INFERTILITAS PADA PRIA

Niniek Fitriani Muin

C 111 12 325

Pembimbing Residen:
dr. Moh. Khaerumayansyah

Konsulen Pembimbing:
Dr. dr. Sharvianty Arifuddin, Sp.OG(K)

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 PENDAHULUAN
 Ketidakmampuan untuk menjadi hamil
setelah paling sedikit selama 1 tahun
melakukan hubungan seksual tanpa
perlindungan Infertil

 Faktor Infertiliti :
 Male 30%
 Both 20%

•Lee HD, Lee HS, Park S, Si D. Causes and classification of male infertility in Korea. Clin Exp Reprod Med, 2012; 39(4); 172-175
•Purnomo, Basuki B. Dasar-dasar Urologi Edisi Ketiga. Jakarta : Sagung Seto, 2012 2
ORGAN REPRODUKSI PRIA

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 FISIOLOGI REPRODUKSI PRIA
HYPOTHALAMUS-PITUITARY-GONADAL AXIS ( HPG )

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 TESTIS
 ENDOCRINE
– LEYDIG CELL  TESTOSTERON + 5g/hari,
2% (FREE)
– INCREASED LEVEL OF ESTROGEN &
THYROID  DECREASED SHBG.

 EXOCRINE
– SERTOLI CELL  GERM CELL GROWTH
 INHIBIN & ACTIVIN

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•Tanagho, Emil A., McAninch, Jack W. Male Infertility: Smith’s General Urology Sixteenth Edition. New York: Lange
Medical Book/Mcgraw-Hill, 2000
 SPERMATOGENESIS
SPERMATOGONIA
SPERMATOZOA

 13 STAGES

74 DAYS

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•Tanagho, Emil A., McAninch, Jack W. Male Infertility: Smith’s General Urology Sixteenth Edition. New York: Lange
Medical Book/Mcgraw-Hill, 2000
 ETIOLOGI

• PRE TESTICULAR :
• HIPOTALAMUS
• Endokrinopati
• Sexual dysfunction
HIPOFISIS
. Malignancy,radiation ,operation
. Hiperprolaktinemia
• TESTICULAR :
• CHROMOSOMAL ABNORMALITY
• UDT
• INFECTION
• MEDICATION
• INJURY
• VARICOCELE

•Purnomo, Basuki B. Dasar-dasar Urologi Edisi Ketiga. Jakarta : Sagung Seto, 2012
•Male infertility. Andrology Australia. 4 edition, 2014
•Sharma A. Male infertility: evidences, risk factors, causes, diagnosis and management in human. iMed Pub J, 2017; 15(3); 1-10
 ETIOLOGI
• POST TESTICULAR :
• CONGENITAL
OBSTRUCTION :
CYSTIC FIBROSIS
• ACQUIRED
OBSTRUCTION :
VASECTOMY
• FUNCTIONAL
OBSTRUCTION :
NEUROGENIC
• IDIOPATHIC 40%

•Purnomo, Basuki B. Dasar-dasar Urologi Edisi Ketiga. Jakarta : Sagung Seto, 2012 8
•Male infertility. Andrology Australia. 4 edition, 2014
•Sharma A. Male infertility: evidences, risk factors, causes, diagnosis and management in human. iMed Pub J, 2017; 15(3); 1-10
History of infertility Medical hystory Gonadotoxin

DURATION Systemic Illness ( i.e, DM ) Chemicals / pestisides

PRIOR PREGNANCIES Multiple sclerosis Drugs (chemo, cimetidine
PRESENT PARTNER Previous / current therapy Sulfasalazine,
PREVIOUS TREATMENT Nitrofurantoin,
EVALUATION & TREATMENT OF Smoking, Alcohol
WIFE Marijuana, Androgen
steroids
Thermal exposure
Radiation

