Counsellor :

dr. Ni Made Indri Dwi Susanti,

Sp.OG
Presentation By:
Puty Annisa
Prilina
61112030

 OVERVIEW

Infertility is the failure to conceive (regardless

of cause) after 1 year of unprotected
intercourse. Infertility affects approximately 10-
15% of reproductive-aged couples

In societies where family planning and

professional career development are
prioritized, some women postpone
childbearing until their 30s and beyond

more difficulty conceiving

and have an increased risk
of miscarriage
 THEORY

A. DEFINITION

Infertility is defined as the

inability of a couple to
conceive within 1 year.
a problem faced by married
couples who have been married
at least one year, having regular
intercourse without using
contraception, but has not
managed to gain pregnancy
B. ETIOLOGY
1. Cervical
( stenosis, or abnormalities of the
mucus-sperm interaction)
2. Uterine
(may be associated with primary
infertility or with pregnancy wastage
and premature delivery)
3. Congenital defects FEMALE
The full spectrum of congenital/ FACTORS
mllerian abnormalities varies from total
absence of the uterus and vagina
4. Acquired defects
Endometritis associated with a traumatic
delivery, dilatation and curettage,
intrauterine device, or any
instrumentation (eg, myomectomy,
hysteroscopy) of the endometrial cavity
may create intrauterine adhesions or
synechiae
 Cont
6. Ovarian
Ovulatory dysfunction -> an alteration in the
frequency and duration of the menstrual cycle. ->
Primary and Secondary Amenorrhea,
oligomenorrhea.
7. Advance Age
The prevalence of infertility rises dramatically as
age increases
8. Tubal
abnormal implantation (eg, ectopic pregnancy)
9. Peritoneal
Anatomical defects or physiologic dysfunctions of
the peritoneal cavity, including infection,
adhesions, and adnexal masses, may cause
infertility
 Pretesticular factors
Pretesticular causes of infertility
include congenital or acquired
diseases of the hypothalamus,
pituitary, or peripheral organs that
MALE
FACTORS alter the hypothalamic-pituitary axis

Testicular factors
Testicular factors can be genetic or
nongenetic in nature. Klinefelter
syndrome is the most common
chromosomal cause of male infertility
and results in primary testicular failure
Posttesticular factors
Posttesticular factors are those that do not
allow the normal transport of sperm
through the ductal system. Such factors
can be congenital or acquired
BOTH
SEXES

Toxic effects
Environmental
related to
and
tobacco,
occupational
marijuana, and
factors
other drugs
Inadequate
diet associated
Exercise with extreme
weight loss or
gain
 C. RISK OF INFERTILITY
Age. A woman's fertility gradually
declines with age, especially in her
mid-30s, and it drops rapidly after
age 37 Tobacco use
Smoking can increase the risk of
erectile dysfunction and a low
Alcohol use sperm count in men
increases the risk of birth defects,
and may contribute to infertility. For
Being overweight
men, heavy alcohol use can decrease
A man's sperm count
sperm count and motility.
may also be affected if
he is overweight
Being underweight
such as anorexia or bulimia

Exercise issues. Insufficient exercise

contributes to obesity, which
increases the risk of infertility
 D. Diagnostic evaluation
OVULATORY
HISTORY AND PHYSICAL EXAMINATION FUNCTION
Serial basal body
temperature
Serum progesterone
Urinary LH
CERVICAL FACTORS Endometrial Biopsy
Speculum examination Transvaginal USG
OVARIAN RESERVE
Checking FSH & estradiol
level
UTERINE Antral follicle counts
FACTORS Ovarian volume
Pelvic Inhibin B
examination AMH
HSG, pelvic USG,
TUBAL AND PERITONEAL FACTOR
hysterosonogra
Laparoscopy, hysterosalpingogram
m, MRI,
laparoscopy,
hysteroscopy
Hysteroscopy
findings
Laparoscopic
findings
INDICATION : fail to Reproductive
achieve a sucessful history
pregnancy after 12 1. Coital freq and
months of regular timing
unprotected intercourse 2. Duration of
infertility and
Semen previous fertility
analysis 3. Childhood illness,
Help to define develop mental
severity of the
male factor.
history
Repeating the 4. Systemic medical
semen analysis illness
at least 1 month 5. Previous surgery
later is important
before a 6. Medications,
diagnosis is allergies
made. 7. Sexual history
8. Exposure to
INTERPRETATION OF SEMEN ANALYSIS

Azoospermia indicates absence of sperm that

could result from congenital absence or
bilateral obstruction of the vas deferens or
ejaculatory ducts, spermatogenesis arrest,
Sertoli cell syndrome, or post vasectomy.
Oligozoospermia indicates a
concentration of fewer than 20
million sperm/mL and may be
associated with ejaculatory
dysfunction
Asthenozoospermia indicates
sperm motility of less than
50%.
Teratospermia indicates an
increased number of abnormal sperm
morphology at the head, neck, or tail
level
Hypospermia indicates a decrease of
semen volume to less than 2 mL per
ejaculation.

