Silent

A 57 year old lady presented to me the other day with a complaint of abdominal discomfort for the last 2 weeks. It was a vague sensation that wasn’t going away, yet her appetite, bowel and urinary habits were all normal. She was 7 years postmenopausal and had 5 grown up children. Generally, she looked well, but there was a mass felt in the abdomen just below the umbilicus. The following are the ultrasound pictures.

Seorang wanita berumur 57 tahun mengadu perutnya tidak selesa sejak 2 minggu lepas. Perasaan ini berterusan dan tiada kelegaan didapati, tetapai selera makan, buang air besar dan kecil semuanya saperti biasa. Dia telah pun putus haid 7 tahun sebelum ini dan mempunyai 5 orang anak dewasa. Pada keseluruhannya, belia nampak sihat, tetapi terasa satu ketumbuhan yang menghampiri pusatnya. Berikut adalah gambar-gambar dari imbasan ultrasound yang dilakukan.

This mass is 14.5 cm long and contains solid and fluid areas.

Ketumbuhan ini sebesar 14.5 cm dan mengandungi cecair serta kawasan pepejal.

Unfortunately for her, these are hallmarks of ovarian cancer. The danger of this type of cancer is, as highlighted here, is the silent onset and progression. The only method of detection is routine ultrasound scans.

Malangnya, ciri-ciri saperti ini adalah penanda kanser ovari. Bahaya kanser ini ialah penimbulan dan perkembangannya yang berlaku secara senyap. Cara pengesanan kanser ovari hanyalah melalui imbasan ultrasound.

Fat uterus

This is a uterus removed recently from a 45 year old multiparous lady who presented with frequent and heavy menstrual bleeding unresponsive to medical therapy. The cut section shows a large area of adenomyosis adjacent to the endometrium with only a thin area of normal myometrium.
Seorang wanita berumur 45 tahun dan beranak ramai telah menjalani pembedahan buang rahim kerana kegagalan mengawal pendarahan haid yang lebat dan kerap melalui rawatan perubatan. Rahim  yang dipotong ini mempamerkan satu ketumbuhan adenomiosis yang besar berdampingan dengan endometrium. Ketumbuhan ini dikelilingi oleh lapisan myometrium yang normal yang nipis.

Selling the Fantasy of Fertility

Satu rencana menarik yang mempamirkan komersialisme rawatan kesuburan demi meragut keuntungan

By MIRIAM ZOLL and PAMELA TSIGDINOS

ON Sunday in New York City, a trade show called Fertility Planit will showcase the latest inventions in the world of reproductive medicine under a banner that reads: “Everything You Need to Create Your Family.” Two dozen sessions will feature many of the sponsors’ products and therapies, with an emphasis on hopeful breakthroughs ranging from genetic testing to embryo thawing techniques to genome sequencing.

But the fair’s most powerful strategy is the suggestion that all your answers can be found within the event hall — and that the power to overcome infertility can be found within yourself.

As former fertility patients who endured failed treatments, we understand how seductive that idea is.

Americans love an uphill battle. “Don’t give up the fight” is our mantra. But the refusal to accept physical limitations, when applied to infertility, can have disturbing consequences.

Medical science has achieved great feats, improved and saved the lives of many. But when it comes to assisted reproductive technologies, science fails far more often than is generally believed.

The European Society of Human Reproduction and Embryology reports that, on average, of the 1.5 million assisted reproductive cycles performed worldwide, only 350,000 resulted in the birth of a child. That is a 77 percent global failure rate. In the United States, the Centers for Disease Control and Prevention puts the overall failure rate at almost 70 percent.

Behind those failed cycles are millions of women and men who have engaged in a debilitating, Sisyphus-like battle with themselves and their infertility, involving daily injections, drugs, hormones, countless blood tests and other procedures.

Thirty-five years after British scientists brought the world’s first “test-tube baby” to life, assisted reproduction is a $4 billion-a-year industry. It’s hard to miss the marketing and advertisements associated with fertility clinics and service providers that are understandably eager to do what any business does best: sell to prospective customers.

