3-samsul hadi protect(2)

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SAMSULHADI. DEP. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA FEB 2006

SAMSULHADISAMSULHADI

FERTILITY CLINIC GRAHA AMERTAFERTILITY CLINIC GRAHA AMERTADEP. OF OBSTETRIC DEP. OF OBSTETRIC && GYNECOLOGY,GYNECOLOGY,

FAC. OF MEDICINE AIRLANGGA UNIVERSITY.FAC. OF MEDICINE AIRLANGGA UNIVERSITY.DR. SOETOMO HOSPITAL SURABAYADR. SOETOMO HOSPITAL SURABAYA


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Techniques that involve manipulation of oocytes, sperm and

Conceptuses to improve fecundity or enhance pregnancy outcome

Strauss Jerome F., Barbieri Robert L. Yen and Jaffe’s, Reproductive Endocrinology. Physiology. Pathophysiology and Clinical Management. Ed Vth. Elsevier Saunders . Pennsylvania. (2004), P : 839 - 873


I.U.I

IVF – ET- ICSI- PESA- TESE

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WHERE ARE THEY ?


Barbieri Robert L. : Female InfertilityIn Yen and Jaffe’s Reproductive Endocrinology. Ed V Th Elsevier Saunders. Philadelphia.2004. P : 633- 668

Identify allIdentify allFertility factorsFertility factors

ExpectantExpectantManagementManagement

CC or CC or CC CC -- IUIIUI

hMG orhMG orhMGhMG--IUIIUI

IVFIVF

Correct allCorrect allFertility factorsFertility factors

Increasing intensiveness of resource utilization

Incr

easi

ng F

ecun

dabi

lity

Figure 20 – 16. Staircase approach to empirical infertility treatment/ For women over 35 years old, the first three steps in the algorithm should be rapidly completed. In women less than 30 years old, more time can be spent on the first three steps in the staircase

35 Years

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INFERTILITY FACTORS

INFE

RTIL

ITY

INFE

RTIL

ITY

Factors :Factors :-- AgeAge-- EmotionalEmotional-- EnvironmentEnvironment-- Freq. / TimeFreq. / Timeof Coitusof Coitus

-- Social EconomicSocial Economic UterusUterus

PPRREEGGNNAANNCCYY

Tube &Tube &PeritoneumPeritoneum

CervixCervix

OvulationOvulationSpermSperm

Treatment :Treatment :•• MedicalMedical•• SurgicalSurgical•• CombinationCombination•• ARTART

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Leon Speroff and Frits marc A. Clinical Gynecologic Endocrinology and Infertility. Ed. VII TH. Lippincott Williams & Wilknis Philadelphia (2005) p : 1013 - 1056

AGING AND REPRODUCTION IN WOMEN

% of maximum fertility Miscarriage rate (%)

100

80

60

40

20

0

50

40

30

20

10

020-24 25-29 30-34 35-39 40-44

% of maximum fertilityMiscarriage rate (%)


INFERTILITY MANAGEMENT

DIAGNOSIS

TREATMENT

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DIAGNOSIS OFINFERTILITY FACTORS

SPERMFACTOR

TUBE &PERITONEUM

OVUL.DISORDERS

Infection

Endometriosis

• Unknown• Infection• Immunology• Hormonal• Others

• Sperm Analysis• Culture• Immunology Test• Others

• HSG / ISS• Laparoscopy

• Hypothal• Pituitary• H – P – O• Ovary• Others

• Menstrual Cycle• BBT• BEM• TVS• Hormonal


DIAGNOSIS TUBAL FACTORS

HSGHSG

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HSG NY. LD


HSGHSGSEPTUM UTERUSSEPTUM UTERUS

PRE OPERATIONPRE OPERATION

POST OPERATIONPOST OPERATION

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NORMALNORMALHSG LAP Dx


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SAMSULHADI. DEP. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA FEB 2006SAMSULHADI. DEP. OF OBSTETRICAL & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA


ADHESION

MILD SEVERE

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MILD ENDOMETRIOSIS MILD ENDOMETRIOSIS


SEVERE ENDOMETRIOSISSEVERE ENDOMETRIOSIS

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Type of Eval.

