Basic Infertility (English)

Introduction Good Morning ma’am, I’m Mrs. XX, 30 yo & Mr. XY, 35
Doctor Yana, the doctor in yo
charge in O&G clinic right Chief complain : Unable to
now. get pregnant for 2 years.
How can i help you?
Anamnesis How long have you been Married 2 years
married ? 2-3x/weeks sexual
How often do you have intercourse
sexual intercourse ? No Dyspareunia
Do you experience any pain No Contraception
when you do sexual Menarche 13 yo
intercourse ? Menstrual cycle regular
Do you ever use Last Mens : 10/10/19
contraception ? Duration 3-4 days
Now i will ask about your Change napkins 2-3x/day
menstrual history : No Dysmenorhea
- How old were you when Don’t have any pregnancy
you have your first time history
menstruation ? No history of surgery, &
- When is the last time systemic ds
you had your Never gone to any of O&G
menstruation ? No Abdominal pain
- Do you have regular No Leuchorea
cycle on the last 3 No Prolonged coughs
months ? No decrease in body weight
- How long does the
menstruation occur ?
- How often do you
usualy change your
napkins a day ?
- Is there any excesive
menstrual pain ?
Obstetric history :
- Have you ever been
pregnancy ?
Past illness history :
- Have you ever undergo
any surgery ?
- Is there any history of
systemic disease like
Diabetic, Hypertension,
Heart ds, or any other
metabolic ds ?
 - Have you ever gone to
any O&G in an attempt
get pregnant ?
Others Complains :
- Is there any abdominal
pain ?
- Is there any history of
leuchorea ?
- Is there any history of
prolonged cough ?
- Is there any decrease of
body weight ?
Physical examination I’m sorry Ma’am, now I will 155 cm, 50 kg
do a complete gynecology Present state normal
examination to help
determine your condition. General state normal
Present state :
W/H/BMI Gynecology state normal
BP,ND, RR, Temp

General state :
Eyes Anemic ?
Excesive acne / smooth
hair?
Thyroid enlargement ?
Cor/Pulmo disorder ?
Extremities disorder ?

Gynecology state :
Abdomen:
Striae?
Mass ?
Hepato/spleenomegaly ?
Any tenderness ?

Vulva inspection : Is there

any external genitalia
disorders?
Inspeculo : Fluor? Fluxus ?
Cervical condition ?
VT : Uterus size and
consistension ? adnexal
mass ?
RVT : Sacral uterine
ligament nodule ?

Supporting examination TVS TVS Normal

 SA SA Normal
HSG day 9-10 HSG ~ Hydrosalphix bilateral
with non patent both tube
Diagnosis Primary infertility 1 year
Non patent both tube
Treatment Plan for laparoscopy
diagnosis and bilateral
salphingectomy if the both
tube were non patent

Education Allright Ma’am, I will explain

about your condition now.
From the examination, we
can assume that the cause
your infertility is that both
of your tube were non
patent.
We will do laparoscopy for
further diagnosis of your
tube condition, if we found
any pathologic condition,
we will do salphingectomy
so your chance to get
pregnant with IVF will be
much greater.