Sexual Hstory Surgical History Family history

POTENCY ORCHIECTOMY CYSTIC FIBROSIS
LUBRICANTS RETROPERITONEAL, PELVIC ANDROGEN RECEPTOR
TIMING INJURY DEFICIENCY
FREQUENCY PELVIC, INGUINAL, SCROTAL INFERTILE FIRST DEGREE
SURGERY RELATIVES
HERNIORRAPHY
Y-V PLASTY, TUR-P
Childhood & Development Infection Review of System
UDT, ORCHIOPEXY VIRAL, FEBRILE RESPIRATORY INFECTIONS
HERNIORRAPHY MUMPS ORCHITIS ANOSMIA
Y-V PLASTY
VENEREAL DISEASE GALACTORRHEA
TESTICULAR TORSION
TERSTICULAR TRAUMA
TUBERCULOSIS, SMALLPOX IMPAIRMENT VISUAL FIELDS
ONSET OF PUBERTY 9
 PEMERIKSAAN FISIK
 Pemeriksaan genital eksterna : Testis,
epididymis, Vas deferens, varicocele,
colok dubur
 Karakteristik seks sekunder ;
penyebaran rambut ketiak,pubis dan
badan tumbuh besar.
 abnormal ; gynecomastia,
anosmia(Kallmann), galaktore,
ggn lap.penglihatan.
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•Purnomo, Basuki B. Dasar-dasar Urologi Edisi Ketiga. Jakarta : Sagung Seto, 2012
 PEMERIKSAAN AWAL

Urinalysis
Semen analyses
 Speciment were obtained correctly !!!
 Abstinence 2-3 days, no delay before the analyses.

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•Purnomo, Basuki B. Dasar-dasar Urologi Edisi Ketiga. Jakarta : Sagung Seto, 2012
 KARAKTERISTIK SPERMA
NORMAL

 Volume 1,5 - 5 ml
 Conc > 20 million/ml,
total > 50 million
 Motile > 50%
 Motile grade >2
 normal morphology
>30-50%
 Fructose +
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•Purnomo, Basuki B. Dasar-dasar Urologi Edisi Ketiga. Jakarta : Sagung Seto, 2012
 Hormonal evaluation
(LH, FSH, Testosteron, Prolactine)

 less then 3% showed abnormalities

 Indications : < 5 million/ml, sugest
endocrinopathy

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•Purnomo, Basuki B. Dasar-dasar Urologi Edisi Ketiga. Jakarta : Sagung Seto, 2012
•Nikoobakht, Mohammad Reza, et al. The Role of Hypothyroidism in Male Infertility and Erectile Dysfunction. Urology Journal, 2012; 9; 405-409
 HORMONE PROFILE
CONDITION T FSH LH PRL

NORMAL NL NL NL NL

PRIMARYTESTIS FAILURE LO HG NL/HG NL

Hypogonadotrophic-hypogonadism LO LO LO NL

HYPERPROLACTINEMIA LO LO/NL LO HIGH

ANDROGEN RESISTANCE HG HG HG NL

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•Purnomo, Basuki B. Dasar-dasar Urologi Edisi Ketiga. Jakarta : Sagung Seto, 2012
•Nikoobakht, Mohammad Reza, et al. The Role of Hypothyroidism in Male Infertility and Erectile Dysfunction. Urology Journal, 2012; 9; 405-409
 PEMERIKSAAN TAMBAHAN
•Antisperm antibody test
•Computerized assisted semen analyses (CASA)
•Hypoosmotic swelling test
•Sperm penetration assay
•Sperm-cervical Mucus interaction
•GENETIC EVALUATION
•Chromosomal study
•Cystic fibrosis mutation testing
• Y chromosome microdeletion analysis
•Radiologis : usg, venography, CT/MRI pelvic
•Biopsi Testis & Vasography
•FNA mapping of testis
•Semen culture

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•Purnomo, Basuki B. Dasar-dasar Urologi Edisi Ketiga. Jakarta : Sagung Seto, 2012
PENATALAKSANAAN

SURGICAL
THERAPY
SEMEN ANALYSIS

HISTORY
NON
HORMONES SURGICAL
TREATMENT
PHYSICAL
ASSISTED
ADJUNCTIVE REPRODUCTIVE
TEST TECHNIQUE

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 Non Surgical Treatment
SPECIFIC THERAPY

HYPOGONADOTROPHIC-HYPOGONADISM

 INCIDENCE ; LOW
 ACQUIRED / CONGENITAL (KALLMANNIS SYNDROME)
 DUE TO DECREASED PRODUCTION OF GnRH
 ASSOCIATED WITH OTHER CONG ANOMALY : ANOSMIA,
DEAFNESS, CLEFT PALATE, RENAL ANOMALIES
 ACQUIRED : PITUITARY TUMOR/TRAUMA, ISOLATED
GONADOTROPIN DEFICIENCY, ANABOLIC STEROID USE.
 DIAGNOSTIC TEST : CT / MRI  RULE OUT TUMOR
 THERAPY : hCG 1500-3000 IU sC 3 times weekly for 8-12
weeks, then hMG 37,5-150 IU sC 2-4 times weekly

