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Transcript of Nur Rasyid Department of Urology Faculty of Medicine University of Indonesia.
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Nur Rasyid
Department of Urology
Faculty of Medicine
University of Indonesia
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Introduction
US & Europe : 20% are unable to conceive
50% : male factor Urologist : first specialist visit for man
factor
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Aetiology
EAU Guidelines 2005
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Causes of male infertility in RSCM
Taher A. Unpublished data
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Aetiology
Pretesticular Testicular Post Testicular
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Pre Testicular Hypothalamic
diseaseGonadotropin
deficiency (Kallmann syndrome)
Isolated LH deficiency (“fertile eunuch”)
Isolated FSH deficiency
Congenital hypogonadotropic syndromes
Pituitary diseasePituitary insufficiency
(tumors, infiltrative processes, operation, radiation, deposits)
HyperprolactinemiaExogenous hormones
(estrogen-androgen excess,glucocorticoid excess, hyper- and hypothyroidism)
Growth hormone deficiency
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Testicular Chromosomal
(Klinefelter syndrome [XXY], XX sex reversal, XYY syndrome)
Noonan syndrome (male Turner syndrome)
Myotonic dystrophy Vanishing testis
syndrome (bilateral anorchia)
Sertoli-cell-only syndrome (germ cell aplasia)
Y chromosome microdeletions (DAZ)
Gonadotoxins (radiation, drugs)
Systemic disease (renal failure, liver failure, sickle cell anemia)
Defective androgen activity
Testis injury (orchitis, torsion, trauma)
Cryptorchidism Varicocele Idiopathic
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Post Testicular Reproductive tract
obstruction Congenital blockages Congenital absence of the
vas deferens (CAVD) Young syndrome Idiopathic epididymal
obstruction Polycystic kidney disease Ejaculatory duct obstruction Acquired blockages Vasectomy Groin surgery Infection Functional blockages Sympathetic nerve injury Pharmacologic
Disorders of sperm function or motilityImmotile cilia syndromesMaturation defectsImmunologic infertilityInfection
Disorders of coitusImpotenceHypospadiasTiming and frequency
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Varicocele Most common correctable cause Occur 15 % of the general population Up 35 % of men being evaluated for
primary infertility Up to 80 % of men with secondary infertility Incompetent venous valve Associated a progressive and time-
dependent deterioration in testicular function
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Varicocele Repair Retroperitoneal
Open (Palomo procedure)
Laparoscopic
Inguinal (Ivanisevich procedure)Using Lense Loupe or
Microscope
Subinguinal
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Improvement
Semen quality improvement : 60 – 80 % Pregnancy rate : 20 – 60 %
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Endocrinopathies
EAU Guidelines 2005
Only
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Endocrinopathies
Disorder of production or secretion of GnRH
Disorders of pituitary function Disorders of testosterone synthesis and
function
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Disorder of production or secretion of GnRH
Disorders of pituitary function
Disorders of testosterone synthesis
and function
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Disorder of production or secretion of GnRH Low levels of FSH and LH Kallmann’s syndrome Hormonal replacement with hCG
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Disorders of pituitary function Pituitary mass
Direct compression of the portal systemDecrease FSH/LH secretion
hypogonadotropic hypogonadism
Must performed imaging to find pituitary adenoma
Sugical, radiation and medical (cabergoline, bromocriptin) treatment
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Disorders of testosterone synthesis and function Defect enzym for systhesis testosterone Defect Androgen receptor Exogenous androgen reversible in 6
month to 1 year Treatment
Testosterone supplementAromatase inhibitorAntiestrogens
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Cryptorchidism & Orchiopexy Histopathologic hallmarks
Decreased numbers of Leydig cells, Degeneration of Sertoli cellsDelayed disappearance of gonocytes, Delayed appearance of adult dark (Ad)
spermatogoniaFailure of primary spermatocytes to developReduced total germ cell counts
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Cryptorchidism & Orchiopexy Also increase malignancy risk Treatment :
Orchiopexy in 1 year of age
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Disorders of ejaculation
Failure of emission or ejaculationSymphatic nerves injury Retrograde ejaculation
Medication, prior surgery to bladder neck
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Disorders of ejaculation Treatment
Neurogenic problem : simpathomimetic agents enhance emission and close bladder neck (successful in 50 % cases)
Post ejaculate-urine specimen Vibratory stimulation under anaesthesia If all above fail IVF / ICSI
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Obstruktif Azoospermia
Tidak adanya spermatozoa dan sel spermatogenesis pada semen dan urine pasca ejakulasi yang disebabkan oleh sumbatan bilateral pada duktus seminalis
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Obstruction
Depend level of obstruction Complete ejaculatory duct obstruction
Low Volume, acidic, fructose negative ejaculate
Vasa or epididimis obstructionNormal volume, basic, fructosa positive
ejaculate
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TRUS ( Trans rectal ultrasonografi)
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Complete ejaculatory duct obstruction
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Vasal obstruction
Most common etiology : post vasectomy Treatment
Modified single layer vasovasostomyTwo layer vasovasostomyVasoepidimostomy
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Modified single layer vasovasostomy
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Two layer vasovasostomy
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Vasoepididimostomy
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Congenital bilateral absence of the vas deferens Sperm harvested from
Epididymis (MESA)Testis (TESE)
ICSI
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Percutaneous Epididymal Sperm Aspiration (PESA)
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MESAMicrosurgical Epididymal Sperm Aspiration
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BIOPSI TESTIS
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Testis Biopsy / TESE
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ART (ICSI)
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Conclusion
Each infertility case must be examine carefully to select spesific treatment
Urologist has a pivotal role in surgery treatment for infertility cases
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