pemeriksaan infertilitas pada wanita

INFERTILITAS PADA PELAYANAN
PRIMER
Dr. Yanasta Moendanoe, SpOG
SUBBAGIAN FERTILITAS ENDOKRINOLOGI REPRODUKSI
BAGIAN OBSTETRI & GINEKOLOGI
RS Dr.M.DJAMIL PADANG/FK UNAND
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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
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Kista ovarium
Operasi pelvis
Tuberkulosis
Appendektomi
Laparotomi
Seksio sesarea
Konisasi serviks
PAST
PRESENT
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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:
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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:
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Massa
Asites
Striae di abdomen
Scar operasi
Genitalia:
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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):
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Sulit, pasti terjadi bila kehamilan
telah terjadi
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Siklus haid teratur, variasi + 2
hari (95% ovulasi)
Kadar progesteron mid-luteal > 30
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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