Infertility has been identified
as a problem to a couple since the history of mankind. In recent world, about 10-15%
married couples are childless. In Nepal, infertility rate is about 13 -15%. It
is experienced that about 40% of these couples have male factor infertility, 40%
female factor & remaining 10% are those in whom no diagnosis can be made
even after complete investigation.
In
this part of the world, due to joint family trend, infertility is not only a
problem of the couple but it is a problem of the whole family & also
society. During counseling, the ladies patients express their tearfulness,
depression, shame, isolation, guilt, anger & suicidal feelings. Due to lack
of education, it is generally accepted that men are usually fertile &
female have to be treated or the man must be allowed second marriage. Polygamy
is still a very popular method of infertility treatment even in male factor
infertility due to male dominating behavioural aspects which ends up in no
result. Interference by family members,
not allowing the treatment but rather convincing for second marriage often
complicates the counseling process. Therefore the doctor is forced to remove
the family members during the counseling session.
The
treatment seeking behavior of patients differs from villages to cities. The
villagers still believe in the witch doctors or alternative medicine etc.
Unfortunately, some ladies have been victim of rape during the course of such
infertility treatment. We heard two suicides news among the treatment seeker
during our 18 years of tenure.
The
villager's belief is so strong that someone treated with positive result by
some doctor will be known to all villagers and they will inform the whole
community of infertile couples about the type of treatment that is necessary
and try to send them for the same. Their friends come to the doctor with full
preparation & they believe that the doctor has divine power. It is very
easy to convince least educated couples about their treatment. They take the
medicine exactly how the doctor prescribes. The fertility recovery is better in
these groups than the city dwellers. In the city however, the health facilities
are better but patients do not have patience. Thus they keep changing doctor
without understanding the exact test & treatment provided to them. Some
patients are treated for years without success yet these patients do not know
what caused their infertility.
Investigations have identified that in
females, the problem of ovulation failure (anovulation) is critical in this
country. Obesity, stress, anemia, irregular cycle with primary or secondary
amenorrhoea, weight loss & excessive hair growth & skin patches are
major complaints of these patients. On thorough examination, majority
of them have polycystic ovarian syndrome (PCOS). If these conditions are not
treated in time they may even turn into irreversible conditions with damage of normal
hormone producing cells of the ovaries. Quite often we have found that these
cases are investigated properly & the hormone test even ultrasound results
show clear diagnosis, yet proper treatment are not prescribed. Trial hormone
treatment can not cure these conditions, it rather complicated them.
Developmental anomalies of
uterus, fallopian tubes & ovaries, hormone secreting tumors, ovarian cysts & dysfunctional
uterine bleeding may also result anovulation. Rare anovulatory conditions include
premature ovarian failure which may be due to primarily failure of hypothalamus
or pituitary.
Higher
levels of prolactin & abnormal thyroid hormone levels often cause irregular
cycles, primary infertility, secondary infertility & miscarriage with
anembryonic sac. These cases are easily identified by imaging & prolactin
assay.
Reproductive
hormones assay has proved to be crucial in diagnosing anovulatory conditions
but test result interpretation is poor due to lack of Endocrinologists. The
test is expensive & not all hormone tests are available in reliable
laboratories. Patients with amenorrhoea bring normal hormone reports. In
addition, patients with frank galactorrhoea show normal prolactin levels. The
related technicians or doctors should be aware of the conditions why the
patient is being investigated. At least the symptoms of the patient should be
correlated with the test reports. It becomes awkward to the doctor to ask the
patient to redo the test which becomes a financial burden to the patient. On
the other hand the doctor has to find out the abnormal level of hormone which
has to be corrected to regularize their irregular cycle. It is specially noted
down for the attention of responsible authorities.
Transvaginal Ultrasonography is also a useful
test measure to differentiate normal pelvic organs from pathological ones. It provides
a reference of pelvic organs before the treatment cycle. PCOS is easily
diagnosed by this technique. It is very easy to assess the ovaries &
follicles specially to retrieve the oocytes for In Vitro Fertilization (IVF)
treatment method. Presence of any cyst
or endometriosis can be eliminated & simple ovarian cystic contents can be
easily aspirated under its guidance as a minor operative measure.
