A private Traditional Chinese Medicine practice focusing on women's health, fertility, pregnancy, and menopause.
“The law of yin and yang is the natural order of the universe, the foundation of all things,
mother of all changes, the root of life and death. In healing, one must grasp the root of the disharmony,
which is always subject to the law of yin and yang”.
–Huang Di, The Yellow Emperor’s Classic of Medicine (~2000 BCE)
Roots of Life Acupuncture is the private practice of Dr. Erin Flynn, Registered
Doctor of Traditional Chinese Medicine and Fellow of the American Board of
Oriental Reproductive Medicine, in Vancouver, British Columbia, Canada.
Are your cosmetics making you infertile or damaging your health?
Our modern, post-industrial revolution society has many conveniences and innovations. The development and use of petroleum and chemical products has made our lives easier in some ways, but we may be sacrificing our health in the process of modernizing our lives.
Sometimes the products we use on the outside of our bodies on a daily basis can make us sick on the inside of our bodies. I am talking about make-up, lotions, creams, and hair products which may contain traces of heavy metals or other endocrine-disrupting chemicals.
Most of us are aware by now of the estrogenic effects of certain kinds of plastics (called “xenoestrogens”). But fewer of us are aware of that there may be toxins in our cosmetics. As with the food you put into your body, make sure that the products you put on the outside of your body are natural and organic, too.
Have a look at the labels on your favourite cosmetics. You want to avoid products with the following ingredients:
imidazolidinyl urea
diazolidinyl urea
methyl paraben
propyl paraben
butyl paraben
ethyl paraben (all the parabens, really)
petrolatum
propylene glycol
PVP / VA copolymer
stearalkonium chloride
synthetic colours
synthetic fragrances
diethanolamine (DEA)
monoethanolamine (MEA)
triethanolamine (TEA)
dioxane
2-bromo-2-nitropropane-1,3-diol (bronopol)
benzalkonium chloride
butylated hydroxyanisole (BHA)
butylated hydroxytolulene (BHT)
chloromethylisothiazolinone
isothiazolinone
In response to concerns which have been raised about the safety of products used in the cosmetic industry, several companies have sprung up in the last few years devoted to natural and organic body products. In Vancouver, local stores such as Choices and Capers provide sections devoted entirely to clean and healthy body products. A local company, Elements Mineral Make-Up, has created a line of cosmetics free of fillers, preservatives, chemicals & dyes, and they have never been tested on animals.
If you are trying to maximize your fertility, or if you are struggling with infertility or other persistent health concerns, please check the contents of your body products and ensure you are only using natural, non-toxic ingredients.
(information about toxins was obtained from The Tao of Fertility by Daoshing Ni, 2008 Harper Collins)
FSH, Ovarian Reserve, and Chinese Medicine
Your follicle stimulating hormone (FSH) level is considered to be an important indicator of your potential for fertility. In fact, some fertility clinics will decide whether or not a woman is a good candidate for IVF based on what her follicle stimulating hormone levels are.
Used in the biomedical model as an indicator of “ovarian reserve” (the number and quality of eggs that are left in the ovary), the level of this reproductive hormone is usually measured on day 3 of the menstrual cycle when all of the reproductive hormones are at their lowest levels. To get the complete picture of how responsive your ovaries are, it is important to also measure at the same time what the estrogen levels are, since these 2 hormones work together.
Where does follicle stimulating hormone come from?
Let’s back this up a little bit and start at the beginning. Reproductive hormones are a bit complicated, involving 3 distinct organs in the body. Together, they are referred to as the hypothalamus- pituitary-ovarian axis (“H-P-O axis”). The hypothalamus and pituitary gland are in the brain, and they communicate with the ovaries in the lower abdomen through the blood.
At the beginning of puberty, the hypothalamus begins to secrete in a pulsatile manner a substance called gonadotropin-releasing hormone (GnRH). This hormone causes the anterior pituitary gland to release luteinizing hormone (LH) and follicle stimulating hormone (FSH). These hormones lead to the changes in the body we see during puberty, and then play a role in regulating the menstrual cycle and producing ovarian follicles (and also in sperm production in men).
What do follicle stimulating hormone & estrogen do?
At the beginning of each menstrual cycle, the pituitary gland releases FSH and LH. These hormones work on the ovary to stimulate the growth of new egg-containing follicles. By about day 7 of the cycle, one (or sometimes two) of the follicles has grown more than the others, and starts to produce a large amount of estrogen. This follicle is referred to as the “dominant follicle”.
Estrogen has 3 main functions at this point. The first is to signal to the pituitary to stop releasing FSH & LH so that no new follicles are stimulated (this communication, where increasing estrogen levels cause a reduction of pituitary hormone levels is called a “negative feedback loop”). The second function of the estrogen is to make the lining of the uterus proliferate (grow and thicken). And the third function of the estrogen is to make the glands in the cervix produce the lubricating, fertile cervical mucus.
As the estrogen level rises above a certain level, it triggers the anterior pituitary gland to start releasing luteinizing hormone (LH) again. In other words, the negative feedback loop between the ovary and the pituitary becomes a positive feedback loop (high estrogen causing higher LH). The release of this LH causes the egg to mature, and also the wall of the follicle to become thin, eventually rupturing and allowing the release of the egg (a process known as ovulation).
So, what do high follicle stimulating hormone levels mean in terms of my fertility?
A high FSH level indicates that the estrogen producing follicles are not responding very well in the ovary. The normally occurring negative feedback loop has not been activated, and the pituitary continues to release FSH without restriction. Gynecologists and reproductive endocrinologists see high FSH levels as an indicator that there are not very many egg-containing follicles left in the ovary, or that those which remain are not of very good quality. They are not growing well, they are not producing adequate estrogen, and they are not shutting off the supply of pituitary hormones. As well, high follicle stimulating hormone levels indicate that the ovaries will likely not respond very well to the medications used in IVF, which mimic the effects of the H-P-O axis.
Can Chinese Medicine lower my follicle stimulating hormone levels?
Indeed, this is a very common question I am asked. In short, the answer often is – yes! However, it is important to clarify this a bit. Traditional Chinese Medicine developed without the concept of hormones. In Chinese Medicine theory, the concept of ovarian reserve / egg-quality is referred to as the Kidney Yin & Essence. After a few months of nourishing the Yin and the Essence with herbal medicine and acupuncture (and, healthy lifestyle choices), many women will see their FSH levels drop, sometimes quite dramatically.
