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.....

Monday, 23 May 2011

WSM 5008

Not my car plate number,
But,
The original code-name for...


CLOMIPHENE CITRATE


Yes,
This drug was born in 1967 (the year my parents got married),
We have many 'super-senior' doctors (I've made it sound much better than 'old' :) who have been treating sub-fertile patients from before this drug came into the market.


So;
the next topic is about this 'medicine'.
It has been given many names (ikut company mana yg produced).


I shall try to answer your question/s about CLOMIPHENE CITRATE
(I like it when patients ask "Dr, boleh tanya tak?" and I would always reply "Boleh...tapi tak semestinya saya boleh jawab")


Questions?
Any takers?
(Don't sell me that number, I don't intend to buy another car)

Saturday, 21 May 2011

"Excite me more"

Their shophouses looked beautiful, but their cottage houses were more beautiful, just like the pictures on the jigsaw-puzzle boxes.


'Pause' lagi sementara menghabiskan carian ilmu sampingan.
Like others, I love reading too.
I'd try to read about one non-medical topic every week.
Kdg2 berjaya,
Byk kdg2 mcm goldfish je (the attention span),
Byk kdg2 juga mcm kura2 (the speed le).
Banyak nak juggle membaca ni - buku medical, buku non-medical, buku cerita, tafsir, suratkhabar, blog, buku resipi, buku teks sekolah dan magazine anak, map-google dll (di samping 'membaca' di dalam tidur).

Tak termasuk menulis artikel, medical report dan mem-blog :)


Usually,
My reading about a particular topic would last for a few days only.
But not this time.
Although school holiday is just around the corner (and I should start preparing for that),
My topic of interest is still about this country,
and the more I feel the inadequacy in my knowledge about it,
(feels like it is never-ending),


the more I'm 'aroused' by it.

THE NETHERLANDS


or


HOLLAND


or


BELANDA



And I shall say it again,

The more I dig about its history, the more I'm in love about this place on earth (or should I say, the land below earth-level)


Why?



  • Not about the 'guilty' Anthony van Diemen (macam Jean Claude Van Damme the-muscles-from-Brussels je nama dia ni), he who led the Dutch onto us on the 3rd attack, with ally from Johor, in 1641.



  • Not so much about its colonial history here that makes me glued with eyes wide open and brain spongy-absorbent,



  • Not that I'm from Melaka and I still see its colonialism in:
- the names of some of the streets (mcm Jln Tun Tan Cheng Lock kat tgh2 bandar tu was named Heeren street)
- their colonial architectures: the shophouses on Jln Tun Tan Cheng Lock were built during the Dutch era (and the way they imposed tax macam they did on the houses back home - according to the width of the house),
- architechture again: the red Stadhuys (have you heard about the story why it was painted red, people spit betel nut juice in hatredness?)
- the food : durian belanda, terung belanda (dulu ada kt blkg rumah, tumbuk dgn sambal belacan, and they r orange too!), ayam belanda (heh)
- they (or we?) imprinted Belanda on these too : tikus belanda, paku belanda
- err....tak cukup nama Belanda, nama Dutch pun ada : Susu Dutch Lady :)



  • Not that I visited Amsterdam 2 years back (IVF conference, of course with Iman - my handbag and the nanny-sister, Liza),


No No NO.
Nay.
A'ou! (No, in Dutch)


but because;


  • -I've spent days and like reading on the long n interesting history of tulip and the well known tulipmania which changed to 'tulip bubble burst' and turned rich merchants into peasants overnight (besides the history about how tulip was brought into the country and how tulip got its name);

(it is as fascinating to learn about tulip itself, the bulb, the virus turning them into vibrant colourful striped rarities, the life cycle and how the Dutch modified it for storage/trading)

- the associated introduction of 'speculation' (the unknown outcome/luck of tulip bulbs through paper-trading) into the world of Economy


  • still on agriculture, they were also the ones who bred orange carrots (hmm...now I know that previously there were only red, purple, black, yellow and white carrots);



  • and why they chose orange as their colour (even for their football team), almost everything but their very own flag (but there is also history as to that why orange was changed to red band) and William de Orange;

- and till today, I'm still searching how Belanda got that name (who gave the name - the Malays or the Indonesians? );


Blue was reserved for Delft industry....otherwise...I suppose...ORANGE!



  • their seafaring power, with 9-month sea journey (sanggup tu, kalau pregnant sempat beranak pun), the United Dutch East India Company (VOC in Dutch acronym) ship that would occupy 200 just to ensure that at least half would return alive.
(sekarang naik 'belon' dalam setengah hari dah sampai Amsterdam)



  • Pepatah Melayu ada berkata - seperti Belanda minta tanah (how ironical it is that later on, the International Court of Justice resides in the Hague, remember our dispute w S'pore on Pulau Batu Puteh?)....err....where is justice?

