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Saturday, 17 May 2014

Aspects of male and female infertility / INFERTILITAS ASPEK PRIA DAN WANITA

Aspects of male and female infertility


 many infertile couples  can be calculated from the number of women who never marry, nor have children who are still alive, then according to the census there were 12% in both rural and urban, or think - about 3 million infertile couples in the whole of Indonesia.
In present-day medical science has managed to help infertile couples have 50% of their children. That means the other half are forced to live without children, adopt a child (adoption, polygamy, or even divorced.
Truly for the health of family planning is never complete without penganggulan infertility problems. In terms of health, family planning should include the prevention and treatment of infertility, especially if it happened before before couples have children - children she wanted. Moreover penganggulan alongside infertility family planning services that make the latter more easily acceptable, because it obviously takes into account programs such as happiness and well-being of the family. 2
Since some twenty years ago has been a lot of investigation that links fertility with husband semen analysis, especially spermatozoanya concentration. MacLeod & Gold in 1951 have reported the results of their investigation to the husband that his wife was 1.000 checkups. At that time there were only 5% with a concentration of less than 20 million spermatozoa / ml, whereas 44% of more than 100 million / ml. Twenty-four years later, Rehan et al reported the results of their investigation to the husband who will divasektomi 1300. Apparently, the 7% concentration spermatozoanya less than 20 million / ml, but only 24% are more than 100 million / ml. Zukermaan et al, 4122 investigated a husband who will divasektomi, there is a 12% concentration of less than 10 million spermatozoa / ml. Thus, the results of recent investigations differ from results obtained by MacLeod & Gold.
Such changes can only be explained by a decrease in fertility minimum standards due to rising fertility potential husband and wife. The wife is not ovulating can always fertilized egg cell, for example due to luteal phase defect, short luteal phase or ignorance when - when fertile in order to make pregnancy intercourse. More advanced treatment of the disorders - disorders in the wife's menstrual cycle and lighting - lighting that adds to the knowledge partner for intercourse at the time - if desired fertile time pregnancy, has increased the fertility potential of the wife so that only the required concentration of spermatozoa is not too high to make the pregnancy. 1



















                                                
                                                             
Definition
Fertility is the ability of a wife to become pregnant and give birth to a child who is able to live by husband menghamilkannya. So fertility is a function of the partner who could make pregnancy and live birth. 1 Sterility is the term used for someone who is absolutely not possible to get offspring for example, women with genital aplasia or male without testes. Infertility is the diminished fertility. A so-called infertile couples when the wife is not pregnant within 12 months (1 year) after mating without practicing contraception (intentional).
According to Whitelaw 56.5% of healthy couples become pregnant in the first month and 78.9% in the first 6 months. Infertility is divided in two, there is primary infertility and secondary infertility. 2
The definition of primary infertility is if the wife had never been pregnant though copulate and faced with the possibility of pregnancy for 12 months. Called secondary infertility when his wife was pregnant, but then does not happen again though copulate pregnancy and faced with the possibility of pregnancy for 12 months. 1

Etiology


Factors that may cause infertility can of factors husband or wife, or both. 18.8% Husband, wife 32%, both 18.5%, of unknown cause 11.1% and 5.6% other causes. Other factors that increase the risk of infertility may include pelvic inflammation, endometriosis, environment / atmosphere, and factors associated with toxin derived from tobacco, marijuana and other drugs, body movement, and increasing age. 4


In general, the cause of infertility associated with physical conditions, processes, and time.
1.   physical condition
Fertility is largely determined by the physical condition of the husband and wife. This is related to the formation and quality of sperm or egg cells. The quality   of sperm and egg cells are influenced by many factors, including: age, genetics kelaianan, certain illnesses.
2.   process
 Success or failure of the process of pregnancy is influenced by many factors, including: method of contraception (condom use in men and women do not allow the diaphragm to the occurrence of pregnancy); some anatomical abnormalities, such as abnormalities in the uterus; ovulation disorders; implantation failure; endometriosis.
3.   Time
in women, the egg is only produced once every month, so it is important   to know the fertile periods.
Because - because infertility: 2
I.                    Infertility intentional:
a.     husband By:
-           coitus interruptus
-           condom
                  -      sterilization (vasectomy)
b.     By wife:
-           how - how people such as irrigation water saturated salt
-           Periodically istibra
-           how the chemical form of an ointment or tablets
-           means - mechanical means: pessarium occlusivum
-           IUD
-           Oral pills
-           injectables
-           Sterilization

II.                 Infertility intentional
                  Because - because the husband:
1.        Impaired spermatogenesis (aspermia, hypospermia, necrospermia): for example, due to abnormalities or testicular disease, endocrine disorders.
2.       mechanical abnormalities so that sperm can not be issued to the top of the vagina, such as: impotence, hypospadia, ejaculatio praecox, closure of the ductus deferens, phymosis.       
                  Because - because the wife:
1.      Disorders of ovulation for example due to ovarian abnormalities or hormonal disorders.
2.     mechanical abnormalities that any particular conception as tubal disorders, endometriosis, cervical canal stenosis or hymen, fluor albus.

