TRIGGER 1 - GROUP E

Reproduction Module
Mrs. M, 28 years old, came to a hospital with
complaints of feel pain in the lower left of
abdomen often and leucorrhea. She has been
married for 3 years with Mr. P, who works as a
personal trainer (PT) at a gym. He was a cyclist
athlete. Until now, they still dont have any
children.

Keywords
Mrs. M, 28 years old
Lower left abdomen
pain
Leucorrhea
Married for 3 years
Husband PT and
cyclist
Dont have any children

Identification of
Problem
The couple has been
married for 3 years
without any child.

Married for 3
years

F, 28 yo

Husband: PT and
cyclist

Leucorrhea

Risk Factors

Background

Unpregnant
Semen analysis

Lower left
abdominal pain

Supporting exam

Other Complain

Causes

Infertility

Diagnosis
Acquired

Congenital

Treatment
M

HYPOTHESIS
The couple dont have any children due to infertility, influenced
by many factors.
KNOWLEDGE NEEDED
1. Normal anatomy of female and male reproduction system
2. Histology of female and male reproduction system
3. Physiology:

Spermatogenesis
Hypothalamic hypophysis gonad axis
Menstrual cycle
Normal sexual intercourse and fertilization process

4. Infertility (definition, etiology, symptomatology, risk factors)

5. Supporting examination (genital exam, Sperm analysis,
Fertile period, HSG, Referral criteria)

Anatomy of Female Reproductive

Organs
Brenda Angeline Tiffany
1206289142
Group E

Pelvis
Pelvis: the space within the pelvic girdle,
overlapped externally by the abdominal and
gluteal regions, perineum, and lower back.
The greater pelvis: pelvic by virtue of its bony
boundaries, but is abdominal in terms of its
contents.
The lesser pelvis provides the skeleton for the
pelvic cavity and deep perineum.

Male vs Female Pelvis

Pelvis

Pelvic Artery
artery

origin

crosses pelvic brim,

descends in suspensory
ligament of ovary

ovarian

uterine

vaginal

course

uterine
artery

distribution
anastomoses
abdominal and/pr
pelvic ureter, ovary, uterine artery via tubal
and ampullary end of and ovarian branches
uterine tube

runs anteromedially in base

of broad ligament/superior
Uterus, ligaments of
Ovarian artery (via
cardinal ligament, gives rise
uterus, medial parts of tubal and ovarian
to vaginal branch, then
uterine tube and ovary, branches); vaginal
crosses ureter superiorly to
and superior vagina
artery
reach lateral aspect of
uterine cervix
Divides into vaginal and Vaginal branch: lower
inferior vesical branches, vagina, vestibular bulb,
Vaginal branch of
the former descending on and adjacent rectum;
uterine artery, superior
the vagina, the latter
inferior vesical branch:
vesical artery
passing to the urinary
fundus of urinary
bladder
bladder

Pelvic Artery

Uterine & Vaginal Arteries

Pelvic Vein

Neurovascular Structures of Pelvis

Pelvic Lymph Nodes

Pelvis
Vascularisation: Supplied by internal iliac artery and
vein

Innervations:
Sacral plexus
Coccygeal plexus
Pelvic splanchnic nerves
Lymphatic drainage into:

Common iliac nodes

External iliac nodes
Internal iliac nodes

15

Ovaries
almond-shaped and almond-sized female
gonads in which the oocytes develop
also endocrine glands that produce
reproductive hormones.

Ovaries & Fallopian Tubes

Fallopian Tubes
conduct the oocyte, discharged monthly from
an ovary during child-bearing years, from the
periovarian peritoneal cavity to the uterine
cavity
also provide the usual site of fertilization.

Fallopian Tubes
From lateral to medial:
Infundibulum: the funnel-shaped distal end of the tube
that opens into the peritoneal cavity through the
abdominal ostium. The finger-like processes (fimbriae)
spread over the medial surface of the ovary.
Ampulla: the widest and longest part of the tube,
which begins at the medial end of the infundibulum;
fertilization of the oocyte usually occurs in the ampulla.
Isthmus: the thick-walled part of the tube, which
enters the uterine horn.
Uterine part: the short intramural segment of the tube
that passes through the wall of the uterus and opens
via the uterine ostium into the uterine cavity at the
uterine horn.

Arteries & Veins of Ovaries & Fallopian

Tubes
The ovarian arteries arise from the abdominal aorta
and descend along the posterior abdominal wall
cross over the external iliac vessel at pelvic brim and
enter the suspensory ligaments
Veins draining the ovary form a vine-like pampiniform
plexus of veins in the broad ligament near the ovary
and uterine tube.
The veins of the plexus usually merge to form a
singular ovarian vein, which leaves the lesser pelvis
with the ovarian artery.
The right ovarian vein ascends to enter the inferior
vena cava; the left ovarian vein drains into the left
renal vein. The tubal veins drain into the uterovaginal
venous plexus

Arteries & Veins of Ovaries & Fallopian

Tubes

Innervation of Ovaries
The nerve supply derives partly from the ovarian
plexus, descending with the ovarian vessels, and partly
from the uterine (pelvic) plexus.
Visceral afferent pain fibers ascend retrogradely with
the descending sympathetic fibers of the ovarian
plexus and lumbar splanchnic nerves to cell bodies in
the T11-L1 spinal sensory ganglia.
Visceral afferent reflex fibers follow parasympathetic
fibers retrogradely through the uterine (pelvic) and
inferior hypogastric plexuses and the pelvic splanchnic
nerves to cell bodies in the S2-S4 spinal sensory
ganglia.