But I still could not comprehend why the Malay proverb put the Dutch at fault as according to the Raffles manuscript, it was the Portuguese Captain who tricked our Sultan Ahmad Shah into giving them (against the Bendahara n Temenggong's advice) 'a piece of land the size of the skin of a dead animal' in change for gold; which they eventually cut the skin into a thin, long cord used to measure a big square size of land. And so they erected a large building (fortress-like), from within they attacked Melaka with cannons and the rest was history.....Melaka being defeated.

Hmm...nape tak cakap seperti Portugis minta tanah?



Above all;

- the fact that the Dutch were once like us, their country too was conquered by another country, Spain, for 80 years (1568-1648) but they fought hard.....

....and we r still not far from where the last colony (that is British dear, in case you slept during History class) left us.....

(btw, the Dutch 'stayed' longer in Indonesia and only granted them independence in 1949, so the claimed title 'big brother' to us yg gained independence 8 years later, iya ke?)


and I believe,
there are more to learn about the Netherlands : the windmills, wooden clogs, cheese, delftware pottery and not least, the magic mushroom aka cannabis (mmm...aaaah....in trance....)
Obviously not the last, but I don't plan to know more about their liberalization on same-sex marriage and euthanasia.


Now....siapa nak sponsor I gi Amsterdam?


Makan, kita 'go Dutch' lah ya :)
Worry not, their Muslim population is 5% (hence halal food availability, hopefully) of the 16 million total.

...and sumpah, saya dulu tak minat (sebenarnya tak pandai, tapi tak nak mengaku) subjek Sejarah langsung.

...so, kenapa sekarang saya minat pasal sejarah Dutch ni?
(unlike En Jake, a good historian apart from a much better surgeon than I am)


It all started because of the topic 'Tulip and the Fall of the Dutch economy'......greed....the BIG sin.


...I better continue reading about it (dan berangan belajar ambik Degree in Ekonomi).


...or maybe I should continue reading about history, and learn from it....

...btw, in the Netherlands, IVF is public funded.....free!

...and one of the 2 recombinant-FSH products (used in ovarian stimulation) comes from the Netherlands! (and so do other reproductive drugs)


at Madurodam, everyone can be a giant, though not many have destructive Calvin-mind like this girl...


...and their 'kedai kopi' free time was actually not mind-free, she was in deep thought....

Monday, 16 May 2011

Ovarian reserve

There are many ways to assess ovarian reserve
What does ovarian reserve mean?
Nak tengok sama ada ovari tu masih 'aktif' atau 'kurang aktif'
Boleh agak sama ada ovari-ovari kita ni ada banyak telur lagi ke tidak
Boleh agak berapa dos ubat subur nak bagi
Tetapi tak le sampai boleh mengira berapa banyak telur yang tinggal


Pilihan pertama
-Ujian darah FSH yang selalunya dilakukan pada hari period ke-3
(sebenarnya anyday dari hari ke-2 hingga ke-5)
-In many private hospitals, the result can be obtained after a few hours


Pilihan kedua
-TVS (trans-vaginal scan) ke atas ovari kanan dan kiri untuk mengira bilangan folikel telur awal (antral follicle count) untuk kitaran tersebut
-Ia sering dilakukan pada hari ke-2 (ya benar, tengah2 period tu :)
-Dr pun boleh tengok sama ada terdapat 'leftover' follicular/luteal cyst, kalau ada yg sebesar >1cm, mungkin Dr tak nak start stimulation menggunakan ubat subur sebab takut cyst tu (especially yg estrogen producing) akan membesar (tak pasal2 kena op nanti kan)
-Sebenarnya bukan telur yg dilihat dalam scan tu tetapi kantung folikel sahaja (sebab telur sangat kecil hanya sebesar titik dawat mata pen) sama ada kantung folikel baru ataupun lama
-Ada kajian kata, pada setiap kitaran ada sekitar 8-15 telur2 baru yg akan berlumba2 untuk membesar dan di-ovulate (walaupun pada akhirnya hanya SATU sahaja yg berjaya, kdg2 satu pun tak besar, jarang2 ada 2 - tu sebab ada yg boleh dapat kehamilan kembar secara spontan)


Pilihan ketiga
-Ujian darah aMH (anti-Mullerian Hormone)
-Malangnya kita bukannya berada di Jerman atau negara2 lain
-Ujian tu tak dibuat di sini, tetapi dihantar ke Australia
-Bukan sahaja kosnya mahal (RM400+), tetapi hasilnya hanya balik dalam SEBULAN!
-Tu sebab saya tak buat pun, ada la dalam 2-3 org je pd patient yg ada premature menopause tapi nak jugak try utk IVF



