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RPS - CASE 2

ndometriosis

Anatomy, Histology, Physiology and Clinical Pathology ofFemale Reproductive System

TIM AKADEMIK

DIVISI SOOCA

SPEKATRIA

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CASE REVIEW

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CONCEPT MAP

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TOPOGRAPHY OF MALE INTERNAL GENITALIA

Anatomi +Histologi

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Vascularization

Tambahan

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TOPOGRAPHY OF MALE EXTERNAL GENITALIA

Anatomy of External Male Reproductive System (glands and ducts that produce and transport spermatozoa andseminal fluid).

External Anatomy of Male Reproductive System

The male external genitalia include the distal urethra, scrotum, and penis.

1. Distal Male Urethra

The male urethral is subdivided into four parts : intramural (preprostatic), prostatic, intermediate, andspongy.

a. Intramural Part of Urethra

The short, most proximal part of the urethra, running almost vertically down from the bladder towhere it enters the prostate.

b. Prostatic

The prostatic portion ( pars prostatica ), the widest and most dilatable part of the canal, is about 3cm. long, It runs almost vertically through the prostate from its base to its apex, lying nearer itsanterior than its posterior surface; the form of the canal is spindle-shaped, being wider in the middle

than at either extremity, and narrowest below, where it joins the membranous portion.

c. Intermediate (membranous) part of urethra

It begins at the apex of the prostate and transverses the deep perineal pouch, surrounded by theexternal urethral sphincter. Posterolateral to this part are the small bulbo-urethral glands and theirslender duct, which open into proximal part of the spongy urethra

d. Spongy Urethra

Begins at the distal end of the intermediate of the urethra and ends of male external urethral orifice,which is slightly narrower than any of the other parts of the urethra. The diameter of lumen isapproximately 5 mm. but it is expanded in the bulb of the penis to form the intrabulbular fossa andin glans to form the navicular fossa.

Arterial Supply of Distal Male Urethra

The arterial supply of the intermediate and spongy of the urethra is from branches of the dorsalartery of penis.

Venous and Lymphatic Drainage of Distal Male Urethra

Veins accompany the arteries and have similar names. Lymphatic vessels from the intermediate partof the urethra drain mainly into internal iliac lymph nodes, whereas most vessels from the spongyurethra pass to deep inguinal lymph nodes, but some lymph passes to the external iliac nodes.

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2. Scrotum

Scrotum is cutaneous fibromuscular sac of the testes and associated structures. Situated postero-inferior to the penis and inferior to the pubic symphysis. The bilateral embryonic formation of thescrotum is indicated by the midline scrotal raphe, which is continous on the ventral surface of penis with

penile raphe. Internally, deep to scrotal raphe, the scrotum is divided into two compartments, one foreach testis, by a prolongation of the dartos fascia, the septum of the scrotum.

Arterial Supply of Scrotum

Anterior scrotal arteries, terminal branches of the external pudendal arteries (from femoral artery),supply the anterior aspect of the scrotum. Posterior scrotal arteries, terminal branches of the superficialperineal branches of internal pudendal arteries, supply the posterior aspect. The scrotum also receivesbranches from the cremasteric arteries ( branches of the inferior epigastric arteries )

Venous and Lymphatic Drainage

The scrotal veins accompany the arteries, sharing the same names but draining primarily to the externalpudendal veins. Lymphatic vessels from the scrotum carry lymph to the superficial inguinal lymph node.

3. Penis

Penis is the male copulatory organ and provides the common outlet for urine and semen. It consists of aroot, body, and glans .

Penis consists of three cylindrical cavernous bodies of erectile tissue : the paired corpora cavernosadorsally and the single corpus spongiosum ventrally.

Each cavernous body has an outer fibrous capsule named tunica albuginea. The corpus spongiosum

contains the spongy urethra.

Root of The Penisa. Consist of crura, bulb, ischiocavernosus, and bulbospongiosus muscle.b. Located in superficial perineal pouch.c. Crura and bulb of the penis have an erectile tissue.