Nerve Suppy of Ovaries

Lymphatic Drainage of Ovaries

Most of tubal lymphatic join the lymphatics
from ovary and drain into the lateral aortic
and preaortic nodes.
The lymphatics from isthmus accompany the
round ligament of the uterus and drain into
the superficial inguinal nodes.

Uterus
a thick-walled, pear-shaped, hollow muscular
organ where the embryo and fetus will
develop.
The cervix of the uterus is the cylindrical,
relatively narrow inferior third of the uterus,
approximately 2.5 cm long in an adult nonpregnant woman.

Layers of Uterus
Perimetrium: the outer serous coat (consists of peritoneum
supported by a thin layer of connective tissue)
Myometrium: the middle coat of smooth muscle (contain
main branches of the blood vessels and nerves of the
uterus ) becomes greatly distended (more extensive but
much thinner) during pregnancy. During childbirth,
contraction of the myometrium is hormonally stimulated to
dilate the cervical os and expel the fetus and placenta.
During the menses, myometrial contractions may produce
cramping.
Endometrium: the inner mucous coat (firmly adhered to
the underlying myometrium). The endometrium is actively
involved in the menstrual cycle, differing in structure with
each stage of the cycle. If conception occurs, the blastocyst
becomes implanted in this layer; if conception does not
occur, the inner surface of this coat is shed during
menstruation.

Excavatio
Rectouterina
(Douglas
Pouch)

Excavatio
Vesicouterina

Vascularisation of Uterus

Lymphatic Drainage Uterus

Fundus: aortic lymph nodes, external iliac
lymph nodes or superficial inguinal lymph
nodes
Corpus: external iliac lymph nodes
Cervix: internal iliac and sacral lymph nodes

Ligament
The ligament of the ovary attaches to the uterus
posteroinferior to the uterotubal junction.
The round ligament of the uterus (L. ligamentum
teres uteri) attaches anteroinferiorly to
uterotubal junction.
The broad ligament of the uterus (assists in
keeping the uterus in position) is a double layer
of peritoneum that extends from the sides of the
uterus to the lateral walls and floor of the pelvis.

Cervix
The cervix is the least mobile part of the uterus
because of the passive support provided by
attached condensations of endopelvic fascia
(ligaments):
Cardinal (transverse cervical) ligaments extend
from the supravaginal cervix and lateral parts of
the fornix of the vagina to the lateral walls of the
pelvis.
Uterosacral ligaments pass superiorly and slightly
posteriorly from the sides of the cervix to the
middle of the sacrum; they are palpable during a
rectal examination.

Innervation of Female Genitalia

Female External Genitalia

Female External Genitalia

Lymphatic Drainage of Female External

Genitalia
The upper third portion will drain into the
external iliac nodes
The middle third portion will drain into the
internal iliac nodes
The lower third portion will drain into the
medial group of superficial inguinal nodes

Nerve Supply to the Female External

Genitalia
The upper two-third part is non-sensitive to
pain.
- Sympathetic (L1,2) and parasympathetic (S2,3)
nerves derived as vaginal nerves from the
inferior hypogastric and uterovaginal plexuses

The lower third part is sensitive to pain

sensitive
-Pudendal nerve through the inferior rectal and
posterior labial branches of perineal nerve

STRUCTURE OF PENIS
Penis is divided into three
region :
Glans penis
Corpus penis
Radix penis

Root
Glans Penis

consists of three masses

of erectile tissue in the
urogenital
triangletwo crura and
the bulbattached to
the pubic arch and
perineal membrane
Crus Penis
Radix Penis

Bulbus Penis

40

Corpus
consists of three masses
of erectile tissuethe
right and left corpora
cavernosa, and the
median corpus
spongiosum

Artery of the Penis

Lymphatic Drainage of Penis

Lymphatic from the
glans drain into the
deep inguinal nodes.
Rest of the lymphatics
drain into superficial
inguinal lymph nodes.

Testes
the primary reproductive
organs or gonads in the
male
responsible for sperm
production and
testosterone production.

The left testis usually lies

lower than the right testis
Three coats
tunica vaginalis
tunica albuginea
tunica vasculosa

Vessels
Testicular Artery arise
from abdominal aorta,
inferior of renal
arteries
It travels together with
Spermatic Cord
Pampiniform Plexus
are the combination
of testicular and
epididymal veins

http://www.endotext.org/male/mal
e1/figures1/figure3.gif

45

Scrotum
Def:a cutaneous fibromuscular sac containing
the testes and lower parts of the spermatic
cords and hangs below the pubic symphysis
between the anteromedial aspects of the
thighs
Divided into right and left halves cutaneous
raphecontinues ventrally to the inferior
penile surface and dorsally along the midline
of the perineum to the anus

Layers of the scrotum

Skin
Tunica dartos
External spermatic fascia
Cremaster muscle/ fascia
Internal spermatic fascia
Parietal layer of tunica
vaginalis
Visceral layer of tunica
vaginalis
Tunica albuginea

Vascular Supply and Lymphatic

Drainage
Artery
the external pudendal
branches of the femoral
artery
the scrotal branches of the
internal pudendal artery
a cremasteric branch from
the inferior epigastric
artery
Veinaccompany the
arteries and join the external
pudendal veins.

The lymphatic
vessels of the
scrotum drain into
the superficial
inguinal nodes.

Spermatic Cord
As the testis traverses the abdominal wall into
the scrotum during early life, it carries its
vessels, nerves and vas deferens with it
These meet at the deep inguinal ring to form
the spermatic cord suspends the testis in
the scrotum and extends from the deep
inguinal ring to the posterior aspect of the
testis
The left cord is a little longer than the right.

