FERTILITY AND INFERTILITY :

THE PURPOSE OF REPRODUCTION

STUDENTS’ WORKSHEET

Contributors :

Nurul Hidayati, dr., M.Sc

Hermawan Wibisono, dr., Sp.OG
Viera Wardhani, dr., M.Kes

Fakultas Kedokteran
Universitas Brawijaya
2013
 Ferlitility and Infertility :
The Purpose of Reproduction
Introduction
One organ system by which humans reproduce and bear live offspring is human
reproductive system. Humans continue their futue generation life allowing delivere of
hereditary traits from one generation to the next through mechanism called reproduction. This
process requires a mutual interdependent cooperation between male and female reproductive
system to be fertile. Conversely, any problems occur during the process may cause inability to
produce offspring. Talking about human growth population, human reproduction concern to
two disticnt condition leading to (very active) fertile or infertile states. Both sides have crucial
implication in a human life personally or in a public area. Hence, a doctor should be able to
identify various clinical conditions underlying problems of being infertile and is required to
promote management of family planning. Emphasis would be placed on covering problems of
infertility and family planning management. Some other materials relevant to the concern are
invited to build comprehensive understanding of the issue. It is recommended that students
revisite material available on blocks of Life Cycle and Endocrine System.

Learning objectives
- Identify problems of (very active) fertility and infertility viewed in biological and social
aspects
- Understand various clinical problems as the pathophysiology of being infertile for both male
and female reproductive system
- Identify the social factors influencing health reproduction
- Promote family planning management

Level of competency : 1, 2, 3B

Conceptual Framework

Human reproductive system works on some requirements and mechanisms. Provided

that the organ system of male and female are present and normally structured with functions
properly, to be fertile subsequent process must occur, including (1) the release of ovum or egg
at a specific time in the reproductive cycle in a process called ovulation, (2) an
internal fertilization of the ovum by spermatozoa, or sperm cells, (3) transport of the fertilized
ovum to the uterus, or womb, (4) implantation of the blastocyst, the early embryo developed
from the fertilized ovum, in the wall of the uterus, (5) formation of a placenta and maintenance
of the unborn child during the entire period of pregnancy. Any problems occur on both
structure and function of the reproductive system from both female and male may result in fail
to conceive a baby, a condition called infertility. The underlying mechanism disturbing the
reproduction process may come from various clinical problems such as endometriosis,
policystic ovary, infection, smoking etc. Students are recommended to identify many diseases
of reproductive system with condition leading to infertility problems by applying SKDI list of
reproductive diseases according to level of mastery to be a general practitioner.

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 INFERTILE

Various clinical problems

parturition such as Endomertiosis
Quality and quantity
F of Sperm PID, STD, Cysta ovarii
Reproductive Infection,
E smoking, etc
sperm
R
pregnanc
T y

I ovum

L
FUNCTION
development implantation fertilization ovulation
E Of
Reproduc
tive System

vagina uterus oviduct ovary

t

Anatomy Structure of Reproductive System

: various possible sites of being infertile

Fig. 1 Schema of being Fertile and Infertile following the present of

normal structure and function of Reproductive System

List of topics
- Fertility and Infertility from biological aspect
- Social determinants and consequences of Family Planning and infertility
- Hormonal Drugs
- Establishing infertility from medical check up

Module tasks
1. When will I become a mother ? (estimated time 15’)
One beautiful woman, Srikandi, a 33 year old nulligravida female with history of
infertility for two years came to your private clinic to do her second visit of medical
consultation with you. Srikandi brough you her result of hystersalpinogram showing
you that her fallopian tubes were open with normal uterine cavity. Previous history
taking reminding you that Srikandi had significant gynecology history for menarche at
age 14, and regularly occuring menstrual cycles at 28-30 days intervals without any
complaints. You were asking her to come with her husband together but she could only

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 come alone again. Srikandi’s husband believed that he would not have problem of
being sterile as he had a big family whereas Srikandi was the only child in her family. As
Srikandi live with her parents in law, she felt underpressure without the present of baby
in her small family. She would do anything to have a baby to defend her long-life
marriage. Srikandi might need your help with such explanation about her current
condition. You could help her by answering the following guidance of explanation :

a. Do you think Srikandi is suffering of primary or secondary infertility ? give

confidential reasons for your preference answer
Primary infertility. Because it is nulilgravida, she has not been pregnant yet before

Clinical definitions (WHO, 2013)

 Infertility is “a disease of the reproductive system defined by the failure to achieve a clinical
pregnancy after 12 months or more of regular unprotected sexual intercourse.”… (WHO-
ICMART glossary1).