Telur-telur dalam ovari kanan dan kiri kita ni pada awalnya ada beratus ribu
Tetapi tu masa dulu la
Bila dilahirkan, bilangannya asemakin berkurangan dan apabila baligh, lagilah tinggal sedikit sehinggalah kehabisan ie menopaus
Seawal kita di peringkat janin lagi, ovari2 dah membentuk telur-telur sebagai bekalan kita masa hidup nanti sehinggalah habis (menopaus)
So, kalau dalam uterus ibu tu dah berada selama 9 bulan, ini bermakna telur-telur kita sekarang dah pun berusia (.... tahun + 9 bulan)
Masa mak kita pregnen-kan kita 5 bulan, ovari2 kita dalam uterus mak tu dah ada 7 JUTA telur!
Ini berbeza dengan sperma lelaki yang sentiasa dibentuk setiap hari
Maka sebenarnya 'perkahwinan' berlaku di antara telur wanita yang jauh lebih berusia dengan sperma lelaki yang sungguh muda (paling tua pun 3 bulan)


...err bersambung kemudian hari

Selamat Hari Guru!!!

Kami guru Malaysia
Berikrar dan berjanji
Mendidik dan memimpin
Putra putri negara kita
Pada Seri Paduka
Kami tumpahkan setia
Rukun Negara kita
Panduan hidup kami semua

Di bidang pembangunan
Kami tetap bersama
Membantu, membina
Negara yang tercinta

Amanah yang diberi
Kami tak persiakan
Apa yang kami janji
Tunai tetap kami tunaikan


Lagu & Lirik : Hashim Ahmad



Not because my parents were teachers
I like to sing this song merely because of it being catchy
(the same reason why I like/know Umno song (posted in my-clone blog) by heart, albeit I'm not inclined to any political party/view)
Macam itu burung 'Rio' yg spontaneously danced to the beat tu
Of the two, I prefer the above song
Lagi Kami Guru Malaysia ni memang rancak bertenaga


My most memorable first-day-of-school was when I was assigned to Merah Team at HUKM under the team consultant, Prof Adeeb (who in HUKM doesn't know her?)
Kena 6-monthly rotation into Teams Merah, Hijau, Oren and Kuning throughout the 4 years

Siapa yg 'suka' masuk Team Merah ni?
We had to be on our nerves all the time
Takut dgn Prof Adeeb

I only revealed my secret to her later on (of course after I graduated)

"I was so scared of you, Prof, that I came to work at 4am on my first day"

Yes. Pukul 4 pagi sudah terpacak dalam wad.
This mother (Iman was still a clingy toddler then) was in her second year of Masters programme, she wanted to be in Prof Adeeb's good book that she came so early to work!
Who doesn't know Prof Adeeb
She takes (yes, she's still teaching) 'no' when it concerns patients
Bukan sahaja medical students & registrars, the specialists pun kena marah depan2
(I was hoping that she forgot about the incidence when she called me and Zura to her office to explain why we didn't attend her teaching session, masa tu we were in Year 4 undergrad and she was also the Deputy Dean)
But Prof Adeeb was being Prof Adeeb
Left right depan belakang saya kena marah, again and again
Bila dah tahu pasal ALL of Merah patients in that ward at my fingertips (and I thought I was safe as that was the requirement of Merah registrars), she scolded me for not knowing about ALL of Merah patients in the hospital!
I felt that she just liked to pin on me (dasar self-pity dulu2 :)


There's this saying that "sapa2 masuk O&G HUKM, the lecturers will pounce on you (he he, maklumlah, kami M/O dari district hospitals ni kan perasan pandai and all-knowing walaupun sebenarnya macam T-rex je),then they will MOULD you again into better doctors, hopefully humble ones"

Tu sebab tak ramai yang tahan dgn Masters O&G ni
Even my good friend who was a top scorer during undergrad opted out half-way

The bashing sessions continued for some time until suddenly without me realising the end-point, she became nice and nicer
The fact that she let me conduct the monitoring of her daughter in-law's labour progress proved that (of course the specialist performed the em Caesarean le)
And she let me walked with her
And she guided me with my thesis
(yes, I was lucky to have been sent to Team Merah TWICE, the second time during my final year, kalau Prof Adeeb tak 'balun' tanya mana paper, mesti kena extend sebab tak suiap thesis)
And she told me stories about her baby grand-daughter "Min"
Someone told me that she's very different at home (masa datang beraya), sampai tak sangka ini ke Prof Adeeb yang garang tu?
Baik sangat2
"When her white-coat is off, she's an angel" I was told

Finally one day, she told me;

"When I was a student, I came across my lecturer who was still reading book past midnight....."