Structure in Spermatic Cord

vas deferens
the testicular artery and veins
cremasteric artery (a branch of the inferior
epigastric artery) and artery to the vas deferens
(from the superior vesical artery)
the genital branch of the genitofemoral nerve and
cremasteric nerve
the sympathetic components of the testicular
plexus
48 lymph vessels draining the testis

Spermatic Cord

Epidydimis
The epididymis lies posteriorly and slightly lateral to
the testis, and the vas deferens lies along its medial
side
Functions in the maturation and storage of
spermatozoa in the head and body and propulsion of
the spermatozoa into the ductus deferens.
Arterysupplied by the testicular artery
Nerves:supplied by sympathetic nerves through the
testicular plexus deriving from T11-L1 segment of
spinal cord
Veins: Pampiniform plexus
Lymphatics: Preaortic and Para-aortic Lymph Nodes

Epidydimis
Part :
head or globus major
superiorly
Corpus
Tail (cauda or globus
minor).

Vas Deferens
Def:Thick-walled tube that enters the pelvis at the
deep inguinal ring at the lateral side of the inferior
epigastric artery.
Crosses the medial side of the umbilical artery and
obturator nerve and vessels, passes superior to the
ureter near the wall of the bladder, and is dilated to
become the ampulla at its terminal part.
Contains fructosenutritive to spermatozoa
Innervation primarily from sympathetic nerves of the
hypogastric plexus and parasympathetic nerves of the
pelvic plexus.

Seminal Vesicle
convoluted pouchlike structures, about 5 cm (2 in.) in
length, lying posterior to the base of the urinary
bladder and anterior to the rectum
Through seminal vesicle secrete an alkaline, viscous
fluid that contains, prostaglandins, and clotting
proteins
The arteries to the seminal vesicles are derived from
the inferior vesical and middle rectal arteriesveins
and lymphatics accompany these arteries.
The innervation of the seminal vesicles and
bulbourethral glands is derived from the pelvic
plexuses.

Prostate Gland
located at the base of the urinary bladder.
Has five lobes:
anterior lobe (or isthmus), lies in front of the urethra and is devoid of
glandular substance
middle (median) lobe, which lies between the urethra and the ejaculatory
ducts and is prone to benign hypertrophy obstructing the internal urethral
orifice;
the posterior lobe, which lies behind the urethra and below the ejaculatory
ducts, contains glandular tissue, and is prone to carcinomatous
transformation
The right and left lateral lobes, which are situated on either side of the
urethra and form the main mass of the gland.

Secretes fluid that produces the characteristic odor of sementhe

secretion from the seminal vesicles and the bulbourethral glands, and the
spermatozoa constitute the semen or seminal fluid.
Receives the ejaculatory duct, which opens into the urethra on the
seminal colliculus just lateral to the blind prostatic utricle.

Bulbourethral Glands
Located inferior to the prostate on either side
of the membranous urethra within the deep
muscles of the perineum, and their ducts
open into the spongy urethra
Function: secrete an alkaline fluid into the
urethra that protects the passing sperm by
neutralizing acids from urine in the urethra.

Histology of Female
Reproductive System
Gryselda

(1) Ovaries

Covered by: germinal

epithelium (simple cuboidal
epithelium)
Under germinal E: tunica
albuginea
Poorly vascularized, dense
irregular collagenous CT
capsule

2 regions of ovary:
Cortex (outer) = highly cellular
stroma and many ovarian
follicles)
Medulla (inner) = loose CT and
BV enter the organ through
hilum from mesenteries
suspending the arteries
(ovarian arteries)
NO distinct border between
cortex and medulla

Ovarian Follicles
Consists of an oocyte with
epithelial cells surrounding
it
Primary oocyte
surrounded by a single layer
of flattened follicular cells
Basal lamina surrounds
follicular cells clear
boundary between follicle
and vascularized stroma

Primordial ovarian follicles

Surrounded by = surface
epithelium (mesothelium
with cuboidal cells)
Sometimes also called
germinal epithelium

Below germinal E = tunica

albuginea

Follicular Growth
Puberty

FSH
released

Primordial
follicles grow

mitosis

Simple cuboidal E
(unilaminar
primary follicle)
proliferate

Stratified follicular E
(multilayered primary
follicle surrounded by
basement membrane)
granulosa cells

Between oocyte and granulosa cells =

zona pellucida
Binds with sperm surface protein
Induce acrosomal activation

Small spaces between granulosa layer

follicular liquid (liquor folliculi)
accumulates >> cavity antrum
(secondary / antral follicles)

Antral follicles

Antral formation some cells form small hillock =

cumulus oophorus
Surround oocyte and protrude into the antrum
Granulosa cells linked to oocyte corona radiata
go with oocyte when it leaves ovary
Follicle development is accompanied with stromal cells
differentiation = follicular theca
Theca interna
Well-vascularized endocrine tissue
Cells differentiate as steroid-producing cells:
androstenedione
Androstenedione granulosa + FSH
aromatase enzyme (F: steroid
estradiol)
Theca externa
More fibrous, contain smooth muscle and
fibroblasts
No distinct border between theca interna and theca
externa
No distinct border between theca externa and the
stroma
Distinct border between theca interna and granulosa
layer distinct cells and presence of thick basement
membrane

Follicular Atresia
Various form of ovarian
follicles undergo atresia &
disposed by phagocytosis
Secondary oocytes
degenerate if not fertilized
after 24 h of the release

Mostly seen from before

birth until a few years after
menopause
Most prominent just after
birth, during puberty and
during pregnancy

Corpus Luteum

After ovulation
granulosa cells and
theca interna of
ovulated follicle
corpus luteum in the
ovarian cortex.

