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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.

The success rate can be reported as either of these;

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


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.


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 Him

Ask your Dr these;

(penatlah, nanti saya sambung ya)


  1. assalamualaikum Dr,

    boleh Dr komen berkenaan wanita yg menjalani rawatan IVF maut di HTAA & ovarian hyperstimulation syndrome..


  2. Hmm...sensitif kalau nak komen di sini. Ubat2 yg digunakan dalam IVF berpotensi memberikan kesan serius kepada aliran/pembekuan darah, buah pinggang, hati dan boleh mengakibatkan maut.
    Mild OHSS ia common in about 30% while moderate OHSS is around 5% sahaja,

    tetapi severe OHSS should be avoidable by :
    -taking precautions especially in the group that has higher risks of developing OHSS (eg PCOS, thin etc) by using low-but-adequate dosage of FSH injections and lower dosage (or avoid langsung) of hCG injection for maturation or buat coasting n postpone embryo transfer or bagi medical attention/closer monitoring
    -Tetapi to be fair kpd Dr yang terkena, hanya mereka shj yang lebih tahu kesukaran sebenar sebab x de ujian spesifik utk diagnose OHSS. It's difficult to predict, kadang2 bagi Clomiphene pun boleh dapat OHSS (tapi tak le sampai severe OHSS). Yg pentingnya is to identify early ie masa peringkat mild or moderate n take actions sebelum jadi severe. I'm sure the Dr concerned with that case had taken necessary measures.

    But it needs both sides. Patients pun kena kenalpasti tanda2 awal dan terus contact Dr or gi hospital. Jangan ingat tak de apa and datang bila dah terlambat or dah muntah2 teruk. Usually Dr2 akan bagi warning siap2 apa tanda2 penting yang perlu dikenalpasti. Tu sebabnya saya hanya beri no handphone saya kepada setiap patient yg menjalani rawatan IVF or yg menggunakan ubat suntikan FSH, dan pesan yg mereka MESTI terus contact saya (asalkan jangan untuk tujuan lain :)

    Tu sebabnya juga Dr yg buat IVF sepatutnya hanyalah Dr yg ada formal subspecialty 1-to-1 training and also be knowlegable dalam bidang ni. Nak bagi protokol IVF treatment memang senang je, nak buat prosedur OPUU or ET pun senang nak train, even bukan specialist pun boleh kalau diajar. The more experienced the Dr is, the more careful and slower he/she is before starting the treatment as they realise very much that OHSS can be fatal. I'd heard from a patient whom I treated for severe OHSS (she also developed DVT) and she told me that her renowned IVF Dr purposely put her on OHSS and he told her that "no pain, no gain". That was so wrong. Yes, there's a theory that by putting patients into some stage of OHSS (mild-moderate), there is a higher chance of her getting pregnant, but would you want it at the expense of risking her life? You'll never know that she might just worsen into severe stage. That patient got pregnant (as expected from OHSS)but luckily she miscarried (or else, the OHSS would get worse) and recovered (I had to get a cardiologist's help for her blood clotting problem). Patients can ask their doctors about this.

  3. salam Dr,
    terima kasih sbb bagi maklumat

  4. Sama2, seronok bila dihargai :)

  5. salam dok, dari segi rawatannya macam mana pulak? takut pulak dengar. walaupun tak berapa faham tapi rasanya benda2 penting dapatlah jugak.

  6. No specific treatment (kecuali kalau dah dapat DVT or thrombo-embolism), hanyalah supportive sahaja. Maknanya, ganti balik apa yang hilang. Tapi kena careful, jgn ganti lebih2 nanti overload pulak, pun bahaya.

  7. Salam WBT Dr Adilah

    Saya Norma, ex-patient Dr di Pusrawi.

    Alhamdulillah lepas buat laparoscopy dengan Dr untuk rawatan PCOS, menstruality back to normal. Cuma belum ada rezeki to conceive.

    Saya merancang nak buat rawatan IVF. Boleh Dr tolong inform anggaran kos rawatan IVF.

  8. Norma- dah Cuba IUI? Nak IVF pun boleh, kos antara 12-17 ribu omit jenis ubat n dos ubat

  9. Assalam dr, berapakah kemungkinan berjaya mendapatkan zuriat melalui proses IUI? dan apakah faktor2 yg diambil kira bagi menentukan kejayaan melalui kaedah ini? TQ

  10. Nana- kalau dapat 1-2 kantung telur matang, 10-%peluang hamil. Kalau dapat bilangan telur lagi banyak, lagi tinggi peluang tetapi lagi tinggi risiko kembar 2/3/4 atau selebihnya. Kena tgk beberapa benda:
    -tiub falopian
    -kualiti sperma hubby
    -ketebalan lapisan endometrium
    -penyakit2 lain

  11. Assalamualaikum...boleh tak minta email doctor?

  12. Boleh tapi saya tak gemar reply personally sbb saya bukan personal dr u. Lebih baik masalah (n jawapan) dikongsi bersama.

  13. I found very good and I would like to congratulate you for your work.
    ivf success rates

  14. salam...
    saya baru berkahwin pada 27/11/2011 yang lalu dimana pada waktu itu, saya baru sahaja habis period iaitu pada 26/11/2011. dan saya period sekali lagi pada 20/12/2011. namun begitu, saya mengalami masalah kencing kotor dan merasakan kesakitan pada bahagian pinggang dan perut di sebelah kiri. kadang-kala perut saya rasa berdenyut2 dan mencucuk2, loya disertai pening. rakan-rakan mengatakan bahawa saya mengandung(istilah bunting harimau). tp hasil UPT adalah -ve. adakah kemungkinan saya telah hamil walaupun saya telah mengalami period?terima kasih