RPS - CASE 2

Endometriosis
Anatomy, Histology, Physiology and Clinical Pathology of
Female Reproductive System

TIM AKADEMIK
DIVISI SOOCA
SPEKATRIA

LEARNING ISSUES

CASE REVIEW

CONCEPT MAP

TOPOGRAPHY OF MALE INTERNAL GENITALIA

Anatomi +
Histologi

Vascularization

Tambahan

TOPOGRAPHY OF MALE EXTERNAL GENITALIA

Anatomy of External Male Reproductive System (glands and ducts that produce and transport spermatozoa and
seminal 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, and
spongy.
a. Intramural Part of Urethra
The short, most proximal part of the urethra, running almost vertically down from the bladder to
where it enters the prostate.
b. Prostatic
The prostatic portion (pars prostatica), the widest and most dilatable part of the canal, is about 3
cm. long, It runs almost vertically through the prostate from its base to its apex, lying nearer its
anterior 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 the
external urethral sphincter. Posterolateral to this part are the small bulbo-urethral glands and their
slender 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 is
approximately 5 mm. but it is expanded in the bulb of the penis to form the intrabulbular fossa and
in 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 dorsal
artery of penis.
Venous and Lymphatic Drainage of Distal Male Urethra
Veins accompany the arteries and have similar names. Lymphatic vessels from the intermediate part
of the urethra drain mainly into internal iliac lymph nodes, whereas most vessels from the spongy
urethra pass to deep inguinal lymph nodes, but some lymph passes to the external iliac nodes.

2. Scrotum
Scrotum is cutaneous fibromuscular sac of the testes and associated structures. Situated posteroinferior to the penis and inferior to the pubic symphysis. The bilateral embryonic formation of the
scrotum 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 for
each 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 superficial
perineal branches of internal pudendal arteries, supply the posterior aspect. The scrotum also receives
branches 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 external
pudendal 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 a
root, body, and glans.
Penis consists of three cylindrical cavernous bodies of erectile tissue: the paired corpora cavernosa
dorsally 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 Penis
a. 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 Penis
d. 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 Penis
g. 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 the
anterior surface of pubic symphisis. The fundiform ligament of the penis is an irregular mass or
condensation of collagen and elastic fibers of the subcutaneous tissue that descends in the middle from
the linea alba interior to the pubic symphisis.

Arterial Supply of Penis

j.

Dorsal arteries of penis run on each side of the deep dorsal vein in the dorsal groove between
the corpora cavernosa. Supplying the fibrous tissue around the corpora cavernosa, the corpus
spongiosum and spongy urethra, and the penile skin.
k. Deep arteries of the penis pierce the crura proximally and run distally near the center of the
corpora 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 and
the 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 duct
that 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 the
sperm; prostaglandins, which contribute to the mobility and viability of the sperm; and proteins that cause slight
coagulation 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 the
size of a walnut and encircles the urethra as it leaves the urinary bladder. Numerous short ducts from the substance
of the prostate gland empty into the prostatic urethra. The secretions of the prostate are thin, milky colored, and
alkaline. 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 of
the penis. A short duct from each gland enters the proximal end of the penile urethra. In response to sexual
stimulation, the bulbourethral glands secrete an alkaline mucus-like fluid. This fluid neutralizes the acidity of the
urine residue in the urethra, helps to neutralize the acidity of the vagina, and provides some lubrication for the tip
of the penis during intercourse.
4. Seminal Fluid
Seminal fluid, or semen, is a slightly alkaline mixture of sperm cells and secretions from the accessory
glands. Secretions from the seminal vesicles make up about 60 percent of the volume of the semen, with most of the
remainder coming from the prostate gland. The sperm and secretions from the bulbourethral gland contribute only
a small volume.
The volume of semen in a single ejaculation may vary from 1.5 to 6.0 ml. There are usually between 50 to
150 million sperm per milliliter of semen. Sperm counts below 10 to 20 million per milliliter usually present fertility
problems. Although only one sperm actually penetrates and fertilizes the ovum, it takes several million sperm in an
ejaculation to ensure that fertilization will take place.

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 from
the testes.
- Sertoli cells, pyramid-shape, to spermiogenesis. In sertoli cells, can be found blood-testis barrier to
prevent 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

B. Endocrine component
Testosterone secreting interstitial cells (Leydig cells)

1. Ductus Epididimis

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

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 of
the ductus epididymidis participates in the uptake and
digestion of residual bodies that are eliminated during
spermatogenesis.

3. Accessories glands

of the spermatozoa during ejaculation.

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 3050 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.