Corpus Albicans
Remnants from degeneration
and regression phagocytosed
by macrophages a scar of
dense connective tissue = corpus
albicans

Stages of follicle maturation

Stages of follicle maturation

(2) Uterine Tubes

(oviducts)
Each of the oviducts a
funnel-shaped end
(infundibulum)
fimbriae
Following is the order of
each tube:
Infundibulum
Ampulla the longest;
fertilization usually
occured here
Isthmus more narrow
region
Uterine / intramural
part

Mucosa of the
uterine tube wall

(a) Cross-section of the uterine tube at the antrum shows the interwoven circular (C)
and longitudinal (L) layers of smooth muscle in the muscularis and in the complex of
folded mucosa, the lamina propria (LP) underlying a simple columnar epithelium
(arrows
(b) The micrograph shows the epithelium (E) contains primarily two columnar cell
types, ciliated and nonciliated, with the latter showing darker staining apical pegs
bulging into the lumen (L)
(c, d) Higher magnification of the epithelium shows the ciliated cells (CC) interspersed
with the secretory cells (SC), which produce the nutritive fluid covering the epithelium

(3) Uterus
The uterine wall has three important
layers:
1. Perimetrium (outer CT layer)
2. Myometrium
Thickest tunic of the uterus
Composed bundles of smooth
muscle fibers separated by CT with
many blood vessels form 4
interwoven layers
The first and fourth layers parallel
to the long axis of the organ, with the
Middle layers circular and contain
larger blood vessels

Uterus

3. Endometrium
Simple columnar
E with ciliated
and secretory
cells
Lamina propria /
stromal CT = type
III collagen fibers,
abundant
fibroblasts &
ground substance
Has 2 zones:
Basal layer = next
to the
myometrium
Superficial
functional layer =
more spongy
important during
menstruation

Menstrual Cycle
3 phase of
menstrual
cycle:
Proliferativ
e phase
Secretory
phase
Menstrual
phase

 Also called follicular or

estrogenic phase
After the last menstrual cycle,
the musosa of uterine will be
shedded until it became thin
(approximately 0.5 mm)
At the end of this phase,
endometrium become 2-3
mm thick
Endometrial lining = simple
columnar surface epithelium
Uterine glands = relatively
straight tubules, narrow,
nearly empty lumens
Spiral arteries lengthen
Functional layer reestablished
and grows
Microvasculature forms

Proliferative Phase

 Starts when corpus

luteum secretes
progesterone
Glands become highly
coiled
Superficial
microvasculature
includes thin-walled,
blood-filled lacunae
Endometrium become
5 mm thick due to
accumulation of
secretions and edema
in the stroma

Secretory (Luteal)
Phase

 Fertilization do not
occur, corpus luteum
regresses
Shredding of the
surface epithelium,
most of each gland,
the stroma and
blood-filled lacunae
At the end of the
phase, endometrium
is reduced until they
become a thin layer

Menstrual Phase

Menstrual Cycle

Placenta
Placenta = the site in which nutrition, wate
products and essential gases are exchanged
between mother and fetus
Embryonic part = chroion
Maternal part = decidua basalis

Term Placenta

(A) arteries (V) vena (MB) maternal blood

(Arrows) Smaller villus branches (CT)
connective trissue (K) knots (S) sinusoids (C)
capillaries

 Endocervix = mucus secreting simple columnar

epithelium on thick lamina propria
Region of the cervix where endocervical canal
opens into vagina external os covered by
exocervical mucose w/ stratified squamous
epithelium
Transformation zone = simple columnar
epithelium transitioned abruptly to stratified
squamous epithelium
Deeper, middle layer of the cervix = smooth
muscle and consists of dense CT
Endocervical mucose has numerous mucussecreting cervical glands
Does not desquamate during menstruation
Ovulation = mucus secretions are maximal,
watery and facilitate movement through the
uterus by sperm
Luteal phase = mucous secretions are viscous and
hinder the mobilization of sperm and
microorganization
Pregnancy = mucous secretions abundant, highly
viscous plug in the endocervical canal

Uterine Cervix

Transformation
Zone

 (EC) endocervical canal (SC) simple columnar

epithelium (Arrows) cervical glands (V) vagina (J)
junction (SS) stratified squamous epithelium (M) mucus

Uterine Cervix

 3 layers that made up the wall

of vagina: a mucosa, a muscular
layer, and an adventitia
Mucosa of the structure consist
of many sensory nerves and the
range of tactile receptors
important for physiology of
sexual arousal
Vagina mucosa = stratified
squamous epithelium
Cells contain keratohyaline but no
keratinization
Cells desquamate bacteria
metabolize glycogen to lactic acid
low pH of vagina

(4) Vagina

External Genitalia
Inner surface of labia majora
(SD) sebaceous duct (SG)
sebaceous gland (Ep) nonkeratinized epithelium

Clitoris = 2 small erectile bodies

(corpora carvenosa)
Vestibule = stratified squamous
epithelium, >> small mucous
glands

Histology of Male Reproductive

System

Testes
A pair of ovoid
organs within
the scrotum
Function:
production of
sperm and male
sex hormones

The tubule is lined by seminiferous

epithelium:
Characteristics:
-Complex, specialized stratified
epithelium resting on basal lamina
-Composed of proliferative
spermatogenic cells (SG, PS) and
supporting sertoli cells (SC)