But in Chinese Medicine it is not quite so straightforward. If a woman comes to me and says she has high FSH, the first question I ask myself is “why are her ovaries not responding?” A woman who presents with high FSH in her late 20s or early 30s is different than a woman who presents with the same thing in her late 30s or 40s. Before looking at reduced number of follicles or poor egg-quality as the only possibility, I want to know if there is something that may be blocking the delivery of pituitary hormones to the ovaries. Is there a build-up of phlegm, damp, or fat? Is there some stagnant blood or poor circulation which is preventing good communication from the pituitary to the ovaries? Is there some inflammation present which is causing the ovary not to respond? Is there so much stress in a woman’s life that her H-P-O axis is being negatively influenced from the top-down, or the bottom-up?
Nourishing the Yin and Essence is a good way to promote fertility in Chinese Medicine theory. However, it is important to consider the physical and mental health of the entire woman when doing so, and clear out any pathogenic influences which may be interfering with her endocrine system. In Chinese Medicine theory, high FSH levels may be indicative of deficient Yin or Essence, but it also may indicate the presence of a pathogenic factor which is interfering with the communication of the reproductive hormones.
Progesterone, the Luteal Phase, and Chinese Medicine
Progesterone, also known as P4, is a reproductive hormone involved in the menstrual cycle. Influencing what is known as the “luteal phase”, it helps prepare the uterine lining for implantation. If implantation does occur, progesterone helps maintain the integrity of the endometrium, helping to secure the new pregnancy. It also plays a role in the development of an embryo.
Where does progesterone come from?
The first half of the menstrual cycle is referred to as the “follicular phase”. During this time, there is a proliferation of several ovarian follicles (each of which contains an egg). The largest of the follicles will eventually release an egg, a process called ovulation. After ovulation, the ruptured follicle turns into the corpus luteum.
The second half of the menstrual cycle is called the “luteal phase”. During this time, the corpus luteum produces increasing amounts of progesterone.
What does progesterone do?
After being released from the corpus luteum, this hormone enriches the uterine lining with glycogen, mucus, and other substances which support the embryo in the first stages of implantation. It also causes a woman’s core body temperature to rise by up to 0.5°C.
If implantation is successful, the embryo will secrete a hormone called human chorionic gonadotropin (HCG – the “pregnancy hormone”, detected in home pregnancy tests). HCG signals the corpus luteum to continue to produce progesterone, thus maintaining the uterine lining and the implanted embryo. If there is no implantation HCG will not be secreted, and the corpus luteum will break down. A disintegrating corpus luteum no longer produces enough hormones to maintain the uterine lining, causing it to break down and shed. This marks the beginning the next menstrual cycle.
Progesterone and In-Vitro Fertilization (IVF)
In an IVF cycle, a woman’s eggs are removed from her follicles with a long needle. They are then fertilized outside of her body before being returned to the uterus for implantation. In the process of egg removal, the follicles and corpus luteum are damaged. For this reason, women need to take an external source of progesterone so that the integrity of her uterine lining is maintained, and implantation can be successful.
What is a “Luteal Phase Defect”?
The time between ovulation and the beginning of menstruation should be 12 to 14 days. If it is shorter in duration than this, likely the corpus luteum is not producing enough progesterone to maintain the endometrium. Even if an egg is fertilized and becomes an embryo, if there is no support for the uterine lining a pregnancy cannot be sustained.
If a woman is charting her basal body temperature (BBT), she should see a rise in temperature just after ovulation, which stays elevated for 12 to 14 days. If her temperature drops suddenly or gradually before that time, the corpus luteum is not producing enough of the hormone.
A blood test on day 21 of a menstrual cycle (or, 7 days after ovulation) can reveal if the corpus luteum is producing enough hormones to support pregnancy.
Can Chinese Medicine treat me during my luteal phase?
A short luteal phase, or a low basal body temperature after ovulation, is not good for fertility. It is important to remember that Traditional Chinese Medicine developed without the concept of hormones – in Chinese Medicine theory, a luteal phase defect is seen as Kidney Yang deficiency. Warming the Kidney Yang and nourishing the Blood after ovulation with herbal medicine and acupuncture (and, wise lifestyle choices) will often result in a longer luteal phase and an elevated basal body temperature.
As with all of Chinese Medicine, it is important to consider a woman’s entire state of health and well-being when treating a luteal phase defect. Is there any evidence of poor circulation? An accumulation of phlegm or dampness? Inflammation? Warming Kidney Yang and nourishing Blood after ovulation is a good way to promote fertility in Chinese Medicine theory, but it is also important to clear out any pathogenic influences which may be interfering with the luteal phase.
One Chinese herb used often in the luteal phase is Shan Yao, or Chinese Yam. Also known as Dioscorea opposita, it produces large amounts of a steroid called diosgenin. Today, progesterone is manufactured in laboratories from Dioscorea.
Estrogen, Hormone Balance, and Chinese Medicine
Estrogen – that quintessential hormone of femininity. Also known as oestrogen, it is actually a group of compounds named for their importance in the estrus (reproductive) cycle of humans and animals. It plays an important role in the menstrual cycle, and can influence key aspects of fertility. It is used in birth control pills (BCP) and hormone replacement therapy (HRT). Imbalances of this sex hormone are associated with some kinds of abnormal cell growth, menopausal syndrome, and infertility.
Where do estrogens come from?
This sex hormone is made primarily by the developing follicles of the ovaries, the corpus luteum, and the placenta. Its production is stimulated by the release of the pituitary gland’s Luteinizing hormone (LH), and it is synthesized from androgens (male sex hormones) by the action of the enzyme aromatase.
There are three naturally occurring forms, produced at different times of a woman’s reproductive life. They are called “steroid hormones” because of their distinctive 4 chain molecular structure. Testosterone, progesterone, glucocorticoids and mineralocorticoids are other steroid hormones.
E1 – estrone, predominate during menopause
E2 – estradiol, predominate in non-pregnant females
E3 – estriol, predominate during pregnancy
There are a range of natural and synthetic compounds which can mimic the effects of naturally occurring estrogen. They are known as “non-steroidal hormones”, and can come from synthetic material (“xenoestrogens”, ex. plastics), from plant materials (“phytoestrogens”, ex. soy) and from fungi (“mycoestrogens”, ex. silage).
What do estrogens do?
