My Wife Havent Pregnant Yet

Anton's wife (Maria, 34 y.o) is not get pregnant after 1 year her married. Anton (35
years old) visited Reproduction Specialist doctor with his wife to have some consultation.
During consultation with doctor, Anton explained that he had his first "wet dreaming"
(ejaculation in sleep) at his 14 years old. Start from 25 years old he always use anabolic steroid
as addition of his fitness muscle building to get more gentle muscle performance. He is worry
if he get infertile. The doctor made some assessment include of Anton's erection and refer him
to do sperm analysis test and also did assessment of his wife reproduction condition include of
her menstruation history. Maria explained to doctor that she always feel pain during her
menstruation and she has not had her menstruation every month.
Learning task (female physiology)
1. Explain of the monthly ovarian cycle and control of ovarian function.
ovarian cycle berlangsung selama 28 hari dan dapat dibagi menjadi 3 fase yaitu fase folikular
(perbesaran folikel), ovulasi dan fase luteal.
a. Fase folikuler peningkatan kadar FSH dan LH akan mengakibatkan proliferasi
folikel primordial sehingga sekarang menjadi folikel primer. Folikel primer akan
mengalami proliferasi lebih lanjut, sel granulosa akan bertambah banyak dan terbentuk
sel theca interna (berfungsi untuk menghasilkan progesteron dan estrogen) serta sel
theca eksterna (sangat vaskuler dan membentuk kapsul folikel). Kemudian sel
granulosa akan mensekresikan cairan folikel yang banyak mengandung estrogen
dimana kumpulan cairan ini bernama antrum.
b. Ovulasi ovulasi dimulai dari perobekan stigma (dinding luar folikel yang menonjol)
sehingga cairan antrum keluar bersama dengan ovum. Pada fase ini, kadar LH yang
tinggi mengakibatkan pembengkakan folikel dan degradasi stigma sehingga folikel
pecah.
 c. Fase luteal sel-sel yang tersisa akan berubah menjadi korpus luteum. Pertumbuhan
korpus luteum bergantung kepada kadar LH dan FSH. Korpus luteum dapat
memproduksi estrogen dan progesteron.

control of ovarian function oleh GnRH, FSH dan LH

2. Explain of the menstruation and factors are related (e.g. behavior)

Menstruasi adalah proses peluruhan dari dinding endometrium akibat tidak terjadinya fertilisasi
ovum. Dimana endometrium dipertahankan oleh progesteron yang dibentuk oleh korpus
 luteum dan lama hidup korpus luteum bergantung pada kadar LH dan FSH. Ketika tidak terjadi
fertilisasi, kadar LH dan FSH akan terus menurun akibat feedback negatif dari progesteron
yang dihasilkan oleh corpus luteum sehingga terjadi penurunan kadar LH dan FSH yang
akhirnya akan mengakibatkan penurunan kadar progesteron kemudian peluruhan
endometrium.

Perubahan yang terjadi selama menstruasi :

Perubahan mood dan depresi (PMS dan PMDD/premestrual dysphoric disorder)
Kram perut/dysmenorhea
Bleeding

3. Discuss the influence of estrogens on female without and during pregnancy

a. tanpa kehamilan
uterus dan external female sex organ deposisi lemak ke mons pubis dan labia
mayora, perbesaran labia minora
tuba fallopii proliferasi lapisan granulosa
breast perkembangan jaringan stromal, deposis lemak
kulit menjadi lebih halus dan lembut
tulang meningkatkan aktivitasi osteoblast pada tulang bertambah tinggi,
dan menyambungkan epifisis
meningkatkan deposisi protein
meningkatkan deposisi lemak pada pantat dan paha
mengakibatkan retensi sodium dan air
b. selama kehamilan
Supporting, regulating, and stimulating the production of pregnancy hormones
Developing fetal organs such as the liver, kidneys, and lungs
Facilitating placental growth and function
Preparing the mother for lactation (breast-feeding) by encouraging maternal
breast tissue growth.

4. Discuss of correlation of ovulation and fertility

Ovulasi terjadi pada hari ke-14 setelah menstrual cycle dimulai dan ovum yang
diovulasikan memiliki waktu 24 jam untuk difertilisasi sebelum mengalami
disintegrasi. Tetapi sperma dapat bertahan dalam genetalia wanita selama 5 hari
sehingga terdapat fertile window yang dimulai 5 hari sebelum terjadinya ovulasi
sehingga antara mestrual cycle hari ke-9 sampai hari ke-14. Mestrual cycle dimulai
pada hari pertama menstruasi.