6. Bulbourethral glands

35 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 mucussecreting 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.

HPT AXIS
A major share of the control of sexual functions in both the male
and the female begins with secretion of gonadotropin-releasing
hormone (GnRH) by the hypothalamus.
GnRH stimulates the anterior pituitary gland to secrete two
gonadotropic hormones: LH and FSH.
LH primary stimulus for the secretion of testosterone by the
testes
FSH stimulates spermatogenesis.
The ending of neurons whose located in the arcuate nuclei of the
hypothalamus release GnRH into the hypothalamic-hypophysial
portal vascular system.

GnRH is transported to the anterior pituitary gland in the

hypophysial portal blood

Stimulates the release of the two gonadotropins, LH and FSH.

LH and FSH exert their effects on their target tissues in the testes mainly by activating the cyclic AMP
second messenger system, which in turn activates specific enzyme systems in the respective target cells .
Testosterone is secreted by the interstitial cells of Leydig in the testes, but only when they are
stimulated by LH from the anterior pituitary gland. Furthermore, the quantity of testosterone secreted
increases approximately in direct proportion to the amount of LH available.
FSH binds with specific FSH receptors attached to the Sertoli cells in the seminiferous tubules. This
causes these cells to grow and secrete various spermatogenic substances. Simultaneously, testosterone
(and dihydrotestosterone) diffusing into the seminiferous tubules from the Leydig cells in the interstitial
spaces also has a strong tropic effect on spermatogenesis. To initiate spermatogenesis, both FSH and
testosterone are necessary.
When the seminiferous tubules fail to produce sperm, secretion of FSH by the anterior pituitary gland
increases markedly. When spermatogenesis proceeds too rapidly, pituitary secretion of FSH

diminishes.The cause of the negative feedback effect on the anterior pituitary is believed to be
secretion by the Sertoli cells of still 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.

TRANSPORTATION OF SPERM

TRANSPORTATION OF OVUM

Seminiferous Tubules

Ovum

Epididymis

Caught by Fimbriae

Vas Deferens

Fallopian Tube

Ampulla of Vas Deferens

Ejaculatory Duct

Urethra

Vagina

Uterus

Fallopian Tube

Ampulla of Fallopian Tube

Ampulla of Fallopian Tube

Two major event that happening is CAPASITATION and FERTILIZATION

Some changes that are occur are:

1.

The uterine and fallopian tube fluids wash away the various inhibitory factors that suppress sperm activity in the male
genital ducts.

2.

While the spermatozoa remain in the fluid of the male genital ducts, they are continually exposed to many floating
vesicles from the seminiferous tubules containing large amounts of cholesterol. This cholesterol is continually added to
the cellular membrane covering the sperm acrosome, toughening this membrane and preventing release of its
enzymes.

3.

After ejaculation, the sperm deposited in the vagina swim away from the cholesterol vesicles upward into the uterine
cavity, and they gradually lose much of their other excess cholesterol over the next few hours. In so doing, the
membrane at the head of the sperm (the acrosome) becomes much weaker.

4.

The membrane of the sperm also becomes much more per meable to calcium ions, so that calcium now enters the
sperm in abundance and changes the activity of the flagellum, giving it a powerful whiplash motion in c ontrast to its
previously weak undulating motion.

5.

In addition, the calcium ions cause changes in the cellular membrane that covers the leading edge of the acrosome,
making it possible for the acrosome to release its enzymes rapidly and easily as the sperm penetrates the granulosa cell
mass surrounding the ovum, and even more so as it attempts to penetrate the zona pellucida of the ovum itself. Thus,
multiple changes occur during the process of capacitation.Without these, the sperm cannot make its way to th e interior
of the ovum to cause fertilization.

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 is 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 Motility
Sperm motility is examined in the freshly liquefied semen sample at a magnification of 400600. This is performed
at room temperature. cells displaying the following classes of motility:

 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.

Factor Affecting validity of the result :

Tobacco

High Activity

Alcohol

High Temperature

Caffeine

Contaminated semen

Drugs

Delivered over 1 hour

MALE SEXUAL ACT

A. Penile Erection
Penile erection is the first effect of male sexual stimulation , and the degr ee of erection is proportional to the
degree of stimulation, whether psychic or physical. Erection is caused by parasympathetic impulses that pass
from the sacral portion of the spinal cord through the pelvic nerves to the penis. These parasympathetic nerve
fibers release nitric oxide and/or vasoactive intestinal peptide in addition to acetylcholine. The nitric oxide
especially relaxes the arteries of the penis. The erectile bodies, especially the two corpora cavernosa, are
surrounded by strong fibrous coats; therefore, high pressure within the sinusoids causes ballooning of the
erectile tissue to such an extent that the penis becomes hard and elongated. This is the phenomenon of
erection.