Lumen

Patency

TubalWall

AnatomyAdhes

ion

Others abnormality

Ovary Note

Uterus

TUBE

BlockedMucosa

Tube Fimbriae

HSG + + + + - + - - - - Simple Cheap

Laparoscopy - - - ++ + + + + ++ + Invasive

Expensive

ISS ++ + - + - - - - ++ + Chepeast Simple

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DIAGNOSIS OFINFERTILITY FACTORS

SPERMFACTOR

TUBE &PERITONEUM

OVUL.DISORDERS

Infection

Endometriosis

• Unknown• Infection• Immunology• Hormonal• Others

• Sperm Analysis• Culture• Immunology Test• Others

• HSG / ISS• Laparoscopy

• Hypothal• Pituitary• H – P – O• Ovary• Others

• Menstrual Cycle• BBT• BEM• TVS• Hormonal


Hypothalamus

GnRH

Pulsatile SecretionIn

“Critical Range”

Pituitary FSH & LH

Ovary

Steroidogenesis

E & P

Menstruation

Foliculogenesis&

oogenesis

SingleOvulation

Long F.B Short F.BUltra Short FB(Down Reg.)

SAMSULHADI. DEP. OF OBSTETRIC & GYNECOLOGY, FAC. OF MEDICINE AIRLANGGA UNIVERSITY. DR. SOETOMO HOSPITAL SURABAYA

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FSH

LH

Estradiol

Progesterone17-OH Progesterone

EstradiolFSH

LH

PHISIOLOGY MENSTRUATION

2 4 6 8 10 12 14 16 18 20 22 24 26 28

Estradiol

FSH

LH Progesterone

17-OH Progesterone

Progesterone17-OHPNg/mL

10

9

8

7

6

5

4

3

2

1

Ov.

FSH• Gran. Cell Prolif.• Arom. Androg – E2• FSH & E2 R / FSH in

Gran. Cells• Stim. Inhibin, Act. Prod.LH (Theca Cells)• Synth Androg.

LH P

FSH & LH OMI Synth PG Elevated P + : - plasminogen - Plasmin

- FSH – SurgeFSH Surge : - Proteolytic enzym activity

- FSH + E2 R/ LH in gran cells

LH MaintainCorpus luteum- Vascul- Steroidogenesis

LH


TOOLSTOOLS

HORMONHORMON••LIPIDLIPID••PROT.PROT.••AMINEAMINE

RECEPTORRECEPTOR

••MEMBRANE MEMBRANE ••INTRACELINTRACEL

COM.COM.SYSTEMSYSTEM

••ENDOCRINENDOCRIN••PARACRINPARACRIN••AUTOCRINAUTOCRIN••INTRACRININTRACRIN

CCOOMMMMUUNNIICCAATTIIOONN

HIPOTALHIPOTAL

HYPOFESAHYPOFESA

OVARYOVARY

OOGENESISOOGENESIS

FOLICULOGEN.FOLICULOGEN.

STEROIDOGENSTEROIDOGEN

UTERINEUTERINE(ENDOMET)(ENDOMET)

MENS.MENS.

ABN. OF OVUL.ABN. OF OVUL.

HIPOGHIPOG--HIPOGHIPOG(CENTRAL)(CENTRAL)

HIPER HIPER –– HIPOGHIPOG( PERIPHERY)( PERIPHERY)

ABN. OF MENS.ABN. OF MENS.

IVIV

AMENOREAMENORE

IIIIII

D.U.BD.U.B

AMENOREAMENORE

AMENOREAMENOREIIII

AMENORHEA AMENORHEA --ABN. OF DEVELOPABN. OF DEVELOP--INFECTIONINFECTION

INFERTIL.INFERTIL.

ABN. ABN. OFOF

OVUL.OVUL.

OTHEROTHERFACTORSFACTORS

ARTART

IUI IUI &&

IVF IVF -- ETET

TRANSPORTTRANSPORT(FREE, BOUND)(FREE, BOUND)

OVULATIONOVULATION

OVUL. DYSFUNC.OVUL. DYSFUNC.

