

  4. ORGAN REPRODUKSI PRIA

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

  6. SPERMATOGENESIS • SPERMATOGONIA • SPERMATOZOA • 13 STAGES • 74 DAYS

  7. ETIOLOGI • 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%

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

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

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

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

  12. 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

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

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

  15. Non Surgical TreatmentSPECIFIC THERAPY HYPOGONADOTROPHIC-HYPOGONADISM • INCIDENCE ; LOW • ACQUIRED / CONGENITAL (KALLMANNIS SYNDROME) • DUE TO DECREASED PRODUCTION OF GnRH • 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 : hCG 1500-3000 IU sC 3 times weekly for 8-12 weeks, then hMG 37,5-150 IU sC 2-4 times weekly

  16. Non Surgical TreatmentSPECIFIC THERAPY HYPERPROLACTINEMIA • INCIDENCE ; LOW • HYPERPROLACTINEMIA  NEG FEEDBACK TO GnRH, 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

  17. Non Surgical TreatmentSPECIFIC THERAPY ISOLATED TESTOSTERON DEFICIENCY • 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

  18. Non Surgical TreatmentSPECIFIC THERAPY CONGENITAL ADRENAL HYPERPLASIA • 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.

  19. Non Surgical TreatmentSPECIFIC THERAPY IMUNOLOGIC INFERTILITY • EVEN oral PREDNISON CAN DECREASED ASA,  ITS RARELY SUCCESSFUL • TREATMENT OF CHOICE ; ART  ICSI • 3 – 7% MALE INFERTIL

  20. Non Surgical TreatmentSPECIFIC THERAPY GENITAL TRACT INFECTION • 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

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

  22. Non Surgical TreatmentSPECIFIC THERAPY ANEJACULATION • INCIDENCE : RARE • ETIOLOGY : • NEUROGENIC, : SPINAL CORD INJURY, RETROPERTONEAL SURGERY, DIABETES MELITUS, TRANSVERSE MYELITIS, MULTIPLE SCLEROSIS • PSYCHOGENIC / IDIOPATHIC • DIAGNOSTIC TEST : POST EJACULATE URINE • THERAPY : • RECTAL PROBE EJACULATION • PENILE VIBRATORY STIMULATION

  23. ERECTILE DYSFUNCTION • ???

  24. Non Surgical TreatmentEMPIRIC THERAPY • INDICATION : IDIOPATHIC OLIGOSPERMIA • DRUGS CATEGORY FOR EMPIRYC THERAPY: • CLOMIPHEN CITRATE • TAMOXIFEN • ANDROGENS • TESTOSTERON REBOUND • AROMATASE INHIBITORS • GONADOTROPINS • GnRH • KALLIKREINS • PROSTAGLANDIN SYNTHETASE INHIBITORS • BROMOCRIPTINE • PENTOXIFYLLINE • ANTIOXIDANTS • CARNITINE.

  25. Non Surgical TreatmentEMPIRIC THERAPY CLOMIPHEN CITRATE • SYNTHETIC, NONSTEROIDAL ANTI-ESTROGEN • BINDS TO ESTROGEN RECEPTOR COMPETITIVELY IN THE HYPOTHALAMUS, AND HYPOPHISE  BLOCKING FEDBACK  AND INCREASING SECRETION OF GnRH, 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

  26. Non Surgical TreatmentEMPIRIC THERAPY ANTIOXIDANT • RECENT STUDIES DEMONSTRATED AN INCREASED OF ROS in IDIOPATHIC SUBFERTILITY • ROS INCLUDE ; HYDROXYL RADICAL (OH), SUPEROXIDE ANION (O2), HYDROGEN PEROXIDE (H2O2) • ROS  DAMAGE SPERM LIPID MEMBRANE • VITAMIN E 400-1200 iu /D IMPROVED CAPACITY FOR SPERM-OOCYTE FUSION IN-VITRO • GLUTHATION 600 mg/d

  27. PEMBEDAHAN • Varicocelectomy • Vasovasostomy, Epididymovasostomy, TUR of Ejaculatory duct • Ablation of Pituitary Adenoma

  28. PROPILAKSIS PEMBEDAHAN • Orchydopexy • Operation for Testicular Torsion • Electroejaculation

  29. 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

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

  31. IVF & ICSI • EXCELLENT TECH, BY PASS MODERATE TO SEVERE FORMS OF MALE INFERTILITY • IVF ; 500.000-5.000.000 MOTILE SPERMA AND EGGS ARE FERTILIZED IN PETRI DISHED • ICSI ; 1 VIABLE SPERM INJECTED INTO CYTOPLASMIC AREA

  32. ICSI

  33. MALE CONTRACEPTIVE

  34. METHODE • ESTABLISHED • CONDOM • PERCUTANEOUS VAS OCCLUSION • TRADITIONAL VASECTOMY • NON-SCALPEL VASECTOMY • RESEARCH • Hormonal : PILL’S, INJECTABLE • Non-hormonal • Vaccine • Imunologic

  35. VASECTOMY • MINOR SURGICAL PROCEDURE • CUTTING / OCCLUSSION OF VAS DEFERENS • MINOR COMPLICCATION • NO CHANGES IN SEXUAL FUNCTION

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

  37. Harapan Suatu KLinik • Memberikan rasa aman • Memberikan penjelasan • Melaksanakan persiapan • Mengatasi penyulit • Melakukan pengawasan lanjutan • Merujuk bila perlu

  38. Pelaksana pelayanan Vasektomi • Dokter yang telah mengikuti pendidikan dan latihan tindak bedah vasektomi

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

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

  41. Syarat Akseptor • 1. Sukarela • 2. Bahagia • 3. Kesehatan

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

  43. Pemeriksaan prabedah • 1. Anamnesa • 2. Pemeriksaan fisik • 3. Pemeriksaan laboratorium sederhana

  44. VASECTOMY • PREPARATION : • SHAVE AND WASH THE SCROTUM • BRING A PAIR OF TIGHT FITTING UNDERWEAR OR ATHLETIC SUPPORT • AVOID ANTIINFLAMATORY DRUGS ( IBUPROFEN, ASPIRIN BEFORE SURGERY

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

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

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

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

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