But what they’re selling is packaged in hope and sold to customers who are at their wits’ end, desperate and vulnerable. Once inside the surreal world of reproductive medicine, there is no obvious off-ramp; you keep at it as long as your bank account, health insurance or sanity holds out.

It’s no wonder that, fueled by magical thinking, the glorification of parenthood and a cultural narrative that relentlessly endorses assisted reproductive technology, those of us going through treatments often turn into “fertility junkies.” Even among the patient-led infertility community, the prevailing belief is that those who walk away from treatments without a baby are simply not strong enough to run the gantlet of artificial conception. Those who quit are, in a word, weak.

As a result, both of us pursued increasingly invasive and often experimental interventions, many of whose long-term health risks are still largely unknown.

Now we know better. Ending our treatments was one of the bravest decisions we ever made, and we did it to preserve what little remained of our shattered selves, our strained relationships and our depleted bank accounts. No longer under the spell of the industry’s seductive powers, we study its marketing tactics with eagle eyes, and understand how, like McDonald’s, the fertility industry works to keep people coming back for more.

Some people do, of course, become parents through this technology. But we rarely hear from the other side, former patients who, in refusing to give up, endured addictive, debilitating and traumatizing cycles. Those contemplating treatments have a right to know about the health risks, ethical concerns, broken marriages and, for many, deep depression often associated with failed treatments. They need objective, independent advice from health care and mental health professionals focused on the person’s well-being instead of the profit.

Being unable to bear children is a painful enough burden to carry, without society’s shaming and condemning those who recognize that their fertility fantasy is over. It is time to rein in the hype and take a more realistic look at the taboos and myths surrounding infertility and science’s ability to “cure” it.

Miriam Zoll is the author of the memoir “Cracked Open: Liberty, Fertility and the Pursuit of High-Tech Babies.” Pamela Tsigdinos is the author of the memoir “Silent Sorority: A Barren Woman Gets Busy, Angry, Lost and Found.”

The New York Times, September 11, 2013

Molar Pregnancy

Mrs ANF, a 35 year old lay in her fifth pregnancy, presented with headache, nausea and vomiting and her period delayed 1 week. Pregnancy was suspected and she had come for a confirmatory ultrasound scan. There was no bleeding and she was otherwise well. Nothing unremarkable was found on physical examination. However, ultrasound scan showed a mass in the uterus which contained multiple small cystic structures, as seen here.

This was characteristic of molar pregnancy. She underwent suction curettage the next day and a large amount of tissue was removed. 

This was confirmed as hydatidiform mole. She is now being monitored for recurrence and counselled to practice contraception for at least the next 6 months.

Hydatidiform mole or molar pregnancy is a rare growth that can occur when a woman gets pregnant. In most instances there is no fetus but occasionally a mole can occur together. Apart from being considered a miscarriage and cause bleeding, a molar pregnancy has the potential to spread out of the uterus and even turn cancerous. Thus steps must be taken to evacuate it completely and prevent progression to cancer.

Questions About Robotic Hysterectomy

This is an article published recently about the use of the robot to do laparoscopic surgery. This is a growing trend among gynae surgeons and sometimes shows "macho". Although the surgery is very precise, it takes longer to set up and the cost is expensive. That is the main reason why I don't do it. The other issue addressed in this article is the removal of the uterus, or hysterectomy. More and more women are tending to keep their uteri and ovaries till late, and I encourage you to question your doctor strongly whether you really require one. Many doctors do this because sometimes it is easier to do than removing a growth.

Artikel ini berkenaan pembedahan laparoskopi dengan mengguna robot. Makin banyak pusat perubatan di negara barat mula mengawal cara ini, tetapi hanya 2 pusat di Malaysia. Walaupun pembedahan jenis ini lebih tepat, belanja menjalaninya lebih tinggi dan hasilnya hampir sama. Ini adalah sebab utama saya tidak mengamalinya. Selain dari ini, artikel ini juga menyentuh berkenaan pembuangan rahim, atau histerektomi. Trend zaman sekarang adalah untuk menyimpan rahim serta ovari kecuali betul-betul perlu dibuang. Jikalau anda berada dalam keadaan memerlukan pembedahan, pastikan dengan betul dan secara mendalam keperluan menjalani histerektomi. Ramai doktor melakukan histerektomi hanya kerana ia lebih senang dilakukan daripada membuang ketumbuhan.