Both men and women have this sex hormone coursing through their bodies, but there are much higher levels in women of reproductive age. Estrogens are best known for their role in the development of secondary sexual characteristics (ex. breast development), the thickening of the uterine lining, and as regulator of the feedback loop of the hypothalamus-pituitary-ovarian axis.
Estrogens have been shown to increase metabolism, reduce muscle mass and increase fat stores, increase vaginal lubrication, thicken the vaginal wall, increase bone formation, influence blood coagulation, decrease LDL cholesterol, increase water retention, and reduce bowel motility. It is also considered to play a role in women’s mental health, since a sudden reduction in this hormone’s levels is correlated to a lower mood, while restoring hormonal levels has been shown to promote clinical recovery in menopausal women.
Low estrogen levels
If a woman’s body is not producing enough of this important sex hormone, symptoms may arise such as hot flashes, night sweats, vaginal dryness, anxiety, depression, or loss of libido. Hormone levels may be lower than desired because of a decreased ovarian response, menopause, hysterectomy, chemotherapy, poor diet, high stress, thyroid disorders, or insufficient body fat. Low steroidal hormone levels are primarily treated with lifestyle changes, alternative or herbal medicine, or hormone replacement therapy (HRT).
High estrogen levels
If a women’s body has too much circulating sex hormone, other symptoms may arise such as weight gain, uterine fibroids, fatigue, irregular periods, headaches, infertility, or depression. There may be too much circulating hormone because of ovarian overproduction, exposure to non-steroidal hormones, obesity, stress, or thyroid disorders. Hormone imbalances are usually treated with lifestyle changes, herbal medicine, or hormone replacement therapy (HRT).
Birth control pills are often a combination of estrogen and progesterone (called combined oral contraceptive pill, COCP). The former acts through the feedback loop to decrease hormones from the pituitary, stunting the growth of ovarian follicles. The later acts to stop the release of sex hormones from the hypothalamus. Both of these effects prevent ovulation. High hormone levels, therefore, can contribute to infertility by interfering with ovulation.
Progesterone and Estrogen Ratio
The relationship between these 2 steroidal hormones is intimate, and balance is important. Estrogen helps stimulate growth of endometrial lining, increases body fat, stimulates breast tissue and reduces vascular tone. Progesterone, on the other hand, helps maintain the endometrial lining, helps use body fat for energy, protects against fibrocystic breasts, and increases vascular tone.
According to experts, the progesterone : estrogen ratio should be about 200-300 to 1. If the ratio is lower than this, it represents what is called estrogen dominance, meaning there is insufficient progesterone to counteract the effects of the more proliferative hormone. In other words, the stimulating effects of the estrogen is not mitigated by the calming effects of the progesterone, and abnormal cell growth (including some forms of cancer) can result. Treatment to restore the ratio of hormones can be done through lifestyle choices, alternative medicine, or hormone replacement therapy (HRT).
Estrogen and Traditional Chinese Medicine
The effects of estrogen are similar to what we call “Kidney Yin” in Chinese Medicine. Kidney Yin is the nourishing and cooling aspects of the body, representing that which is precious and life-cultivating in the reproductive system. A deficiency of Yin produces “hot & dry symptoms” such as hot flashes, night sweats and vaginal dryness (corresponding to symptoms we see during menopause when estrogen levels are lower). An excess of Yin produces “cold & wet symptoms”, such as weight gain, fatigue, and infertility (similar to symptoms we see in PCOS, when estrogen levels are often higher).
Traditional Chinese Medicine originated without the concepts of hormones. It is the balance of nourishment versus the accumulation of dampness representing a harmonious state of the body’s Yin that Traditional Chinese Medicine strives to achieve. A balance of the warming and cooling functions of the body also signifies a balance of Yin & Yang, often indicating a regulated hormonal system. For women showing signs of Yin deficiency, our principle of treatment is to nourish the body and cool any heat. For those showing signs of excess Yin, our principle of treatment is to drain dampness, transform phlegm, and either warm the body or clear heat as needed. Establishing balance in the body often corresponds to improved levels of hormones, including estrogen.
In-Vitro Fertilization Medications, and Acupuncture & Chinese Medicine
In-Vitro Fertilization (IVF) is an amazing advance in medical technology. The idea of human reproduction which occurs partly outside of a woman’s body is the stuff that science fiction writers dream about. Today this is our reality, and the procedure has helped countless couples who would otherwise be infertile become parents. It is not a simple course of action, however, as the science behind this methodology is both remarkable and complicated.
There are a few concepts and terms which are important to be aware of in order to understand how IVF medications work. The choice of medication, protocol, and the particular preferences of each reproductive endocrinologist are unique to each IVF cycle. This is why one woman’s experience at a fertility clinic may be completely different from another woman’s experience. Even if they are the same woman, and even if they are at the same fertility clinic.
Hypothalamus – Pituitary – Ovarian Axis (H-P-O Axis), or “How Babies are Made in Nature”
To understand how IVF suppression and stimulation medications work, we first need to see how a woman’s reproductive cycle functions without medical intervention. An organ found in the brain, called the hypothalamus, releases a hormone called Gonadotropin Releasing Hormone (GnRH). This GnRH stimulates the pituitary gland (also in the brain) to release other hormones called Gonadotropins (i.e. follicle stimulating hormone (FSH) and Luteinizing Hormone (LH)). These pituitary hormones travel through the blood stream and stimulate the ovaries to generate egg-containing follicles, which produce increasing amounts of estrogen. As estrogen levels rise, they first signal the pituitary to stop the release of Gonadotropins. But once estrogen levels rise to a certain level, the pituitary is triggered to release more Gonadotropins again. This results in ovulation. The now empty follicle becomes the corpus luteum, and begins to produce progesterone. Progesterone acts to nourish the uterine lining and prevent its breakdown. If an embryo, derived from a fertilized egg, implants into the uterine lining it will begin to produce the hormone Human Chorionic Gonadotropin (HCG), which maintains the integrity of the uterine lining and allows the pregnancy to continue. If there is no implanted embryo, all hormone levels begin to drop until the uterine lining is finally shed, marking the beginning of the next menstrual cycle.
In-Vitro Fertilization – overriding the reproductive hormone system in order to maximize ovarian response
The purpose of the medications involved in an IVF cycle is to encourage the ovaries to produce many more follicles than during a normal menstrual cycle. Lots of follicles mean lots of eggs which can be harvested, and for reproductive endocrinologists this is important to help improve the odds for a successful pregnancy. By using medications which mimic the effects of the naturally occurring hormones, the response of the ovaries can be influenced. There are 2 main protocols that are used in IVF – the “long protocol” and the “short protocol”.
