Sebelum mencedok atau memetik 'ilmu' dari laman ini, anda tidak perlu meminta kebenaran tetapi diingatkan membuat semakan sendiri terlebih dahulu dengan doktor anda atau guru anda sebelum mem'forward'nya kepada orang lain dan memikul tanggungjawab akibatnya.

Pohon doa kesejahteraan dan limpahan rahmat Allah ke atas ibubapa saya dan ibubapa mertua saya. Juga ke atas guru-guru saya dan juga pesakit-pesakit saya yang banyak mengajar saya bidang ini. Segala pujian bagi Allah (peringatan ini untuk diri sendiri) . Mudah-mudahan, taubat saya diterimaNya dan segala dosa saya diampunkanNya serta saya terus dilimpahi rahmatNya. Sekiranya ada kesalahan, pohon dibetulkan, saya terbuka kepada teguran.

Sebarang percubaan berbentuk komen atau soalan bertujuan mengiklankan apa sahaja perniagaan atau blog sendiri tidak akan disiarkan. Blog ini bukanlah untuk iklan menjual barang. Peace.....

Friday, 31 December 2010

Success rate

1. The problem in Malaysia is :
- the said success rate was published by that very own IVF centre
- there is no external auditor or any independant body to verify that every patient entered the analysis or whether the calculation/interpretation was made correctly
- the data was actually collected and interpreted by their goodselves

2. e.g. in Germany;
- There is this national-level software used called RecDate.
- However, participation is still voluntary ie it is not compulsary for all centres to join this RecDate
- but, once you join, you must comply with its protocols. So, the data entered from each participating centre should be accurate at national level
- EVERY patient that enters IVF programme MUST be registered into RecDate
- The data is then collected by RecDate (also by the centres), tabulated, analysed and reported it collectively as a country or per individual centre.

3. another e.g. ESHRE (European Society for Human Reproduction and Embriology);
- also produced analysis on fertility treatments (IVF and even IUI) in European countries
- the latest report was out during the last ESHRE meeting which I attended in Rome (with dear lokong :)

4. I find it fascinating and sometimes amusing when patients told me that;
- "this Dr said his success rate is 80%" or even
- "that Dr said his is 100%"
- Wow! That's super fantastic! Maybe the European countries (where IVF evolved) can come and learn from our local IVF centres
- Are our doctors God?

5. Perhaps we can look into TAFF report (please see my previous entry on TAFF);
- even the popular IVF centres that joined TAFF did not produce the so-called "very high success rate". Why?
- because, indirectly TAFF has all the datas on these couples and would follow-up their results. So, semuanya terang lagikan bersuluh.
- Still, after given TWO FRESH CYCLES, the accumulated pregnancy rate was reported not more than 40%.
- I repeat, AFTER TWO FRESH CYCLES! (They could also have had frozen transfers in between or after that)

6. I am not saying that our IVF centres are not good. They are good, but I hope the public is not misled by the reports. To declare that we produce better results than the 'senior IVF centres abroad' can be embarrassing if they come here and check. If we are so good, I'm sure the European or American patients will flock into our country for IVf treatment (mind you, the cost of treatment here is cheaper and they get to enjoy our beautiful beaches n good food too)
- We have to be critical when analysing the reports


Let me give an example;

We have 100 couples entering IVF cycles.
Of those 100;
- 98 had egg follicles developed and went for OPU (or sometimes called OR or FA)
- only 92 completed the cycles till ET or embryo transfer (the other 8 either ; no egg retrieved during the OPU or there was no fertilization of the eggs or the embryos died along the way)

Pregnancy result
Of the 92 ET;
- 40 women had biochemical pregnancy (blood test for bhCG done at least 15 days after the hCG injection to avoid false positive result)
- 28 of these 40 women had clinical pregnancy (presence of fetus seen from the ultrasound examination). The other 12 were actually not pregnant (blood test done too soon; or the embryo/s did not further develop ie miscarriage)
- 7 of these 28 women had twin pregnancies
- 50 of the initially not pregnant then had frozen ET. Of these 50, 11 became pregnant
- 10 of those futher had second IVF cycles till ET and 2 became pregnant.

So;
The success rate can be reported as either of these;

BIOCHEMICAL PREGNANCY RATE
1. 43.5% biochemical pregnancy rate PER TRANSFER ie 40 women got pregnant level blood bhCG result OUT OF 92 women that underwent ET

or

2. 40% per CYCLE STARTED ie 40 pregnant women by blood test out of 100 women who joined these IVF cycles. But actually this is not true because a futher 10 had second IVF fresh cycles. So, it should be reported as 40+2 out of 100+10, the most.

Still, ada centres yang interpret 'cycle started' as 'cycle mula sehingga ET TERMASUKLAH jika pt tu x pregnen dan followed by rounds of frozen ET yg diperolehi dari cycle started itu), sedangkan 'per cycle started' should be "per fresh ET" SAHAJA and tak boleh kira resultt dari frozen ET embrio2 dr cycle tersebut.

or

3. 57% per WOMAN (finally 40+11+2 got pregnant after combining 1 cycle and 2 cycles and frozen transfer that is 92+50+10)

Banyak lagi ni boleh di-interpret fr the above data, silalah kira sendiri. Kalau nak tulis, kena banyak2 page ni.
- what to see : biochemical pregnancy or clinical pregnancy or delivery or take home baby or multiple pregnanies or stillbirth or miscarriage
- what to compare : per ET (fresh only or fresh&frozen ?) or per cycle started or per patient. Also : did the data include donor (ovum or sperm)? If so, the result should be higher tha other centres which didn't.
- the age distribution : especially 34 and below, they should produce better results.
- to be more specific : according to the problem/s identified.