Body of Penisd. Free pendulous ( menggantung ) part that is suspended from the pubic symphisis.e. The body of the penis has no muscle.

f. Consist of skin, connective tissue, blood and lymphatic vessels, fascia, the corpora cavernosa,and corpus spongiosum containing the spongy urethra.

Glans of Penisg. Expanded from corpus spongiosum.h. The margin of the glans projects beyond the end of the corpora cavernosa to form corona of the

glans.i. The neck of glans separate the glans from the body of penis.

The skin of penis is thin, darkly pigmented relative to adjacent skin, and connected to the tunica

albuginea. The suspensory ligament of the penis is a condensation of deep fascia that arises from theanterior surface of pubic symphisis. The fundiform ligament of the penis is an irregular mass orcondensation of collagen and elastic fibers of the subcutaneous tissue that descends in the middle fromthe linea alba interior to the pubic symphisis.

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Arterial Supply of Penis

j. Dorsal arteries of penis run on each side of the deep dorsal vein in the dorsal groove betweenthe corpora cavernosa. Supplying the fibrous tissue around the corpora cavernosa, the corpusspongiosum and spongy urethra, and the penile skin.

k. Deep arteries of the penis pierce the crura proximally and run distally near the center of thecorpora cavernosa, supplying the erectile tissue in these structures.

l. Arteries of the bulb of the penis supply the posterior (bulbous) part of the corpus songiosum andthe urethra within it as well as the bulbo-urethral gland.

Glands and Ducts That Produce and Transport Spermatozoa and Seminal Fluid

The glands of the male reproductive system are the seminal vesicles, prostate gland, and the bulbourethral glands.These glands secrete fluids that enter the urethra.

1. Seminal Vesicles

The paired seminal vesicles are saccular glands posterior to the urinary bladder. Each gland has a short ductthat joins with the ductus deferens at the ampulla to form an ejaculatory duct, which then empties into the urethra.The fluid from the seminal vesicles is viscous and contains fructose, which provides an energy source for thesperm; prostaglandins, which contribute to the mobility and viability of the sperm; and proteins that cause slightcoagulation reactions in the semen after ejaculation.

2. Prostate

The prostate gland is a firm, dense structure that is located just inferior to the urinary bladder. It is about thesize of a walnut and encircles the urethra as it leaves the urinary bladder. Numerous short ducts from the substanceof the prostate gland empty into the prostatic urethra . The secretions of the prostate are thin, milky colored, andalkaline . They function to enhance the motility of the sperm.

3. Bulbourethral Glands

The paired bulbourethral (Cowper's) glands are small, about the size of a pea, and located near the base ofthe penis. A short duct from each gland enters the proximal end of the penile urethra. In response to sexualstimulation, the bulbourethral glands secrete an alkaline mucus-like fluid . This fluid neutralizes the acidity of theurine residue in the urethra, helps to neutralize the acidity of the vagina, and provides some lubrication for the tipof the penis during intercourse.

4. Seminal Fluid

Seminal fluid, or semen, is a slightly alkaline mixture of sperm cells and secretions from the accessoryglands. Secretions from the seminal vesicles make up about 60 percent of the volume of the semen, with most of theremainder coming from the prostate gland. The sperm and secretions from the bulbourethral gland contribute onlya small volume.

The volume of semen in a single ejaculation may vary from 1.5 to 6.0 ml . There are usually between 50 to150 million sperm per milliliter of semen . Sperm counts below 10 to 20 million per milliliter usually present fertilityproblems. Although only one sperm actually penetrates and fertilizes the ovum, it takes several million sperm in anejaculation to ensure that fertilization will take place.

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HISTOLOGY OF MALE REPRODUCTIVE SYSTEM (TESTIS)

Each testis (testicle) is surrounded by a capsule of dense connective

tissue, the tunica albuginea . The tunica albuginea is thickened on the

posterior side of the testis to form the mediastinum testis , from which

fibrous septa penetrate the organ and divide it into about 250 pyramidal

compartments or testicular lobules. The septa are incomplete, and there

is frequently intercommunication between lobules. Each lobule is

occupied by one to four seminiferous tubules that are surrounded by

interstitial loose connective tissue rich in blood and lymphatic vessels,

nerves, and endocrine interstitial cells ( Leydig cells ) which secrete

testosterone. Seminiferous tubules produce male reproductive cells, the

spermatozoa, whereas interstitial cells secrete testicular androgens.