B. Lubrication
During sexual stimulation, the par asympathetic impulses, in addition to promoting erection, cause the
urethral glands and the bulbourethral glands to secrete mucus.This mucus flows through the urethra during
intercourse to aid in the lubrication during coitus.

C. Emission and Ejaculation

Emission and ejaculation are the culmination of the male sexual act. When the sexual stimulus becomes
extremely intense, the reflex centers of the spinal cord begin to emit sympath etic impulses that leave the cord
at T-12 to L-2 and pass to the genital organs through the hypogastric and pelvic sympathetic nerve plexuses to
initiate emission, the forerunner of ejaculation. Emission begins with contraction of the vas deferens and the
ampulla. The contractions of the muscular coat of the prostate gland foll owed by contraction of the seminal
vesicles expel prostatic and seminal fluid also into the urethra, forcing the sperm forward. All these fluids mix
in the internal urethra with mucus already secreted by the bulbourethral glands to form the semen. The
process to this point is emission.
The filling of the internal urethra with semen elicits sensory signals that are transmitted through the
pudendal nerves to the sacral regions of the cord, giving the feeling of sudden fullness in the internal genital
organs. Also, these sensory signals further excite rhythmical contraction of the internal genital organs and
cause contraction of the ischiocavernosus and bulbocavernosus muscles that compress the bases of the penile
erectile tissue. These effects together cause rhythmical, wavelike increases in pressure in both the erectile
tissue of the penis and the genital ducts and urethra, which ejaculate the semen from the urethra to the
exterior. This final process is called ejaculation. This entire period of emission and ejaculation is called the male
orgasm.

FEMALE SEXUAL ACT

Stimulation of the Female Sexual Act
Local 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 spinal cord through the pudendal nerve and sacral plexus.
Once these signals have entered the spinal cord, they are transmitted to the cerebrum. Also, local reflexes
integrated in the sacral and lumbar spinal cord are at least 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 accumulation of blood in the erectile tissue so that the introitus tightens around the
penis. Parasympathetic signals also pass to the bilateral Bartholins 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
epithelium and a small amount from the male 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 that
cause 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.

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

Hypospadias

Scrotal problems

Cyptorchidism (Undescended Testicle)

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

Problems with the foreskin of an

uncircumcised penis

inguinal canal into the groin.

Sebaceous cyst Infections

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

A testicle (orchitis).

The epididymis (epididymitis).

The urethra (urethritis).

The prostate (prostatitis).

The bladder (cystitis).

A low sperm count and low sperm motility are indicators of this condition. Also, elevated FSH
levels and other hormonal problems are indicative of testicular damage. Some STDs like gonorrhea
and Chlamydia can cause infertility by blocking the epididimis or tubes. These conditions are usu ally
treated by hormonal replacement therapy and surgery in the case of tubular blockage.

C. Hormonal Imbalance

Hyperprolactinemia
Elevated protein mild elevation of prolactin levels produces no symptoms, but greater
elevation of the hormone reduces sperm production, reduces libido and may cause
impotence. This condition responds well to the drug Parlodel (bromocriptine)

Hypothyroidism
Low thyroid hormone levels can cause poor semen quality, poor testicular function and
may disturb libido. may be caused by a diet high in iodine. Reducing iodine intake or
beginning thyroid hormone replacement therapy can elevate sperm count. This condition is
found in only 1% of infertile man.

Congenital adrenal hyperplasia

Occurs when the pituitary is suppressed by increased levels of adrenal androgens. Symptoms
include low sperm count, an increased number of immature sperm cells, and low sperm cell
motility. Is treated with cortisone replacement therapy. This condition is found in only 1% of
infertile men.

Hypergonadotropic hypopituitarism:
Low pituitary gland output of LH and FSH. This condition arrest sperm development and
causes the progressive loss of germ cells from the testes and causes the seminiferous
tubules and leydig cells to deteroriate.

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 congenital
adrenal 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
Mllerian 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.

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

Other abnormalities include septate uterus (uterus with midline septum), arcuate
uterus (uterus slightly indented in the middle) and unicornuate uterus (second blindending rudimentary horn).

Vaginal abnormalities
o

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

Vaginal atresia

Mllerian aplasia

Transverse vaginal septa

Associated anomalies

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, chemotherapy
and/or surgery, and early menopause (premature ovarian failure) also contribute to female
infertility.

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 Analysis
The 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 hypothalamicpituitary 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

 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.

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.

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