There
was a general trend few years ago that most of the infertile ladies underwent D&C
as an indirect ovulation test or even a treatment measure. It has been found that majority of these women
undergo D&C during post menstrual period which is not a test of ovulation.
To test ovulation the curettage must be obtained during premenstrual period
when the endometrium is expected to be at the secretory phase. Anovulatory
conditions due to Primary or Premature ovarian failure do not have properly
developed endometrium. Such cases show scanty endometrium in their curettage.
Overzealous curettage in these cases may even cause trauma of the basal layer
of endometrium leaving adhesions. Such endometrium is irresponsive to
estrogenic action, hence does not proliferate. On the other hand, implantation
of functional layer of endometrial tissue into the myometrium may facilitate development
of adenomyosis.
Often
it has been found those who who have undergone several D&C procedures lose
their endometrium & cannot proliferate even with Hypothalamic &
pituitary hormonal stimulants.
Postmenstrual
D&C remains only a treatment procedure in conditions where cervical
obstruction & due to polyposis or developmental anomaly.
Before
the use of clomiphene citrate as ovulation inducer, reproductive hormones
profile must be done. Its use may prove harmful in low estrogenic conditions.
Clomiphene citrate possesses some anti-estrogenic effect which may prevent
recruitment of good quality follicles & it may also thicken the cervical
mucus which prevents the access of sperm to ovaries via cervical & uterine
cavities.
As
proper investigations for fertility are not available everywhere & patients
have been undergoing same investigations by different techniques. For example,
the patency of the fallopian tubes can be tested by the most economic, lesser
invasive & simple radiological method of Hysterosalpingography (HSG).
Hysterosalpingography
as a simple radiological test method is useful to detect Tubo-uterine factors
including patent or blocked tubes, intrauterine cavity fibroids, polyps, adhesions,
developmental anomalies like septa within the uterus, bi-cornuate uterus,
double uterus.
Similar
non-radiological HSG, by using sonography is used for the same purpose & has
been introduced at the infertility centre from 2002 onwards as
Sonosalpingography (SSG), and has been proved to be easy & better test
method.
During counseling, couple's past treatment
records are analyzed. Some patients undergo even laparotomy for tubal surgery
without any obvious reason. Often tubal surgery held for patients with normal
hysterosalpingography. This is because of lacking guidelines to proper evidence
based treatment in this area. The Ministry of Health has to provide guidelines
in this regard & must outline the condition for referral to centre of super-specialization.
The RCOG, 1998 recommends that infertile
patients should be seen in a dedicated specialized secondary care infertility
clinic by an appropriately trained team with facilities for investigating and
managing problems in both partners. Moreover, any ART procedure including IUI
or IVF requires laboratory based training with specialist knowledge &
multidisciplinary skills.
In
Nepal, endoscopic surgery is not advanced therefore least successful. This
technique has been proved better than laparotomy in tubal reversal. However, conception
after tubal surgery has higher possibility of ectopic.
Presence
of free fluid in the peritoneal cavity on ultrasound scan is suspected of
peritoneal tuberculosis. Such cases must get Mantoux test done & in case of
positive test results they must undergo anti-tubercular therapy. We have
detected several cases of tubercular infertility with free ascitic fluid in the
peritoneum in female.
Endometriosis
in the form of severe dysmenorrhoea with para-uterine or ovarian chocolate
cystic structures & adhesions is regarded as serious infertility
conditions. It has been experienced that even after removal of such cysts,
fertility does not easily recover. Recent trend is to use Gonadotropin agonist depot
to stop further progress of the disease. These patients may conceive by careful
retrieval of oocytes & fertilization in vitro with the transfer of the
embryo into the uterus using Assisted Reproductive Technology.
Uterine
tumours developed in the form of sub-serous are less harmful than intramural
& sub-mucus ones. In addition, adenomyosis as extension of endometrium in
the form of tumour is another difficult condition of infertility. As yet, major
surgical removal is only choice of treatment in these conditions Laparoscopic
method of removal of these tumours has very useful role but this skill has yet
to develop in this country. Although this has not been very useful in
infertility practice as a treatment procedure, however it is very much popular
as a diagnostic method of tubal patency test.
The
role of cervical factor is crucial in the fertility process. Presence of
cervical polyp obstructs the passage of sperm leading to infertility.