The long protocol – downregulation / suppression
In some IVF protocols, the H-P-O Axis is disrupted completely in order to fully control the response of the ovaries. In the “long IVF protocol”, the response of the pituitary gland is blocked from functioning by GnRH agonists, like Lupron (injection) or Synarel (nose spray). This serves to “down-regulate”, or “suppress” the pituitary gland from its normal job of stimulating the ovaries. GnRH agonists are usually started in the menstrual cycle before the IVF cycle, and prevent the pituitary gland from interfering with the intended effects of the ovarian stimulation medications. GnRH agonists also prevent ovulation from happening before the time is right.
Some reproductive endocrinologists choose to have their patients take oral contraceptive pills (OCP) for a month or a few months before their IVF cycle begins. This is thought to help prevent Ovarian Hyperstimulation Syndrome (OHSS), a potentially life threatening complication to IVF where too many follicles are generated too quickly. Birth control pills are also used to help prevent ovarian cysts or a dominant follicle from forming, which can disrupt the IVF cycle.
After a menstrual bleed and the confirmation of pituitary suppression (which is confirmed with ultra-sounds and blood tests), the stimulation phase of the IVF cycle begins. Daily injections of medications which imitate the effects of Follicle Stimulating Hormone (called “FSH analogues”, such as Gonal-F, Puregon, Repronex, or Follistim) stimulate egg-containing ovarian follicles to grow en masse. Throughout the stimulation period, the growth and progress of the follicles is continuously monitored with ultrasound, and hormone levels are checked with blood tests. Most woman are stimulated for approximately 2 weeks until their follicles grow to a size where the eggs are mature and are ready to be retrieved from the ovaries.
The short protocol – The flare protocol
The short IVF protocol seeks to maximize the response of the ovaries without suppressing the function of the pituitary gland for weeks or months before the IVF cycle begins. In this protocol, medication to stimulate the growth of ovarian follicles (usually an FSH analogue) is administered at the beginning of a new menstrual cycle. To prevent a spontaneous ovulation, pituitary suppression medications are also administered at the beginning (GnRH agonists) or at the end (GnRH antagonists) of this ovarian stimulation phase. This protocol is also called the “flare protocol” because the initial dosage of GnRH agonist causes the pituitary to release an initial “flare” of FSH and LH, which “jump-starts” the ovarian stimulation. Ultrasound and blood tests monitor the growth and size of the follicles; once they reach maturity they are ready to be harvested from the ovaries.
IVF, Acupuncture and Chinese Medicine
Over the last few years, research has shown that acupuncture can help increase the success rates of an IVF cycle. Reasons for this may include increased blood circulation to the organs of reproduction, a sensitization of the body to IVF medications, and a reduction in stress. Please click here for more information about IVF acupuncture.
Because there hasn’t been very much hard research done to explore any interaction between herbal medicine and either GnRH agonists or FSH analogues, most reproductive endocrinologists prefer that women undergoing an IVF cycle do not take Chinese herbs (or, any herbal medicine) at the same time as medications. Since this is an extremely precise process, reproductive endocrinologists want to be able to eliminate as many variables as possible, and Chinese herbs (while perhaps being helpful) may interfere with the desired effects of the medications. However, Chinese herbal medicine can be used in the weeks and months before IVF medications begin, as part of pre-conception care and preparing your body for the IVF cycle. But in almost all cases in Vancouver, your fertility doctor will ask you to stop taking all herbal supplements before IVF medications begin.
The Internal Organs (ZangFu) in Traditional Chinese Medicine
The internal organs of the body (called the ZangFu) in Traditional Chinese Medicine theory are a little different from their biomedical counterparts. Anatomy in Traditional Chinese Medicine results from classifying organs and their functions as viewed from the outside of the body. In contrast, biology’s anatomy is a result of dissecting the body and cataloging its internal parts. The ZangFu organs of Chinese Medicine represent not only the body parts themselves, but they also correspond to a related tissue, sense organ, aspect of emotion, flavour, colour, and more.
The Zang organs are the Yin organs, which store vital substances (Heart, Pericardium, Lungs, Liver, Spleen, and Kidneys). The Fu organs are the Yang organs, which transform food and drink to produce Qi and Blood for the body (Stomach, Large Intestine, Gallbladder, Small Intestine, Triple Burner, and Urinary Bladder). Their state of balance is analyzed extensively in Traditional Chinese Medicine diagnosis.
The Heart is considered to be the most important of the ZangFu. Its primary job is to govern the Blood, its vessels and circulation. In Traditional Chinese Medicine, the Heart is where the mind resides, and it opens into the tongue, manifesting as speech and laughter. It is said to have influence on the sweat of the body, a substance intimately connected to the Blood in TCM theory. The Pericardium is considered to be an extension of the Heart. They are associated with the Fire element.
The Lungs govern the Qi, in particular through the actions of respiration. The Lungs are seen as an extension of the skin and hair, as they together represent the continuum between the inside of a human and its external surface. The Lung open into the nose, and are responsible for the circulation of the body fluids. They are associated with the Metal element.
The Liver’s primary responsibility in TCM theory is to ensure smooth circulation throughout the body. The Liver is also said in Traditional Chinese Medicine to store the Blood. The effect of stress in our lives has a particular effect on this organ’s function, often manifesting as stagnant circulation of energy and Blood. The Liver is said to open into the eyes. It is associated with the Wood element.
The Spleen’s main job is to assist the Stomach with the digestion of food. Sometimes it is translated as Spleen/Pancreas, because of its role in regulating metabolism (and, by extension, blood sugar). It is considered to be in control of the muscles, opens into the mouth, and manifests on the lips. The Spleen’s balance is most influenced by the dietary choices we make. It is associated with the Earth element.
The Kidneys are sometimes called the “root of life”, because they store the Essence. They are the source of all of the Yin, and all of the Yang, of the body. Since the Essence is in charge of reproduction, growth, and development, the balance of the Kidneys is of particular importance for both fertility and longevity. The Kidneys govern all water, and are said to open into the ears. They are associated with the Water element.
