INFERTILITAS PADA PELAYANAN PRIMER
Dr. Yanasta Moendanoe, SpOG SUBBAGIAN FERTILITAS ENDOKRINOLOGI REPRODUKSI BAGIAN OBSTETRI & GINEKOLOGI RS Dr.M.DJAMIL PADANG/FK UNAND
• • • •
Nama : dr. Yanasta Moendanoe, Sp.OG Ttl : Pekanbaru, 23 Januari 1981 Status : Menikah Jabatan : Staf Pengajar Universitas Andalas Divisi fertilitas dan Endokrinologi Reproduksi
• Pendidikan : Fakultas Kedokteran Universitas Andalas • Spesialis Obgyn Universitas Andalas • Fellow Minimal Invasif Surgery World Class Laparascopy India • Member Of Indonesian Society Endoscopy Surgery • Pelatihan Asia Pasific Gynecologist Endoscopy • Tim Penyusu Panduan Nasional Pelayanan Kedokteran Infertilitas dan PUAI HIFERI Center padang
PREFACE • One in six couples have an unwanted delay in conception. • Roughly half of these couples will conceive either spontaneously or with relatively simple advice or treatment. • The other half remain subfertile and need more complex treatment, such as in vitro fertilisation and other assisted conception technique about half of these will have primary infertility.
DEFINISI PASANGAN INFERTIL Pasangan yang gagal mendapatkan kehamilan setelah menikah 1 tahun atau lebih dengan melakukan “hubungan” secara teratur dan tanpa proteksi 1 thn hrs dimulai investigasi
Pemeriksaan lebih Dini
• Umur lebih 35 tahun • Riwayat Oligo / Amenorrhea • Diketahui/curiga ada kelainan tuba / endometriosis • “Partner” juga subfertil
Definisi • Primary infertility—a delay for a couple who have had no previous pregnancies • Secondary infertility—a delay for a couple who have conceived previously, although the pregancy may not have been successful (for example, miscarriage, ectopic pregnancy) Sferof, Leon. Clinical Gynecologic Endocrinology & Infertility,
• ClickNational to add text Collaborating Centre for Women’s and Children’s Health 2004 84% dari pasangan dalam populasi umum bisa hamil dalam 1 tahun bila tidak memakai kontrasepsi dan melakukan hubungan seksual secara teratur.
Dari pasangan ini yang tidak hamil dalam tahun pertama, kira-kira setengahnya akan hamil dalam tahun kedua
Waktu yang dibutuhkan untuk konsepsi
PENYEBAB INFERTILITAS Faktor Pasangan 10%
5%
faktor tuba atau pelvis 35%
15%
Faktor Istri
faktor laki-laki
10%
10% 40%
gangguan ovulasi
gangguan ovulasi 40%
35%
faktor tuba atau pelvis
unexplained
unexplained
unusual (miom,polip)
unusual (miom,polip)
Factors affecting Fertility
Age • A strong association exists between infertility and increasing female age. • The reduction in fertility is greatest in women in their late 30s and early 40s. • For women aged 35-39 years the chance of conceiving spontaneously is about half that of women aged 19-26 years. • The natural cumulative conception rate in the 35-39 age group is around 60% at one year and 85% at two years.
Age • Recent evidence shows that male fertility also declines with age. • Genetic defects in sperm and oocytes that are likely to contribute to impaired gamete function and embryonic development increase with age. • The age related decline in female fecundity is caused by a steadily reducing pool of competent oocytes in the ovaries.
Timing of intercourse during ovulatory cycle • The window of opportunity lasts six days, ending on the day of ovulation • . A study by Dunson et al (2002) showed that the probability of conception rose from six days before ovulation, peaked two days before ovulation, then fell markedly by the day of ovulation. • This is consistent with the progesterone induced changes in cervical mucus that occur immediately after ovulation and impede the penetration of sperm.
Weight • Pregnancy is less likely if the woman’s body mass index (BMI) (weight (kg)/(height (m)2)) is > 30 or < 20. • Women with a BMI > 30 need advice about modifying their diet and doing more exercise to lose weight and they should aim for a BMI < 30. • Women with a BMI < 20 should be advised to gain weight and reduce exercise if they are exercising excessively.