A. Exocrine component

1. Seminiferous tubules (Place for spermatogenesis process)

- Myoid cells function as muscles that function to pull the spermatozoa that not fully mature go out fromthe testes.

- Sertoli cells , pyramid-shape, to spermiogenesis. In sertoli cells, can be found blood-testis barrier toprevent ASA (anti sperm antibody)

2. Intratesticular genital ducts

The intratesticular genital ducts are the tubuli recti (straight tubules), the rete testis, and the ductuli

efferentes. These ducts carry spermatozoa and liquid from the seminiferous tubules to the ductus

epididymidis.

3. Excretory genital ducts ductus epididimis, ductus deferens

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B. Endocrine component

Testosterone secreting interstitial cells (Leydig cells)

1. Ductus Epididimis

Single highly coiled tube, about 4-6 m in length . It is

lined with pseudostratified columnar epithelium

composed of rounded basal cells and columnar cells.

These cells are supported on a basal lamina

surrounded by smooth muscle cells, whose peristaltic

contractions help to move the sperm along the duct,

and by loose connective tissue rich in blood

capillaries. Their surface is covered by long, branched,

irregular microvilli called stereocilia. The epithelium ofthe ductus epididymidis participates in the uptake and

digestion of residual bodies that are eliminated during

spermatogenesis.

2. Ductus deferens

A straight tube with a thick, muscular wall,

continues toward the prostatic urethra and

empties into it . Characterized by a narrow

lumen and a mucosa with longitudinal folds,

covered along most of its extent by

pseudostratified columnar epithelium with

stereocilia. The lamina propria is rich in elastic

fibers, and the thick muscular layer consists of

longitudinal inner and outer layers separated

by a circular layer. The abundant smooth

muscle produces strong peristaltic

contractions that participate in the expulsion

of the spermatozoa during ejaculation.

3. Accessories glands

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4. Seminal vesicles

Consist of two highly tortuous tubes about 15 cm in length . It

has a folded mucosa that is lined with cuboidal or

pseudostratified columnar epithelium rich in secretory granules

that have ultrastructural characteristics similar to those found in

protein-synthesizing cells. The lamina propria of the seminal

vesicles is rich in elastic fibers and surrounded by a thin layer of

smooth muscle.

5. Prostate Glands

A dense organ surrounding the urethra below the bladder. It is

approximately 2 cm x 3 cm x 4 cm in size and weighs about 20 g .

The prostate is a collection of 30 –50 branched tubuloalveolar

glands, all surrounded by a dense fibromuscular stroma covered by

a capsule. The glands are arranged in concentric layers around the

urethra: the inner layer of mucosal glands , an intermediate layer of

submucosal glands , and a peripheral layer with the prostate's main

glands . The prostate has three zones, corresponding to the

glandular layers:

1) The transition zone occupies about 5% of the prostate volume, surrounds the prostatic urethra, and

contains the mucosal glands emptying directly into the urethra.2) The central zone occupies 25% of the

gland's volume and contains the

submucosal glands with longer ducts.

3) The peripheral zone occupies about

70% of the prostate and contains the

main glands with still longer ducts.

Glands of this area are the most

common location of both inflammation

and cancer.

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6. Bulbourethral glands

3 –5 mm in diameter, are located in the urogenital diaphragm and empty into the proximal part of the

penile urethra. Each gland has several lobules with tubuloalveolar secretory units lined by a mucus-

secreting simple columnar epithelium dependent on testosterone. The septa between lobules contain

smooth muscle cells. During erection the bulbourethral glands, as well as numerous, small, and

histologically similar urethral glands along the urethra, release a clear mucus-like secretion containing

various small carbohydrates, which coats and lubricates the urethral lining in preparation for the

imminent passage of sperm.