The Stomach is the partner of the Spleen, and together they digest food. The Large Intestine is related to the Lungs, as both represent a continuation of the inside of the body with the outside of the body. The Small Intestine is the Yang to the Yin of the Heart, but that relationship is perhaps the least obvious. They are both closely related to the Fire element. The Gallbladder assists the Liver with the smooth flow of circulation, mimicked by its flow of bile through the Liver and into the digestive process. The Urinary Bladder works with the Kidneys to govern water, by removing the waste. The Triple Burner represents the functioning of water metabolism of the entire body, and is paired to the Pericardium, most particularly through the Meridian system.
In addition to the ZangFu organs, there are Six Extra-Ordinary Organs. They are considered to be special in that they have posses both Yin and Yang function. They store a precious substance (Yin), yet they have the hollow shape (Yang). These Six Extra-Ordinary are the Brain, Marrow, Bones, Blood Vessels, Gall-Bladder, and Uterus. Note that the Gall-Bladder is both a Fu organ, and an Extra-Ordinary organ, which further typifies just how complicated TCM theory can sometimes get!
Blood and the Vital Substances in Traditional Chinese Medicine
In Chinese Medicine, the body and the mind are seen as a dynamic interaction of Blood, Qi, Body Fluids, and Essence. This matter and energy are collectively referred to as the “Vital Substances“.
Blood (known in Chinese as “Xue”) has a slightly different meaning in Traditional Chinese Medicine than it does in bio-medicine. While they both represent the red liquid that courses through our vessels, the Chinese version is a dense material which is intimately connected to (and inseparable from) its energetic counterpart (Qi). There is an important saying in Chinese Medicine:
“Xue is the mother of Qi, and Qi is the commander of Xue”
This means that Blood nourishes and anchors the Qi, providing a material basis which prevents Qi from floating away. However, without its energetic component, Blood would be an inert substance which did not provide the body with any nourishment.
The quality of the Blood is an important component of health and fertility in Chinese Medicine theory, and can be interpreted by characteristics of the menstrual flow. There are three main pathologies which can negatively affect this vital substance. If Blood is not circulating properly, it can become stagnant or static. This can manifest as sharp menstrual pain or as clots in the menstrual flow. If it becomes hot (which can arise from improper diet or chronic emotional distress) it can start to “boil over” from the vessels, manifesting as heavy menstrual flow. If there is not enough Blood (similar but not identical to the concept of anemia in bio-medicine), it can manifest as scanty menstrual flow, pale skin, and generalized fatigue.
The characteristics of a person’s Qi are also an important indicator of health and fertility. If energy is not circulating properly it becomes stagnant, and can result in menstrual cramps, irregularity, or PMS. If not enough energy is produced (or, if its supply has been exhausted by overwork) generalized fatigue can be the result. If energy gets weak and starts to fall, called “Qi sinking”, we can see prolapse of the uterus or heavy menstrual flow. Energy can circulate in the opposite, or a “rebellious” way from which it is intended. For example, if the energy of the Stomach is not flowing the way it should, nausea or vomiting is the result.
The third important vital substance of the body are the Body Fluids. Known as “Jin-Ye” in Chinese, it actually represents two different kinds of fluids in the body. The Jin is the watery, clear, lighter liquids that move quickly and help nourish the skin and muscles (sweat, tears, saliva and mucus). The Ye, in contrast, are the thicker, possibly turbid, and heavier fluids that move more slowly. They function to lubricate the deeper parts of the body such as the joints (synovial fluid), spinal cord (cerebrospinal fluid), and bone marrow. Ye also lubricates the sense organs such as the eyes, ears, nose and mouth.
There are two main ways that the Body Fluids can become out of balance – not enough, or too much. When there is not enough, symptoms which take the characteristics of deficiency of Yin develop. Dry eyes, mouth, skin, lips, or tongue are examples, as are feelings of heat due to a lack of cooling fluids. When there are too much fluids, the imbalance will display as edema, or phlegm.
The fourth Vital Substance is known as Essence, or “Jing”. This is considered to be the most refined, distilled, and precious substance of our bodies. In some ways it can be compared to our genetic constitution (heredity), and the expression of our genetic potential (epi-genetics). We obtain our Jing from two main sources – our “pre-heaven Essence” is obtained from our parents. Those people who are born to healthy, strong parents with a strong genetic complement receive the best form of this important material.
Our “post-heaven Essence” is derived after we are born from the food and drink we consume, and the air we breathe. This reflects the importance of eating a healthy, balanced diet and getting proper amounts of exercise throughout our entire life.
The two kinds of Jing are collectively referred to as the Kidney Essence, and their supply and quality are a very important factor for fertility. Kidney Essence represents the vitality of the sperm and eggs, growth, development, sexual maturation, conception and pregnancy. It also represents generalized health and longevity, as it is the fundamental “stock” of energy and matter which we consume during the course of our lives.
A healthy and balanced state of the Vital Substances are important foundations of vitality, fertility, and longevity.
How do we get sick, according to Traditional Chinese Medicine?
Before answering this question, it is important to understand the concept of “Health” in Chinese Medicine. Health is more than just the absence of disease. Health is a state of balance within the body, with an adequate reserve of energy and resources so that we can thrive.
Balance is the key to health in Traditional Chinese Medicine. It is important to have a balance between work and exercise, a balanced diet, a balance in sexual activity, a balance in exposure to climate, and a balance of emotions.
In Chinese Medicine theory, there is a constant dynamic interplay between the internal defences of our bodies and the pathogenic influences which can weaken our strength. It is only when the relative strength of the pathogen is greater than our resistance to it that we fall ill. There are three categories of things which can make us sick in TCM – internal causes, external causes, and other causes.
Internal causes of disease are our emotions. The holistic view of the body is that we are a mind-body continuum, and that our mental state can directly influence our physical state. When our emotions are particularly strong, or if they are long-lasting, they can begin to affect our physical bodies. In Chinese Medicine theory, states of emotion can be a cause of (and a symptom of) organ imbalance.
Anger is said to make the Qi rise (seeing red, or the bulging of the temporal artery). Sadness dissolves the Qi (consuming our energy in times of grief). Joy slows Qi down (living in the moment when happy). Anxiety knots the Qi (abdominal discomfort and loss of appetite when worried). Fear makes Qi descend (cold sweat running down our backs). Shock scatters the Qi (fainting when we receive upsetting news).