Inadequate quality & quantity of cervical mucus also hampers sperm passage
to the uterine cavity & towards ovaries. Presence of sperm antibodies in
the cervical mucus may kill the sperm as soon as they are deposited in the
vagina. This is tested by using Post-coital test (PCT). If all the sperms are
found dead after few minutes of intercourse there is no chance of fertility. We
experienced only about 5-7% of female infertility is due to cervical factor.
As
mentioned above, almost 40% of infertility in this country is found to be due
to male factor. Majority of these men are professionals, working as policemen,
military men, accountants, drivers, engineers, doctors etc. Careful evaluation
of these men is necessary to relate the present condition with the history of
male organ development, history of surgery, childhood mumps & tuberculosis.
In addition, any narcotics used in the past, eating habits, alcohol &
tobacco consumption must also be enquired about during counselling. In our
early infertility practice there were only few couples attending counselling
sessions. Usually the female partners are brought by their relatives for
counselling. In contrast, in recent years men having done the semen analysis
find out their defects & they come alone with the report for counselling.
Occasionally, they counsel for themselves & get their test done before the
wife is disclosed about their infertility factor. We experienced two suicide
cases news due to polygamy in male factor infertility during our 12 years
tenure.
A
standard fertility centre with andrology lab can provide the facility to test
sperms within normal parameter, which makes diagnosis of male factor
infertility easier.
In
our experience, majority of male factors presented with normal physical
activities even when they had no sperms in their semen. On the other hand some
fertile men with children in the past had no sperms at all in three episodes of
semen analysis. The major problems observed were low sperm count & motility
rather than poor sperm morphology.
Anti-sperm
factors may be present in the male themselves which form anti-sperm antibodies
after intercourse in the cervical mucus thus creating difficulty for
conception. In such cases, conception may be possible only either with
specially processed husband's or donor's sperms carefully deposited into the
uterine cavity with the help of a special intrauterine catheter, the process
commonly known as intrauterine insemination (IUI) Before insemination, each specimen is
evaluated and washed in preparation for intrauterine insemination (IUI) into
the female. The sperm washing process removes impurities from the semen
improving motility of sperms thus increasing pregnancy rates. Insemination of
unwashed sperms can cause serious adverse reactions. This is one of the popular treatments
for male factor infertility. For this process, ovulation has
been optimized in the female and her fallopian tubes are known to be open.
Ultrasound is used to time the IUI procedure. Poor quality
semen, the husband's or the donor's, are processed in the same way. All the sperms used for donor insemination must be stored frozen in liquid
nitrogen jars. It is not wise to use the semen from known donors because of the
psychological and social problems. In our centre donors must undergo a rigorous
screening including HIV, HBsAg, and VDRL testing as well as documentation of
medical, family, and genetic history. The donors also sign consent about
keeping the matter confidential to all except his wife. The semen is frozen and
quarantined for use for six months.
We
strictly take consent from the couple undergoing donor
insemination, ovum donation & IVF. In
this society, it is quite usual that male factor is regarded as an ordinary
defect. If the wife is normal the husband & the family members instantly
decide for donor insemination to the wife. Often the male
partners try to convince us to keep such treatment information from the female
about the need of donor insemination for their fertility.The situation is not the same if
the wife is not able to conceive due to blocked tubes or irreversible
anovulation. At this point the husband & his family start arrangement for
his second marriage. In such situations the doctor has a great
role to convince the family about availability & possibility of conception
with Assisted Reproduction with ovum donation & IVF at home or abroad.
On the other hand, few azoospermic cases
were due to blocked vas. Some cases of blocked vas were opened and the couple
conceived. Rarely but few cases come with the request of reversal of vasectomy
either due to loss of children or due to polygamy or after divorce.
All
the couples are tested for STD, HIV, HBsAg, men during semen analysis. We
identified only three cases of HIV positive infertile cases till date but many
were treated for STD and few for HBsAg were asymptomatic. These cases were
especially cared during ante-natal period followed by careful deliveries of
these babies. They were followed-up till all the tests were negative.