Others factor • The chance of conception may be reduced by smoking, caffeine, and use of recreational drugs • Excess alcohol consumption in men can contribute to impotence and difficulties with ejaculation and may impair spermatogenesis
Investigations: who and when • infertility is defined as failure to conceive after one year of unprotected regular sexual intercourse. • Although usually it would be reasonable to start investigations after this time, earlier investigations and referral may be justified where there are important factors in either partner’s history
Ovulasi
Starting investigations in primary care Does the woman ovulate and if not why not? Initial investigations should be completed within three to four months and should establish the following points. • Does the woman ovulate? • If not, then why not? • Is the semen quality normal? • Is there tubal damage or uterine abnormality? Both partners must be investigated because an appropriate plan of management cannot be formulated without considering both male and female factors that may occur concurrently. I
Starting Investigation • Important to know the mechanism and characteristic of menstruation • Adequate physical examination included a Initial Pelvic examination need to perform. • There is no urgent situation of infertile condition • Preconception advice need to be done before secondary care (gynecologist)
PEMERIKSAAN INFERTILITAS WANITA
• • • • • • •
Kista ovarium Operasi pelvis Tuberkulosis Appendektomi Laparotomi Seksio sesarea Konisasi serviks
PAST
PRESENT
• • • • • • • • • • • •
Umur Pekerjaan Keluhan saat ini Galaktorea Eating disorder Diabetes mellitus/hipertensi Obat NSAID, steroid Rokok, alkohol Riw.menstruasi, menars, nyeri haid, amenorea Riw.obstetri: abortus, sepsis puerperalis Riw.KB: IUD Riw. Coitus: frek, lubrikan, vaginal duse, loss of libido, disparenia
PEMERIKSAAN INFERTILITAS WANITA UMUM: • • • • • • •
Tanda vital Berat badan dan tinggi badan BMI Karakter sekunder Pertumbuhan rambut >>, akne Akantosis nigrikan Abnormal skin depigmentation (vitiligo) Kelenjar tiroid
Mamae:
• evaluasi perkembangan, galaktorea Dada : • jantung dan paru
Abdomen: • • • •
Massa Asites Striae di abdomen Scar operasi
Genitalia: • • • • • • •
Ukuran dan bentuk klitoris Himen Ukuran, lokasi, mobilitas uterus Massa adneksa Vaginal discharge Kekakuan Nodul di cavum Douglasi endometrioisis/TBC
PEMERIKSAAN INFERTILITAS WANITA FAKTOR SERVIKS: • Keadaan serviks normal : mukus encer (watery) ok pengaruh hormon estrogen shg memudahkan sperma masuk. • Lendir serviks di bawah pengaruh hormon estrogen bisa diregangkan di antara 2 jari atau di antara 2 slide mikroskop > 10 cm(uji spinnbarkeit)
PEMERIKSAAN INFERTILITAS WANITA FAKTOR OVARIUM (OVULASI): •
Sulit, pasti terjadi bila kehamilan telah terjadi
•
Siklus haid teratur, variasi + 2 hari (95% ovulasi) Kadar progesteron mid-luteal > 30
• • • • • •
nmol/L (10-30 ng/ml)
Ultrasonografi (USG) serial : folikel de Graaf > 1.6 cm pecah, cairan di kavum Douglasi Lonjakan LH (LH surge) pd urine Suhu basal badan Penipisan mukus serviks
Sitologi hormonal mungkinkah
Preconception advice • Areas for discussion should include things that may improve the chances of conception or increase the chance of a successful outcome to the pregnancy (by minimising the risk of abnormality or of pregnancy related complications for baby and mother)
Preconceptional conseling
Counselling and fertility treatment • Adequate preparation through counselling before treatment can substantially decrease the “roller coaster” effect to which many couples have likened the experience of infertility treatment. • Expectations of reproductive technologies are often too high and, where treatment is unsuccessful, personal inadequacy and a sense of failure leave many feeling emotionally exhausted and vulnerable.
Investigasi lanjut
PEMERIKSAAN INFERTILITAS WANITA FAKTOR TUBA: • Patensi : sumbatan • Silia: rambut getar • Mobilitas: mendekap ovarium FALLOPOSCOPY
HISTEROSALPINGOGRAFI (HSG)
LAPAROSKOPI
PEMERIKSAAN INFERTILITAS WANITA FAKTOR UTERUS: • Tebal endometrium • Polip • Mioma
PENATALAKSANAAN INFERTILITAS WANITA FAKTOR SERVIKS: Faktor tuba: • Swab vagina + kultur • Kedua tuba tersumbat • Estrogen H8-9 (non paten) : In vitro • Inseminasi intra uterin fertilization + embrio suami transfer (bayi tabung), GANGGUAN OVULASI: adopsi • SOPK: induksi ovulasi, • Satu tuba tersumbat : metformin inseminasi intra uterin • Hiperprolaktinemia: bromokriptin
Take Home message 1. Skrining masalah infertilitas seharusnya sudah bisa dimulai dari tahap pelayanan primer bagi sejawat GP 2. Pengetahuan tentang siklus menstruasi,Ovulasi, kelainan ginekologi dasar melalui anamnesa, pemeriksaan fisik, dan ginekologi serta pemeriksaan penunjang sederhana sangat diperlukan sebagai tahap skrening awal infertilitas
3. Konseling terhadap faktor-faktor pendukung, penghambat dan faktor yang mungkin mempengaruhi fertilitas perlu dilakukan sedini mungkin melalui layanan primer sehingga dimungkinkan terapi yang lebih tepat dan cepat pada layanan sekunder dan tersier “ Lebih cepat, lebih tepat, lebih baik”
UMUR WANITA DAN MASA REPRODUKSI < 25 tahun, kesuburan wanita paling tinggi Usia 30 tahun mulai menurun dan umur 35 tahun menurun tajam Umur 40 tahun: kesuburan sangat rendah Tingkat Keguguran (%)
% Fertilitas maksimum
% Fertilitas maksimum Tingkat keguguran (%)
100
50
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 & Wilkins Philadelphia (2005) p : 1013 - 1056
BACK
Leon Speroff and Frits marc A. Clinical Gynecologic Endocrinology and Infertility. Ed. VII TH. Lippincott Williams & Wilkins Philadelphia (2005) p : 1013 - 1056 Back
Riw. Peny.radang panggul
Riw. Operasi tuba/KE
Kerusakan tuba >>
Riw. Ruptur appendiks
Riw. Abortus sepsis
