1 / 66

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

gerda
Télécharger la présentation

DIAGNOSIS DAN PENANGANAN INFERTILITAS PADA PRIA

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

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

  2. PENDAHULUAN • 10 – 15% pasutri ,hub.seksual normal tanpa kontrasepsi,belum hamil  Infertiliti Primer. • Faktor Infertiliti pasangan : • 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. ETIOLOGI • DISORDERS OF SPERM FUNCTION AND MOTILITY • Immotile Cilia Syndrome • Maturation defects • Immunologic infertility • Infection • DISORDERS OF SPERM DELIVERY / COITUS • Erectile dysfunction • Hypospadia

  9. 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.

  10. 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

  11. 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 +

  12. 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

  13. 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

  14. 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

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

  16. 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

  17. 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

  18. 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

  19. 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.

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

  21. 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

  22. 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

  23. 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

  24. ERECTILE DYSFUNCTION • ???

  25. 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.

  26. 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

  27. 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

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

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

  30. 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

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

  32. 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

  33. ICSI

  34. MALE CONTRACEPTIVE

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

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

  37. 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

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

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

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

  41. 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

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

  43. 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.

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

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

  46. 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

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

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

More Related