The European countries (I have to refer to them as they 'invented this technique' and they do thousand of cycles per year) reported around 20-30% clinical pregnancy rate per ET. This is very good to them. They always report as CLINICAL PREGNANCY RATE PER ET PROCEDURE. They are very confident that they do not take into account the biochemical pregnancy as sahih. More confident/established ones would also publish on take-home-baby rate PER CYCLE STARTED

From the above, the clinical pregnancy rate was actually 28/92 ET that is 30%(if we only take 1 cycle but 28+11+2/92+50+10 that is 27% if we also take second cycle and frozen transfer.

Having said that, bear in mind that centres can achieved higher success rates 60-70 or even 80% when the embryos are transferred back at blastocyst stage. We call it 'blastocyst transfer', simply because these embryos have proven that they can last for at least that age.

Also, centres that do egg or sperm donor IVF or ICSI cycles are also expected to produce better results.

Plus, government centres usually produce lower rates as they have limited budget thus strict criteria for patients 'eligible' for IVF treatment. In private practice, sapa2 pun boeh request nak buat IVF and of course, the younger you are and the less severe your problem is, the higher your chance is.

And of course too, the more embryos are put back, the higher successful pregnancy rates are achieved. Tengok2lah mana IVF centres yg produce many twins or triplets. The transfer of 5 and more embryos also happened here, so I heard from the Dr himself (with my jaw almost dropped onto the floor). Abroad, the IVF centres are penalised (tak dapat money reimbursement from the insurance companies) kalau patients dapat OHSS and they are seriously looking into the matter of multiple pregnancies. It should not have happened if we doctors are not too eager to get pregnancy results that we put patients at risk of complications from conceiving multiple foetuses.

I sincerely wish that my concern that "IVF can become a business material" would not come true (or has it?)

Have faith...in Him

Ask your Dr these;

(penatlah, nanti saya sambung ya)

Sunday, 26 December 2010

Explaining the silence

Am taking a break.

Holidaying...

The clinic in Pantai is also under renovation,
I hope it is as expected from them,
and worth the money spent,
before we move to the new building in 2-3 years time, insyaAllah.


hours across the continents in this position, lenguhnya... Well, the leg area is more now compared to years ago.

Hyde Park, upon arrival, the weather is better now

our beautiful accommodation in West End...

...so home-away-from-home feeling.

night at the Oxford street

a day in Paris (memujuk the younger 2 yg nak gi Gold Coast naik rides)...

...and hoping that the dotter (her 1st visit to Paris, 5th to London) would be an artist too. The pyramid of Musee de Louvre where Mona Lisa 'resides'.

about time to go home,
and start back the clock.

Happy New Year everyone!
May 2011 brings us many good things, insyaAllah.

Friday, 17 December 2010

Year-end break




...

and I shall try to write a post before we take off.


Kalau tak sempat,
Here's a wish;
Happy new year!

Thursday, 9 December 2010

Sharing is caring



This is the do'a that a patient-friend taught me.
They made a request that I recite this do'a before performing the procedure.
I also made them taught me the meaning of the do'a;


"Bismillahirrahmanirrahim.
Bismillah
Al-ladzi la yadhurru ma'asmihi syai-un fil-ardhi wa la fis-ssama'
Wa hua as-sami' al-'alim"


In the name of Allah, Most Merciful, Most Compassionate.
In the name of Allah.
There is no harm/bad thing (that can happen) on His Name, be it on this earth nor in the sky,
and He is All-Listening, All-knowing.


Dengan mama Allah yang Maha Pemurah Maha Mengasihani
Dengan nama Allah
Tiada kejahatan/keburukan (yang boleh berlaku) di atas NamaNya sama ada di mukabumi mahupun di langit
dan Dialah Maha Mendengar Maha Mengetahui.


Let us impart knowledge, even it be one sentence....

Sunday, 5 December 2010

Finally, the result is here

I like the fact that I was addressed as 'dear colleague'. Coming from senior/more exprienced persons, they still respect you and they shared/taught you, tak de kedekut2 ilmu punya.
Kat sini, the housemen n junior doctors are been ridiculed n 'verbally harrassed' without them realising that they were once 'inexperienced n not-so-clever-aka-******' housemen jugak dulu. No one was born clever kan?
In the world of medicine, never look down on your junior doctors for one day, she/he will be your working partner or might even be your boss/medical director or PM :)


They emailed as promised,
Berdebar2 jugak ni.
Nak jugak tahu where I stood kalau ikut standard mereka.
Maklumlah, they have been conducting this course/test for some time.
They even produced scientific paperS about the course.
and this group of 'teachers' was selected by ESHRE.
(I shall elaborate on ESHRE later ya).


First;
Based on what type and the number of endoscopic surgeries we've been doing (kira exposure la ni),






Based on the criterias above, we were then allocated into groups : MINIMAL, INTERMEDIATE, MAJOR
I was allocated into the MAJOR EXPOSURE group :(
Saspen jugak, nape saya dimasukkan dalam 'major exposure' group ni? Patutnya saya masuk intermediate group je, senang sikit nak compete kan?


Second
We were tested TWICE.
-before the course/teaching started (pre-test)
-at the end of the course (post-test)

-At each task, we were given 3 attempts and were timed on how fast we could complete each task.

Third;
We were compared like this.

For each exercise, the result was tabled like this.


Since I belonged to major exposure, let us concentrate on the lowermost row. Based on their cumulative data, 76.8% of those who have major exposure completed exercise 1 with excellent result! Exercise 1 tested us on 30' camera navigation ie how fast we can identify (using the laparoscope n focus it in the small circle on the monitor) the big and small objects placed at different angles. The time given was 120 seconds.