Interstitial cells (IC)

scattered in the connective
tissue (CT) between the
seminiferous tubules

External to basal lamina of SE is

tunia propria or peritubular tissue
Characteristics:
- A multilayered fibrous connective
tissue
Layers of fibroblasts (F)
The innermost layer is the site of
flattened, smooth muscle-like myoid
(M) cells and collagen fibrils

Sertoli cell
They are columnar or
pyramidal cells nonreplicating cells that
adhere to basal lamina of
seminiferous epithelium
Functions:
Support, protection and
nourishment of
spermatogenic cells
Exocrine and endocrine
secretion inhibin and
antimullerian hormone
Phagocytosis

Structure:
Abundant smooth ER,
some rough ER, welldeveloped Golgi
complexes, as well as
numerous mitochondria
and lysosomes
Cell nucleus is euchromatic

Tight occluding junctions

between the basolateral
membranes of adjacent
Sertoli cells form a bloodtestis barrier

 Blood-testis barrier:
It prevents autoimmune
attacks against the
spermatogenic cells
It divides the tubule into
basal & adluminal
compartment
Spermatogonia and early
primary spermatocytes are
restricted to the basal
compartment
More mature
spermatocytes and
spermatids are restricted to
the luminal side

Spermatogenic
cells

-Spermatogonia (SG) reside in the basement

membrane small cells which divide mitotically,
then proceed to meiosis
-The meiotic cells grow and undergo
chromosomal synapsis primary spermatocytes
(PS)
- Largest spermatogenic cells, abundant at all
levels between the basement membrane and the
lumen
-Each primary spermatocyte will divide to form
two secondary spermatocytes
-Newly formed round spermatids (RS)
differentiate and lose volume become late
spermatids (LS)
- Motile, highly specialized sperm cells.
- All stages of spermatogenesis and
spermiogenesis occur with the cells associate with
the surfaces of adjacent Sertoli cells (SC)

Interstitial (Leydig) cells

The site of androgen
production produce
testosterone
During puberty:
Rounded or polygonal
with central nuclei
Eosinophilic cytoplasm,
rich in small lipid
droplets
The cytoplasm contains
an abundance of sER

Intratesticular Ducts
It consists of: tubuli recti, the rete testis, and the
efferent ductules

Tubuli recti (T) and Rete

testis (R) are lined by
simple cuboidal
epithelium

The efferent
ductules (E) are
lined by an
unusual
epithelium with
groups of
nonciliated
cuboidal cells
alternating with
groups of taller
ciliated cells
A thin circular
layer of smooth
muscle outside
basal lamina of
epithelium

Genital
Excurrent
Duct:
Epididymys

The epididymal duct is lined with

pseudostratified columnar epithelium
(arrows)
It is composed of rounded basal cells (B)
and columnar cells with long, branched,
irregular microvilli called stereocilia

Stereocilia: reabsorbing testicular fluid

and for transferring nutrients and
secretions to the sperm stored in the
lumen
They are supported on a basal lamina
surrounded by smooth muscle (SM) cells

Genital Excurrent
Duct: Vas deferens

1. Mucosa (M)
2. A thick muscularis with inner and outer
layers of longitudinal smooth muscle (LSM) and an intervening layer of circular
smooth muscle (C-SM)
3. An external adventitia (A).

The epithelium is pseudostratified

with basal cells and many columnar
cells with some stereocilia

Accessory Sex
Organs: Seminal
vesicles

-The seminal vesicles are exocrine glands that

secrete most seminal fluid consist of highly
tortuous tubes
-The folds include smooth muscle (SM)
covered by a thin lamina propria (LP) and an
epithelium.
- The epithelial cells are simple or
pseudostratified columnar, varying with
activity and location in the gland, and contain
lipid droplets, secretory granules, and also
commonly lipofuscin

Accessory Sex Organ: Prostate

The prostate is a collection of branched
tubuloalveolar glands, 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
a peripheral layer with the prostate's main glands

Ducts from individual glands may converge but all

empty directly into the prostatic urethra

The prostate has a dense fibromuscular stroma

(S) in which are embedded a large number of
small tubuloalveolar glands (G)

a corpus amylaceum (CA) concretion,

shows a secretory simple or
pseudostratified columnar epithelium
(E) surrounded by lamina propria (LP),
which is in turn surrounded by smooth
muscle

Accessory Sex Organ: Bulbourethral

glands
The glands are compound
tubuloalveolar glands
The ducts are lined by
simple columnar
epithelium varies
considerably in height
depending on the
functional state of the
gland
They secrete mucus that
contains galactose and
galactosamine,
galacturonic acid, sialic
acid, and methylpentose

External genitalia: Penis

3 cylindrical masses of erectile tissue:
Two corpora cavernosa placed dorsally
It is surrounded by tunica albuginea

Corpus spongiosum placed ventrally

It surrounds the penile urethra, which is lined by
pseudostratified columnar epithelium
Small mucus-secreting urethra glands (glands of Littre) are
found along the length of the penile urethra

At its end, the corpus spongiosum expands glans

penis
The penile urethra is now lined by stratified squamous
epithelium

The corpus spongiosum (CS) surrounds the

urethra (U).
All three bodies of erectile tissue are covered
by dense, fibrous tunica albuginea (TA).
Along the dorsal side run the major blood
vessels (V) and deep in each mass of erectile
tissue are smaller blood vessels (V)
Externally the penis is covered by skin (S)
attached to the tunica albuginea

-The corpus spongiosum (CS) is surrounding

the penile urethra (PU) with its longitudinally
folded wall.
- Near the penile urethra are small urethral
glands (UG) with short ducts for the release of
a mucus-like secretion into the urethra during
erection.