••E E FSHFSHL HL H

••E E FSHFSH

&&

Prof. Dr. H. Samsulhadi, SpOG (K). Seksi Fertilitas Endokrinologi Reproduksi, Bag / SMF Obstetri & Ginekologi RSU Dr. Soetomo / FK Unair Surabaya

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INFERTILITY MANAGEMENT

DIAGNOSIS

TREATMENT


INFERTILITY TREATMENT

INFERTILITY

UNEXPLAINED MILD SEVERE / MULTIPLEFACTORSOR / AND

MEDICAL SURGERY

1 – 2 YEARS(INCLUDED IUI3 – 6 CYCLES)

IVF – ETICSI

*

*Micro surgery or laparoscopic surgery

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INFERTILITY FACTORSIN

FERT

ILIT

YIN

FERT

ILIT

Y

Factors :Factors :-- AgeAge-- EmotionalEmotional-- EnvironmentEnvironment-- Freq. / TimeFreq. / Timeof Coitusof Coitus

-- Social EconomicSocial Economic UterusUterus

PPRREEGGNNAANNCCYY

Tube &Tube &PeritoneumPeritoneum

CervixCervix

OvulationOvulationSpermSperm

Treatment :Treatment :•• MedicalMedical•• SurgicalSurgical•• CombinationCombination•• ARTART


Barbieri Robert L. : Female InfertilityIn Yen and Jaffe’s Reproductive Endocrinology. Ed V Th Elsevier Saunders. Philadelphia.2004. P : 633- 668

Identify allIdentify allFertility factorsFertility factors

ExpectantExpectantManagementManagement

CC or CC or CC CC -- IUIIUI

hMG orhMG orhMGhMG--IUIIUI

IVFIVF

Correct allCorrect allFertility factorsFertility factors

Increasing intensiveness of resource utilization

Incr

easi

ng F

ecun

dabi

lity

Figure 20 – 16. Staircase approach to empirical infertility treatment/ For women over 35 years old, the first three steps in the algorithm should be rapidly completed. In women less than 30 years old, more time can be spent on the first three steps in the staircase

35 Years

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MonitoringInfertility

Complicated

• Costly• Takes Time

Standard Evaluation(“Marker”)

Fertility(Women)

Age Related

TIMEPregnant


• Mens. Cycle• BBT• Endom. Biopsy• P

INFERTILITY

FEMALE MALE

> 30 Years. Married > 3 Years. Suspect Adhesion,

Endometriosis and or mass

LAPAROSCOPY

TUBE &PERITONEUM

OVULATION

< 30 Years.

NormalAbnormal

HSG / ISS

• 6 Months• Others F. “N”

NormalAbnormal

Op.

Op. ReconstructiveSurgery

1,5 – 2 Y.

Pregnant Pregnant

6 Months.

IVF -ET

Ovulation Abnormal

Tx / Induction

Failed

• COH• IUI(Tube F. N)

6 Cycles. Gonadotropin

Normal Abnormal

Tx Tx

Success Failed

> 37 Years orMultiple FactorsInfertility

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WHEN A.R.T WILL BE DONE

Indication

Requirement Contra Indication


A.R.T

IUI IVF - ET

Indication• Unexplained Inf.• Ov. Factor• Mild Endometriosis• Oligo zoopspermia• Etc.

• Severe Abnormality• Failure of previous Treat.• Multiple Factors• Unexplained Inf.

There is• Sperm• Oocyte• Uterus

Normal Tube

Requirement(Legal Couple)

There is • Sperm• Oocyte• Uterus

ContraIndication

- Poor ov. Reserve- > 40 yrs of old- C.I. to be Pregn.

- Poor ov. Reserve- > 40 yrs of old- C.I. to be Pregn.

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OVARIAN RESERVEOVARIAN RESERVE

BASAL FSH & EBASAL FSH & E22 AGEAGE

PATHOLOGICAL CASESPATHOLOGICAL CASES•• Post pelvic surgeryPost pelvic surgery•• Immun or genetic F.Immun or genetic F.•• Etc.Etc.