7. Penis

The main components of the penis are three

cylindrical masses of erectile tissue, plus the

urethra, surrounded by skin. Two of these

cylindersthe corpora cavernosa of the penis

are placed dorsally. The other the corpus

cavernosum of the urethra, or corpus

spongiosum is ventrally located and

surrounds the urethra. At its end it dilates,

forming the glans penis . Most of the penile

urethra is lined with pseudostratified

columnar epithelium; in the glans penis, it

becomes stratified squamous epithelium. Mucus-secreting glands of Littre are found throughout the length

of the penile urethra.

The prepuce is a retractile fold of skin that contains connective tissue with smooth muscle in its

interior. Sebaceous glands are present in the internal fold and in the skin that covers the glans.The corpora cavernosa are covered by a resistant layer of dense connective tissue, the tunica

albuginea . The corpora cavernosa of the penis and the corpus cavernosum of the urethra are composed of

erectile tissue. This is a tissue with a large number of venous spaces lined with endothelial cells and

separated by trabeculae of connective tissue fibers and smooth muscle cells.

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diminishes.The cause of the negative feedback effect on the anterior pituitary is believed to be

secretion by the Sertoli cells of s till another hormone called inhibin.

Many psychic factors, feeding especially from the limbic system of the brain into the hypothalamus, can

affect the rate of secretion of GnRH by the hypothalamus and therefore can also affect most other

aspects of sexual and reproductive functions in both the male and the female.

PHYSIOLOGY OF

SPERMATOGENESIS

Spermatogenesis occurs in seminiferous

tubules during active sexual life as the result of

stimulation by anterior pituitary gonadotropic

hormones. Begin at an average of 13 years and

continuing throughout most of the remiander

of life but decreasing markedly in old age.

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SEMEN ANALYSIS

Purpose and Indication Evaluate Fertility/Infertility

Evaluate Donor

Diagnosing Klineferter Syndrome

A. Macroscopic Examination

Liquefaction

Semen will be complete liquefaction within 60 minutes. Normal liquefied semen sample may contain jelly-like

granules which do not liquefy.

Viscosity

After liquefaction, the viscosity of the sample can be estimated by gently aspirating it into a wide-bore

(approximately 1.5 mm diameter) plastic disposable pipette, allowing the semen to drop by gravity and observing

the length of any thread. A normal sample leaves the pipette in small discrete drops. If viscosity is abnormal,the drop

will form a thread more than 2 cm long.

Appearance of the ejacuate

Normal i s grey-opalescent appearance, it may appear ess opaque if the sperm concentration is very low. If the

colour is red (haemospermia), or yellow with jaundice or taking drugs.

Volume

The volume is contributed mainly by the seminal vesicles and prostate gland, with small amount from the

bulbourethral gland and epididymides, lower semen volume is 1.5 ml

pH

pH of semen reflects the balance between the PH values of the different accessory gland secretions, mainly the

alcaine seminal vesicular secretion and the acidic prostatic secretion. Lower pH 7,2

B. Microscopic Examination

Microscopical examination can be accomplished with a phase contrast microscope on wet preparations of

undiluted semen

Sperm MotilitySperm motility is examined in the freshly liquefied semen sample at a magnification of ×400 –600. This is performed

at room temperature. cells displaying the following classes of motility:

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• PR: progressive motility (all space-gaining motion, both linear and in large arcs).

• NP: non-progressive motility (motion on the spot flagellation or motion in small circles).

• IM: immotility (no motion).

Sperm Count

This is a count of the number of sperm present per milliliter (mL) of semen in one ejaculation.

Sperm Vitallity

Sperm vitality refers to the percentage of live sperm in the semen sample. This is especially important to measure if

sperm motility is low, so differentiate between live non-motile sperm and dead sperm.