Male factor infertility: 3
Impaired spermatogenesis
Genetic                                  
Klinefelter's syndrome (XXY sex chromosomes): enukoid body shape, there is gynecomastia, small testes and hard, low libido and sexual potency, volume of ejaculate a little, azoospermia. Eifenstein syndrome (hypogonadism post-puberty): testicular atrophy occurs before puberty, gynecomastia there and hypospadias. Gonadotropin levels increased. Male Turner syndrome (genotype characteristics of men with Turner syndrome): a small agency, web neck, Cubitus valgus, small testes, testicular tissue are histological abnormalities. High gonadotropin levels.
Congenital
Anorchidi there is no testicles. No puberty. There is no sign of progress - sexual sign. Del-castille syndrome is testicular cells containing only sertolli, no tubular network. Can be unilateral or bilateral. May occur for example if there is a decrease in testicular disorders (undescended testes). Testia abnormal, for example, there is impaired Leydig cell function.
Testicular tissue abnormalities due to other causes
Orchitis is inflammation of the testicles, can be caused kompilkasi mumps, varicella, tuberculosis, sifiis, gonorrhoeae, or infection - other infections. Destruction or testicular atrophy can be caused by tumors, torsion, trauma, irradiation, postoperative urogenital. Varicocele is a buildup of fluid in the lining of the testicles, causing increased pressure in the testicular tissue and disrupt testicular physiology.
Disorders of sperm transport
Anatomical abnormalities
 Intratestikular levels difficult to detect. For example, there are levels of epididymal abnormalities such as congenital hypo / agenesis entire ductus epididymis, obstruction due to inflammation (epididymitis), tumors and so on. The level of the vas deferens for example due to congenital abnormalities (agenesis / regression), infection, narrowing / blockage for example due to complications of hernia surgery, vasectomy operation. Ejakulatoris duct level, can be due to congenital abnormalities (agenesis / regression), infection. The level of the urethra, eg hypospadias, Peyronie's disease.
Physiological disorder / disfunction
Impotence / erectile dysfunction can not cause penile penetration - vaginal optimal. Retrogarde ejaculation ejaculation disorders eg due to complications of the disease / pelvic area surgery, so that ejaculation does not occur in the direction of forward / backward rather urethra (urinary bladder).




INFERTILITY OF WIFE FACTOR 1
Vaginal Problems
Ability deliver semen into the vagina around the cervix needs to fertility. Vaginal problems that can hamper the delivery is blockage or inflammation. The blockage is called vaginismus or dyspareunia psikogen, whereas anatomic obstruction can be due to congenital or acquisition. Vaginitis due to Candida albicans or Trichomonas vaginalis Violent is a problem, not because antispermisidalnya, but antisanggamanya.       

Cervical Problems                                                         
Sims in 1868 was the first to connect the cervix with infertility, cervical mucus examination pascasanggama, and perform artificial insemination. It was some time later Huhner introduce pascasanggama test conducted in mid-menstrual cycle.
Cervical usually leads to under-back, so face to face with the back wall of the vagina. Such a position enables it flooded in semen delivered at the posterior fornix.
The seminal canal is lined grooves - grooves like glands that secrete mucus, a portion of the cells - the cells have cilia epitelnya cervical mucus that drains into the vagina. Kanalia shape as it allows ditimbu and maintenance of motile spermatozoa from the possibility of phagocytosis, and also ensuring the delivery of spermatozoa into the cervical canal continuously for a long time.
Migration of spermatozoa into the cervical mucus can already occur on day 8 or 9, reaching a peak at the time - the time of ovulation. spermatozoa are able to get to the cervical mucus 1 ½ - 3 minutes after ejaculation. Spermatozoa are left in the vaginal environment more than 35 minutes are no longer able to migrate into the cervical mucus. Motile spermatozoa in cervical mucus can live up to 8 days post-coitus.
Infertility associated with cervical factor may be caused by blockage of the cervical canal, the cervical mucus is abnormal, malposition of the cervix, or a combination thereof. There are a variety of anatomical abnormalities of the cervix that can play a role in infertility, which is a congenital defect (atresia), cervical polyps, stenosis due to trauma, inflammation (chronic cervicitis), synechiae (usually in conjunction with intrauterine synechiae) after conization, and inadequate insemination.

Uterine problems
Spermatozoa can be found in the human Fallopian tube as soon as 5 minutes after insemination. Compared with spermatozoa and the large distances that must be gone through, would not be possible migration of spermatozoa takes place only because the movement itself. Admittedly, vaginal and uterine contractions play an important role in the transport of spermatozoa. In humans oxytocin did not affect the non-pregnant uterus but prostaglandins in semen can make the uterus to contract rhythmically. turns prostaglandinlah that plays an important role in the transport of spermatozoa into the uterus and uterine boundary passes through the constriction on the tube. Anyway it turns out, the uterus is very sensitive to prostaglandins in the late proliferative phase and early secretory phase. Thus, the lack of prostaglandins in semen can be an infertility problem.
Another problem that can interfere with sperm transport through the uterus is due to distortion of the uterine cavity synechiae, myomas, or polyps; endometrial inflammation, and disorders of uterine contractions. Disorders - disorders that can interfere in the case of implantation, intrauterine growth, and nutrition and fetal oxygenation.



Problems Tuba
The frequency of tubal factor in infertility is very dependent on the population investigated. The role of tubal factor that makes sense is 25-50%. Accordingly, it can be said the most common tubal factor in infertility problem. Therefore, the assessment of tubal patency is considered as one of the most important examinations in the management of infertility.