REDUCED OVARIAN RESERVEREDUCED OVARIAN RESERVEDIAGNOSIS

The diagnosis of reduced ovarian reserve is supported by :

if any of the FSH levels are > 10 mIU/ ml or the estradiol is > 70 pg/mlThe test is considered abnormalDocumented poor response to aggressive ovulation induction

1. Cycle day 3 : - FSH > 10 mlU/ml or - Estradiol > 70 pg /ml

2. Abnormal CCCTTo perform :• Cycle day 3 : FSH, estradiol levels• Clomiphene citrate 100 mg cycle

days 5 – 8• Cycle day 10 : FSH level

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REDUCED OVARIAN RESERVEREDUCED OVARIAN RESERVE


DOCUMENTED POOR RESPONSE TO AGGRESSIVE OVULATION INDUCTION

TREATMENT OPTIONSFSH 10 – 19 mIU / ml FSH > 20 mIU / ml

Aggressive ovulationInduction with

IntrauterineInseminations

Adequate response

Try 3 cyclesthen IVF

Poor response Counsel on other options Egg donation Adoption

Steven R. Bayer, Michael M. Alper, Alan S. penzias : The Boston IVF Handbook of Infertility, Practical guide for practioners who care for infertile couples. The Parthenon publishing Group. Massachusetts. 2002. 67 - 74


InfertilityManagement

Education

Social -Economy

Culture

Age InfertilityFactors

HospitalCompetence

Diagnosis&

Treatment

• Experties• Equipment• Trained skill

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INFERTILITY PROBLEM

COMPLICATED

COSTLY TAKES TIME

PATIENTS

TREATMENT• Medical• Surgical• ART

WORK UP

HEALTHSERVICES

• Human Resources- Experties- Technicians- Trained Paramedics

• Equipments

Referral System

Total Partial Networking

Guide Line(Standardized)

Needed

Multiple Factors(Long Work Up)

Varies Examination

Varies Treatment


Referral System in ART

Diagnosis Treatment

Partial Total

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PREGNANCY

SCREENING SPERMPREPARATION

INSEMINATION

LUTEALSUPPORT

WashingSperm

OvarianReserve

Indication

Requirement

Contra Indication

CC & Gonadotr.

Gonadotropin

Monitoring

hCG


Unexpl. Infertility

Ovulation Factors

Endometriosis

Male Factors

Etc.

Strategies of Superovulation

Monitoring

Sperm Preparation

Luteal Support

REFERRAL SYSTEM OF IUIINFERTILITY - IUI

PATIENTSELECTION IUI

Ov. Reserve

• Adequate sperm• Normal Oocyte• Normal Uterine• Normal Tube• No Peritoneal

adhesion

Poor Ov. reserve

> 40 years of old women

Contra indication to be pregnant

Indication Requirement Contra Indication

Age Hormonal

Assay

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Indication

Requirement

Contra Indication

PatientSelection

OvarianReserve

GnRHa or GnRH Antagonist

Gonadotropin

Monitoring

hCG

OPU

FERTILIZATION

Embryoor blastocystSelection

PGD

ET

LutealSupp.

PREGNANCY

AZOOSP

PESA / TESE

OLIGO

ICSI

“N”

S P E R M


Severe / Multiple Factors

Failure Previous Management

Unexplained Infertility

Strategies of Superovulation

Monitoring

Getting Sperm- Natural- PESA- TESE

Sperm Preparation

Fertilization Natural or ICSI

Luteal Support

REFERRAL SYSTEM OF IVF - ET

PATIENTSELECTION IIVF - ET

Ov. Reserve

Contra indication to be pregnant

Poor Ov. reserve

> 40 years of old wife

Indication Requirement Contra Indication

HormonalAssay

There are :

Oocyte Sperm Uterine

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COMPLETELY AND INTEGRATEDCOMPLETELY AND INTEGRATEDFERTILITY CLINIC GRAHA AMERTAFERTILITY CLINIC GRAHA AMERTA

DR. SOETOMO HOSPITAL / MEDICINE FACULTY UNIV. AIRLANGGA SURABAYADR. SOETOMO HOSPITAL / MEDICINE FACULTY UNIV. AIRLANGGA SURABAYA

Telp. 031 Telp. 031 –– 70906307 Fax. 03170906307 Fax. 031--5501704 e5501704 e--mail:[email protected]:[email protected]

3-samsul hadi protect(2)

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