The external causes of disease in TCM literally refer to environmental factors around us. Under normal circumstances, the weather will have no pathological effect on our bodies. However, when weather becomes unseasonably excessive, or when the body is weak in relation to climatic factors, illness can be the result. This explains the man who knows it is about to rain because his arthritis acts up, for example.
The six external causes of disease are wind, cold, dampness, dryness, fire, and summer-heat. They can attack the body separately or simultaneously with two or more in combination. The word “invasion” is used to describe how they enter the body, which is through the skin, nose, mouth, or through all three. Cold can also directly attack the Large Intestine, the Stomach, and the Uterus.
There are additional pathogens in TCM theory, which are collectively referred to as the “other causes of disease“. An individual’s constitution, or their genetic pre-disposition, can be a major influence on their health. A poor diet is probably the most influential and under-rated cause of disease. Fatigue, over-exertion, and excessive sexual activity are other causes of disease as they weaken our defences. Trauma is sometimes unavoidable but represents a cause of injury to our bodies. Epidemics can cause illness, where large portions of the population fall ill to the same disease. Parasites and poisons can also negatively impact our health. Finally, a wrong treatment strategy in Chinese Medicine or BioMedicine is also considered to be a cause of disease.
Yin Yang in Traditional Chinese Medicine
The concept of Yin and Yang is critical for understanding Traditional Chinese Medicine theory. The easiest way to understand these concepts is to look at the Chinese characters themselves, and the ideas they are trying to capture.
This is the symbol for Yin. The left side of the character represents a hill, and the bottom right portion of the character represents a cloud. Therefore, the character for Yin depicts the shady side of a hill. This side of the hill is darker, cooler, more moist.
This is the symbol for Yang. Again, the left side of the character represents a hill, and the right side of the character represents a sun over the horizon, with rays of light. Thus, the character for Yang depicts the sunny side of a hill. This side of the hill is brighter, warmer, more dry.
These concepts (which are called YinYang in Chinese, not Yin “and” Yang as we say in English) represent two opposite, but complementary and interdependent, qualities.
Some basic YinYang correspondences:
YinYang is not a static. Rather, it represents phases of cyclical movement, or stages of transformation. For example, day is Yang, but it turns into night, which is Yin. In the morning, as the sun warms the dew on grass, the water is turned into vapour (Yang). As the sun goes down and the air cools, that same vapour re-condenses back into dew (Yin).
This symbol is called the “supreme ultimate”, and represents the relationship, and the interdependence, of Yin and Yang. The main points represented in this symbol are:
a) Yin and Yang form a whole and are complementary, even though they represent opposites.
b) Within Yin and Yang are the seeds of each other. This is what the black and white dots represent.
c) Nothing is totally Yin, nothing is totally Yang.
d) Yin changes into Yang, Yang changes into Yin.
In Traditional Chinese Medicine theory we apply YinYang to the human body.
Illness arises if YinYang become out of balance. There are four possible states of imbalance that create disease:
a) too much Yin / excess Yin (ex. phlegm accumulation, stagnation of Blood)
b) too much Yang / excess Yang (ex. fever, inflammation)
c) not enough Yin / deficient Yin (ex. dryness, hot flashes due to lack of proper cooling)
d) not enough Yang / deficient Yang (ex. feeling cold, fatigue)
The organ systems (the ZangFu and the Extra-ordinary organs) and a complex interplay of Blood, Qi, and Body Fluid, together with factors such as diet, lifestyle, exercise, emotions, environmental changes, and pathogenic invasions can influence our balance of Yin Yang.
Qi (Chi) in Traditional Chinese Medicine
Qi, also known as Chi, is an important part of Traditional Chinese Medicine theory. Usually associated with that magical, mystical, indescribable and immeasurable force that separates Traditional Chinese Medicine from the rational approach of science and BioMedicine, in TCM ”Qi” is also used to describe the functioning of the organ systems & the refined essences that the organs and body produce.
This is the Chinese character for Qi. The bottom left part of the symbol means (uncooked) “rice”. The upper part of the symbol means “steam”, or “gas” or “vapour”. When taken as a whole, this character represents a range of states of matter and energy, from the dense and material (rice) to the sparse and immaterial (steam). Every phenomenon in the universe can be considered to be a form of Qi, differing only in the degree to which its matter is condensed, the energy it contains, and how it is manifested.
In modern science, this is the continuum between matter and energy, a concept central to modern physics. Water, for example, can be densely packed with less movement of individual molecules (ice), and it can also be loosely packed with more movement of individual molecules (vapour). The liquid form of water is a state of matter and energy which lies somewhere between ice and vapour.
Atoms (such as hydrogen & oxygen) and molecules (such as water) are simply different manifestations of matter and energy. They differ only in the number and arrangement of protons, electrons, and neutrons which compose them, and how they bond to each other.
Wave-particle duality in chemistry and physics further illustrates this point. In some situations, light behaves similar to particles (matter). In other situations, light acts more like waves (energy). This is Qi; sometimes it manifests as matter, sometimes it manifests as energy.
The Qi of the internal organs in Chinese Medicine is really two things. It is the functional activity of an organ system. The Heart beats. The Lungs breathe. The Stomach digests food. The Bladder holds and excretes waste liquid.
It is also a refined essence produced by the organs, which nourish the body and the mind. For example, the functional activity of digestion (energy) extracts the most important aspects of the food (matter) which goes on to nourish our muscles, blood, brain, etc…
Those who choose not to “believe” in Chinese Medicine often cite the mysteriousness of Qi as their main reason. This implies only that which can be measured and analyzed within the Cartesian paradigm is “real”.
The Chinese Medicine concept of the circulation and cultivation of Qi in the body refers in part to the circulation of arterial blood, venous blood, lymphatic fluid, extra-cellular fluid, hormones, and neurotransmitters. It includes the functioning of the central nervous system, the peripheral nervous system, the autonomic nervous system, all of the internal organs, and the synergism of voluntary muscles. But it also includes that as-yet-undocumented energy, the one which martial artists and acupuncturists have been conscious of for millenia.
Traditional Chinese Medicine Philosophy
To understand Traditional Chinese Medicine (TCM) theory, it is important to compare it to the bio-medical model which most of us born in the western hemisphere are more familiar with. Without getting too overwhelmed with the history of philosophy (a fascinating yet extremely complex subject), there are two main differences in the development of the medical models which should be identified. The first difference is the basic form of logic which influenced the ancient cultures from which these medical models developed. The second major difference is the form of analysis used to understand the universe and, by extension, the human body.
