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 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.....

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