In the pre-test for exercise 1 ie 30' camera navigation, I got excellent performance, but I was positioned 64th in the rank, which meant; of 100 participants, there were 36 participants in the 'Major Exposure' group who performed this task bettter than me. As I remember, I managed to finish them in 75-90 sec. Hmm...janji masuk excellent. As told by Dr Rudi earlier on, this group (20 of us) was the first group that performed very well in this exercise. Almost 78% of us were placed 'excellent'.


In the post-test pulak, saya dapat result lebih teruk (main2 macam anak saya je ni, haha). Still excellent, tapi only positioned 59th and ada 41 org dalam Major group yg lebih cekap daripada saya dalam memegang/navigate teropong ni. Kira macam dapat markah 59% utk group Major Exposure ni. And 94% of this group were excellent in the post-test!


Exercise 2 was on hand-eye coordination, this involved placing small rings into the pins placed at different heights n angles. 48.8% with major exposure were excellent in completing, the time given was 180 seconds.

In the pre-test, I only fared "intermediate" in the 'Major Exposure' group and placed 23, maknaya ada 77 orang dalam 'Major Exposure' group tu yg lebih pandai daripada saya, sedihnya.... Actually I couldn't complete the 3rd attempt in time sbb the ring terpelanting n tersorok belakang board tu, terkial2 nak ambik balik sampai le masa tamat, haha. Our group pun tak ramai yg excellent, only about 1/4 of us.


However, in the post-test, I successfully positioned myself obtaining excellent score for the major group. This time, no more ring terpelanting :) In fact, I finished it in less than 50 seconds! And placed 94th, meaning; there were only 6 people in the 100-Major group who had better result than me. Yahoo!!!err...Alhamdulillah. Malaysia boleh!



and in exercise 3 (bimanual coordination), we had to take objects with the non-dominant hand, and use the dominant to take back the object before placing it into the short well. We were given 180 seconds. Based on their data, there were close to 44% people in the Major group who obtained excellent result in this exercise while more (48%) were categorised as 'intermediate skill' only.


In this pre-test also, I only fared 'intermediate' and not excellent, and positioned 27. Pun asyik terpelanting je sampai habis masa :) So, out of 100 dalam major group, there were 73 people better than me, pun sedih...


However, likewise, during the post-test, I seemed to have improved so much! Mana tidaknya, I managed to finish it in less than 90 seconds! See me hopped obtaining 'excellent' result and repositioned myself into 94th in the rank, so of 100 people in the Major group, there were only 6 people ahead of me. Yayy!!! Rasa macam dapat result exam SPM pulak.


So,

Was the course beneficial?
Of course, within that short period, I saw myself gaining A LOT OF knowledge n improving my skill!

Would I recommend my colleagues to attend this course?
Of course! It was worth the money and time spent!

Am I more confident with myself?
Yes, having being assessed by the renowned group according to their standards somehow boosts my confidence to a higher level. Being grouped into Major Exposure and positioned 7th out of 100 persons (in 2 of 3 tasks) in the 'Major Exposure' group was sooooo exciting.

I hope that I have become a more skillful and still a safe doctor in performing laparoscopic surgeries, and would continue to upgrade my skill. In fact, at the nearest opportunity (and bila ada duit lebih), I would not hesitate to attend this course again (they are having it twice a year, same place). and if my patients ask; "how good are you with laparoscopic surgery?", I can reassure them and this time, with proof :). But I still have my limitation (saya tak le pandai semua) and would not hesitate to refer if the operations are better performed by other Drs. That's the hard part in some Drs, admitting their limitations. Drs should KNOW WHEN TO REFER to other colleagues (for the benefit of our patients, please) or WHEN TO CALL FOR ASSISTANCE and not just 'borong' semua kes and get suboptimal results. It doesn't mean that we are incapable or incompetent. The best chance/result is always during/from the first surgery, subsequent surgeries would always be more challenging/difficult. Also, we must always remember and have faith in Him.


So, what next?
Hmm.......rehat dulu,
Kerja balik,
Berangan2 (I call this vision :) lagi,
Tapi jangan tamak ya Mokcik,
Just concentrate,
Only 2 fields;
General gynaecology and infertility.
And 3 more fields;
Family, friends and hobbies :)


Sempat mengimbau kenangan lama.....

(insert music, please :)
Hampir 9 tahun yang lepas....

Before being allowed to sit for the final Part II Masters Exam, everyone had to prepare thesis comprising 10 write-ups on Obstetrics cases, 10 write-ups on Gynaecology cases, and a long commentary for each Obstetrics & Gynaecology (based on the researches we performed on HUKM patients).

During preparation of our thesis, we were guided by our lecturers and the cases/commentaries were revised (and revised and revised countless times) before finally being 'book'ed and sent to external assessor. We had to complete it at least 6 months before the exam. Saya sempat hantar just on time, haha memang suka procrastinate. Mine was assessed by Prof Dr Kulenthran (he also obtained degree in law) from UM.


I think the assessor was being kind/nice but hey, after tireless effort in finishing this thesis, I deserved a pat too.


Anybody notice the comments made on gynaecology cases that I chose to discuss? Not on infertility/endometriosis/PCOS. Bila masa minat/kepandaian infertility datang ya? ;)


I was so happy when I received this assessment report that I went into Prof Adeeb's room and showed to her and thanked her VERY MUCH.

and so I sat for the exam.
Berkat doa mak abah n cikgu2,
Passed on my first attempt.
In fact;
-"The external examiner (Prof James Drife from Leeds, UK) was impressed with you" told Prof Adeeb (masa jumpa dia dalam bilik lepas dapat result), Prof Zainul (masa dia bagitau result) .
-I got the highest mark for theory
-and also for clinical cases
-but I didn't fare well in my Viva (oral) sangat teruk dalam ilmu interview ni
-So, I got 2nd place (by only 1 mark) for the exam.
-Janji pass kan Man?