Ovarian Problems
                        
          Detection of ovulation infertility examination is an integral part of pregnancy is not possible without ovulation. Infrequent ovulation can cause infertility.
          Prompt detection of ovulation is needed if artificial insemination, determine when sexual intercourse is rarely done, or if the menstrual cycle is very long. Regular menstrual cycles and duration of menstruation is usually the same menstrual cycle is ovulating. According to Ogino, next menstruation 14 ± 2 days after ovulation. Irregular menstrual cycles, with duration of menstruation that is not the same, very likely due to anovulation. Amenorrhea is almost always accompanied by a failure of ovulation.
          Ovulation sometimes - sometimes characterized by abdominal pain under the left or right, to think - about the middle of the menstrual cycle is considered a sign of ovulation, which has been proven to be true by the way Wharton & Henriksen laparotomy.
When - when ovulation sometimes - sometimes accompanied by vaginal discharge, cervical mucus as a result of excessive spending; and sometimes - sometimes accompanied by bleeding a little.

Hormonal Problems
          Appropriate hormonal balance is also an important requirement for the physiology of the female reproductive system cycle is good. The state of infertility which may be due to hormonal problems, for example:
  1. gonadotropin deficiency (hypogonadism)
  2. malfunctioning sex glands (hypogonadism)
  3. hypogonadotropic hypogonadism combined-
  4. hyperprolactinemia

Diagnosis 1
The diagnosis of infertility include history, physical examination and investigation. The diagnosis that covers things mentioned above should be done by both parties, both husband and wife.
Terms - examination requirements:
Every infertile couples should be treated as one entity. That means if the wife alone while her husband does not want to be examined, the couple was not examined.
As for the condition - a condition inspection infertile couples are as follows:
1. The wife is aged between 20-30 years will be inspected after trying to have children for 12 months. Checks can be done earlier if:
    • have had recurrent miscarriages           
    • known to have endocrine disorders
    • had experienced pelvic inflammation or abdominal cavity,
    • never experienced gynecologic surgery.   
2. Wives between the ages of 31-45 years can be checked on the couple's first chance came to the doctor.
3. Wives of infertile couples aged 36-40 years of infertility examination only if you do not have children of this marriage.
4. Infertility examination is not performed on infertile couples in which one partner members diseases that can endanger the health of his wife or children.


The main examination: 2
1.      examination of ovulation
2.     examination of sperm
3.     examination of the cervix mucus
4.     examination of tubal
5.     examination of endometrial
The existence of ovulation, sperm good, normal cervical mucus, tubal patent, and normal endometrium is a necessary condition to allow a pregnancy.

Plan and schedule the examination 1                           
Plan and schedule inspection infertility husband and wife during the wife's menstrual cycle 3.

I. Examination in men
2 To assess sperm then was examined over the number of spermatozoa, shape and movement. Preferably sperm checked, accommodated after the couple not to practice at - least 3 days and sperm should be examined within 1 hour after exit.
Normal ejaculate:                           
  • Volume: 2-5 cc
  • The number of spermatozoa: 100-120 million percc
  • Movement: 60% of spermatozoa are still moving for 4 hours after issued
  • Abnormal shape: 25%    
  • To fertile spermatozoanya: 60 million cc or more
        • Subfertil   : 20-60 million per cc
        • Sterile        : 20 million per cc ​​or less


Shelter semen. 1
Semen collected by masturbation directly into the path clean glass bottle wide mouthed, after abstinence 3-5 days.
Semen characteristics :
1.      coagulation and likuefaksi. Ejaculated semen in liquid form will soon be "in order" or coagulum, and then melikeufaksi again in 5-20 minutes into a somewhat thick liquid that allows the sperm to move freely. Likuefikasi coagulation process and is regulated by the enzyme. One factor could be separated from likuefikasi have normal semen, which turned out to be a proteolytic enzyme with a molecular weight of 33,000. enzyme was shown to melikuefikasikan semen can not berlikuefaksi.
2.     Viscosity.   Upon berlikeufaksi, ejaculate will be rather dense homogeneous fluid, which can be interminable kalu dicolek a stick. Membenangnya power can reach 3-10 cm. More precise measurements with pipette Eliasson is at atmospheric calibrated 0.1 ml 0.05 ml and 0.1 ml. The time required from removable suction pressure to drop a drop of semen is recorded with a stopwatch. Normal viscosity takes 1-2 seconds.
3.     Visual and odor. Newly ejaculated semen apparently white gray, like that - that. After berlikuefaksi becomes liquid, it seems clear or cloudy, depending on the concentration of spermatozoa contains. It smells like acacia flower.
4.     Volumes. After 3 days of abstinence, semen volume approximately between 2-5 ml. At less than 1.5 ml volume actually good for artificial insemination husband (IBS) due to less volume it will not be enough to inundate the panhandle of cervical mucus, so it can be an infertility problem.
5.     pH. Newly ejaculated semen pH ranged from 7.3 to 7.7, which, if left for longer will increase due to the evaporation of its CO2. If the pH is more than 8, probably due to the sudden gland inflammation or genital tract, while a pH of less than 7.2 may be due to chronic inflammation of the gland.
6.     Fructose. Fructose semen is the result of the seminal vesicles, which showed the presence of androgen stimulation. Fructose is found in all semen, except on:
- Azoospermia, since the formation of the two vas deferens. Not coagulate semen immediately after ejaculation because seminalisnya vesicles were not formed.
- The second duct closed ejakulatorisnya
- Exceptional circumstances of ejaculation retrogard, where a fraction of the ejaculate does not contain sperm that could come out.

