LABORATORY MANAGEMENT OF INFERTILITY

Suwarso. Dr.Med.dr, Viroimmunol, SpPK(Kinf)

Sub Virologi-Immunologi, Patologi Klinik
FK-UGM/RSS, Yogyakarta

TYPE OF INFERTILITY

FECUNDABILITY (Chance of pregnancy per month exposu

Young healthy couples frequent intercourse
: 25-30%
Women 30-40 years old
: Begin decrease
Women >40 years old
: Most decrease

SUB/IN-FERTILITY
80% of couples experiencing unprotected intercourse will a
pregnancy/conceive within 1 year; 90% in second year
STERILITY:
Intrinsically inability to achieve pregnancy

EPIDEMIOLOGI DI INDONESIA

Soegiharto.S. Pengkuhan Gurubesar Obsgin-UI, Kompas 07.06.2010:12

Jumlah pasangan subur

: 40 jt
Infertil
: 6 jt
Perlu teknik reproduksi bantu (B.Tabung) : 30%
Biaya TRB (jt)

INA
50

USA Engl Skand

369 360 220

Keberhasilan Age 37th

27.4%
Age 48th 0% lahir hidup
3x TRB
45-53%
6x TRB
51-71%

(25% lahir h

MEDICAL HYSTORY OF INFERTILITY

MALE

FEMALE

General health, diet, exercise General health, diet, exercise

Prior paternity
Prior pregnancy
Infection, surgery, drug, toxin Infection, surgery, drug, toxin
Frequency of intercourse
In utero DES exposure
Congenital abnormalities
DES = Diethylstilbestrol

Contraceptive
In utero DES exposure
Pubertal development
Abnormal pap smear,
Menstrual (length, duration)

CAUSES OF MALE INFERTILITY

ENDOCRINE
Hypothalamic dysfunction (Kallmann.S)
Pituitary failure (Tumor, radiation, surgery)
Hyperprolactinemia (Drug, tumor)
Exogenous androgens
Thyroid disorder
Adrenal hyperplasia
SPERMATOGENESIS
Chromosomal abnormalities
Mump orchitis
Cryptochidism
Chemical, radiation
Varicocele

ANATOMIC DISORDER
Obstruction/Absence of vas deferens
Congenital abnormalities of ejaculatory
System
MOTILITY
Absent cilia (Kartageners syndrome)
Varicocelle
Antibody formation
SEXUAL DYSFUNCTION
Retrograde ejaculation
Impotence
Decreased libido

THE UNSUCCESSFUL FERTILITY

Un-succesfull in:
Production and transport of sperm in the male
Transport sperm and oocyte in the female
Ovulation and endometrial preparation for implant
(Mioma, TORCH, T.Palida, IgG/M anti-ACA)
Fertilization and embrionic development (TORCH,
IgG/M anti-ACA)

SPERMATOGENESIS, MIOGENESIS, MIATION AND

EJACULATION
Capillary
FS
H

T. Seminiferous

mRN
T,ADHT

Spermatogonium

Sertoli
1st , 2nd spermatocyte Spermatogenesis
T

Early, late spermatideSpermiogenesis

Spermatozoa

B.uretral
Urethral
Fluid
Transport
Total Vol
2-6ml

3 days

30% Vol
Prostate
Alkalis
Pnase, As
Pospat, Zn
Citric acid
Fibrinase
Cholestol

60% Vol
Seminal vesicle
Nourishment
Fructosa, Flavin
Ascorbic, Ergotin
Phosphorilcholin
Prostaglandin

5% Vol
Epididymis
Reservoir to
Maturation
Morphology
Function
Capacity

T. Recti
Rete testis
Duct eferet

5% Vol

Leydig
Ampula
Reservoir
Fertilization

L
H

Spermiation

EJACULATE
1st Fraction: Seminin: Prostat
:
Spermatozoa
Bulbourethral

0.5 ml

2nd Fraction

: Seminal vesicle
Vas deferens
Epididimis

: 1,5-2.0 ml

Normal

: 3-3.5 ml (2.0-6.0ml)

: 0.1-0.2 ml

PROSTATE SECRETE COMPONENTS

Zink

Normal
Prostatitis
Role

140ug/ml ejaculate, 350ug/ml prostate

50 (0-139ug)/ml ejaculate
Antibacterial

Spermine
(Proteinase)

Normal
Role

50=350 mg/ml ejaculate

Protect the genital tract from infection

Cholesterol
(80% Phos

Normal

103 (11-103mg)/ml ejaculate

Linearly by prostate volume/ in BPH
Protect the spermatozoa from temperature

Role
Citric Acid

Normal
Role

376 (480-2688mg)/100ml ejaculate

Linearly by testosterone content
Anion

PROSTATE SECRETE COMPONENTS

Seminin (Proteo
litic.Enzyme)