After
having ten years of practice of only Infertility treatment, we experienced that
the internationally available treatment for infertility must be made available
to those Nepalese who cannot afford treatment abroad. These are couples with
blocked fallopian tubes, severe male factor, Endometriosis, failed IUI &
idiopathic or unexplained infertility. Except these conditions, any couple who
cannot conceive should not accept IVF. In this program stimulation of ovulation
is done by injecting excessive doses of hypothalamic, pituitary, ovarian
hormone analogues. There are usually three stimulation protocols laid out for
this purpose. However we have found the long protocol very useful for IVF
treatment. If conception does not take place, such higher doses of stimulants
may prove harmful for normally functioning ovaries. There may be cystic growth
in these ovaries. Due to their hazardous effect, IVF should not be recommended
to those who really do not need it.
Monitoring
growth of the follicles is done by using serial scanning of the ovaries with
transvaginal ultrasonography & hormone assay. When at least two follicles
reach 18mm ovulation is triggered & within 34 hrs. follicles are aspirated
to collect the eggs. They are cultured with the sperm for fertilization &
growth of embryos. When the embryos reach four-cell stage of development,
maximum two embryos are transferred carefully into the uterine cavity for
implantation & development of foetus. The extra embryos are frozen in
liquid nitrogen jars for transfer in subsequent cycles. We check for conception
after two weeks of transfer. The successful ones will be switched into the
antenatal group. The failed IVF couples will have disastrous feeling, feeling
of loss of money & loss of only chance of pregnancy. They will be counseled
again for further attempt. The probability of success depends on many factors
including age of the patient, cause of infertility, and the talent and
experience of the IVF team.
However, proper investigation will help problem
identification as to whether it is a case of anovulation or mechanical blockage
of the tubes or a case of male factor. The cost is another factor which may not
be within the reach of all till conception takes place in both conventional
infertility treatment & Assisted Reproductive Technology. It seems
necessary to balance between cost & effectiveness of the treatment.
However,
the pain of treatment becomes negligible in them as soon as their fertility
returns.
SOCIAL ASPECTS OF INFERTILITY
Women comprise more than half of Nepal’s
23 million people as given by CBS (Central Bureau of Statistics, 2002). They
are less educated and work longer hours than men. In a society where social
security does not exist and property is passed on to male descendants, sons are
looked upon as old age insurance. It is also widely believed that sons “open
the gates of heaven” by carrying out the last rites of parents. Daughters are
“given away” in marriage. These explain, to an extent, the prevalence of
sayings like “let it be later but let it be a son.” The resultant
discriminations in upbringing of girls perhaps explain why Nepal is one of the
few countries in the world where men live longer than women. Thus, if a couple
fails to conceive the baby after one year of the continue sexual relationship, therefore
the women is discriminated and seen in a sinful way and as a result the husband
get married to the other woman in order to conceive a baby. The recent survey of infertility in the
country has raised the questions about the biological disability with social
stigma that is mostly prevalent in the women.
Infertility
alters an individual’s perception of his/her self, of his/her concept of
identity. As a result of the strong link between femininity and motherhood,
women may experience an identity crisis as there is a conflict between their
ideal sense of self as a woman who can become a mother and their real self as
being infertile. The experience of infertility requires both men and women to
adapt and to integrate infertility into their sense of self.
Many Nepalese girls get married soon after the
puberty. Nearly, 40 percent of currently married women are married before the
legal age of 18 (UNICEF 2002). Soon
after marriage a women is expected to have children. In Nepalese society child
bearing is the central in defining the women’s identity, affirming her worth
and establishing her position in the household and husband’s Kin group.
Traditionally our society favors high
fertility. Children are a symbol of well being both socially and economically.
This is evident from the popular saying which goes "may your progeny fill
the hills and mountains". High fertility is desired because by producing
children, preferably sons, a woman raises her status in the family. She avoids
the chance of having a co-wife, makes herself socially eligible to inherit some
property from the family, and above all, wins the support and affection from
her husband and the other members of the family, particularly the
ever-dominating mother-in-law.
Marriage is considered the most important
event in a Hindu women’s life and girls grow up with a notion of temporary
membership in her parent’s home. In the process of her socialization there is a
considerable emphasis on submissiveness, obedience and as feminine ideals. She
learns to accept that preference is always shown to male children and learns to
accept her brothers are privileged family members.
Women are materially connected to food, water
and energy, biologically connected to reproduction, and socially connected to
family and community in ways that men are not (Jiggins, 1994). Although women's infertility is of greater research
consideration, health care attention and social blame, male conditions cause or
contribute to around half of all cases of infertility.