Later I knew that Prof Adeeb slept by her patient's bedside
That dedicated
That hardworking
Dah jadi Consultant pun she never fail to appear in the ward by 0730hrs
(imagine how early we had to 'clerk' the patients before presenting to her without reading from the files?)
And she went to all of the 4 wards
And the labour ward
And she took the stairs
And she walked fast
I can still feel the tireness as I am writing this

She was the first O&G consultant to being honoured with "Emeritus Professor" title.
The title that allows one to carry the "professorship" title even when he/she's out of the university practice (unlike standard professorship title which you have to leave behind as you resign/retire from the university)

Now, whenever I meet her (biasanya during O&G conference), saya tak pernah lupa salam & cium tangan

Dear Prof Adeeb,
I can never thank you enough
Thank you for everything
May Allah bless you and your generation
May you be in great health


To other teachers too (I already mentioned in my other blog last year), THANK YOU! THANK YOU! THANK TOU! THANKS TO ALL OF YOU!

What about me?
I like teaching because I like sharing knowledge (it makes that knowledge melekat kuat dalam raksun ni), but I don't like the associated paperwork n meetings
That is why I blog
Through blogging, I can still share my knowledge (of course, with disclaimer on top of the page :) and I can do it at my own free time


More importantly, we should also learn
I find 'learning' to be a mother is a looooooooong journey and very much challenging too
(sigh) patience...patience

Saturday, 14 May 2011

When the time comes...

A fertilised egg, the beginning of our trillion-cell-bodily life. We are indeed rich, multi-trillionaires!




Just have faith
The time will come
InsyaAllah



2 stories, 2 couples,1 fine Friday
(who says Friday the 13th is bad?)

A 46 year-old lady who has been married for 15 years
She watched the interview in NLKO last February
(NLKO - Nasi Lemak Kopi O in TV9)
I spoke about the importance of healthy eating
and the role ofnanti-oxidants in improving fertility in both men and women
Together with the fact that there are many FRESH anti-oxidants in the supermarket
FRESH and CHEAP
Unprocessed and with no preservatives
(we are not living in outer space, so why do we need processed food products?)
And I gave examples
And I mentioned prunes
Prunes has 5800 ORAC (double the ORAC in raisin)
This lady followed my so-called advice

And she had her last period in March
And she got pregnant afterwards
When I scanned her yesterday, the pregnancy was already into the 8th week
I asked her (ye la, kena tanya petua kan?);

"Makan banyak mana? Sehari berapa biji?"

She answered;

"Saya makan bila teringat je doktor. Saya dah nak habis 2 bekas tu"

"Ada rahsia/petua lain ke?"

She said no. No other changes
She kept praying
Ada satu ayat al-Quran tapi dia lupa surah apa, she promised to give it the me next we meet
(and I shall post it here, insyaAllah)

I did not do any magic
(What is so magical about prunes anyway?)
There is no magic in any 'medicine' after all
But it's HIM who decides as HE wishes.




Same Friday
Another lady, 40 years old, been married for 8 years
I first saw her in March when they seeked second opinion
She had tried a few stimulation cycles before seeing me, including an IUI with FSH injections
She has retroverted uterus
I offered IUI using FSH injections
One try before more invasive procedure
Advised her to take folic acid and multivitamins
Added 2 other medicines to increase her initially thin endometrium
hCG for final follicular maturation and ovulation induction as usual
So she underwent IUI under ultrasound guidance
Luteal support as usual
Yesterday, her pregnancy was confirmed with blood test - BhCG
And today, the level is almost doubled (so, she's pregnant and it's an on-going pregnancy!)
Same story again
No magic
(and who says women with retroverted uterus could not get pregnant?)
Not that the previous doctor is not good
Believe in HIM
Their prayer during Hajj last year was answered



There were 'sad' stories as well during the same week
A younger lady, thus lower dosage of FSH
But had sub-optimal follicular growth and endometrial thickening
I'm still working at it (and puzzled)
Maybe I have not done/read enough
But I believe her time will come
And who knows, she might get pregnant this time (the result is still pending)



The hard part for a fertility doctor is to break the bad news
Be it on the phone
or face-2-face with them
I always feel awkward
We feel the pain too...
But we must never lose hope
In every cloud, there is always a silver lining...

Thursday, 5 May 2011

IVF workshop

A workshop on IVF will be held at Pantai Hospital KL this Saturday
1.30 - 3pm (after my clinic session)

We allow only 20 couples
They must call to register prior to that date as we do not allow/accept on-site registration (bukan jual mahal, it's free pun)

Not only on IVF, but :

- infertility as a whole
- managing infertility cases
- diseases that may be associated with infertility (endometriosis, PCOS)
- demo on some medicines and techniques used in infertility treatment
- Q&A session

The talk would be in English/Malay (ikut majority)


Pls call 03-22960892 (Ms Chuah) to for RSVP