Microscopic examination
Semen with no sperm (azoospermia) or slightly spermatozoa will soon appear on microscopic examination. Duct blockage can be removed if it looks cells - cells that rounded young. All azoospermic semen should be checked that there is fructose, which is produced by the seminal vesicles. No growth on both the vas deferens and seminal vesicle, semen contains no fructose and can not coagulate after ejaculation. Similarly, if the second duct is clogged or the retrogard ejaculation.
1.      the concentration of spermatozoa. Calculate the concentration of spermatozoa in the semen the same way to calculate the concentration of blood cells. Diluent is a liquid solution containing formaldehyde George 40%, so that spermatozoa become immobile. To calculate the concentration of spermatozoa moving, use a solution of NaCl 0.9%, which does not kill spermatozoa moving.
2.     motility of spermatozoa. A drop of semen was placed on a glass object, then covered with a glass cover. The percentage of motile spermatozoa was estimated after examining 25 large field of view.
3.     morphology of spermatozoa. The morphology of spermatozoa should be considered as important as the concentration of spermatozoa. This check can only be done with semen swab smear preparations, and then calculate the type spermatozoanya.

II. Examination in Women 1
A. Examination of the cervix
Test pascasanggama   
Although test-Huhner sims or pascasanggama test has long been known throughout the world, but it has not been accepted values ​​uniformly clinic. One reason is the lack of standardization of how to do this. Most of the researchers agree to do it in the middle of the menstrual cycle, which means 1-2 days before increasing the estimated basal body temperature. However, there is no agreement on how many days of abstinence should be done before, although most recommend 2 days. Similarly, there has been no agreement when the inspection was done after intercourse. According to the literature, there is nothing to do after 90 seconds after 8 days. As noted above, the spermatozoa are able to come to the cervical mucus immediately after copulation, and can live in it until 8 days. According denezis new pascasanggama reliable test when performed within 8 hours after intercourse. Perloff doing research on the fertile and infertile groups, and concluded there was no difference in outcome differences between the two groups was that the examination carried out more than 2 hours after copulation. So the conclusion pascasanggama test done immediately after copulation.
How examination: after abstinence for 2 days, couples are encouraged to do coitus 2 hours before the appointed time to come to the doctor. With dry vaginal speculum, the cervix is displayed, then the cervical mucus that looks cleaned with a dry cotton anyway. Never use a cotton swab soaked with antiseptic because it can kill sperm. Cervical mucus taken with suction tuberculin syringe, then squirted out on the object glass, then covered with a glass cover. Microscopic examination carried out by a large field of view.
Circumstances and nature of the cervical mucus affect the state of spermatozoa. 2
  1. thickened cervical mucus. Cervical mucus liquid more easily traversed spermatozoa. At this stage cervical mucus proliferation rather liquid due to the influence of estrogen, whereas in stage cervical mucus secretions thicker due to the influence of progesterone.
  2. pH of cervical mucus. Cervical mucus is alkaline with a pH of   9. the atmosphere alkalis spermatozoa can live longer. The atmosphere became acid in cervical.
  3. Proteolytic enzymes. In addition to estrogen apparently also an enzyme - proteolytic enzymes such as trypsin and chemotripsin affect cervical mucus viscosity.
  4. In the cervical mucus can also be found immunoglobulins can cause agglutination of spermatozoa.
  5. A variety of germs - bacteria in the mucus of the cervix can kill sperm.    
Whether or not the cervical mucus is usually checked by:
-           Sims Huhner test (post coital test)
-           Kurzrock Miller test.    
SIMS Huhner TEST:
Examination were post coitum cervical mucus around the time of ovulation. Sims Huhner test is considered good if there are 5 motile spermatozoa per high powerfield .
Sims Huhner good test indicates:
- Techniques well coitus
- Cervical mucus normql
- Estrogen ovarial enough
- Sperm is good enough.

Kurzrock Miller Test:
Conducted in mid-cycle when sims Huhner test results are less good. One drop of the cervix lenders placed side by side with the drops of sperm on the object glass; seen whether there is penetration of spermatozoa. If there is no invasion of spermatozoa, unfavorable cervix mucus.

B. Examination of the uterus 1
Endometrial biopsy
Conducted to assess the typical changes that occur in the biopsy tool. Endometrial picture is a mirror image of the effect of hormones - hormones the ovaries. However, as is true for any medical procedure. Biopsy was performed, depending on the information to be obtained. If you want to obtain information about the effects of estrogen or other non-hormonal, endometrial biopsy performed on day 14. wanted to know if chronic inflammation (tuberculosis), ovulation or neoplasia, the biopsy is done after ovulation. In general, the best time to do a biopsy is 5-6 days after ovulation, which is just prior to the implantation of the blastocyst to the endometrial surface.
Tredway et al showed a precise relationship between endometrial changes that occur with that calculated from the date of ovulation. This knowledge is very important to diagnose defects luetal phase. Moyer most recommend that starts when the ovulation calendar rather than the calendar that begins from the first day of menstruation.
Luteal phase defect means the corpus luteum does not produce enough progesterone. The diagnosis is confirmed by basal body temperature curve, hormonal vaginal cytology, endometrial biopsy, and examination of plasma progesterone. If basal body temperature curve shows an increase in temperature can only be maintained less than 10 days, luteal phase defect diagnosis can be established. Luetal menstrual cycle phase is not always repeated. According Speroff et al, menstrual cycle with luteal defects occur repeatedly only in less than 4% of infertile couples. Therefore, the indication of treatment only if it is recurrent luteal phase defect.