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•Purnomo, Basuki B. Dasar-dasar Urologi Edisi Ketiga. Jakarta : Sagung Seto, 2012
 Non Surgical Treatment
SPECIFIC THERAPY

HYPERPROLACTINEMIA

 INCIDENCE ; LOW
 HYPERPROLACTINEMIA  NEG FEEDBACK TO GnRH,
INHIBITORY EFFECT on LH BINDING to LEYDIG
INFERTILITY, ERECTILE DYSFUNCTION
 ETIOLOGY : HIPOPHYSEAL TUMOR, HYPOTHYROIDSM, LIVER
DISEASE, DRUGS (Phenothiazine, Tricyclic Antidepresant, some
antihypertensive)
 DIAGNOSTIC TEST : CT/MRI  RULE OUT TUMOR
 THERAPY :
– CAUSAL or
– BROMOCRIPTINE 2,5 -7,5 mg 2-4 TIMES DAILY

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 Non Surgical Treatment
SPECIFIC THERAPY

ISOLATED TESTOSTERON DEFICIENCY

 PRIMARY HYPOGONADISM ( LEYDIG CELL FAILURE ) 

DECREASED LEVEL OF TESTOSTERON  DECREASED LIBIDO
& SEXUAL FUNCTION ( ERECTILE DYSFUNCTION, etc)
 INCIDENCE ; RARE
 THERAPY :
– TESTOSTERON ENANTHATE / PROPIONATE im
– Hcg 1500 iu t.i.w

ISOLATED LH DEFICIENCY / FERTILE –EUNUCH

SYNDROME

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 Non Surgical Treatment
SPECIFIC THERAPY

CONGENITAL ADRENAL HYPERPLASIA

 INCIDENCE : RARE
 DEFICIENCY OF ADRENAL HYDROXYLASE  DECREASED
CORTISOL SECRETION  INCREASED ACTH  INCREASED
ADRENAL ANDROGEN PRODUCTION  DECREASED Gnrh 
SUPPRESSES SPERMATOGENESIS.
 DIAGNOSTIC TEST : Urinary 17-KETOSTEROID or
DEHYDROEPIANDROSTERON (DHEA)

 THERAPY : GLUCOCORTICOID REPLACEMENT.

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 Non Surgical Treatment
SPECIFIC THERAPY

IMUNOLOGIC INFERTILITY

 EVEN oral PREDNISON CAN DECREASED ASA,  ITS RARELY

SUCCESSFUL
 TREATMENT OF CHOICE ; ART  ICSI
 3 – 7% MALE INFERTIL

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 Non Surgical Treatment
SPECIFIC THERAPY

GENITAL TRACT INFECTION

 EFECT of GTI
  ABNORMAL SEMEN QUALITY < 2%
 Severe (Enterobacteriaceae, Chlamydia, Gonorrhoeae) 
TESTIS ATROPHY / EPIDIDYMAL DUCT OBSTRUCTION
  generate ROS  harm sperm’s ability to fertilize

 Therapy ; Antibiotics
 Persistent Obstruction  Surgery

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 Non Surgical Treatment
SPECIFIC THERAPY

RETROGRADE EJACULATION
 ETIOLOGY :
– ANATOMIC, : BLDDER NECK SURGERY
– NEUROGENIC, : SPINAL CORD INJURY, RETROPERTONEAL
SURGERY, DIABETES MELITUS
– PHARMACOLOGIC : NEUROLEPTICS, TRICYCLIC
ANTIDEPRESSANT, ALPHA BLOCKERS, ANTIHYPERTENSIVE
– IDIOPATHIC
 DIAGNOSTIC TEST : POST EJACULATE URINE

 THERAPY :
– ALPHA ADRENERGICS AGONIST (EPHEDRINE,
PSEUDOEPHEDRINE, IMIPRAMINE, PHENYLPROPANOLAMINE
– ART  INTRAUTERINE INSEMINATION

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 Non Surgical Treatment
SPECIFIC THERAPY