Role

Liquo-coagulation seminal plasma

Semino-/Prosta
glandin
spermatozoa

Normal
Role

100-300ug/ml ejaculate
Motility and transport

Prostate/Acid
Normal
Phosphatase/Gp103kd
Role

in female genital
800-1500 u/ml ejaculate
Increase in prostate carcinoma
Monitoring prostate carcinoma

Prostate specific Ag
(PSA, GP33kd)

Normal
Role

Prostate/acid phosphatase conform

IgG and IgA

Normal

7-22 and 0-6 ml/100ml ejaculate

SEMEN, MUCUS STUDIES

1000
sperm
2-3 d ays
abstinent
in 30-60at
laboratory

Maturate

Flagelate

MALE

Mucus
Study:
Pre/post
coital

USG

FEMALE

Sperm penetration
assay

Speramtogenese

Liquefaction Coagulation

Semen analysis:
2-5ml vol, 7.2-7.8 PH.
30 liquefaction, 20-250 M/ml
>50% normo-motility-morphology

Normo
Oligo
Astheno
Terato
spermia

PRECOITAL MUCUS STUDY : COMPOSITION, PROPERTIES OF

CERVICAL MUCUC IN THE MENSTRUAL CYCLE

Spinbarkeit
(CM)
Fern test
PH
Viscosity
Cell
Quantity

7 7
7.5
+4 +3
+2
+4 +3
+3
+1 +2
+1

7.5
+3

8
+1

+3
+2

+4

7.5

7.5

+3

+3

+3

+3

+2

+2

Basal temp
Day of cycle 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5
6 Menstruation
78
Best fertilization

MUCUS STUDIES: POST COITAL EXAMINATION

Preovulatory/Estrogen/Sperm reservoir mucus:
Thin, watery, acellular and fern crystal in dry
48h Ovulation/Progesterone/sperm non reservoir
mucus: Thick, tacky, cellular, non-ferning

Interpretation

Result

Normal
: Sperm forwardly progressive
False coital technique : Absence of sperm
Undeterminate
: 1-2 sperm with normal semen, mucus analysis
Autoantibody test
: More sperm immobile
Unfavorable timing : Mucus unfavorable
Abnormal USG
: Absence/deficient of follicle

OTHER LABORATORY STUDY

Head, tail, mid-piece autoantibody assay:

Abnormal repeated semen analysis in man with history surgery,
trauma or infection of genital tract
Sperm penetration assay in hamster egg/human zone/
hemizone assay (Predictor to favorable in-vitro fertilization
(IVF).
Unfavorable results if sperm success penetration is <10%
IVF assay
Abnormal sperm analysis in man with unexplained infertility
Infertile is male factor if IVF is failure to fertilization

CLINICAL LABORATORY IN CHRONIC INFECTION

/INFLAMMATION OF MALE GENITAL TRACT: Before-After
treatment. Study in 30 Infertile Male

Symptom
(+)ve

Sign Leucospermia
Oligoastheno
(+)v
(+)ve >5 leuco/hpf(+)ve
>1000 cfu/ml
ejaculate

50%

66.7% 100%

66.5%

E. Coli
Staphylococen
Ureaplsma

6-8 months R/Cotrimoxazole/Doxycicline/Erythromycin

Symptom
-ve

Sign Leucospermia
Oligoastheno
-ve -ve
-ve
-ve

79.7%

85%

100%

70%

100%

(+)

LITERATURES
Consilium CEDIP 1999:

Sexualstuerungen Mann in Handbuch fuer diagnose und

therapie:1186-1188

Faculty of medicine 2006:

Clinical pathology in block 17: Laboratory manual: 25-28

Martin.MC. 1994:

Infertility in DeChenney.AH and Pamoll.ML: Current obstetric &

gynecology diagnosis and treatment. 8th.ed:996-1006

Parslow.TB Et.al. 1977:

Infertility and spontaneus abortion in Lange medical immunology.

9th.ed:555-558

Weidner.W, Madsen.PO, Schiefer.HG. 1994: Prostatitis: Etiopathology, Diagnosis and therapy.

Springer-Verlag, Berlin, Heidelberg. New york
WHO

PRAKTIKUM INFERTILITAS
4 Metode analisis sperma:
Test Makroskopik
Test Mikroskopik
Test Biokemik
Test Spesifik
Preparation Specimen
Abstinence 2-7 Hari
Masturbasi & Kumpulkan ejakulat dalam kontainer
mulut lebar, jangan sampai tumpah &1 jam sudah
diperiksa