Primary infertility (WHO, 2013)

When a woman is unable to ever bear a child, either due to the inability to become pregnant or
the inability to carry a pregnancy to a live birth she would be classified as having primary
infertility. Thus women whose pregnancy spontaneously miscarries, or whose pregnancy results
in a still born child, without ever having had a live birth would present with primarily infertility.

Secondary infertility (WHO, 2013)

When a woman is unable to bear a child, either due to the inability to become pregnant or the
inability to carry a pregnancy to a live birth following either a previous pregnancy or a previous
ability to carry a pregnancy to a live birth, she would be classified as having secondary
infertility. Thus those who repeatedly spontaneously miscarry or whose pregnancy results in a
stillbirth, or following a previous pregnancy or a previous ability to do so, are then not unable to
carry a pregnancy to a live birth would present with secondarily infertile.

b. What do you think about chance of Srikandi to bear offspring? give confidential
reasons for your preference answer. How about her husband ?
Prognosis terjadinya kehamilan tergantung umur suami, umur istri dan lamaya
dihadapkan pada kemungkiann kehamilan (frekuensi sanggama dan lamanya
perkawinan), (Sarwono, 2007). Seggama 4 kali seminggu paling meluangkann
terjadinya kehamilan karena kualitas dan jenis motilitas sperma meningkat dnegna
seringnya ejakulasi
Hasil penelitian Dor et al : istri yang baru dihadapkan kepada kemungkinan
kehamilan elama 3 tahun kurang, prognosis kehamilannya masih baik. Kalo sudah 5
tahun atau lebih, prognosis buruk. Begitu juga yag dikatakan Jones dan Pourmand
3 tahun : 50% kemungkinan hamil

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 5 thaun atau leih : 30%
Perlu pemeriksaan pada suaminya untuk mengetahui apakah ada masalah pada alat
reproduksi suami

c. How to confirm that someone is suffering of infertility ?

1. Pemeriksaan air mani
- Penampungan air mani, dnegna jalan masturbasi dimasukkan ke botol
bersih bermulut lebar setelah ansen seks 3-5 hari. Dari rumah pasien
dalam 2 jam dibawa ke lab
- Karakteristik air mani
Enzim likuefaksi, pengukuran viskositas dengan pipet Eliaasson. Menurut
Tjioe dan Oentoeng, tidak ada korelasi langsung antara viskositas yang
tinggi dan gerakan buruk sperma
- Rupa dan bau
- pH normalnya 7,3-7,7
jika pH lebih dari 8 : keradangan mendadak pada kelenjar
pH urang dari 7,2 : peradangan menahun
- fruktosa, hasil dari vesikula seminalis
pemeriksaan mikroskopik sperma
- konsentrasi sperma
menurut McLeod : konsentrasi untuk bis amenghamilkan adalah lebih
dari 20 juta/ml
- motilitas sperma
- morfologi sperma
uji ketidakcocokan imunologik (SCMC test)
2. masalah vagina , infeksi
3. masalah serviks, sumbatan kanalis servikalis, lender serviks yang abnormal,
malposisi dari serviks, atau kombinasi
uji pasca sanggama : pada tengah siklus haid , melihat jumlah spermatozoa
dalam lender serviks
uji in vitro : kemampuan sperma masuk ke lender serviks
4. masalah uterus
biopsy endometrium
histeroskopi : peneropongan kavum uteri
5. masalah tuba
pertubasi atau uji rubin : patensi tuba dengna jalan meniupkan gas co2 melalui
kanula atau kateter Foley yang dipasang di kanalis servikalis
6. masalah ovarium
perubahan lender serviks : uji membang lender serviks
catatan suhu basal badan
pemeriksaan hormonal
7. maslah peritoneum

d. Lists some possible causes influencing both male and female infertility, specific
female causes and specific male causes for the infertility ! and, in context of Srikandi
case, which causes might present ?
8. Pemeriksaan air mani

