I am doing fertility medicine with a doctor here in Jacksonville, FL.

Stephanie

Hi, Stephanie. Thank you for your email. I think a lot of readers can benefit from the discussion of this topic. I’m going to address the reply to everyone in general, but there should be some food for thought in this discussion that you can toss around with your own RE.

Just a reminder for those of you who have decided to see RE’s — You are already getting the ultimate in specialist care, so take advantage of the chance to ask them questions, especially when something unexpected, like a cyst, occurs. You should expect to have your questions addressed to your satisfaction. If they don’t have time to answer in great detail at that very moment, they can always talk with you on the phone later in the day. Set a time to do so if you ever have nagging questions. Some of you have vented that you’re getting your treatment through an HMO, and citing that as a reason why your questions aren’t getting answered. The quality of HMO doctors is not necessarily any different. It’s just that they have many more patients with whom you will have to compete for their time and attention. The tradeoff is that your service is usually close to free, so it’s not all bad. =) But if this is the case, be vocal. You have a right to have your questions answered, regardless of whether you’re seeing an RE or not.

In a monitored cycle, one of the first things to do is to check for cysts prior to taking the Clomid. If you have already read the previous post on cysts, it might help give you some basic understanding of the terms used. There are many different ways to approach ultrasound monitoring of a clomiphene (Clomid) cycle. Some people opt to take Clomid with no monitoring at all. This is the cheaper way. However, keep in mind that the more diligent the monitoring, then the more information you have with which to make better decisions, so it is a tradeoff.

It is acceptable in most cases to take Clomid without monitoring. So starting around cycle day 3, 4 or 5, depending on your doctor’s preference or depending on your convenience factors, most doctors will prescribe five consecutive days of Clomid. Then you are on your own as far as having sex, either just every 2 days or by timing with assistance from ovulation kits. The downside to this is that you never know for sure if you are ovulating and you never know how many follicles you have.

ADVANTAGES OF MONITORED CYCLES: A monitored cycle is a more deluxe version of the standard Clomid cycle. It adds some inconvenience and cost in that you have to go to the doctor for ultrasounds, but it has some clear advantages:

• Ability to avoid cysts. For all women, there will be an occasional month in which things are "off". You might end up with a leftover cyst which has not fully gone away yet from your previous cycle. Or you might have a fast-growing out-of-sync follicle that is growing much quicker than normal. These problems are more likely when the previous cycle was a medically-stimulated one. In either case, it would not be optimal to take Clomid that cycle because of decreased efficacy. There is also the slight concern of the cyst growing excessively large under the stimulation of the Clomid and causing other problems. By getting monitoring prior to starting the Clomid, you can catch these cycles and avoid taking the Clomid. I find these cysts at the start in about 5-15% of my patients’ cycles. In general, I use 12-13 mm as the cutoff size for postponing a stimulation cycle, but there are other several factors I take into account as well. In general, if the cysts are smaller than that, then we go ahead with the cycle.
• Assurance of follicular growth. Some times when you take Clomid, you don’t even make any mature follicles at all. Monitoring catches this problem early and avoids the scenario of you wasting time taking 3 or more cycles of Clomid when in fact there is no chance of pregnancy, due to complete failure of the Clomid at initiating ovulation. In this case, it’s time to switch strategies to something stronger or to do additional testing.
• Optimal timing of intercourse and/or insemination. The only 100% accurate way to document ovulation is with ultrasound monitoring. Theoretically, if you get your ultrasound done at precisely the right time, you can pinpoint ovulation to the exact second. That has only happend to me twice in over ten years. I was doing an ultrasound on a patient and we all clearly saw a large follicle on one side. I went to scan the other side and when I returned to the original side, the follicle was instantly gone and there was increased fluid in the pelvis, a sign of recent ovulation (follicular rupture). Temperature, mucus evaluation and urinary ovulation-kit testing can only give you a crude estimate. In fact, by adding the strategy of taking an injection of hCG to trigger your ovulation, you can actually control ovulation so that you can time insemination close to the exact hour.
• Assurance of ovulation. Sometimes, patients will have all the signs of ovulation (temperature change, positive ovulation kits, pain, rise in progesterone), but the follicles themselves do not actually physically burst, thereby causing the egg to remain trapped inside the follicle until it’s too late to be viably fertilized. Ultrasound monitoring will pick this up if this is the case and alert the need for different strategies. One way in which monitoring gives my patients peace-of-mind is by providing confirmation that their follicles have successfully ovulated.