Spermatogenesis
Seminiferous tubules: contains sertoli cells,
spermatogonia, developing sperm cells
Layers of germ cells in progression of sperm
development least differentiated in the outer layer
moving inward through various stages of division
to the lumen highly differentiated sperm exit
from testis

Takes 64 days from a spermatogonium to a

mature sperm
Different seminiferous tubules are in different
stages of differentiation at any given time up
to several hundred million sperm mature daily

Sherwood, L. Human physiology.

7th edition. Belmont: Brooks/Cole;
2010. Chapter 20; p.749-57

Sertoli Cells

Functions of Sertoli Cells

Tight junction between adjacent sertoli cells
blood-testes barrier only selected
molecules can pass through tubule, prevents
antibody
Provide nutrition for developing sperm cells
metabolize glucose to lactate as energy
source
Phagocytic function engulf cytoplasm
from spermatids during remodeling, destroy
defect germ cells

Functions of Sertoli Cells

Secrete seminiferous tubule fluid
flushes the released sperm into
epididymis, contain androgen-binding
protein maintain a very high level of
testosterone within tubule to sustain
sperm production
Has receptors for FSH and testosterone
Release hormone inhibin negative
feedback to regulate FSH secretion

Sherwood, L. Human physiology. 7th

edition. Belmont: Brooks/Cole; 2010.
Chapter 20; p.749-57

MENSTRUAL CYCLE AND

FOLLICULOGENESIS
Jonathan Darell Wijaya
1206230025

HORMONAL PROFILES DURING THE MENSTRUAL

CYCLE

Normal Sexual Intercourse and

Fertilization Process
Antonia Christa Paramitha
1206289256

Phase of Sexual Response

1. Excitement Phase: erection and increase sexual
awareness
2. Plateau Phase: response intensification and
other general body responses (elevating heart
rate, BP, RR, muscle tension)
3. Orgasmic Phase: ejaculation and other
responses that reach peak of sexual excitement
strong physical pleasure
4. Resolution Phase: body system and genital
return to prearousal condition.

Erection

Ejaculation
Occurs when the stimuli that generate erection
intensifies and reaches the critical peak.
Sympathetic impulse contraction of prostate, reproductive
duct, seminal vesicles delivery of semen to urethra.
Sphincter at neck of bladder tighten.

Emission

Expulsion

Semen in urethra triggers nerve impulse activated skeletal

muscle at base of penis rhythmic contractions semen is
expelled to the exterior.

Fertility volume and quality of sperm.

Average volume 2.75 ml with 66 million/ml sperm.

Physiology of Sexual Response in

Female
Similar with male.
Stimulus vasodilation of arterioles throughout
vagina and clitoris increase blood flow
swelling of labia and erection of clitoris.
Clitoris many erectile tissues large and most
part is located inside.
Function of clitoris erection:
Squeeze urethra closed
Support vaginal wall
Strengthen pleasure signaling

Fertilization
Follicle rupture egg is released enter fallopian
tube.
Sperms accumulated in vagina undergo final
maturation (capacitation) able to swim rapidly and
fertilize egg.
Egg can be fertilized for 12 24 hours after
ovulation
Sperm life span: 4 6 days
Egg has 2 barriers:
Corona radiata (outer layer) consist of
loosely connected granulose cells
Zona pellucida glycoprotein coat

IMPLANTATION
Zygote remains in ampula constriction of canal
undergo mitotic cell divisions morula.
After ovulation newly developing corpus
progesterone release glycogen as energy for
developing embryo and relax oviduct constriction
oviductal peristaltic contraction and ciliary
activity.
6 7 days post ovulation uterus is in
progestational phase increase glycogen
storage and vascularization prepare for
implantation.

Endometrial tissue undergo

alteration to support embryo
decidua secretes
prostaglandin increase
vascularization and nutrient
storage

Infertillity
The inability to conceive after 1 year of
unprotected intercourse of reasonable
frequency
Primary no prior pregnancy
Secondary at least one prior pregnancy

Etiology
Male 2

Semen
Testicles
Absence of sperm
Sterilisation
Ejaculation
disorder
Hypogonadism
Medicine and
drugs
Acohol

Female
Ovulatory
dysfunction1
Pelvic
Inflammatory
disease 1
Uretrine
abnormalities1
Endometriosis1
Other

Both

Weight
STI
Smoking
Stress

Risk Factors Male3

History of Prostatitis,
genital infection, or STD
Exposure to radiation,
radioactivity, welding,
and chemical (lead,
ethylene dibromine, and
vinyl chloride)
Cigarette or marijuana
consumption
Heavy alcohol
consumption

Exposure of the genitals

to high temperatures
Hernia repair
Undescended testicles
Prescription drugs for
ulcers or psoriasis

Risk Factors Female3

Age
Endometrosis
Chronis disease
diabetes, lupus, arthritis,
hypertension, or asthma)
Hormonal imbalance
Environmental factors
Cigarrettes smoking,
alcohol consumption
Excessive or very low
body fat

Abnormal pap smear that

have been treated with
cryosurgery or cone
biopsy
DES taken by mother
during pregnancy
STD
Fallopian tube defect
Multiple miscarrieges

