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.