18. Infertilitas wanita

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Dr. H. Undang Gani, SpOG.

Depart. of Obstetrics & GynecologyFaculty of Medicine, Jend. Ac!ad "ani Uni#ercity $

% M A H %



InfertilityInfertility : one year of unprotected inter-: one year of unprotected inter- course without pregnancy course without pregnancy

Primary infertility : no previous pregnancy havePrimary infertility : no previous pregnancy have

occurred occurredSecondary infertility : a prior pregnancy, although notSecondary infertility : a prior pregnancy, although not

necessarily a live birth has occure necessarily a live birth has occure

FecundabilityFecundability : probability of achieving pregnancy: probability of achieving pregnancy

within single menstrual cycle within single menstrual cycleFecundityFecundity : probability of achieving a live birt: probability of achieving a live birt

within a single menstrual cycle within a single menstrual cycle



Infertility is a problem of the couple

The presence of the male partner beginningwith the initial evaluation involves him in the

therapeutic process



1!bnormalities in the semen "male factorinfertility#

$%vulatory disorders "ovulatory factors#&Tuba in'ury, bloc(age, paratubal adhesion orendometriosis "tubal)perotoneal factor#

*!bnormalities in cervical mucus-sperm interactio

"cervical factor#+arer condition uterine abnormalities, infection,

immunologic aberation



The relative prevalence of the etiologies of infertility prevalence.ale factor $+-*/0oth 1/0Female fator */-++02ne3plained infertility 1/0

The appro3imate prevalence of the causes of infertility in thefemale

%vulatory dysfunction &/-*/0Tubal)peritoneal factor &/-*/02ne3plained infertility 1/-1+0.iscellaneous causes 1/-1+0

Table 1 4ause of infertility



5isorders of ovulation account for appro3imately &/-*/0 of allcases of female infertility6ormal length of menstrual cycle : $+-&+ days

.ost women : $7-&1 days

.ethods to 5ocument %vulation

asal body temperature

ecord patient8s temperature each morning on a basal bodytemperature "T# chart

The characteristic biphasic pattern indicative of ovulation

.idluteal serum progesteron

9levation in serum levels of progesterone constitute indirectevidence of ovulation




uteini;ing hormone monitoring

5ocumentation of the < surge is a reproducible method ofpredicting ovulation

%vulation occurs &*-&= hours after onset the < surge andappro3imately 1/-1$ hours after < pea(

9ndometrial biopsy

Finding of secretory endometriumThe biopsy is performed $-& days before the e3pected onsetof menses

Invasive procedure




2ltrasound monitoring

.onitoring the development of the dominant follicle

%vulation : decrease in follicular si;e and appearanceof fluid in the cul-de-sac

Si;e of follicle : $1-$& m "17-$> mm#It is recommended to the monitoring of ovulationinduction in !T patients



!ccount for &/-*/0 of cases of female infertilityTubal factors : 5amage or obstruction of fallopian tubes

Peritoneal factor : Peritubal and periovarian adhesions

4auses : endometriosis, pelvic)tubal surgery, PI5 eg,

subclinical chlamydial infections

<ysterosalpingography "<S?# : Initial test of tubal patencyPerformed cycle days =-11

aparoscopy is the @gold standardA for diagnosing

tubal)peritoneal factorsFalloposcopy : 5irect observation of the the lumen offallopian tube

T2! ) P9IT%69! F!4T%S



.ore than +0 of cases

Post coital test "P4T# is to asses the Buality of

cervical mucus, the presence and number of motilesperm in the female reproductive tract after coitus,

and the interaction between cervical mucus and sperm

P4T should be performed 'ust before ovulation



!bnormalities of the uterus

Fibroids

59S e3posure in utero : T shape endometrial cavity

!sherman8s syndrome : Intrauterine adhesions

9ndometrial polyps

<ysteroscopy should be used to further define and treatabnormalities detected by <S?



!ntisperm antibodies "Ig? C Ig.# have been detected inhuman males and female

Ig? molecules may be found in serum as well as in

cervical mucus and semen

!gglutinating antibodies "Ig!# are typically found incervical mucus and seminal plasma

Ig. are found e3clusively in serumThe etiology of antisperm antibodies is not well definedand may be multifactorial



!ntisperm antibodies may interfere withfertili;ation by :

5isrupting sperm transport

%bstructing gamete interaction

Promoting sperm phagocytosis



Sperm !gglutinating test "Dibric(s8s or Fran(lin5u(es# and Sperm complement-dependentimmobili;ation test "Iso'ima8s# have been replaced

by the immunobead or mi3ed agglutination tests".! E mi3ed agglutination reaction#

The proper role of such testing is unclear

2se antibody testing in selected cases



Infections

The relationship between subclinical infectionand fertility has received considerableattention

Two potential pathogen :4hlamydia trachomatous

.ycoplasma species

4hlamydia may produces an asymptomaticinfection silent tubal infection tubaldamage



2ne3plained Infertility

easonable !pproach :1 ! semen analysis, <S? and documentation of

ovulation should be performed

$ 6ormal results laparoscopy

& 9tiology remains enigmatic endocrine evaluation"TS<, FS<, prolactin#

* 4ervical factor P4T and chlamydia cultures

+ 9valuation of sperm function hamster-egg test,9ndometrial maturation endometrial biopsy



Summary of the evaluation of the infertile couple



Treatment option

!bsolute infertility very few

.ost infertility therapy is directed towarddecreasing the time it would ta(e toconceive without intervention

Such therapy is often under ta(en in aneffort to achieve pregnancy before or

during the natural age-related decline infemale infertility



Treatment option

.ale factor infertility :1 .edical therapy

$ Surgical therapy

& !rtificial insemination : Intrauterine insemination Intracervical insemination Fallopian tube sperm perfusion

5irect intraperitoneal insemination Intrafollicular insemination



Treatment option

%vulatory factor ?reatest success rate

1 4lomiphene citrate

$ ?onadotropins

& Pulsatile ?n< therapy

* romocriptine and de3amethasone supplementation

+ Surgical therapy P4%

= uteal phase defect progesterone supplementatiand follicular phase clomiphene citrate use



Treatment option

Tubal and peritoneal factor!s success rates continue to improve for !T theindications for surgical therapy for tubal factorinfertility may become increasingly limited

Pro3imal tubal occlusion

5istal tubal occlusion

Sterili;ation reversal

Peritoneal factor endometriosis



4ervical factor infertility

Treatment directed for cervical stenosis or

poor mucus Buality!bnormalities not amenable to surgical therapymay bypassed by I2I, or by ovulation inductioncombined with IGF, ?IFT or HIFT

Treatment option



Treatment option

2terine factor predominantly surgical

2ne3plained infertility : %vulation induction

I2I

!T ?IFT



Treatment option

!ssisted eproductive Technologies "!T#

! typical protocol for standard IGF :1 ?n< agonist down regulation-prior ovulation inductio

$ Follicular maturation and ovulation are effected withh.?)h4? administration

& %ocyte retrieval is performed transvaginally by 2S?guidance

* !nalgesia for oocyte retrieval individuali;ed basis

+ 9mbryo transfer transcervical into the intrauterincavity

= uteal phase support

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18. Infertilitas wanita