Sperm Morphology

Papanicolaou, Shorr and Diffquik staining procedures provide adequate coloration for spermatozoa and permits

some differentiation of “round” cells.

http://www.webmd.com/hw-popup/milliliter-mlhttp://www.webmd.com/hw-popup/milliliter-ml

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Factor Affecting validity of the result : Tobacco

Alcohol

Caffeine Drugs

High Activity

High Temperature

Contaminated semen Delivered over 1 hour

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FEMALE SEXUAL ACT

Stimulation of the Female Sexual ActLocal sexual stimulation in women occurs in more or less the same manner as in men because

massage and other types of stimulation of the vulva, vagina, and other perineal regions can create sexual

sensations . The glans of the clitoris is especially sensitive for initiating sexual sensations. The sexual sensory

signals are transmitted to the sacral segments of the spi nal cord through the pudenda l nerve and sacral plexus .

Once these signals have entered the spinal cord, they are transmitted to the cerebrum. Also, local reflexes

integrated i n the sacral and lumbar spinal cord are at leas t partly responsible for some of the reactions in the

female sexual organs.

Female Erection and Lubrication

Controlled by the parasympathetic nerves that pass through the nerve erigentes from the sacral

plexus to the external genitalia . parasympathetic signals dilate the arteries of the erectile tissue , probably

resulting from release of acetylcholine, nitric oxide, and vasoactive intestinal polypeptide (VIP) at the nerve

endings. This allows rapid accumula tion of bl ood in the erectil e tissue so that the introitus tightens a round the

penis. Parasympatheti c signals also pass to the bilateral Bartholin’s glands located beneath the labia minora

and cause them to secrete mucus immediately inside the introitus.This mucus is responsible for much of the

lubrication during sexual intercourse, although much is also provided by mucus secreted by the vaginal

epitheli um and a small amount from the mal e urethral glands.

Female Orgasm

When local sexual stimulation reaches maximum intensity , and especially when the local sensations

are supported by appropriate psychic conditioning signals from the cerebrum , reflexes are initiated thatcause the female orgasm , also called the female climax .

During the orgasm, the perineal muscles of the female contract rhythmically, which results from

spinal cord reflexes similar to those that cause ejaculation in the male. It is possible that these reflexes

increase uterine and fallopian tube motility during the orgasm, thus helping to transport the sperm upward

through the uterus toward the ovum.

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PATHOLOGICAL CONDITION INTERFERING FERTILITY

IN MEN

A. Abnormalities of External Genitalia

Penis and skrotum

o Aphallia

Agenesis of penis caused by failure in embryologic development of genital tubercle

o Chordae (Chordee)

Fibrous band associated with hypospadias or epispadias that causes bending of penis

o Concealed penis

Also called hidden or buried penis

o Diphallia

Duplication of penis

o Epispadias

Urethra opens onto dorsal surface of penis

o Hypospadias

Most common congenital abnormality of male external genitalia other than cryptorchidism

Urethra opens onto ventral surface of penis or scrotum

B. Abnormalities of Internal Genitalia

Testicular cancer

Erection problem Torsion of a testicle

Scrotal problems

Problems with the foreskin of an

uncircumcised penis Hypospadias Cyptorchidism (Undescended Testicle)

Inguinal hernia . A hernia occurs when a small portion of the bowel bulges out through the

inguinal canal into the groin.

Sebaceous cyst Infections

Infections can occur in any area of the genitals, including:

o A testicle (orchitis) .o The epididymis (epididymitis) .

http://www.webmd.com/cancer/testicular-cancer-21225http://www.webmd.com/erectile-dysfunction/erection-problems-and-dysfunctionhttp://www.webmd.com/hw-popup/torsion-of-a-testiclehttp://www.webmd.com/children/hypospadias-and-undescended-testicleshttp://www.webmd.com/hw-popup/inguinal-herniahttp://www.webmd.com/hw-popup/inguinal-herniahttp://www.webmd.com/digestive-disorders/understanding-hernia-basicshttp://www.webmd.com/hw-popup/epidermal-cysthttp://www.webmd.com/hw-popup/orchitishttp://www.webmd.com/hw-popup/epididymitishttp://www.webmd.com/hw-popup/epididymitishttp://www.webmd.com/hw-popup/orchitishttp://www.webmd.com/hw-popup/epidermal-cysthttp://www.webmd.com/digestive-disorders/understanding-hernia-basicshttp://www.webmd.com/hw-popup/inguinal-herniahttp://www.webmd.com/children/hypospadias-and-undescended-testicleshttp://www.webmd.com/hw-popup/torsion-of-a-testiclehttp://www.webmd.com/erectile-dysfunction/erection-problems-and-dysfunctionhttp://www.webmd.com/cancer/testicular-cancer-21225

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PATHOLOGICAL CONDITION INTERFERING FERTILITY

IN WOMEN

A. Abnormalities of External Genitalia

Labia minora abnormalities : can have labial fusion or hypertrophy in otherwise normal

females. Hypertrophy can be unilateral or bilateral and may occasionally require surgical

correction.