FEBRUARY 25, 2013, 5:01 PM

By RONI CARYN RABIN

in The New York Times

You can access the original article here

Ever since it was approved by the Food and Drug Administration in 2005, robotic surgery for hysterectomy has been heavily advertised. Surgeons promise that using the da Vinci robotic device will bring better results and an easier recovery, and many hospitals claim that patients will experience less pain and fewer complications, getting back on their feet faster.

The company that makes da Vinci robotic surgery equipment promoted it last May at free health workshops organized by the federal Office on Womens’ Health. On Sunday, the Liberty Science Museum in Jersey City will host its first “Let’s Operate Day,” offering guests “hands-on” practice peering into video monitors and using da Vinci’s robot arms to pick up and manipulate small objects.

The cost of the new technology is rarely mentioned. But last week, a new study that evaluated outcomes in more than a quarter of a million American women raised questions about the manufacturer’s claims. The paper, published in The Journal of the American Medical Association, compared outcomes in 264,758 women who had either laparoscopic or robotically assisted hysterectomy at 441 hospitals between 2007 and 2010. Both methods are minimally invasive and involve smaller incisions than open abdominal surgery.

The researchers found no overall difference in complication rates between the two groups, and no difference in the rates of blood transfusion, even though one of the claims regarding robotic surgery is that it causes less blood loss.

But the researchers did find a big difference in cost. Robotically assisted surgery for hysterectomy costs on average about one-third more than laparoscopic surgery.

“It’s important to separate the marketing from the data,” said Dr. Jason D. Wright, the study’s lead author, an assistant professor of obstetrics and gynecology at Columbia University Medical Center. “For the surgeon, there is a greater degree of movement and control of the instruments and the visualization is better.

“But the ultimate question is, does this change outcomes for patients? This study suggests that there really is not a lot of difference as far as quantifiable outcomes.”

The majority of patients in both groups left the hospital in less than two days, though patients who had robotic surgery were slightly more likely to go home that early: 80 percent went home in less than two days, compared with 75 percent of those who had laparoscopic surgery.

But the cost of robotic surgeries was significantly higher, with a median cost to the hospital of $8,868, compared with $6,679 for laparoscopic hysterectomy. The study did not look at the difference in patients’ bills, but according to Newchoicehealth.com, the average patient price for a laparoscopic hysterectomy ranges from $7,700 in Dallas to $11,600 in Los Angeles.

With laparoscopic surgery — sometimes called keyhole surgery — narrow instruments and a small video camera are inserted through tiny incisions; the surgeon sees the image on a monitor and can cut and sew tissue with the instruments. With robotically assisted surgery, the surgeon sits at a console with a 3-dimensional view of the surgical site, and computer technology translates his or her hand movements into precise, scaled movements of the instruments.

Even without offering clear advantages the proportion of hysterectomies performed robotically has increased rapidly, up to nearly 10 percent of hysterectomies in 2010 from less than 1 percent in 2007, Dr. Wright said. Minimally invasive surgeries for hysterectomies are increasing across the board, he found, even at hospitals not performing robotic surgery.

Dr. Myriam J. Curet, chief medical adviser to Intuitive Surgical, which makes the da Vinci systems, did not dispute the study’s findings, but said the important message was that more women were able to receive minimally invasive surgeries because more options were available.

“That’s good for patients and for the health care system,” Dr. Curet said. Women who are not candidates for laparoscopic surgery might still be candidates for robotically-assisted surgery, she added.

Right now, however, it is not clear how to identify which women would benefit from robotic surgery and which would do well with a less expensive method.

The growing use of robotic surgery in hospitals will continue to drive up health costs, said Joel S. Weissman, of Brigham and Women’s Hospital and a co-author of an editorial published with the study.