Aristotle was a Greek philosopher who lived from 384-322 BCE. He is considered to be one of the most significant founding figures of Western philosophy. His concept of the “opposition of contraries” is one that forms the basis of western logic, even to this day. According to this logic, contraries (such as “that dog is small” and “that dog is not small”) cannot both be true. In other words, for every statement that is made, there is exactly one opposite statement that can also be made. One of those statements must be true, and one of those statements must be false. They cannot both be true. “Logic”, as we usually define it in the western hemisphere, is based on this fundamental premise.
Lao Tzu was a Chinese philosopher (or possibly many philosophers) who lived several hundred years BCE. He is usually credited with writing the Tao Te Ching, a book considered to represent the foundations of the Taoist philosophy. This book contains the ancient Chinese concepts of Yin and Yang, which represent opposite but complementary qualities (such as “that dog is small when compared to a great dane” and “that dog is not small when compared to a poodle”). In other words, for every statement that is made, an opposite statement can also be made. However, in contrast to the Aristotelian form of logic, it *is* possible for both statements to be true. This is because the Taoist philosophy, similar to other forms of Eastern philosophy, takes into account the relativism of such statements. “Logic” in this sense, while equally valid, is not as black and white. Traditional Chinese Medicine uses this Taoist principle extensively.
The bio-medical model of medicine (also referred to as “Western Medicine”), is heavily influenced by the scientific revolution of the 17th century. This scientific revolution was largely introduced by Rene Descartes. Descartes believed that there are fundamental, mechanical laws which govern all phenomena of the universe. By extension, it is possible to have absolute truths if we can understand these unchanging laws. He used a reductionist form of logic, which assumes that we can understand the world by breaking it down into its basic components, and the relationships between its smallest parts. Further, Descartes believed that the mind (immaterial) and the brain (material) were 2 separate things (“dualism”), which causally interact with each other. His mind-body concept remains to this day difficult to explain philosophically – in a reductionist model, how can the immaterial affect the material?
The Traditional Chinese Medicine model, in contrast, is a holistic one. It assumes that the world, including humans, is more than just a sum of its parts. It is the system as a whole that determines how the individual parts behave. Humans can be influenced by our environment, as indeed humans are a part of nature as a whole. In Traditional Chinese Medicine theory, there is no separation of the body and the mind – imbalances in the body can create disharmony in the mind, and imbalances in the mind can create disharmony in the body. Taoism, a philosophy central to TCM theory, is considered to be one of non-dualism.
The biomedical model and the Traditional Chinese Medicine model both have their strengths and their weaknesses. It is the reductionist form of thinking that lead us to such medical breakthroughs as immunizations, surgical intervention, and advancements in technological diagnostics. However, reductionism is also responsible for the myriad of unrelated side-effects which accompany pharmaceutical therapies for specific conditions (ex. NSAIDs can reduce joint pain, but can also increase the risk of heart attack).
It is the holistic form of thinking which can provide simple, less invasive solutions to a plethora of medical problems we face today. This model shows us that we can reduce symptoms of arthritis and joint pain by eliminating the sugar, caffeine, and wheat from our diet because of the generalized inflammatory responses that such substances create. Holism shows us that we can reduce pain by improving the circulation in our entire body, whether that is through massage therapy, meditation-induced activation of the parasympathetic nervous system, or acupuncture. However, if faced with traumatic injury or acute, severe infection, you are probably going to fare better by using the focused, reductionist tools of emergency medical care and antibiotics.
I believe the best model of medicine incorporates both the bio-medical and the Traditional Chinese Medicine paradigms. Neither is “better” than the other, rather they complement each other and allow us to see outside the box. While there are some people who believe the scientific methodology is the only true method of analyzing what “truth” is, there are also people who believe that science may be missing the point entirely, limiting itself within the boundaries it has created. I think to be truly wise, we must remember both philosophies. As a Doctor of Traditional Chinese Medicine, it is the holistic paradigm that I use on a daily basis. However, I would be amiss if I did not also incorporate the biomedical model at the same time.
Fertility and Chinese Herbs to Nourish the Yin
Chinese herbal medicine has been used for thousands of years to treat infertility in both men and women. Possessing a wide variety of actions which can be used to treat many different imbalances, these herbs have traditionally been classified according to the effects they have on the body. Some herbs clear heat, some invigorate the Blood. Some herbs strengthen the energy, while some herbs resolve dampness, or have another effect on the body.
When we talk about “Yin” in Chinese Medicine theory, we are talking about the material of the body which serves to cool, nourish and moisten. Blood is Yin, tears are Yin, sweat is Yin. Saliva, lymphatic fluid, mucus, extra-cellular fluid, and body secretions are all Yin, too.
In some ways, Yin is considered to be the “substance of youth”, which is consumed throughout our lives. Lifestyle factors such as overwork, stress, poor diet, lack of sleep, drug abuse, heavy blood loss (such as can happen with heavy menstruation) and / or a polluted environment can all lead to a deficient quantity of Yin. And a deficient quantity of Yin can lead to difficulties in fertility, among other things.
It is very difficult to make generalizations or equivalences between western medicine physiology and Chinese medicine theory, since they originate from very different paradigms. However, there is a similarity between the actions of estrogen and the manifestation of Chinese Medicine’s Yin of the Kidneys (i.e., the generation of follicles, the proliferation of the uterine lining, and the secretion of ovulatory cervical mucus). Nourishing and moistening the Yin often has a regulatory effect on the reproductive hormones of the body.
As with all of Chinese herbal medicine, it is best to have a registered Herbalist or Doctor of Traditional Chinese Medicine advise you on which herbs are correct for your constitution. Yin tonics are not the best fit for everyone, if used inappropriately they can be too “cloying” and can result in the accumulation of dampness (also not helpful for fertility).
Some of the more commonly used herbs to moisten and nourish the Yin (especially when working to maximize fertility) are:
Gou Qi Zi (Lycii, Fructus)
Shu Di Huang (Rehmanniae Glutinosae Conquitae, Radix)
Sang Ji Sheng (Sangjisheng, Ramulus)
Han Lian Cao (Eclipta Prostratae, Herba)
He Shou Wu (Polygoni Multiflori, Radix)
Bai Shao (Paeoniae Lactiflorae, Radix)
E Jiao (Asini, Gelatinum Corii)
Treatment of Infertility with Chinese Medicine, Jane Lyttleton. Churchill Livingstone, 2004.