Labia majora abnormalities : can be hypoplastic or hypertrophic . Abnormal fusion is usually

associated with ambiguous genitalia of female pseudohermaphroditism due to congenitaladrenal hyperplasia.

Clitoral abnormalities : these are generally rare, agenesis is extremely rare and is double

clitoris or bifid clitoris . Hypertrophy can be associated with a number of intersex disorders.

B. Abnormalities of Internal Genitalia

Uterine abnormalities

The most common types of uterine abnormalities are caused by incomplete fusion of the

Müllerian or paramesonephric ducts .

o Complete failure is rare and results in double vagina, double cervix and double

uterus. Variants may occur depending on the degree of fusion.

o Single cervix and double single-horned uteruses which are partially fused.

o Other abnormalities include septate uterus (uterus with midline septum), arcuate

uterus (uterus slightly indented in the middle) and unicornuate uterus (second blind-

ending rudimentary horn).

Vaginal abnormalities

o Vaginal agenesis : Usually occurs with absent uterus but ovaries present.

o Vaginal atresia

o Müllerian aplasia

o Transverse vaginal septa

o Associated anomalies

http://www.patient.co.uk/search.asp?searchterm=AMBIGUOUS+GENITALIA&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=PSEUDOHERMAPHRODITISM&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=CONGENITAL+ADRENAL+HYPERPLASIA&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=CONGENITAL+ADRENAL+HYPERPLASIA&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=GENDER+UNCLEAR&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=GENDER+UNCLEAR&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=CONGENITAL+ADRENAL+HYPERPLASIA&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=CONGENITAL+ADRENAL+HYPERPLASIA&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=CONGENITAL+ADRENAL+HYPERPLASIA&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=PSEUDOHERMAPHRODITISM&collections=PPsearchhttp://www.patient.co.uk/search.asp?searchterm=AMBIGUOUS+GENITALIA&collections=PPsearch

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The urethra can open into the vaginal wall or the vagina can open into a persistent

urogenital sinus. ( Fistula )

Sexually Transmitted Infection /STI (Chancroid, Genital herpes, Granuloma inguinale ,

Molluscum contagiosum , Syphilis and Genital warts )

Nonsexually transmitted diseases (Atopic dermatitis, Contact dermatitis and

nonspecific vulvovaginitis)

Less common causes include:

Skin conditions such as lichen planus , lichen sclerosis , seborrheic dermatitis, and vitiligo

Noncancerous (benign) cysts or abscesses of the Bartholin's or Skene's glands

C. Hormonal Abnormalities

Disruptions in the GnRH, FSH and LH pathway , triggered by hormonal imbalances in androgen

(polycystic ovary syndrome or PCOS) and prolactin, can disrupt normal ovulation and also cause

infertility.

Medical conditions such as thyroid problems, cancer and its treatment with radiation, chemotherapyand/or surgery, and early menopause (premature ovarian failure) also contribute to female

infertility.

http://www.nlm.nih.gov/medlineplus/ency/article/000635.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000857.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000636.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000826.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000886.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000853.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000869.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000897.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000867.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000963.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000831.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/001489.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/001489.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000831.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000963.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000867.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000897.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000869.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000853.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000886.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000826.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000636.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000857.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000635.htm

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EVALUATING AND TREATMENT OF INFERTILE

COUPLES

Infertility is defined as 1 year of unprotected intercourse without pregnancy.