But along the road,
Saya belajar teknik interview ni when I worked at LPPKN,
Asyik kena masuk TV je (thanks to the Minister yang pandai mengajar kita mem'project'kan diri).

Pokoknya kena belajar.
And nak belajar.
And nak meng-update diri.
In Europe, more and more are doing myomectomy ikut laparoskopi je. and I'm talking about LARGE fibroids (their limit is 12cm diameter!) .
(The fibroids are cut into pieces using a morcellator)
Histerektomi pun.
Apatah lagi ovarian cystectomy.
During the live surgery, Dr Arnold Wattiez performed multiple myomectomies laparoscopically (mind you, the sizes of the fibroids were 10cm and 6cm!) in less than 1.5hrs!
Salutations!!!
He said ; "the difficult part is not removing the fibroid, but suturing the uterus (after myomectomy)"
Saya belum sampai peringkat itu (tu sebab kena tabik hormat).
I only performed small and subserosal myomectomies laparoscopically.
and itu sebabnya saya gi belajar menjahit ikut laparoskop ni.
Rupa2nya ada teknik, patut pun selama ni saya 'kura-kura' dalam menjahit.
Ya la, yg mengajar pun tak attend this course :)
Hmm....now dah ada the 'right' knowledge ni, I just need to practice and practice to sharpen my skill.

Anyway,
I thank all my teachers.
Dari saya sekolah 'tumpang' ikut mak dan abah saya,
Sehinggalah sekarang.
Especially the ones in MRSM Jasin - for opening the opportunity,
and the ones in HUKM - for 'moulding' me.
I can never thank them enough.

Kat rumah ni pun ada Cikgu:)
My husband is a better laparoscopic surgeon than me.
He's a better surgeon than me.
He was my teacher....
...and he still is.

Thursday, 2 December 2010

Leuven - the university town

at Schipol Amsterdam airport. Took a train to Mechelen then changed to Leuven (dah buat homework internet, mah). The hotel is right across the road and the Academy building is just 200m to its left, so convenient. Saya balik detour fr Brussels to London (jumpa ex-classmate kat MRSM Jasin yg dah jadi PR katt sana), malam baru balik KL via Dubai.


the room is big considering European standard. The bathroom is also big with tub. Euro445 for 4 nights.


dinner courtesy of ESHRE. I had this grilled salmon, tak habis pun, huge portion.


the restaurant where we had dinner was at the far corner tu, which was actually 20-30 metres from the hotel I stayed in (I took this pic fr right in front of my hotel).



Leuven, Belgium.
Bandar yang mahasiswanya lebih ramai daripada penduduk itu sendiri.

Leuven is a small town east to Brussels.
This town existed long time ago, thanks to the world-known university.
K.U.L.


What fascinated me was the fact that its university, KUL or Katholieke Universiteit Leuven was founded hundreds of years before Malacca was conquered by Holland, Belgium's nothern neighbour.

Imagine...

Kita (err, moyang2 kita) sibuk berperang dgn jiran mereka (tapi masih pakai bunga silat n keris),
Dia org dah ada universiti sejak tahun 1425 ! (>200 years before that).
(siapa ingat lagi bila Belanda menjajah kita ? ha....tahun 1641 selama lebih 150 tahun sebelum dia passed to British)
Compare with our own university pulak, paling tua UM baru lebih 60 tahun.


Belgium yang penduduknya diberikan 6 kali tanggungan IVF secara percuma (reimbursement).
ENAM KALI!!!
Alangkah bertuahnya mereka.
Err, ada sapa2 nak pindah sana ke :)


Saya sebenarnya pergi belajar di LIFE (Leuven Institute of Fertility &Embryology)
Short course
Berserta personal pre and post skill evaluation/tests (nak jugak tahu tahap mana kita ni kan? tak nak lah main self-claim sahaja)
Serta lectures
Serta hands-on training
Serta live-telecast surgeries performed by renowned endoscopic gynaecologists
Yg 'popular' n menulis berkajang2 hasil kajian


The trainer group was appointed by ESHRE - 12 of them)
Doctors :
- Marco Gergolet (Italy)
- Rudi Campo, Stephan Gordts, Sylvie Gordts, Patrick Puttemans & Michelle Nisolle (Belgium)
- Vasillos Tanos (Cyprus)
- Grigoris Grimbizis (Greece)
- Arnold Wattiez etc etc


I was the only participant from Malaysia/Asia.
In fact, the only one from outside European countries n Russia.
There was one Singaporean lady, but she's working in UK.
and there was one lady from Saudi Arabia, but she's doing training in Belgium.


The working culture was the same macam gi IVF training kat Hamburg, Germany dulu.
Saya keluar masih gelap2, balik pun dah gelap2 semula.
Mula 8 pagi, habis 6.30 ptg,
Rehat 1/2 jam lunch makan sandwich n fruits.
In between ada rehat minum pagi n minum ptg tapi makan biskut n minum kopi je.
Berasap otak sponge-bob ni nak menyerap ilmu.


So, kalau saya tak kena food poisoning tu pun memang saya tak sempat gi shopping sebab kedai2 di sana ditutup pkl 6 ptg.
Lepas 6 ptg, pub banyak le (sebab ramai students kan?)
Boring kan?


it's true. Endoscopic skill is influenced by your skill in computer games n musical instruments.


during the tests, this stopwatch was used, to its hundredth second! macam lumba pecut 100m pulak. and we had to finish every task within 120 seconds.


hands-on training, guna chicken leg n gauze, takkan nak pakai orang hidup kot.


saya pun tak paham kenapa company Storz (yg buat alat2 endoscopic ni) guna 'ibu ayam' sbg aktres/model poster dia org.


The test results?
- tgh saspen ni. Dia kata nak email within this week, tapi tak de pun.