ANEJACULATION

 INCIDENCE : RARE
 ETIOLOGY :
– NEUROGENIC, : SPINAL CORD INJURY, RETROPERTONEAL
SURGERY, DIABETES MELITUS, TRANSVERSE MYELITIS, MULTIPLE
SCLEROSIS
– PSYCHOGENIC / IDIOPATHIC
 DIAGNOSTIC TEST : POST EJACULATE URINE

 THERAPY :
– RECTAL PROBE EJACULATION
– PENILE VIBRATORY STIMULATION

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 Non Surgical Treatment
EMPIRIC THERAPY

 INDICATION : IDIOPATHIC OLIGOSPERMIA

 DRUGS CATEGORY FOR EMPIRYC THERAPY:
– CLOMIPHEN CITRATE
– TAMOXIFEN
– ANDROGENS
– TESTOSTERON REBOUND
– AROMATASE INHIBITORS
– GONADOTROPINS
– GnRH
– KALLIKREINS
– PROSTAGLANDIN SYNTHETASE INHIBITORS
– BROMOCRIPTINE
– PENTOXIFYLLINE
– ANTIOXIDANTS
– CARNITINE.

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 Non Surgical Treatment
CLOMIPHEN CITRATE EMPIRIC THERAPY

 SYNTHETIC, NONSTEROIDAL ANTI-ESTROGEN

 BINDS TO ESTROGEN RECEPTOR COMPETITIVELY IN THE
HYPOTHALAMUS, AND HYPOPHISE  BLOCKING
FEDBACK  AND INCREASING SECRETION OF GnRH,
FSH, LH
 DOSES ; 12,5-50 mg/d, CONTINUOUSLY FOR 25 d, WITH 5-
d REST PERIOD each MONTH, FOR 6 MONTHS
 FOLLOW-UP : TESTOSTERON LEVEL MUS BE IN NORMAL
LIMIT. FREQUENT SEMEN ANALYSES.
 SIDE EFFECT : GYNECOMASTIA, NAUSEA, DIZZINESS,
VISUAL COMPLAINT, ALLERGIC DERMATITIS
 RESULT : 3-9 MONTHS, PREGNACY RATE 22-58%

 TAMOXIFEN : WORK IN MANNER AS CLOMIPHEN, BUT

WITH LESS ESTROGENIC EFFECT
 DOSES ; 10-15 mg/ TWICE d

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 Non Surgical Treatment
ANTIOXIDANT EMPIRIC THERAPY

 RECENT STUDIES DEMONSTRATED AN INCREASED OF

ROS in IDIOPATHIC SUBFERTILITY
 ROS INCLUDE ; HYDROXYL RADICAL (OH), SUPEROXIDE
ANION (O2), HYDROGEN PEROXIDE (H2O2)
 ROS  DAMAGE SPERM LIPID MEMBRANE

 VITAMIN E 400-1200 iu /D IMPROVED CAPACITY FOR

SPERM-OOCYTE FUSION IN-VITRO
 GLUTHATION 600 mg/d

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 PEMBEDAHAN

 Varicocelectomy
 Vasovasostomy,
Epididymovasostomy, TUR of
Ejaculatory duct
 Ablation of Pituitary Adenoma

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PROPILAKSIS PEMBEDAHAN

 Orchydopexy
 Operation for Testicular Torsion

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 ASSISTED REPRODUCTIVE
TECHNIQUES
If neither Surgery nor medical therapy is
apropriate  A logical treatment, technique
atempt to overcome the problems of reduced
sperm motility and number is ART
Sperm Donation :
Husband or Others
Technique of sperm extraction :
Ejaculate
MESA
TESE

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INTRAUTERINE INSEMINATION
 PLACEMENT OF WASH PELLET
EJACULATE WITHIN UTERUS
 INDICATION ;
 BY PASS CERVICAL FACTORS
 IMUNOLOGIC INFERTILITY
 LOW SPERM QUALITY
 MECHANICAL PROBLEM OF SPERM DELIVERY

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 IVF & ICSI
 EXCELLENT TECH, BY PASS MODERATE
TO SEVERE FORMS OF MALE
INFERTILITY
 IVF ; 500.000-5.000.000 MOTILE
SPERMA AND EGGS ARE FERTILIZED IN
PETRI DISHED
 ICSI ; 1 VIABLE SPERM INJECTED INTO
CYTOPLASMIC AREA

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THANK YOU

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