“Once you have that robot, the tendency is to use it for all kinds of things, for which it may or may not have great value,” Dr. Weissman said. Studies like this one, he said, demonstrate the waste of health care dollars on “something that costs a lot more and doesn’t offer any added benefit over current treatment options.”

Each year approximately 600,000 American women have hysterectomies, according to the Centers for Disease Control and Prevention. By age 60, one in three American women has had her uterus removed, often along with her ovaries and cervix.

Critics who say far too many hysterectomies are done in the United States worry that all the attention to surgical method distracts from the question of whether patients should be having the surgery at all.

Most hysterectomies are prescribed for conditions that are not life-threatening, and advocates worry that women are not fully informed of the long-term harms, which may include a loss of sexual responsiveness, depression and chronic constipation, and higher risk for osteoporosis and heart disease, said Nora W. Coffey, the founder of the nonprofit Hysterectomy Educational Resources and Services Foundation.

“That’s the conversation we should be having,” Ms. Coffey said.

Nora W. Coffey and other experts emphasize that women considering a hysterectomy should discuss all options with their doctors.

¶Ask what the alternatives are and whether watchful waiting is an option. Remember that it is irreversible, regardless of how the surgery is done.

¶Learn about the nonreproductive functions of the uterus, ovaries and cervix, and the potential long-term consequences associated with their removal, as well as the function of the ovaries and cervix.

¶If you proceed, discuss the advantages and disadvantages of different surgical methods with your doctor. Interview several surgeons and inquire about the cost and how much insurance will cover. Your co-pay may vary depending on the surgical method.

¶Tell your surgeon if you do not want your ovaries and cervix removed.

Hyperstimulation

This is an image taken from a patient who presented with left lower abdominal pain. She has a past history of surgery for endometriosis, GnRHa therapy and is currently seeking to get pregnant. She had been taking Clomiphene for the past 3 months prescribed by her gynaecologist. The ultrasound scan shows a bizarre multiloculated cyst about 9 cm in size. This looks like a hyperstimulated ovary due to clomiphene. Hyperstimulation with clomiphene is not common and usually subsides without complications. The main point here is to observe rather than to rush into any further surgery. 

Ini adalah gambaran yang diambil dari seorang pesakit yang mengadu perasaan sakit dibahagian kiri abdomen. Beliau pernah menjalani pembedahan dan rawatan ubat hormon untuk penyakit endometriosis. Buat masa kini, pesakit ini sedang melalui rawatan kesuburan dengan ubat clomiphene 3 bulan yang lepas yang diberi oleh pakar sakitpuannya. Imbasan ultrasound menampakkan sebuah sista sebesar 9 cm yang mempunyai banyak ruang dalamnya. Ini merupakan sebuah ovari yang telah terangsang berlebihan oleh ubat clomiphene. Rangsangan hiper saperti ini jarang belaku dengan ubat clomiphene dan biasa surut tanpa komplikasi. Tindakan utama ialah pemerhatian dan elak dari melakukan pembedahan tergesa-gesa.

Clear 4D Pictures

Right ear and neck/Telinga dan leher kanan

Both feet/Kedu-dua kaki

Everybody likes to see clear pictures of their baby, so it is important that a 4D scan is done at the right time. This is around 20-24 weeks of gestation, but a lot depends on the amount of liquor within the uterus. These pictures are from a pregnancy with excessive liquor, termed polyhydramnios, so the 4D scan pictures are particularly clear.

Semua ibu-bapa ingin melihat gambaran yang jelas kandungan mereka. Dari segi imbasan 4D, penting supaya ia dilakukan pada waktu yang betul, biasanya antara 20-24 minggu usia kandungan. Walaupun demikian, banyak bergantung pada jumlah air ketumban yang ada dalam rahim. Gambar-gambar ini diambil dari kandungan yang mengalami air ketumban yang berlebihan, lebih dikenali sebagai polyhydramnios, dan nyata kejelasan gambarnya.

Right thigh and knee/Peha dan lutut kanan