According
to Manusmriti, where it refers to the most
important and earliest metrical work of the (Dharmasastra) textual
tradition of Hinduism, woman and servant are of same value in the
Nepalese patriarchal society. Before marriage a father has the responsibility
to take care after his daughter and find a husband for her and after marriage
it is husband's duty to protect her and with the passage of time when she gets
old the son takes care after her. Son is felt essential in Nepalese society.
And a woman is often made guilty for not bearing a son. Thus, a woman does not
have any right to make any decision regarding herself or her family. In other
words, women do not have their independent personality. Whatever the male member does that should
always be acceptable to female. Thus, in the socialization process while women
are taught to be non aggressive, submissive, soft spoken and shy. Men on the
other hand are taught aggression, violence and boldness.
Majority
of women in Nepal are engaged in household works. Their expenses depend on
their husband’s income and will. There is high level of domestic violence,
mental torture and trend of polygamy. The domestic violence stems from the
assumption that once a man marriage a women he has absolute control over her.
It is usually due to the right to domination of females. This principally owes
to the influence of the tradition idea of men “Men are senior to women".
It has severe effect on human rights and dignity of women. It is the result of
unequal power relation between women & men.
In our society sons are desired more because
they represent insurance for old age and patrilineal inheritance ensures that
property is passed on through the male line. The necessity for a son is to
carry out the death rites for parents. Therefore, there is rejoicing in the
birth of a son and unhappiness at the arrival of daughter. To be born a
daughter is a misfortune “let it be late, but let it be a son”. Special
attention has been given to male baby from early child hood and sons have a
special priority over issues such as education and (boarding school for male
baby and government school for female baby) nutrition (sons always have a
priority to have special and tasty food and daughter have to eat only after
him). Similarly, sons can have choice over clothing but daughter is compelled
to wear whatever the parents provided to her. There was a common understanding
that rituals surroundings, the birth, naming and introduction of supplementary
foods for male babies are more colorful and extravagant occasions than in the
case of girls.
In
such a son preferred society like Nepalese society, infertility can become a
huge problem for a happily married couple for not being able to conceive the
baby resulting to various social and psychological problems on women such as
polygamy, domestic violence etc. In a society
where social security does not exist and property is passed on to male
descendants, sons are looked upon as old age insurance. It is also widely
believed that sons “open the gates of heaven” by carrying out the last rites of
parents. Daughters are “given away” in marriage. These explain, to an extent,
the prevalence of sayings like “let it be later but let it be a son.” The
resultant discriminations in upbringing of girls perhaps explain why Nepal is
one of the few countries in the world where men live longer than women.
Currently
many stigmas and myths about infertility exist. Although there is much more
scientific information about the biological or medical aspects of infertility,
understanding the psychological and social implications of infertility have
lagged behind. One of the most prevalent myths about infertility is that since
women ultimately conceive and become pregnant, infertility or the inability to
conceive and become pregnant is perceived almost exclusively as a “woman’s”
problem.
The infertile
women are socially stigmatized and have to bear the impact of being infertile,
irrespective of who is responsible for infertility. The infertility has negatively
affected the marital relationship and subjected the women to hatred and
exploitation. These women, who could not reproduce at all, faced poor outcomes
of pregnancy or were unable to give birth to sons, were being laughed at or
ridiculed. These women not only faced
the threats of divorce, husband’s remarrying or sending back to parents’ home
but experienced these consequences too.
Moreover, due to the problem of infertility, the women become the
victims of verbal and physical abuse both by the husbands and in laws. The
resulting trauma could be immense.
Being a female they have to suffer
a lot. Women are known as the image of patience, they can bear everything their
husbands do even if that does not respect her. But it is said that a woman
cannot bear if her husband marriages another wife if she is unable to conceive
a child. Nepalese women have incomplete access to resources, due to the existing
social structure, strong patriarchal norms and practices, few opportunities and
mobility constraints due to which they cannot take necessary decisions
regarding the infertility treatment. Finally this leads to psychological impact
leading to isolation from the family. To
be infertile, is not only because of the women, there is equal chances of
weakness from the part of husband. Due to ignorance of this fact, women were
blamed for infertility.