5. Explain Marias body changes and mechanism if she is getting pregnant

a. Hematologi
Volume plasma pada saat kehamilan mencapai usia 34 minggu, volume
plasma meningkat 50% dan sebanding dengan berat lahir bayi. The increase
in plasma volume plays a critical role in maintaining circulating blood
volume, blood pressure and uteroplacental perfusion during pregnancy.
 Hematokrit, RBC count, konsentrasi hemoglobin menurun karena terjadi
hemodilusi akibat ketidakseimbangan penambahan volume plasma dan
pembentukan RBC
Platelet count menurun tetapi masih dalam batas normal (100150 109
cells/L)
b. Cardiac changes
COP meningkat 20% dimulai dari usia kehamilan 8 minggu
Peripheral vasodilation leads to a 2530% fall in systemic vascular
resistance dimulai dari minggu ke-6 kehamilan, and to compensate for this,
cardiac output increases by around 40% during pregnancy. The maximum
cardiac output is found at about 2028 weeks gestation
The heart is physiologically dilated and myocardial contractility is increased
sehingga HR meningkat
c. Renal changes
GFR meningkat 50% akibat penurunan resistensi vaskuler sistemik dan
kembali normal 20 minggu postpartum
Penurunan BUN dan creatinine
increased renal blood flow leads to an increase in renal size of 11.5 cm,
reaching the maximal size by mid-pregnancy.
dilation of the ureters, renal pelvis and calyces, leading to physiological
hydronephrosis (right-sided predominance of hydronephrosis due to the
anatomical circumstances of the right ureter crossing the iliac and ovarian
vessels at an angle before entering the pelvis)
the reabsorption of glucose in the proximal and collecting tubule is less
effective glucosuria (110 g of glucose per day)
fractional excretion of protein may increase up to 300 mg/day
d. metabolisme air
sodium and water retention in the kidneys and create a hypervolaemic,
hypoosmolar state
e. respiratory changes
4050% increase in minute ventilation, mostly due to an increase in tidal
volume, rather than in the respiratory rate. This maternal hyperventilation
causes arterial pO2 to increase and arterial pCO2 to fall, with a
compensatory fall in serum bicarbonate to 1822 mmol/l.
f. Alimentary tract
Nausea and vomiting (resolve by week 20) due to elevated B-hCG
prolonged gastric empty time
decreased gastroesophageal sphincter tone, which can lead to acid reflux
decreased colonic motility, which leads to increased water absorption and
constipation.
g. Endocrine changes
Thyroid increase in the production of thyroxine-binding globulin (TBG)
by the liver, resulting in increased levels of thyroxine (T4) and tri-
iodothyronine (T3). Pregnancy is associated with a relative iodine
deficiency. The causes for this are active transport of iodine from the mother
 to the foeto-placental unit and increased iodine excretion in the urine. iodine
intake in pregnancy from 100 to 150200 mg/day
Adrenal gland The RAA system is stimulated due to reductions in
vascular resistance and blood pressure, causing a three-fold increase in
aldosterone levels in the first trimester and a 10-fold increase in the third
trimester. Increase in serum levels of deoxycorticosterone, corticosteroid-
binding globulin (CBG), adrenocorticotropic hormone (ACTH), cortisol
and free cortisol striae, facial plethora, rising blood pressure or impaired
glucose tolerance
Pituitary gland enlarges in pregnancy and this is mainly due to
proliferation of prolactin-producing cells in the anterior lobe. Increase in
prolactin is most likely due to increasing serum oestradiol concentrations
during pregnancy. Posterior pituitary produces oxytocin and arginine
vasopressin (AVP). Oxytocin levels increase in pregnancy and peak at term.
Levels of antidiuretic hormone (ADH) remain unchanged but the decrease
in sodium concentration in pregnancy causes a decrease in osmolality. There
is therefore a resetting of osmoreceptors for ADH release and thirst
Metabolisme glukosa Insulin-secreting pancreatic beta-cells undergo
hyperplasia, resulting in increased insulin secretion and increased insulin
sensitivity in early pregnancy, followed by progressive insulin resistance.
Maternal insulin resistance begins in the second trimester and peaks in the
third trimester. Insulin resistance and relative hypoglycaemia results in
lipolysis, allowing the pregnant mother to preferentially use fat for fuel,
preserving the available glucose and amino acids for the foetus and
minimising protein catabolism
Metabolisme lemak increase in total serum cholesterol and triglyceride
levels mainly as a result of increased synthesis by the liver and decreased
lipoprotein lipase activity. Increased triglyceride levels provide for the
mothers energy needs while glucose is spared for the foetus.
Metabolisme protein increased intake of protein during pregnancy.
Amino acids are actively transported across the placenta to fulfill the needs
of the developing foetus. During pregnancy, protein catabolism is decreased
as fat stores are used to provide for energy metabolism.
h. Skeletal and bone density changes Bone turnover is low in the first trimester and
increases in the third trimester when foetal calcium needs are increased.
i. Peningkatan berat badan akibat enlarging uterus, the growing fetus, the placenta
and liquor amnii, the acquisition of fat and water retention
j. Peningkatan ukuran dada karena persiapan laktasi.