Comment?
The knowledge gained was definitely worth the money (touched RM-----) and travelling time and lost clinic hours spent!
Saya memang suka belajar (tu sebab saya suka tulis artikel)
Unlike my dotter yang suuuuuka ponteng sekolah.....(sigh)
Nanti bila senang2 menaip, saya share ya....
Ntah mengapa sekarang mood nak mem-blog tak de
(padahal tahu - sbb anakku tiada di sisi, wua......)


bought a new notebook and guess what my dear dotter wrote. Her excellent example of the theory of negative+negative=positive. and dia sempat tulis nak kirim lotsastuff.

Tuesday, 30 November 2010

Rehat

Terpaksa
Penat
Dehydrated
Lembik....


Serangan cirit birit yang paling teruk setakat ini.
Countless times, sleepless nights.
I practically had to sleep on the toilet bowl.
Purging.
Disulami adegan muntah2.
LAPARRRRR!
Tapi tak boleh nak makan.
Hilang nikmat makan.
Aruah nenek saya selalu cakap;
"sementara sihat, makan. Nanti dah sakit macam nenek, satu pun tak sedap"


So,
In Leuven....not even a single shop,
In London....not even a thing for myself,
Beg pun tak bertambah isinya kecuali nota belajar.
But I visited many toilets,
and admired them :))


The episode lasted only yesterday.
Hari ini hari pertama saya boleh menikmati makan semula,
Mmmm.....
Nikmatnya anugerah Allah.
Terasa sedapnya setiap biji nasi itu.
Walaupun dimakan bersama kubis masak tumis air n ikan masin goreng sahaja.


So,
am recuperating :)
Will be back in a few days time,
InsyaAllah.

Monday, 22 November 2010

Doa itu lebih kuat


Hari ini saya akan berangkat ke obersi,
Untuk mengilatkan semula organ yang semakin berkarat di dalam raksun ini.

Hari yang dimulakan dengan berita gembira.
Another frozen IVF patient of mine is pregnant!
Her 2nd pregnancy.
Alhamdulillah.

Kalau puan2/adik2 (sbb saya dah tua) rasa adik2 kurang bernasib baik,
Kisah pesakit saya ni pun bermula dengan penyakit juga.
Semoga kisahnya menjadi panduan yang dapat memberi semangat kepada semua...

PCOS
Stage III pelvic endometriosis (with ovarian endometriotic cyst, adenomyosis and raised Ca125 60IU/ml)
Large cervical fibroid (5cm tu kira besau utk serviks yang comel)

She came to see me in 2007 kot
then underwent laparoscopic surgery.
At that time she was still young (early 30's)
I didn't remove the fibroid because of the location and also in general, fibroid does not impair fertility

Then she underwent IUI once - unsuccessful
Following that she decided to try IVF

Long protocol using r-FSH 225IU (I gave higher dosage as she had endometriosis, kalau tak usually 150 IU je below 35years).
1st attempt ie fresh cycle - unsuccessful.
Saya pun tumpang sedih.

But she didn't give up.
Used the frozen embryos in the same year 2007.
and she got pregnant!
Delivered LSCS (ada cervical fibroid kan?)
Dah besau pun anaknya yang cantik itu.

Recently she decided to add another.
Yg tinggal 3 embrio.
Bila thawed - 2 je yang survived (lagi 1 lysed).
Of the 2 - by day 3 (sepatutnya 8 cell),
Hers were 8C3 and 5C2.
And this morning, the blood test showed that she's pregnant!

Sebenarnya, jarang nak dapat frozen embrio transfer menjadi.
Inikan pula frozen embrio transfer berturut-turut.
Kalau fresh embryos, better result.
I hope this time it's a boy (yg ari tu girl).
I don't do sex selection via PGD,
Tak dibenarkan di dalam Islam pun.

So, I asked her to tell me her secret.
Rupanya dia sembahyang hajat setiap malam selepas prosedur embryo transfer.
The first week dia sembahyang duduk.
Husband pun sembahyang hajat.
Mak n mertua pun doakan.
Inilah kekuatan doa ibubapa.
Ada 3 pasangan ibubapa dalam kes ini,
Ber-triple2 le makbulnya.

An Arabic couple recently saw me for IVF.
What I admired was their faith they had in Allah.
Siang2 lagi dah cakap (though I told them that their chance of proceeding to IVF was slim sebab ada 2 folikel je, baik buat IUI je, jimat kos)
It's not worthy to do OPU/aspirationof only 2 follicles, the chance that one or neither of them dapat telur memang ada.

But,
They told me;
"It's OK Dr, just proceed with IVF. We have first, faith in Allah and then second, we also we trust you. If Allah says yes, then it is. If Allah says no, then it's OK"
Tak de tanya pun nape.
Tak de blame themselves or the Dr.
Tak de compare pun.
Anyway, of 2 follicles, dapat 1 telur je bila 'sedut'.
IVF - that single egg got fertilised!
Now kept frozen, I plan to transfer later on.
Dia dah belajar tahfiz al-Quran.
and she taught me a doa (dengan makna sekali),
and made a request that I recite it masa nak buat prosedur tu.
Nanti saya ajar ya!
Macamana nak type bahasa jawi dalam ni ya?

So,
Don't give up,
Berusaha,
Have faith.
My dotter's name is also Faith (translated :)
Just have faith...

Doakan saya selamat di atas angin ni,
Tiap2 kali naik kpl terbang esp bila sampai kawasan teluk kat India tu, mesti saya saspen,
Sebab selalu ada turbulence.
Saya nak baca doa yg patient tu ajar banyak2 kali.

Friday, 19 November 2010

Pap smear

Inilah rupa 'plastic brush' yang digunakan untuk menyapu secara lembut ke atas permukaan lubang  serviks. Cuba sentuh berus botol susu budak2 tu kat tangan, tak sakit pun kan? 2-3 sapu dah cukup untuk mendapatkan contoh sel-sel.
Pap smear pakai berus atas tu. A more accurate assessment is via Thin prep solution using the brush below (of course, more expensive). But, Pap smear is good enough.