Examinations to diagnose
infertility
By Maria Nathania
1206220346

Anamnesis: medical history and

information from couple

History of STD
Surgical contraception (e.g.
vasectomy, tubal ligation)
Lifestyle, alcohol consumption,
tobacco and recreational drugs
(amount and frequency
Occupation
History of weight changes, hirsutism,
frontal balding and acne
Physical activities
Male medical history:
Current medical treatment if
Previous semen analysis results,
any, reason and history of
history of impotence, premature
allergies
ejaculation, change in libido, history of
Complete review to identify
testicular trauma, previous
relationships, history of any previous
endocrinologic or immunologic
pregnancy in or offspring from
abnormalities that may be
previous female partners
associated with infertility
Copy of pervious medical records
Completed medical history
questionnaire
History of previous infertility
evaluation or treatment
Female menstrual history, frequency
and pattern since menarche

Fertility Tests for Women [Internet]. 2014 [Cited 15 October 2014]. Available from: http://www.webmd.com/infertility-andreproduction/guide/fertility-tests-for-wome

Physical Examination
Routine records of blood pressure, pulse rate and
temperature
Height and weight to calculate BMI
Head and neck assessment
Presence of exophthalmos associated with hyperthyroidism
Presence of epicanthus, lower implantation of ears and hairline,
and webbed neck associated with chromosomal
abnormalities
Exclude thyroid gland enlargement or nodules indicates
thyroid dysfunction

Breast evaluation: assess breast development, seek for

abnormal mass or secretions
Abdominal evaluation: assess abnormal mass at
hypogastrium level
Puscheck E. Infertility [Internet]. 2013 [Updated 2013 Jun 10; Cited 2014 Oct 14]. Available from:
http://emedicine.medscape.com/article/274143-overview

Webbed neck

Exophthalmos

Epicanthus

Physical Examination
Gynecologic evaluation: assess hair distribution, clitoris
size, Bartholin glands, labia majora/minora, any
condylomata acuminatum or other lesions that indicate
STD
Speculum examination:
Papanicolau test and cultures for gonorrhea, chlamydia,
ureaplasma urealyticum, Mycoplasma hominis
Assess cervical stenosis

Bimanual examination:
Direction of cervix, size or position of uterus exclude
presence of uterine fibroids,
Adnexal masses, tenderness or pelvic nodules indicates
infection or endometriosis
Assess defects (e.g. absence of vagina and uterus, vaginal
septums
Puscheck E. Infertility [Internet]. 2013 [Updated 2013 Jun 10; Cited 2014 Oct 14]. Available from:
http://emedicine.medscape.com/article/274143-overview

Table 1. Laboratory, imaging and/or

surgical evaluation of female fertility

Table 2. Laboratory, imaging and/or

surgical evaluation of male fertility

Cervical

Sims-Huhner test (post-coital

test)

Semen
analysis

Uterine

Sperm
function
tests

The acrosome reaction test

with fluorescent lectins or
antibodies
Computer assessment of
sperm head
Computer motility
assessment
Hemizona-binding assay
Hamster penetration test
Human sperm-zona
penetration assay

Hysterosalpingogram
Pelvic USG
Saline infusion sonograms
Pelvic MRI
Hysteroscopy
Endometrial biopsy

Tubal and Laparoscopy

peritoneal Hysterosalpingogram
Ovarian

Progesterone levels and/or

serial ultrasonography
FSH and estradiol levels
Clomiphene citrate challenge
test

Volume
pH level
Concentration
Motility
Morphology
WBC count

Puscheck E. Infertility [Internet]. 2013 [Updated 2013 Jun 10; Cited 2014 Oct 14]. Available from:
http://emedicine.medscape.com/article/274143-overview

Huhner test
Evaluates compatibility of sperm and cervical mucus
Procedure:
Carried out 4 to 8 hours after intercourse near ovulation time;
mucus sample is collected from the cervix and examined
Microscopic exam of mucus how many sperms are present?
(1 drop = 12 or more sperms) swim with a strong forward
motion? Presence of other cells (immune and yeast cells)?
Presence of yeast cells infection affecting sperms survival and
motility

Cervical cells secrete mucus which changes in consistency

depending on phases of menstrual cycle
Near ovulation greater amount of mucus is secreted
The quality of mucus also changes as ovulation approaches
pH: 7 to 8,5, and certain degree of viscosity and stretch to
facilitate sperm migration
Lloyd E, Harris B. What is Huhner Test? [Internet]. 2014 [Updated 2014 Sep 29; Cited 2014 Oct 14]
Available from: http://www.wisegeek.com/what-is-a-huhner-test.htm

Pelvic Ultrasound
Uses high frequency sound waves
captured by a transducer to create
images of the organs and
structures in the pelvic area
What is observed: the bladder,
ovaries, uterus, cervix and
fallopian tubes
It can be done in 3 ways:
transabdominal (used to look for
uterine fibroids), transrectal (for
males) and transvaginal (to look
for fertility problems)
Purpose: examine size and shape
of uterus, thickness of
endometrium, size and shape of
ovaries and to check for uterine
fibroids
Pelvic Ultrasound [Internet]. 2014 [Updated 2014 Mar 12; Cited 2014 Oct 14]. Available from: http://www.webmd.com/women/pelvic-ultrasound

Saline Infusion Sonogram

Done during transvaginal ultrasound
Procedure: small volume of saline is
inserted to the uterus
To allow lining of uterus to be more
visible on ultrasound

Purpose: to assess any thickening of

endometrium, presence of polyps
(small growth on the endometrium)

Pahuja M. Saline Infusion Sonohysterography (SIS) [Internet]. 2009 [Updated 2009 May 1; Cited 2014 Oct 14]. Available from:
http://www.insideradiology.com.au/pages/view.php?T_id=71#.VD4WrymvaFd