Chinese Medical Herbs to Prevent Miscarriage and “Calm the Fetus”
What we refer to as “threatened miscarriage” in allopathic medicine corresponds to two disease categories in Traditional Chinese Medicine, known as Tai Lou (“vaginal bleeding during pregnancy”) and Tai Dong Bu An (“restless fetus”). These are considered to be different from the benign You Jing (“swimming menses”), which is the harmless, slight vaginal bleeding that sometimes occurs during the first month of pregnancy.
Tai Lou and Tai Dong Bu An differ only in terms of degree of severity. In Tai Lou, there is a small amount of vaginal bleeding with no other symptoms. In Tai Dong Bu An, there is vaginal bleeding but also other symptoms such as backache, abdominal pain, and / or a bearing-down sensation. The threat of miscarriage is higher in the latter situation.
Over the millennia that TCM has been used to treat women during pregnancy, various different herbs and herbal formulas have been prescribed to help prevent miscarriage. As with all of Chinese Medicine, a TCM diagnosis according to the pattern(s) of disharmony is necessary in order to match the correct herbs to the correct situation. In some cases, there may be evidence of Stagnant Blood – in other cases, there may be evidence of Kidney Yang Deficiency. A Doctor of Traditional Chinese Medicine or Chinese Medicine Herbalist can advise you on which herbs best suit your pregnancy.
Some of the more common herbs used to treat a threatened miscarriage in Traditional Chinese Medicine are:
Ai Ye (Artemisiae Argyi, Folium) (“warms the womb and pacifies the fetus”)
E Jiao (Asinim, Gelatinum Corii) (“nourishes blood, stops bleeding, and helps prevent miscarriage”)
Huang Qin (Scutellariae Baicalensis, Radix) (“clears heat and calms the fetus”)
Tu Si Zi (Cuscutae Chinensis, Semen) (“tonifies Kidney Yang, calms the fetus”)
Xu Duan (Dipsaci Asperi, Radix) (“stops uterine bleeding and calms the fetus”)
Du Zhong (Eucommiae Ulmoidis, Cortex) (“tonifies the Kidney Yang, calms the fetus”)
Sang Ji Sheng (Sangjisjeng, Ramulus) (“nourishes the blood and calms the womb”)
Bai Zhu (Atractylodis Macrocephalae, Rhizoma) (“strengthens the spleen and calms the fetus”)
Dang Shen (Codonopsitis Pilosulae, Radix) (“augments the Qi, for prolapse of uterus”)
Huang Qi (Astragali Membranacei, Radix) (“raises the Yang Qi, for prolapse of uterus”)
Zi Su Ye (Perillae Frutescentis, Folium) (“calms a restless fetus and used for morning sickness”)
Sha Ren (Amomi, Fructus) (“calms the fetus”)
These herbs are also often used when using Chinese Herbal Medicine to help maximize fertility, especially in the luteal phase of the menstrual cycle.
If a pregnancy is threatened because of a genetic abnormality or other physiological concern with the fetus which makes it not viable, unfortunately no amount of intervention will be able to save the pregnancy. This is nature’s way. However, if a pregnancy is threatened because of poor circulation, a pathogenic influence, or deficient energy Chinese Medicine may be able to help prevent a miscarriage.
-Bensky & Gamble’s Chinese Herbal Medicine Materia Medica, Revised Edition. Eastland Press, Incorporated, 1993.
-Maciocia’s Obstetrics & Gynecology in Chinese Medicine. Churchill Livingstone, 1998.
IVF Egg Retrieval and Acupuncture
During an In-Vitro Fertilization (IVF) cycle, a woman’s eggs are removed and fertilized outside of her body. A few days later, the best one or two are then introduced to her uterus, where they will hopefully implant into her uterine lining and grow into a healthy baby. The process of removing the eggs is called “oocyte retrieval”, or sometimes “egg collection”.
After thesuppression / down-regulation phase and during the stimulation phase of a long protocol IVF cycle (or, during the stimulation phase of a short IVF protocol), an IVF doctor will monitor closely with ultrasound how the uterine lining and follicles are developing. Once the uterine lining is ready (usually about 7 mm thick), and once a majority of the follicles are ready (usually measuring about 18 mm), the doctor will order a “trigger shot”. This is an injection of Human Chorionic Gonadotropin (HCG), which helps finalize the growth and maturation of the eggs. The timing of this trigger shot is important – the IVF doctor will retrieve the eggs from the follicles just before ovulation would occur (about 24-36 hours after the trigger shot). Reproductive endocrinologists like to retrieve as many eggs as they can, since the more eggs are collected the more likely some viable embryos will be created.
Ooocye Retrieval – Egg Collection Day
Although this procedure is perhaps one of the more “invasive” parts of an IVF cycle, a local anesthetic and possibly an intravenous sedative will help ease any discomfort. Guided by a small ultrasound, a needle is passed through the vaginal wall and into each developed follicle. The fluid inside each follicle is aspirated out, then given to an embryologist who separates the mature eggs from the fluid. Once all of the follicles on one ovary are aspirated, the needle is withdrawn and the procedure is repeated on the opposite side. The woman is allowed to recover for a while in the IVF clinic before being sent home to rest.
Shortly after the eggs are isolated, they are combined with a man’s sperm. Embryologists watch for fertilization, cell division, and the general quality (based largely on appearance) of each egg. After a few days, one or two of the fertilized eggs (now considered to be embryos) are selected to be transferred into the woman’s uterus. Any remaining embryos may be frozen, and can be used for future transfers a week, a month, or even several years later.
Ooctye Retrieval and Acupuncture
Even if a woman has been receiving acupuncture in the weeks or months before egg collection, in most cases Chinese medicine is not used on the actual day of egg retrieval. Since the oocyte retrieval process causes some bleeding from the aspirated follicles, the goal after the procedure is to minimize any trauma and blood loss. Increased blood flow to the ovaries and uterus is not necessary (or desired) at this particular time.
There are some rare cases, however, where a woman is not able to take the anesthetic which is usually used during the ooctye retrieval. For these cases, and also to explore any relationship between the method of pain management used during egg collection and pregnancy rates, studies have been completed to examine whether acupuncture can be used during an ooctye retrieval when no anesthetic is used. The results of these studies (two of which you can find by clicking here or here) suggest acupuncture may be helpful as a method of controlling pain during oocyte retrieval if anesthetic is not used.