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 - Penampungan air mani, dnegna jalan masturbasi dimasukkan ke botol
bersih bermulut lebar setelah ansen seks 3-5 hari. Dari rumah pasien
dalam 2 jam dibawa ke lab
- Karakteristik air mani
Enzim likuefaksi, pengukuran viskositas dengan pipet Eliaasson. Menurut
Tjioe dan Oentoeng, tidak ada korelasi langsung antara viskositas yang
tinggi dan gerakan buruk sperma
- Rupa dan bau
- pH normalnya 7,3-7,7
jika pH lebih dari 8 : keradangan mendadak pada kelenjar
pH urang dari 7,2 : peradangan menahun
- fruktosa, hasil dari vesikula seminalis
pemeriksaan mikroskopik sperma
- konsentrasi sperma
menurut McLeod : konsentrasi untuk bis amenghamilkan adalah lebih
dari 20 juta/ml
- motilitas sperma
- morfologi sperma
uji ketidakcocokan imunologik (SCMC test)
9. masalah vagina , infeksi
10. masalah serviks, sumbatan kanalis servikalis, lender serviks yang abnormal,
malposisi dari serviks, atau kombinasi
uji pasca sanggama : pada tengah siklus haid , melihat jumlah spermatozoa
dalam lender serviks
uji in vitro : kemampuan sperma masuk ke lender serviks
11. masalah uterus
biopsy endometrium
histeroskopi : peneropongan kavum uteri
12. masalah tuba
pertubasi atau uji rubin : patensi tuba dengna jalan meniupkan gas co2 melalui
kanula atau kateter Foley yang dipasang di kanalis servikalis
13. masalah ovarium
perubahan lender serviks : uji membang lender serviks
catatan suhu basal badan
pemeriksaan hormonal
14. maslah peritoneum
air mani yang abnormal jika pada tiga kali pemeriksaan berturut turut abnormal
, varikokel, sumbatan vas, dan infeksi

pada masalah Srikandi kemungkinan masalahnya ada pada suami.

e. If Srikandi insist to do any effort to have her own baby, what would stages of
medical intervention she should take ? explain in details
- The induction of ovulation by use of FSH plus chorionic gonadotropin or clomiphene citrate
remarkably enhances the likelihood of multiple ovulations. The incidence of multifetal gestation
following conventional gonadotropin therapy is 16 to 40 percent, 75 percent of which are twins
(Schenker and co-workers, 1981). Tuppin
- ART (assisted reproductive therapy)
a. Inseminasi

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 b. IVF (in vitro fertilization)
f. What are the consequences of infertility to the health status and well being of
mother, couples, family and society

g. What are the social determinants that influences the burden of infertility problem to
the well being of mother, couples, family and society
- Loss of social status
- Social isolation
- Loss of social security
h. What would you suggest as the intervention strategy to control the social impact
(explain by identifying the health problem, risk factor, contributing risk factor; goal,
objective, sub objective, strategy and target population in each)
Health problem : infertility
Risk factor : kelainan pada alat kelamin pada pria ataupun wanita

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 Contributing risk factor : stress karena infertilitas sehingga meningkatkan
kemungkinan tidak memiliki anak
Goal : pasangan srikandi dan suami
Objective : membuat srikandi hamil dengan intervensi medis
Sub objective :Menurunkan tingkat stress srikandi
Target populasi : keluarga srikandi

2. “A lot of kids a lot of luck”

One other beautiful woman, Nawangwulan was a 27-year old breastfeeding
mother came to your private clinic while bringing her 6-month old cute baby. Applying
an exclusive breastfeeding with requency of at least 9 times a day to her baby,
Nawangwulan was still not confident whether the breastfeeding would prevent her to
get pregnant. Marrying Arjuna, her husband, about last ten years, Nawangwulan had
already gave him five children including the baby. Although her husband, would be
happy having many kids, Nawangwulan felt tired in passing all the process. She was very
busy in taking care all the children. She asked your help to find any contraception
intervention suitable to her current condition.
a. In selecting the most suitable contraception, what condition of Nawangwulan
should be considered ?
lactation
b. According to your above answer, why should we consider it? What clinical
implication might occur for inappropriate selection of contraception ?
Because she wants contraception in lactation period so the doctor should consider
the lactation. if we choose the wrong one, the milk will not be went out and it will
affect the health status of baby
c. What the specific feature of contraception required to select the most appropriate
one for Nawangwulan ?
Progestin-only
d. List examples of the recommended contraception for Nawangwulan !
- Progestin only
- Depo provera ( obat suntikan, 6-alfa-medroksiprogesteron)
- Norplant (AKBK) karena hanya mengandung progesterone (estrogen menghambat
prolaktin)
- AKDR
- tubektomi
e. What are the social determinant (behavior, husband, and acceptance) that need to
be considered when choosing the right contraception method

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 f. Explain the public health program related to this problems

g. Provide a communication steps for this case.

3. Ways to be infertile
In group of three person, you are assigned to complete task 3 to identify various
problems leading to infertility. The question sheet is available to your tutor

Note :
 We attach two references for public health discussion along with this worksheet. You may take
benefit of them in completing your assignment.