Hyperspermia indicates an increase of

semen volume to more than 8 mL per
ejaculation.
Physical
Examination
1. Examination of the penis, noting
the location of urethral meatus
2. Palpation and measurement of
the testes
3. Presence and consistency of
both vasa and epididymides
4. Presence or absence of a
vaicocele
5. Secondary sex characteristics
6. Digital rectal examination where
indicated
E. TREATMENT
Options progress from at least to
most invasive or use of donor sperm
MILD TO MODERATE can be
treated with IUI (intrauterine
Insemination)
ICSI (Intra-Cytoplasmic Sperm
Injection) is conjunction with IVF
for severe disease (<4% normal
sperm)
The sperm can be retrieved
from the testes by MESA
or TESA
 CERVICAL FACTORS
Chronic cervicitis may be
treated with antibiotics
Artificial insemination can be
performed by depositing the
sperm at the cervical level
(cervical insemination)or
inside the endometrial cavity
(intrauterine insemination

UTERINE FACTORS
Chronic cervical factor of absence
of mucus - Intrauterine
insemination
Cervical incompetence - Cerclage
Damage/absence of fallopian tubes
(ectopic) - In vitro fertilization
ENDOMETRIAL POLYPS
are removed through operative
hysteroscopy associated with a
dilatation and curettage, if
necessary
MYOMA
Three modalities are used to
treat myomas: medical
treatment, surgical treatment,
and embolization
TUBAL AND PERITONEAL FACTOR
Tubal obstruction and lysis of adhesions can
be corrected through laparotomy, operative
laparoscopy, and, in special circumstances,
through operative hysteroscopy and tubal
cannulation.
OVARIAN FACTORS
The ovulation induction agents
used include clomiphene
citrate,aromatase inhibitors,
and hMG .

The standard dose of CC is 50 mg PO qd

for 5 days, starting on the menstrual
cycle day 3-5 or after progestin-induced
bleeding. As an antiestrogen, CC requires
that the patient have some circulating
estrogen levels; otherwise, the patient will
not respond to the treatment. The CC
response is monitored using pelvic
Aromatase inhibitors (letrozole,
anastrozole) inhibit the action of
the enzyme aromatase, which
converts androgens into
estrogens by a process called
aromatization

The usual dose for letrozole

ovulation induction is 2.5 mg on
cycle days 3-7.

Human menopausal gonadotropin

(hMG [eg, Repronex, Menopur])
contains 75 U of FSH and 75 U of
LH per mL, although the
concentration may vary among
batches (ranges from FSH at 60-
90 U and LH at 60-120 U).
Assisted Reproductive Technologies
(ART)

In Vitro Fertilization (IVF) is a process

which egg cells are fertilized in vitro, that is, by
sperm outside the womb.

IVF is a major treatment in infertility when

other methods of ART have failed. ART include
multiple techniques that allow gamete
manipulation outside the body and have
IVF indications
evolved have
greatly over departed
the from the
past 2 decades.
narrow scope of tubal infertility to other
indications that were almost impossible to
overcome, including infertility related to
oligospermia and obstructive azoospermia
 INDICATION OF
ART
Male factor endometriosi
infertility s

Tubal
disease Preimplantati
Unexplained Age related
( tubal and on genetic
infertility infertility
pelvic diagnosis
adhesions)
Absent or Donor eggs
damaged or
fallopian gestasional Recurrent
Decreased
tubes surrogate intrauterine
ovarian
insemination
reserve
failure
The following steps are required
during an IVF cycle:
Ovarian stimulation
Follicular aspiration
Oocyte classification
Sperm preparation
Oocyte insemination
Embryo culture
Embryo transfer
F. UNEXPLAINED INFERTILITY

A diagnosis of unexplained infertility is assigned to

couples with normal results of a standard
infertility workup. The main treatment options
include expectant observation with timed
intercourse, ovarian stimulation with or without
IUI and IVF. Studies support the use of clomiphene
with IUI for up to 4 cycles. The next step is usually
hMG with intrauterine insemination for 3 cycles;
if unsuccessful, IVF should be considered. Donor
oocytes or donor sperm may be considered in couples
with continued difficulties in achieving pregnancy. For
many, the hardest course to contemplate is no
G. COMPLICATION
The major complication ,associated with
ovarian stimulation is OHSS (ovarian
hyperstimulation syndrome)
Risk factor
Young
age
PCOS

Higher dose
of
gonadotropi
ns
High serum
estradiol
levels
 Primary infertility and endometriosis are
independent risk factors for ovarian cancer.
Although additional investigation is necessary, the
low incidence of ovarian cancer makes it difficult
to design an adequate study to detect an
association of infertility drugs with ovarian cancer

H. PROGNOSIS
The success rates of treatment for infertility
depends on a variety of factors, including cause
of infertility, womans age, duration of infertility,
and treatment modality