Hysterosalpingography                                         
Since Rubin and Carey did Hysterosalpingography for the first time, many reforms have taken place in terms of equipment and contrast media used. The principle of equal examination with pertubasi, just blowing gas injecting contrast medium was replaced with that will overflow into the cavity peritonei if tubanya patents, and radiographic assessment basis.
Is now considered to be the best tool to inject contrast media is a pediatric Foley catheter number 8, as described by Ansari, to avoid injury and cervical bleeding, uterine perforation avoid, reduce pain, and because it is easily set pasie attitude. The catheter is inserted into the uterine cavity with the help of clamps, then held in place by injecting 2 ml of water. After a vaginal speculum is removed, the contrast medium is injected into the uterine cavity under the supervision of fluoroscopy taste.
Sometimes - sometimes happen tubal spasm, as a reaction to pain or fear when done Hysterosalpingography, which would give a false picture of such blockages. Effort is to dissuade the drug nitroglycerin under the tongue, sedatives, anesthetic paracervical, or parenteral administration isokuprin, which is not always going to succeed.

Hysteroscopy
Hysteroscopy is the observation of the uterine cavity previously been inflated by the media dextran 32%, 5% glucose, normal saline, or CO2. In infertility, hysteroscopy is done when there is:
a.     abnormalities on examination Hysterosalpingography
b.      history of habitual abortion
c.     Given submucosal myoma or polyps
d.     Abnormal bleeding from the uterus, or
e.     Prior to tubal plastic surgery, to place the catheter as a splint at the proximal part of the tube.
Hysteroscopy was not performed if there is a suspected acute pelvic infection, pregnancy, or a lot of bleeding from the uterus. Hysteroscopy can directly view the uterine cavity may prevent diagnostic errors that can occur in as curettage or endometrial biopsies were blindly. Anyway, through hysteroscopic surgery can be done lightly, like releasing adhesions, polyps and myomas submucosal lifting.

C. Examination of the fallopian
Pertubasi
          Aiming to check tubal patency by way of CO2 gas blowing through a cannula or Foley catheter is placed in the cervical canal. If the patent tube (not closed) then the gas will flow freely into the cavity peritonei. Tubal patency will be assessed from the record when dilakukan.Kalau pressure gas flow pressure   of 180 mmHg is not passed, then the tube patent. And if over 200 mmHg, then there is obstruction. In kymogram also apparent wave - a wave with an amplitude of 10-30 mmHg, which is caused by the peristaltic tube. Another sign of tubal patency is supporting hearing on auscultation suprasimfisis gas puffs into the cavity peritonei as "jet sound" or shoulder pain soon after the patient may be seated after the examination, due to accumulation of gas under the diaphragm.
          Contraindications pertubasi is not ruled out pregnancy, genital inflammation, uterine bleeding, and a recent curettage. The existence of pregnancy cause miscarriage, while the inflammation can spread. Inflammation and curettage of the uterus that can lead to new do air embolism or blockage of the tube because tertiupnya air into the veins, and clot - a blood clot in the tube.
D. Examination of ovulation 2
Ovulation can we know the various examinations.
a.     recording basal temperature in a curve: if ovulatoar cycle, the basal temperature is bifasis. After ovulation basal temperature rise due to the influence of progesterone.
b.     the vaginal smear examination; formation of progesterone cause changes - cytological changes in cells - superficial cells.
c.     examination of cervical mucus: the presence of progesterone cause changes in cervical mucus is mucus becomes more viscous, also picture of fern (fern leaf) is visible on the dried mucus is lost.
d.     examination of the endometrium: curettage on the first day of menstruation or the phase premenstruil produce secretory stage endometrium in the histologic characteristics.
e.     Examination of hormones such as estrogen, ICSH and pregnandiol.
Because - because ovulation disorders:
1.      factors - factors of central nervous system tumors, dysfungsi hypothalamus, psikogen factors, dysfungsi hypogfise.
2.      factors - intermediate factors: nutrition, chronic disease, metabolic disease
3.     factors - ovarial factors: tumor - a tumor, dysfungsi, Turner syndrome.

Changes in cervical mucus 1
          Ovulation occurs simultaneously with the mounting influence of estrogen on the middle of the menstrual cycle. Indeed the effect of estrogen decline after peaking that is used as a cue to ovulation. Examination of the vaginal and cervical mucus vaginal swab can determine one key series and have the time of ovulation; based on the changes - changes as follows:
1.      increase the magnitude of the opening of the cervical os eksternum
2.     increase the number, length increased fibrous power, increased clarity and increased the low viscosity of cervical mucus
3.     increased high power rifle spermatozoa
4.     the increase in the percentage of cells - cells and eosinophilic kariopiknotik the vaginal swab.

Note Basal Body Temperature
          It is often said when ovulation occurs at the lowest basal body temperature. Greulich et al suggested that the rise in basal body temperature precedes the time of ovulation. Similarly, according to Strott et al, basal body temperature greatly influenced the increase in plasma progesterone, so that the reading of the basal body temperature curve, ovulation occurs after the beginning of the body basal temperature increases.
          Basal body temperature curve is not normal at all rule out the possibility that lack of progesterone secretion. According strott et al, in the luteal phase of the menstrual cycle with a short basal body temperature curve looks normal, although actually less progesterone in plasma. Phase of the menstrual cycle with such hipertermik with endometrial bersekresi, often found in treatment with clomiphene citrate.