So let’s go back to the issue of what to do when you DO see a cyst. There are two main options. One is just waiting for the cysts to go away on their own. Over 80% of the time, new simple cysts WILL just go away on their own by the start of the next menstrual cycle. The other option is to take birth control pills. This further raises the odds that the cyst will go away. It also serves to lower the chance of developing new cysts. You can imagine the frustration of my patients who have their cycle postponed because of a cyst on their right ovary only to come back next month and find a new cyst on their left ovary, even though the original cyst on the right had resolved successfully. The decision whether or not to take BCPs is one of personal preference between you and your doctor. I usually suggest my patients wait one month for the cysts to resolve naturally and if they’re not gone by then, we can start BCPs, but some more proactive patients opt to start BCP’s right away.

Now what happens if months and months go by and the cysts are still there, unchanged, neither growing nor shrinking? At some point, the option of doing surgery has to be considered. I usually don’t advise surgery for a cyst unless it is clearly persistent and not going away (over 4 months) or if it looks suspicious. By this, I mean that not all cysts are simple cysts as seen on ultrasound. Some cysts are echogenic meaning there are shadows on the inside. This might indicate that it is filled with blood, or with medically dangerous components, such as cancerous tissue. This is rare, but certainly not impossible.

One more general tip. There are some patients who consistently end up with cysts and consistently fail to ovulate their follicles. One area I explore in these patients is the remote possibility that they are taking high doses of aspirin, Motrin, Advil, Aleve or other related drugs known collectively as Non-Steroidal Anti-Inflammatory Drugs. This usually happens in patients with chronic back pain or migraine headaches. High dose aspirin or NSAID’s block prostaglandins, which are substances in the body that regulate many things, one of which is ovulation. I had a patient once who consistenly failed to ovulate, despite making many nice follicles each month. It turns out she was taking massive doses of Exedrin for her migraines. After taking her off those medications, she has gone on to have three babies with us through insemination.

So, in summary, the decision whether or not to have your cycles monitored is based on many factors. I hope this information was helpful.

Happy New Year! I’m looking forward to many new pregnancies in 2008!

According to this clock, my life is predicted to end some time after the year 2050. Please don’t misinterpret my sharing this as an example of morbidness and pessimism. On the contrary, I reflect on this from time to time to remind myself the importance of enjoying and appreciating each and every day with which we have been blessed.

Earlier this year, my father signed up with some plan from our local electric company to install energy regulators and shut-off devices on his air conditioning unit at home. As a reward for his contribution to energy conservation, they sent him a $20 gift card to Starbucks. You should understand that my father had never stepped foot into a Starbucks in his entire life, but ever since he received the gift card, it started burning a hole in his pocket. His thrifty upbringing (or dare I say, his traditional Chinese upbringing) will not allow him to let anything go to waste, especially if it is free. Every week, he has been calling regularly, asking if I will go with him to Starbucks on some Saturday to have a relaxing morning of father-son conversation. I finally was able to grant his wish this past week, which was especially nice because my sister was visiting with her family from Sacramento. So the three of us got to have some quality time as a family, reminiscing together over three cups of latte. It was an unbeatable experience, even if the coffee would not have been free.

This past year, many of my friends have had the misfortune of losing one of their parents. There’s not much one can say or do to change the fact that we all grow old and move on some day. However, one lesson I learned long ago keeps me inspired and focused. Because we can’t prevent the inevitable, we should focus on what we CAN control. Someday, when our loved ones are gone, rather than mull with regret over things we could have done, words we could have said or times we could have shared, why not seize the golden opportunities NOW, while we still can? My parents are amazing in that they both run at least a mile almost every day. Their health would predict that they will be around for quite a while, but I’m not taking any chances. I do my best to spend time with them on a regular basis, using the chance to build up great memories. Someday, these memories will be all I have left of them, so I’m greedily accumulating them now while I have the chance. If it’s not too late for you, I pray that you take the chance to enjoy the company of your loved ones now and make this a resolution for 2008!

My work place is hazardous. This is all because of our patients’ generosity. We receive on average, well over ten gifts of sweets every month, culminating near Christmas time in a tumultuous onslaught of donuts, boxed chocolates, goodie baskets and other random acts of sugar. It is heartwarming to know that our patients are truly generous in spirit, but it is also a tremendous test to our will power to resist the urge to continuously sample the decadent treats that are ALWAYS readily available. Our friends and families are well aware of our bounty because whenever things pile up to the breaking point, we start taking things home rather than throw anything away. We once came up with this bad idea of putting the candy out in our waiting room with a sign saying "Please help yourself". However, it didn’t take much common sense to realize that this wasn’t a good idea. We might as well have put it out with a sign saying "Please allow us to further impede your fertility by adding to your body fat."