Siapa yang pernah buat Pap smear?

Siapa yang perlu buat Pap smear?
- Sesiapa (wanita ya) sahaja yang telah pernah lakukan hubungan seks penetratif

Saya belum pernah bersalin, jadi tak payah buat Pap smear.
- Siapa kata?

Saya baru ambil vaksin HPV, kena ke buat Pap smear lagi?
- Ya semestinya! 

Takutlah nak buat
- Ish! Bukannya sakit pun, bukannya kena potong apa2 pun. Ambil darah lagi sakit tau.


Pap smear
-as named by the person who invented it (Mr Papaniculao). Thanks to him, with Pap smear (and of course, the necessary treatment), cervical cancer can be prevented.

How does Pap smear prevent cervical cancer?
The explanation goes like this...
- Pap smear can detect abnormality in the cervical cells.
- When dyskariosis is detected, women are further subjected to a more definitive test via colposcopic assessment.
- During colposcopy, visualization of the cervical surface is magnified enabling the Dr to identify suspicious area/s (which can be made clearer using certain solution eg acetic acid). The Dr then will take a biopsy of this area and this tissue will be sent for histologic confirmation. Only then, the pre-cancerous lesion is confirmed.
- The pre-cancerous lesion is named CIN (carcinoma intra-epithelial neoplasia). In grades I, II and III these (especially CIN III) may predispose women to cervical cancer within 10-15 years if left untreated. 
- but if treated accordingly, it will prevent CIN from progressing into carcinoma/cancer.
- senang kan?

Apa lagi kelebihan Pap smear?
- murah (free kat klinik kerajaan n kempen2 kesihatan)
- mudah (out-patient je, tak yah masuk wad pun n tak yah ambil MC)
- tak sakit (cuma kena tahan masuk spekulum dalam faraj SAHAJA). Kalau tak masuk spekulum, macamana nak tengok serviks kat hujung faraj tu kan?

Kalau tak nak buat jugak?
Nak buat macamana, Dr tak boleh paksa.....

Mintak2 tak dapat kanser serviks (nanti kaya husband saya, Dr gynae cancer tu).
Sebab kalau dapat kanser walaupun sebesar 1cm, kena operate.
Major case tau : buang serviks, rahim, tiub falopian kanan kiri, dinding tepi, sebahagian faraj
Saya sendiri tak pandai buat.
Kalau dah stage 2b ke atas- dah tak sesuai surgery, kena radiotherapy pula.

When compared,
- in Malaysian women, cervical cancer is just second to breast cancer
- in developed countries, this is not the case. With effective cervical screening programme, the rate of cervical cancer has dropped so much that it is only no 8-9th commonest cancer in women.
- ???
- We Muslims (with single partner) vs them with history of multiple sexual partners and early sexual exposure (cervical cancer is closely related to sexual activity, but?)


Fikir-fikirkanlah...
Jom buat Pap smear!

Sunday, 14 November 2010

Ovarian cyst

The term 'cyst' refers to the nature of its content,
It means fluid or anything not fleshy (thin watery or glue-like or cheesy material or pus or blood etc).
When the swelling contains solid/fleshy tissue - it is no longer called a cyst but instead a growth/tumour/swelling.

OVARIAN CYST
- there are many types depending on the origin

- kalau asalnya dari folikel telur, it is classified as functional ovarian cyst (as the ovarian function is to produce eggs!)
- There are FOLLICULAR CYST (that fails to ovulate), LUTEAL CYST (that fails to decompress because the ovulation hole is clogged ), CORPUS LUTEAL CYST .
- Sometimes they can bleed inside - thus called HAEMORRHAGIC (bleeding) ovarian cyst
- Sometimes the ovary can be twisted at its peduncle - then it becomes TWISTED ovarian cyst
- Sometimes the cyst can rupture and cause severe pain - RUPTURED ovarian cyst


- small egg follicles that become trapped (as they failed to enlarge and ovulate) and accumulate forming a chain of small follicular cysts (8mm or less in diameter) cysts - the ovaries are then called POLYCYSTIC OVARIES


- kalau dari darah period yg turun ikut tiub fallopian, it's called ENDOMETRIOTIC CYST (or ENDOMETRIOMA or CHOCOLATE CYST)


- kalau dari the ovarian capsule or stroma (tissue in the ovary), then the names can be...;
- epithelial cell eg CYSTADENOMA (SEROUS or MUCINOUS)
- germ cell eg ovarian cyst that contains anything (including everything) that our body may eg hair, sebum, teeth etc that is called DERMOID cyst or TERATOMA


Most of the times, the cyst is follicular ie functional (hypo-echoic, thin walled, no solid area) and considered small (less than 5cm in diameter), so no surgery is required except for careful monitoring of the changes in its appearence n size and except kalau cik2/puan2 nak buang jugak (and bagi Dr kaya).
Worry not, it is expected to spontaneously 'disappear' within 3 months,
Meanwhile, monitor its progress (bigger or smaller) together with any complications that may arise - twisted, haemorrhagic, ruptures etc etc.

So,
When the Dr tells that "you ada ovarian cyst",
Ask ;
- Berapa?
- Apa jenis cyst tu?
- Bahaya tak? Ada isi/daging tak?
- Perlu ke operate?
- Kalau saya tak nak buang dulu, macamana?
- Kalau op, buang cyst ke buang ovari?
- Ada air/ascites tak? (fluid collection at the lower pelvis, this is NOT a good sign especially when the content is solid/fleshy)
- dan banyak lagi soalan, tanya je la.....