Hormonal Vaginal Cytology
              Investigating hormonal vaginal cytology cells - cells that detached from the vaginal mucous membrane, as the influence of hormones - hormones the ovaries (estrogen and progesterone). This check is very simple, easy, and painless, so it can be done at regular intervals throughout the menstrual cycle.
The purpose of hormonal vaginal cytology is:
1.      examine the effect of estrogen by knowing the cytologic changes in the proliferative phase of the typical
2.    checking for ovulation to know cytologic picture in the luteal phase
3.    determine when ovulation with ovulation familiar picture of a typical cytologic
4.    examine abnormalities in ovarian function that is not ovulating menstrual cycles.
         
Hormonal examination    
          Examination of FSH in a row to check the rise in FSH is not always easy, because the increase is not very noticeable differences, except in the middle - the middle of the menstrual cycle. On ovarian function is not active, the value is low to normal FSH showed abnormalities in the hypothalamic or pituitary level, whereas a high value indicates abnormalities in ovarian primary.
          Examination of LH every day on wnaita which can ovulate very real show LH peak, which is usually used as a benchmark time of ovulation. However, because his pituitary LH issued periodically, determining when ovulation with this examination can be mistaken ± 1 day.
          Examination of serum or urinary estrogen may provide information about ovarian activity and determining the time of ovulation.
          Examination of progesterone plasma or urine pregnandiol useful to indicate ovulation. Ovulation will be followed by an increase in progesterone, which can already be measured starting 2 days before ovulation, but very real in 3 days after ovulation.

E. Examination of the peritoneum
          Diagnostic laparoscopy has become an integral part of infertility management to examine last peritoneum problem. In general, to diagnose subtle abnormalities, especially on the wife infertile couples over 30 years old, or who have experienced infertility for 3 more years. Indications for diagnostic laparoscopy is:
a.     , if during the first year of treatment pregnancy has not occurred
b.     if irregular menstrual cycles or basal body temperature monophasic
c.     infertile couples when the wife's 28 years old, or experienced infertility for 3 years
d.     if there is a history of laparotomy
e.     've done if Hysterosalpingography with oil-soluble contrast media
f.      if there is a history of appendicitis
g.     pertubasi that many - times of abnormal
h.     if suspected endometriosis
i.      artificial insemination that will be done.
          The best time to perform a diagnostic laparoscopy was soon after ovulation. Immediately after ovulation will appear corpus rubrum, whereas before ovulation will appear follicle de Graaf. In a 28-day menstrual cycle laparoscopy performed on day 14 and 21.
          Tuba enlarged entirely showed hydrosalpinx. Showed a thickened fallopian tube wall damage due to infection or endometriosis. Tuba small shows before former inflammation. Sakulasi tube bending and may be normal, or may also be due to inflammation fibrosis. Tuba short may be a result of inflammation, bending at some places, or fibrosis.

Handling problems infertilas 1
Handling multiple tailored to the etiology of infertility problems that cause infertility, such as:
I.   abnormal semen
The new so-called abnormal semen if the examination three consecutive times - were the result remains abnorma.
Therapy:
1.      general: general hygiene, smoking, and drinking alcohol is reduced, adequate rest, tension is removed, the treatment of chronic and metabolic diseases.
2.     Hormonal:
a.     testosterone that stimulates the gland physiology acesoir male genitalia - male. Which is a rebound phenomenon commercialized.
b.     Gestyltesto gestyl is a combination that is gonadotrofin and testosterone
c.     Humegon abbreviation of human menopausal FSH gonadotrropin that properties such as eg given 200 U, 2 X a week for 6 weeks.
3.     Operative: fix closure of the ductus deferens
4.     way - another way: centrifuge sperm.
This can be done for couples with abnormal semen is planning to engage in sexual intercourse during the wife's fertile period. The abnormal semen that can still be improved if it is caused by a varicocele, obstruction, infection, gonadotropin deficiency, or hyperprolactinemia.
1.   varicocele
The presence of a varicocele with sperm motility is less advisable to perform the operation. According to MacLeod, poor sperm motility was found in 90% of men with varicocele, although gonadal hormones and normal gonadotrofiknya. Kira - about two-thirds of men with varicocele that surgery would have improved motility spermatozoanya.
2.   blockage vase
The man who would be clogged demonstrates azoosperma, with large testicles and FSH levels are normal. The last two signs are very consistent for normal spermatogenesis. Vasoepididimostomi operating results are not satisfactory. Although 90% of ejakulatnya contains spermatozoa, but the pregnancy rates ranging from 5-30%.
3.   Infection
Acute infection of the genital tract can clog or damage the testicular tissue vase so that the man in question to be sterile. However, chronic infection may only decrease the quality of spermatozoa, and still be able to be repaired to normal with treatment. Semen which always contain many leukocytes, especially if accompanied by symptoms of dysuria, pain during ejaculation, lower back pain, chronic infection is suspected because the genital tract.
Best antibiotic for chronic genital tract infection is antibiotics collected in the genital tract with a large number, such as erythromycin, dimetilklortetrasiklin, and trimetoprimsulfametoksazol. Nitrofurantoin should not be used, because it can inhibit spermatogenesis.
4.    gonadotropin deficiency
Men with congenital gonadotropin deficiency often experience slow puberty, which usually never found treatment with testosterone. If you have not been treated, usually azoozpermia semen with a low volume, lanky, small testicles (less than 4ml). Gynecomastia may also occur. These patients may also suffer from other congenital diseases, such as anosmia partially or completely. The existence hipogonadismus with anosmia syndrome refers to hipogonadismus-hipogonadotrofik (Kallman's syndrome).
To treat infertility with this result can be treated with gonadotropins. Most require treatment with LH and FSH. Starting with LH in the form of HCG for 3 months with doses of 1000 and 3000UI, two to three times a week. This treatment will stimulate the development of characteristics - secondary sex characteristics, and adding large testicles. Sexuality libido, potency, and volume of ejaculate will increase as well, although ejakulatnya not contain spermatozoa. But usually require treatment also HCG and FSH to stimulate spermatogenesis. With the discovery of GnRH for use in clinics, Kallman syndrome treatment gives hope more successful. However, this hormone is still expensive.                                                                                   
          Hyperprolactinemia in men may cause impotence, shrinking testicles, and galaktoria. Segal et al. and Saidi et al., reported that the dopamine agonist treated with 2-bromo-alpha-ergo-kriptin can fix spermatogenesisnya.