Hysteroscopy
Uses a thin viewing tool called a hysteroscope
The tip is inserted into the vagina and gently moved
through the cervix and into the uterus
Its hooked with a light and camera endometrium
can be seen on a video feed
A sample biopsy may be taken during the procedure
and looked at under a microscope (if indicated)
Function: assess shape or size of uterus, scar tissue in
uterus, uterine openings to the fallopian tubes (if
blocked may be able to be opened using a tool
inserted to the hysteroscope), find and remove small
fibroids or polyps
Laparoscopy may be done at the same time if infertility is
found to be the problem
Hysteroscopy [Internet]. 2014 [Updated 2014 Mar 12; Cited 2014 Oct 14]. Available from:
http://www.webmd.com/infertility-and-reproduction/guide/hysteroscopy-infertility

Hysteroscopy

Hysteroscopy [Internet]. 2014 [Updated 2014 Mar 12; Cited 2014 Oct 14]. Available from:
http://www.webmd.com/infertility-and-reproduction/guide/hysteroscopy-infertility

Acrosome reaction test

Artificially cause the sperm to
release their acrosome caps
Fresh sperm sample from a fertile
man is needed as a normal control
Uses follicular fluid from egg
retrievals to stimulate the cap
release
Examined using a fluorescence
microscope sperm with dark tip
have undergone acrosome
reaction and bright green ones
does not react calculate
percentage of sperm that
artificially react in the essay
Puscheck E. Infertility [Internet]. 2013 [Updated 2013 Jun 10; Cited 2014 Oct 14]. Available from:
http://emedicine.medscape.com/article/274143-overview

Basic Components of the genital

examination (M)

Checking the cremaster reflex

Inspecting the pubis
Inspecting the penis
Inspecting the scrotum
Palpating the scrotal contents
Palpating for inguinal hernia
Inspecting the perineum and anal orifice
Examining the prostate gland

Interpreting Laboratory Test Results

(Male)
Part of the male genital examination involves laboratory
test results that help to make a differential diagnosis and
determine the appropriate treatment
Urine Test. When present in urine;
Ketones insulin deficiency
Nitrites bacterial infection in the UT, kidneys, bladder
Leukocyte esterase WBC & probable bacterial infection
in the genitourinary system

Prostate Secretions Test

Normally few WBCs are present in prostatic secretions;
many WBCs indicates prostatitis

Genital Examination (Female)

Abdominal Inspection and Examination

External Genital Examination
Vaginal Examination
Speculum Examination routine examination and
inspection of cervix
Bimanual Genital Examination
Examination of Cervix
Palpation the uterus
Examination of the adnexa

Semen Analysis
Measures the amount and quality of a man's semen
and sperm sometimes called a sperm count
One of the first tests done to evaluate a man's fertility
Help determine if theres a problem in sperm
production or quality of the sperm is causing infertility
May also be used after a vasectomy make sure there
are no sperm in the semen
May also be performed for the Klinefelter syndrome
Preparation before the test: Do not have any sexual
activity that causes ejaculation for 2 - 3 days before the
test

Semen Analysis Result

The normal volume varies from 1.5 to 5.0 milliliter per
ejaculation.
The sperm count varies from 20 to 150 million sperm
per milliliter.
At least 60% of the sperm should have a normal shape
and show normal forward movement (motility)
Normal value ranges may vary slightly among different
laboratories
It is not completely clear how these values and other
results from a semen analysis should be interpreted
An abnormal result does not always mean there is a
problem with a man's ability to have children.

Abnormal Result
May suggest a male infertility problem
if the sperm count is very low or
very high, a man may be less fertile
The acidity of the semen and the
presence of white blood cells
(suggesting infection) may affect
fertility
Testing may reveal abnormal
shapes or abnormal movements of
the sperm
However, there are many unknowns in
male infertility further testing may be
needed if abnormalities are found.
Many of these problems are treatable

Things that may affect

a man's fertility:
Alcohol
Many recreational
and prescription
drugs
Tobacco

HSG
Check for a blocked fallopian tube
an infection may cause severe scarring of the fallopian tubes
and block the tubes, preventing pregnancy.
occasionally the dye used during a hysterosalpingogram will
push through and open a blocked tube.
Find problems in the uterus
such as an abnormal shape or structure, an injury, polyps,
fibroids, adhesions, or a foreign object in the uterus may
cause painful menstrual periods / repeated miscarriages
Check whether surgery to reverse a tubal ligation has been
successful

How HSG is done

The cervix may be held in place with a clamp

called a tenaculum
The cervix is washed with a special soap and a
stiff tube (cannula) or a flexible tube (catheter)
is put through the cervix into the uterus
The X-ray dye is put through the tube
If the fallopian tubes are open, the dye will
flow through them and spill into the belly
where it will be absorbed naturally by the body
If a fallopian tube is blocked, the dye will not
pass through. The X-ray pictures are shown on
a TV monitor during the test
If another view is needed, the examination
table may be tilted or you may be asked to
change position.

After the test, the cannula or catheter

and speculum are removed
This test usually takes 15 to 30 minutes.

HSG Result

What affect the test?

If your fallopian tube
has a spasm -fallopian tube look
blocked.
If the doctor can't
put a catheter in the
uterus.
This test is not done
on women who are
having their period,
are pregnant, or
have a pelvic
infection

CONCLUSION
Hypothesis accepted. However, in order to
determine the cause of unpregnancy, further
examinations are needed such as semen
analysis, pelvic ultrasound, HSG and hormone
levels. Furthermore, more complete
anamnesis is needed.