Family should be the safest place
for women in time of trouble. It is an institution where one should get
emotional support, comfort, care, food and shelter. Yet this institution can be
the unsafe place for women. In Nepalese society, women are known as the image
of patience, they can bear everything their husbands do even if that does not
respect her. But it is said that a woman cannot bear if her husband marriages
another wife if she is unable to conceive a child. Nepalese women have limited
access to resources, due to the existing social structure, strong patriarchal
norms and practices, few opportunities and mobility constraints due to which
they cannot take necessary decisions regarding the infertility treatment.
Eventually this leads to psychological impact leading to isolation from the
family.
Similarly, the infertile women are
also affected and bounded by the strong traditional norms of the society where
she cannot express herself without frustrations. As our society is a
patriarchal or male dominating society, male is recognized as the bread winner
and female is recognized as the homemaker where she has to play the role of
various characters as such the mother, sister, wife etc. In our society, women
are categorized as the child bearing machine where if she is unable to give
birth to the child then she is termed as the failure being a female and her
husband and their family would give various kinds of tortures and tries to
verbally abuse them.
Being physically unable to conceive
a baby thus becomes the greatest sin that a woman commits in her life. It can be concluded that the literacy,
occupation, age at marriage, income status knowledge and accessibility are the
major variables which are playing vital and determinant role for determining
the social status of a female in the society. Hence, due to illiteracy, patriarchy,
traditional social norms and backwardness among the females has leaded them to
suffer, take stresses and depressed in society
An Infertility Case
Study
Mrs. K. Paudel, aged
46, wife of a prestigious fellow Mr. B. Paudel, aged 46 had visited Infertility
Centre in March 1999 with the complaints no living issue for 21 yrs. married
life. They lived in Pokhara & were referred to us by a Senior Gynaecologist
for their complicated infertility problem.
They had two abortions
at three to four months gestation. The last abortion took place after treatment
only with six yrs. ago. Since then she could not conceive but the details of
the previous treatment was kept confidential within the doctor & the
husband. Their past treatment record showed that she had artificial
insemination of donor sperm because the husband had no sperm in his semen. She
did not know that she got pregnant by donor insemination. During our
counselling, the lady did not show any interest in treatment for herself
because her menstrual cycle was already getting late & she lost hope of
getting pregnant. Her physical built was good with her body weight of 65 Kg.
Her cycle interval was 23-43 days with flow of 1-2 days scanty flow. On the
second visit however she was ready only for Hysterosalpingography (HSG) which
revealed normal looking uterus with patent both fallopian tubes.
On third visit she
brought her sister & wanted us to examine her whom the lady forced to marry
with her husband for the sake of a child in their family.
Hence, it was clear
that the second wife Mrs. S. Paudel was married five years ago & she also
could not conceive. The younger sister was 31 years when she came for
treatment. She was thin built with short height but her general physical
condition looked quite fair. Her body weight was only 39 Kg. Her menstrual
cycle was 28-30 days with 5-9 days of flow. On pelvic examination the use of
speculum could not clearly distinguish the cervix from vagina. In addition, the
vaginal cavity was also narrow. The outline of cervix looked rather
rudimentary. Careful surgical excision was done to separate the vaginal flaps
which covered the cervix. She was then asked not to try conception for at least
three months.
After surgical
correction she was properly investigated for conception.
Her
D2 hormone profile:
FSH=7.4mIU/ml;
LH=1.1mIU/ml;
Estradiol=40.5pg/ml;
Prolactin=30.8ng/ml;
TSH=3.3mIU/ml.
Hyperprolactinemia
was corrected with bromocriptin therapy.
This time, it was easy
to access the cervix to perform HSG. Her HSG showed normal uterine cavity with
patency of both tubes. Semen was analysed again had no sperm. Thus, the
conception was only possible with donor insemination. With written consent of
the couple, Intra Uterine Insemination (IUI) of donor sperm was planned.
Ovulation was stimulated for the recruitment of more follicles with cyclic
clomiphen citrate 50-150 mg. Development of follicles was serially monitored by
transvaginal ultrasound. When at least one follocle reached 18mm, Human
Chorionic Gonadotropin was injected & IUI was done within 30-48 hrs. Since
they lived far away, their treatment was not regular. However, she finally
conceived after total three months of IUI treatment. She was followed up by us till 30 wks &
referred back to the same doctor for the delivery. She delivered a healthy baby
boy in October 2001.
Dr. Uma Shrivastava
Founder, Director
Infertility Centre.