5.    myoma uteri
How myoma uteri mechanism can inhibit pregnancy is not clearly known. May be caused by pressure on the tube, distortion or elongation of the uterine cavity, myometrium irritation, or torque by the sessile myomas.
The mechanism, myomectomy can be done but do not always seed myoma uteri can be removed with surgery. The time it takes to become pregnant after myomectomy guess - about 18 months.
7.   Problems tubes are clogged
Wife with a history of recurrent pelvic can be tested with long-term antibiotics. Giving antibiotics to taste a lapse of one month for 6-12 months to more than a tubal patency allowing the wife group were not given the treatment.
Tubal endometriosis can be treated with birth control pills, progesterone or danazol, given continuously or hose - alternately. But healing will leave a scar endometriosis which can clog or bend the tube so that eventually need surgery to resolve it.
The problem is a clogged tube can be done with surgery. Indications of this surgery is the blockage of all or a portion of the tube, tube bending pathological, sakulasi tuba, peritubular and periovarial particular attachment to free movement of tubes and ovaries. The purpose of this surgery is to repair and restore the anatomy to normal tubes and ovaries are very concerned with the possibility of muscle movement and tubal cilia, secretion tuba, and effective ovum perception. The most appropriate time transform and perform tubal surgery is in the middle of the proliferative phase (regenerative phase).
The general procedure tubal surgery: the patient was placed in the lithotomy posture as for diagnostic laparoscopy, to be easily performed tubal patency test immediately before, during and after surgery. Installation of vaginal tampon as far as possible to encourage the uterus and adneksanya as close as possible to the abdominal wall, so that makes it easy surgery. This is important, especially on micro surgery, to display the external genitalia without traction, because otherwise it can cause trauma to the time of interest, pinning, or sewing tools - these tools. Once the abdominal cavity is open, it is important to prevent damage to the tubes and peritoneum with the road surface to fill the abdominal cavity with normal saline solution, continuous surgical field irrigation, and protects the tool - a tool that is not dissected with plastic sheets. Tubes should be used for surgical nylon thread 4-0, 6-0, 8-0. hemostasis should be performed with bipolar diathermy. At the end of surgery performed hodrotubasi to rinse the rest - the rest of the blood in the tube, and to test whether the seams watertight.
8.   Endometriosis
Endometriosis is the growth of endometrial glands and stroma outside the still functioning in its usual spot, the uterine cavity. Symptoms and signs of endometriosis vary widely. Women with mild endometriosis can suffer from severe pelvic pain, and conversely, women with severe endometriosis may be mild complaint once. Pelvic pain in the form of dysmenorrhoea (painful menstruation) is often considered typical symptoms of this disease. Other symptoms are dyspareunia if the disease has spread to the ligaments and the pouch of Douglas sakrouterina. Abnormal bleeding from the uterus, blood prahid brown, and primary or secondary infertility are also symptoms and signs of endometriosis. At check in is getting a small lump on the ligament sakrouterina and retroflexed uterus or adnexal should be driven hard suspected of having endometriosis.
Endometriosis can do therapy which consists of waiting until the pregnancy itself, hormonal treatment, and conservative surgery. In elderly patients and have long infertility, should be encouraged to pursue conservative surgery. Provision of danazol, a new drug that is efficacious antigonadotrofik endometriosis and inhibits ovarian steroidogenesis would lead to a state of "quasi meopause". Ovulation will be inhibited, and thus will become atrophic endometrium. Will result in the symptoms of estrogen deficiency - postmenopausal symptoms, such as sweating, and other vasomotor disturbances. Virilization and acne may also occur.
9.   Hormonal
If there is a hormonal disorder treatment can be carried out according to the       location, for example, high prolactin can be treated with bromocriptine or pariodel. Clomiphene citrate is the drug of first choice for patients with menstrual cycles are not ovulating and oligomenorrhoea, and definitely the first choice for patients with secondary amenorrhea levels of FSH, LH and normal prolaktinnya.
10. Idiopathic
Idiopathic is a term used when everything is fine, but the couple had not couple idiopathic hamil.Bagi recommended to always strive to continue and always pray to Allah SWT.