Seperti biasa, Dr akan beri jawapan 'selamat' yg ala2 defensive gitu;
"Nampak macam ovarian cyst, tapi keputusan tepat hanya tahu setelah dioperate n dihantar ke makmal utk pengesahan (ujian HPE), baru tahu jenis apa dan confirm bahaya ke tidak"

Sebab sometimes, bukannya ovarian cyst pun.
Tapi para-tubal cyst (cyst kat tiub falopian).
Tu yang tak besar2 tapi tak hilang2 kot?

Now,
More and more doctors are trained to perform 'cystectomy' via laparoscopy,
Better wound healing,
dan yg lebih penting - better assessment (the view through the telescope is magnified so the visual is clearer that you can see even small 'bleeders', I wish it cd show the blood cells :),
Be it panoramic view or focussed areas, boleh tengok all around...liver surface, appendix etc etc.
If the Dr is not trained to do it that way, then it is safer for he/she to open it,
Sebab laparoscopic surgery requires experience to avoid injury (even in experienced hands complications can happen, inikan pulak yg tidak).

So, jangan lupa mintak Dr salinan result HPE.
Kalau kat private hospital, boleh dapat within a week.
Kalau mintak urgent evaluation (esp dlm suspicious case, boleh dapat dalam 2-3 hari).
Kalau gov hospital, dalam 6 minggu.


besar, tapi yg ni bukan ovarian cyst. It's a para-tubal cyst.


yg ni baru ovarian cyst


this is a para-tubal cyst, just next to the ovary.


ni pun ovaian cyst


kalau besar macam ni, buang ya

Thursday, 4 November 2010

18 more days

Tidak lama lagi saya akan pergi menimba ilmu lagi,
Di atas biayaan SENDIRI.
Ulangkaji yg lama dan update yang baru


It's about 'endoscopy in reproductive medicine'
In my humble opinion
and thru my limited experience
Endoscopic surgery utk infertility patients ni kena ada tambahan caranya
Not quite the way we were taught sblm jadi specialist dulu2
Kena ada modification


Contohnya
In endometriosis
We were taught that the main principle is to clear as much endometriotic tissue as possible
Either gunting/ambik buang or kalau melekat sangat, guna diathermy je (ie karen letrik yg bertukar menjadi haba)
But when it comes to the ovaries
PATIENCE is 'rule no 1'
I will TRY NOT TO use the diathermy at all
Kalau ada bleeding, I just pressure to it and wait for a while before I check again (this may take longer time)
or jahit thru the small laparoscopic hole (this will take much longer time)
Small 'bleeder' - biarkan je, it will stop (macam kalau jari kita terluka)
Under telescopic view, things appear BIG, padahal sikit je tu
Kalau ada arterial 'bleeder', barulah 'bakar' kejap or cuba jahit cepat2 (this require skill) or buka besar and repair (depending on the amount and urgency)


Nape tak sesuai kalau guna 'diathermy' banyak2 ni?
Sebab?
The heat can cause damage to the budding eggs yg aakan menjadi bekalan kita sampai le ke menopaus nanti
This is my theory which is logical
Either the eggs boleh mati kepanasan
or they can undergo mutation can produce unhealthy embryo
I hope I'm wrong.
(harap2nya mutated jadi super clever baby, in this case, bagus jugak kan?)


I've come across (every year)
Patient/patients yang became 'menopausal' after such surgeries
Bila buat blood test
The FSH level tinggi sangat


Talk about this also
This week ada lagi sorang who had not had her periods for many months
Her FSH was also very high
Her liver enzymes were also increased
She's still young <40
No surgery before
Bila tanya pasal 'health product'
Rupanya dia ada amalkan 'satu produk' ni
The uterus and ovaries had become small too
I've seen this type of cases a few times jugak so far
and they used 2-3 familiar products yg org dok jual ni
and I told them to stop using them
Fortunately the FSH slowly came back to 'better' (not normal yet)


We must remember the basic thing of Islam

"MODERATION"

Ubat/produk yg selamat adalah produk yg disediakan dalam DOS yang serendah mungkin tetapi masih MAMPU memberi kesan baik dan pada masa yang sama mempunyai kesan samping yg paling minima
The stronger/higher the dosage - of course the effects are noticable earlier (and we will start telling our friends to use/but it, this is mouth-to-mouth marketing), BUT the negative effects are usually stronger too (be it noticable shortly or in the long term)
Ingatlah,
Kita nak hidup ke hari tua dengan SIHATNYA
Not with 'premature rotten' ovaries, heart, kidneys and liver
Bukan senang nak cari donor untuk transplant


Anyway
Back to my study-journey
Bersendirian
Solo betul2 ni
In one of the oldest university town
LEUVEN


Ada ESHRE campus rupanya
European Society of Reproductive Medicine
Utk ahli macam saya
Dapat murah sikit
Euro800
(compared to Eu1000)

Dan jauh lebih murah drp yuran IVF training saya 7 tahun yg lepas di Hamburg
It was Eu500/day
Sbb yg tu one-to-one training, dgn d big boss pulak tu
Yg ni bukan 1-2-1 tetapi a small group of 20 in its laboratory
3 full days


Masih men-surfing the web utk flight n hotel
Sebab belum sure nak masuk ikut mana
Definitely not thru Brussels sbb mahal utk connecting flight
So, either:
- via Amsterdam (n naik intercity train via Mechelen) or;
- via London (tapi kena gi St Pancras station from Heathrow)
- via Paris (tak de sebab apa2)
- via Dusseldorf (nearer but rasanya less frequent)
- via Hamburg (then saya boleh singgah kat kedai model anatomy n beli, <50% harga berbanding sini)
Any idea anyone?