A. Initial Assessment

The physician's initial encounter with the infertile couple is the most important one because it sets

the tone for subsequent evaluation and treatment. The male partner should be present at this first

visit because his history is a key component in the selection of diagnostic and therapeutic plans. The

physician should obtain a complete medical, surgical, and gynecologic history from the woman .

B. Semen AnalysisThe basic semen analysis measures semen volume, sperm concentration, sperm motility, and

sperm morphology . The optimal period of abstinence before semen collection is 2 to 3 days.

Treatment:

Treatment of reversible endocrine or infectious causes of subfertility.

e.g: Clomiphene citrate acts on the hypothalamic –pituitary axis and, in men, increases serum

levels of LH, FSH, and testosterone.

Improve behavior and body : Personal hygiene, decrease tobacco and alcohol consumption,

adequate rest, treatment for chronic and metabolic diasease.

C. Ovulation Factor

Pelvic ultrasonography can provide evidence for ovulation

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The basal body temperature (BBT), should be taken shortly after awakening in the morning after

at least 6 hours of sleep and prior to ambulating

The use of an endometrial biopsy (EMB) near the end of the luteal phase can provide

reassurance of an adequate maturational effect on the endometrial lining

Within 48 hours of ovulation, the cervical mucus changes under the influence of progesterone

to become thick, tacky, and cellular, with loss of the crystalline fernlike pattern on drying.

Treatment :

Oral pills, that contain estrogen and progesterone. When it stopped, it will give rebound effect. Substitution therapy :

a. Given FSH and LH

b. Chorionic gonadotropin (LH) Given by clomiphen citrate to stimulate FSH and LH production.

D. Tubal, Paratubal and Peritoneal Factor

Tubal and peritoneal factors account for 30% to 40% of cases of female infertility. Damage or

obstruction of the fallopian tubes, peritoneal factors include peritubal and periovarian adhesions,

which generally result from PID, surgery, or endometriosis.

Hysterosalpingography (HSG) has a sensitivity of 85% to 100% in identifying tubal occlusion.

HSG usually is performed between cycle days 6 and 11

Falloposcopy allows the visual identification of tubal ostial spasm, abnormal tubal mucosal

patterns, and even intraluminal debris causing tubal obstruction

Laparoscopy allows careful assessment of the external architecture of the tubes and, in

particular, visualization of the fimbria. Identified abnormalities, can be treated at the time of

diagnosis.

E. Cervical and Immunologic Factor The Post Coital Test (PCT) is designed to assess the quality of cervical mucus, the presence and

number of motile sperm in the female reproductive tract after coitus, and the interaction

between cervical mucus and sperm.

Consistency of mucus : estrogenization of the cervical mucus is critical to the

interpretation of the results.

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pH of mucus : in alkaline environtment (± 9), sperm can live longer

proteolytic enzime :affect viscocity of mucus Antisperm Antibodies (ASA) can lead agglutination of spermatozoa. Treatment : Estrogen or

antibiotic

F. Uterine Factor

Sonohysterography detect uterine malformations, correctly identifying 90% of abnormalities in

infertile patients

Reduce of progesterone production or endometrium does not react to progesteron at

secretion phase

Treatment : given progesterone hormone. If found signs of infection, can be given antibiotics.

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BHP

Informed consent untuk breast examination, pelvic examination, dan speculum examination

(gynecological examination) Buat pasien nyaman, tanyakan mau ditemani keluarga pasien atau tidak Informed consent buat ultrasound scanning, laparoscopy surgery, dan GnRH therapy

Breaking bad news

Menjelaskan kepada pasien tentang diagnosis endometriosis cyst Rujuk pasien ke dokter spesialis jika kita tidak begitu paham dengan masalah pasien

Memberitahu pasien waktu- waktu “fertile periode” Memilih treatment/management yang terbaik bagi pasien

PHOP

Mengedukasi masyarakat tentang endometriosis cyst, ataupun penyebab infertile lainnya

Mengedukasi masyarakat/ pasangan suami istri yang memiliki program kehamilan kapan

seharusnya waktu yang tepat untuk melakukan hubungan seks

Mengedukasi tentang treatment dan terapi yang dapat dilakukan untuk mengatasi infertilitas

kepada masyarakat