Progress means infertility treatment 3
1.      Superovulation and intrauterine insemination : how the use of hormones to stimulate ovulation the egg and sperm in the uterus.
2.     in vitro fertilization : using hormones to stimulate ovulation the egg and the egg gain. Fertilization is done in the laboratory and then transferring the embryo into the uterus results.
3.     Gamete intrafallopian transfer : use a piece of equipment called laparoscopy as the fertilization of the egg and sperm into the fallopian tube by making small holes in the abdomen.
Zygote intrafallopian transfer : infertilisasi process conducted in the laboratory and then using laparoscopy to transfer the zygote into the fallopian tube.



Prognosis 1
According to Behrman and Kistner cit Wiknjosatro Hanifa, the prognosis of pregnancy depends on the age of the husband, wife's age, and the length is faced with the possibility of a pregnancy (frequency of intercourse and duration of marriage). Maximum fertility of women is achieved at the age of 24 years, then decreased gradually until the age of 30 years, and decline rapidly thereafter.
According to MacLeod, the man reached the maximum fertility at ages 24-25 years. Almost in every age group the proportion of male pregnancy in less than 6 months increased with increasing frequency of copulation. Apparently, most copulations 4 times a week to take the pregnancy; because it turns out the quality and kind of get better sperm motility with frequent ejaculation.
Advanced management of the infertile couple can carry a pregnancy to more than 50% of couples, although there is always a 10-20% partner of unknown etiology. The other half are forced to live without children, or have children with another way, for example by insemination   donor artificial or raised a child (adoption).

Artificial insemination 2

Funny Artificial.
There are 2 kinds:
a.     heterologous insemination: Artificial insemination donor (AID)
b.     homologous insemination: Artificial insemination husband (AIH)
Insemination can be done well but ejaculated sperm that can not be put into the vagina, for example on impotentia coundi ejaculatio parecox or hypospadias. Sometimes - sometimes also done on circumstances complicate rise spermatozoa into the uterus as a narrow cervical os internum yan, retroflexio uteri, etc..

In Vitro Fertilization 3
          There are religious views / beliefs / culture that does not support a particular method of in vitro fertilization, because the implementation of which will be many embryos are created from some of the ovum fertilization by sperm mother's father, but then only a few good-quality embryos are selected for implanted while the rest only will die.
          If it was decided to choose this method, the couple must explain all possibilities and risks that may occur. Couples should also explained all procedures that require the full attention and perseverance.
          In vitro fertilization is ethically acceptable: the sperm and ovum are from a husband and wife are legally valid.
The order of in vitro fertilization procedure techniques:
1.      superovulation: maternal stimulation to produce multiple ova in one cycle.
2.     ultrasound examination to assess the development of follicles in the ovaries, as required at least 3-4 mature follicles at the same time to increase the likelihood of success ovum retrieval.
3.     monitoring of hormones: check serial hormone - reproductive hormones and therapy if needed.
4.     taking ova: aspiration by laparoscopy or percutaneous probe-transvesical or transvaginal. Ovum is then stored in the laboratory.
5.     identification of ova: ova examined maturity. Mature ovum is characterized by extensive cumulus oophorus and have completed the first meiotic division. immature ovum incubated in the laboratory for 36 hours then until cooked.
6.     capacity of sperm: the sperm from the ejaculate directly can not fertilize an ovum, so do capacitation through multiple long incubation in culture medium specific.
7.     Fertilization: about 10-50 thousand motile sperm are placed with each - each ovum, and after fertilization, the zygote incubated.
8.     Incubation: The incubation in culture medium using mixture also from maternal serum. During incubation, assessed the emergence pronucleus (as a sign of fertilization) and the emergence of blastomeres (as a sign of early cleavage embryos). Incubation for 48-72 hours.
9.     transfer embryos: embryos are selected, generally at 2 to 8 cell stage, aspirated with a small catheter is then inserted through the cervical canal into the uterus, is injected into the mother's uterine cavity.
                                                                                            



                                                                                      















CHAPTER III
CONCLUSIONS AND RECOMMENDATIONS
Conclusion
Infertility is the diminished fertility. A so-called infertile couples when the wife is not pregnant within 12 months (1 year) after mating without practicing contraception (intentional). Infertility is divided into two, namely primary and secondary infertility. Factors that may cause infertility can of factors husband or wife, or both. Other factors that increase the risk of infertility may include pelvic inflammation, endometriosis, environment / atmosphere, and factors associated with toxin derived from tobacco, marijuana and other drugs, body movement, and increasing age.  
Infertility in men can be caused by disruption of spermatogenesis and sperm transport disruption. While infertility that occurs on the wife could be due to problems - problems in the vagina, tubes, uterus, ovaries, cervix and hormonal.
Examination was conducted on the examination in men and women. Examination includes examination of sperm in men, whereas in women inspection includes examination of the vagina, uterus, cervix, ovaries and tubes.
Management of infertility essentially based on etiology.
Suggestion
        In men and women who are already married when for 1 year and without practicing contraception and coitus was not disturbed, but has not given the child expected soon to see her obstetrician.
          Examination of infertility not only for his wife, but the husband should also be checked. Because we see the husband and wife as a single unit.
          For couples who have been trying to have a child but have not been successful due to certain reasons can try IVF in vitro fertilization methods. But there are many ways you can do in addition to IVF, adoption of such child.
Bibliography
1.     Budi Marjono: Obstetrics Gynecology. Faculty of Medicine, 1999.
  1. Department of Obstetrics and Gynecology, Faculty of Medicine, University of Padjadjaran, Bandung.
  2. http://cakul-ui.com
  3. Garcia, Jairo E.: infertility ".






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