Balik?
No problem
Mesti ikut London punya
Sebab mahu singgah kedai beli a few things
The satin/silk pyjamas sangat elok n cantik
The playfish cards yg Iman kirim


O yes
She's not going
Not this time
Sebab mamanya betul2 nak gi belajar, bukannya berjalan

Monday, 1 November 2010

Bayi tabung uji

Sungguh pelik nama ini
Memang tidak menggambarkan apa yang dibuat oleh kami di dunia IVF

Tabung uji
Macam dalam makmal Chemistry masa sekolah dulu je kan?

Padahal hakikatnya
Embrio dan sperma2 dicampurkan di sini (dgn bergema)

Persenyawaan telur(ovum) oleh sperma sebenarnya dibiarkan berlaku dalam bekas bulat2 macam perigi cetek tu di dalam inkubator.






Soalan : Nape tak pakai tabung uji?
Jawapan : (tanya balik, hehe) nape pulak kena pakai tabung uji?
Jawapan sebenarnya tuan2 puan2 ((yg atas tu acah je):
  • leceh nak label tiap2 tabung uji tu especially kalau dapat banyak telur (lagi berkemungkinan tersilap). Satu kotak piring tu ada 4 'perigi'
  • bhg bawah tabung uji tu tak meleper, kena sandarkan/letak dalam rak. kotak perigi tu leper
  • tabung uji kan tinggi, memakan ruang je n leceh nak handle

Cuma...

Tak sedap pulak bunyinya kalau nak namakan bayi 'perigi'

Sungguh tidak saintifik

Wednesday, 20 October 2010

Jasamu dikenang

Indeed...Allah is the Most Gracious, the Most Merciful.....



Ustadz Fadhil Ahmad.
Bekas guru MRSM Jasin,
Juga Ketua Warden asrama semasa saya di sana,
Telah meninggal dunia malam tadi,
Di Miri Sarawak,
Difahamkan jenazahnya akan dibawa pulang hari ini ke Kulim untuk disemadikan.


He's younger than my abah,
Suffered from kidney failure.


Terima kasih Ustadz,
Kerana menjaga kami di asrama,
dan mengajar kami di kelas,
dan di surau.


Semoga Allah membalas jasa Ustadz,
Semoga ilmu yang Ustadz turunkan akan terus berpanjangan,
Menjadi bekalan Ustadz sepanjang masa di sana.


al-Fatihah...

Thursday, 14 October 2010

The kissing ovaries

Hari ini kita belajar suatu perkara "kecil" tetapi penting.

KISSING OVARIES

Pernah dengar istilah ini?
Kami Dr2 je yg bagi nickname ni.

Bagaimanakah rupanya kissing ovaries?


Haa....inilah yg dinamakan "kissing ovaries".
Dalam satu screen view, boleh kelihatan kedua-dua ovari, bersentuhan lagi.
Lokasi ovari tu betul2 di atas selepas dinding vagina (sepatutnya begitu pun).


Tetapi yg ni pula bukan kissing ovaries berpenyakit tau.
Ovari2 ni besar sbb tgh dirangsang utk IVF,
kantung2 telur tgh banyak yg besar tu,
membesar sehinggakan bersentuhan dgn ovari lagi satu,
bukanlah kissing sebenar :)


Kenapa boleh jadi macam tu ek?

Biasa2nyalah....sebab endometriosis
Bleeding tisu endometriosis tu kan bersifat melekit2
Maka bukan setakat ovari2nya shj yang melekat sesama sendiri, tak mustahil surrounding organs yg lain pun turut melekat

Satu lagi possible reason...melekat sebab infection (PID)
Tapi untuk Muslim couples yg sepatutnya setia kepada pasangan ie tidak mempunyai berbilangan pasangan seks, penyebab ini jaranglah menjadi puncanya
Wallahua'lam

Ingat lagi sekali
Bila tgk2 monitor scan doktor tu
Dalam pemeriksaan secara TVS (trans-vaginal scan);
Di tengah2 patut ada uterus sahaja,

Bila Dr halakan hujung scan probe ke kanan anda (masih dalam vagina)
Ovari kanan akan kelihatan betul2 di hujung atas scan probe (hanya terpisah oleh dinding vagina sahaja)
Di tepi atas ovari pula akan kelihatan salurdarah pelvis

Begitu juga sebaliknya di kiri

Ovari yg ni (sebelah kiri tak le kissing tetapi lokasinya JAUH ke atas daripada dinding vagina, sehinggakan ternampak sebahagian uterus.


Scan probe diletak di tengah2,
kelihatan uterus dalam axis sebenar, tetapi pada masa yg sama kelihatan satu ovari di belakangnya.
Dapat disimpulkan, ovari ini tidak berada di kedudukan sebenar (tidak sepatutnya di tengah2).
(maklumat tambahan, secara kebetulan, pt ni ada endometrial polyp)


Melihat imej ultrasound ini memerlukan kepakaran yang membuatnya,
Sama seperti mencari gambar tersembunyi,
Gambarnya dan maklumat sebenarnya ada terpampang,
Cuma terpulang kepada mata operator yang melihat untuk mengesannya,
dan CPU motherboard di dalam jumjumatunnya utk menganalisa data,
Jika tidak, beli mesin yg RM 500K pun sia2 sahaja.

Saya biasanya "ajar" patient2 saya melihat imej scan pada monitor,
Berkongsi ilmu dan memberitahu yg benar,
Lama2, patient saya pun dah tau,
Bila saya mula scan, sebelum saya buka mulut, mereka dah bagi running commentary :)
Rasa macam kat dalam kelas pulak.
Pandai sungguh patient2 saya ni.
Sedangkan saya berbelas2 tahun nak belajar jadi Dr ni tau.
Maklumlah, mereka masih muda dan generasi cyber n elektronik.

Saya selalu berseloroh dgn mereka,
"Kalau dah pandai tgk scan macam ni, U je la buat sendiri"