Today, I’m back after the holiday break and I see our break room has five boxes of unopened chocolates remaining. I’m still without a good plan what to do with it all. Do we just buckle down and start working on finishing it all, piece by piece? Do we donate it to the next person we see begging on the side of the freeway ramp? If only we could ship it to the kid in Willy Wonka whose grandfather had to save up for a year to afford him one precious candy bar.

By the way, I should very importantly add that the average BMI of our entire office staff is an amazingly trim 21.4!!! And that’s counting my own contribution of 24.8 as the highest one. I guess the hectic pace at which their jobs keep them racing burns off a lot more calories than is readily imaginable. I know for a fact, that I’m not the one in the office eating the bulk of all that candy.

Anyway, I have no right to speak on behalf of other doctors’ offices. Maybe they want more and more chocolate. But as for us, I would make a request that in the future, patients can show gratitude and appreciation by giving us cards or notes written from the heart, rather than chocolate. But if you INSIST on giving us chocolate, can you at least make it either chocolate-covered strawberries or Assorted Nuts and Chews? Thank you very much.

This past month, NEWSWEEK featured a cover story on Fertility and Diet. Feel free to read the article in its entirety, but I’ll share with you what I got out of it.

We’ve known all along that lifestyle factors such as exercise, smoking, diet and stress can affect us in important ways including longevity, energy level, mood and risk of diseases. It’s not a stretch of the imagination to think that lifestyle factors could also impact fertility.

Harvard researcher Jorge Chavarro has co-authored a book entitled The Fertility Diet, based on data collected from The Nurses’ Health Study, a large ongoing research project which gathers information on a variety of lifestyle factors and their relationship to medical conditions.

I’m going to go on to be one of those annoying people who sort of does a pseudo book review without having read the whole book ( I did read the entire ARTICLE ), but you can be the judge of whether what I say is helpful or not.

First of all, contrary to how it has sometimes been marketed, what this book is NOT is a magic remedy to BOOST your fertility. It does show some very interesting findings on the differences in fertility between women who have different dietary habits. However, there are two important points to remember. These are merely women who are trying to conceive, not women with established fertility problems. As you know, advice that is given to regularly fertile women (relax and take a vacation and oops, you’ll get pregnant easily) doesn’t work for those who have been unsuceessfully trying for years and years already. Second, all the data really shows is a CORRELATION between women who have certain diets and the % of them who conceive. It does not show that the diet CAUSES the fertility. It’s possible that the opposite direction is the case and that a woman’s fertility situation actually affects her dietary choices. It’s even more possible that there is a yet identified third factor that affects both one’s fertility and one’s diet.

Even more importantly, there is no hard PROOF that actively changing your diet will change your chances of conceiving, again because no causality has been shown. Pretend someone does a research study and finds out that people with Ivy League college diplomas hanging on their walls make better engineers (I’m not actually saying this is the case, by the way). It would be wrong then to jump to the conclusion that if we started handing out Ivy League college diplomas to everybody, then we could have a nation of better engineers. Having said all that, it’s still my personal guess or opinion that changing ones diet, WOULD, at least to some extent, positively affect ones chances at conceiving.

According to the article, here is a summary of the specific dietary features that might be better:

• Eating more so-called SLOW cabohydrates (dark bread, brown rice and pasta, whole grains) in place of fast carbohydrates (cold breakfast cereals, potatoes, white rice).
• Eating more unsaturated fats (avocados, vegetable oils) in place of trans fats (palm and coconut oils, hydrogenated fats, dietary cholesterol, animal fats, lard, butter). This was one of the more important factors according to the study.
• Having a lower body mass index. Being overweight is correlated with fertility problems. The best range of BMI was between 20-24, with 21 being optimal. If you wish to calculate your BMI, try this useful calculator.
• Eating more plant protein is place of animal protein.
• Consuming whole milk and whole dairy products instead of skim milk. This was the most counterintuitive finding. It was a surprise to find out that milk with natural milk fat was actually better than skim milk. However, the benefits were seen with amounts as small as one cup of ice cream per WEEK. So if you buy that small pint of Ben and Jerry’s Chunky Monkey, it should last you two weeks.
• Exercising regularly was better than no exercise. Unless you have very low body fat, like a gymnast or ballerina, you should aim for doing more exercise rather than less. A good target is to do 30 minutes daily.

If the thought of making drastic lifestyle changes feels overwhelming, remember the principle of trying different things in an attempt to improve your odds of conceiving.  The easiest approach is to pick one or two of the above areas and see whether or not making a change in your life results in pregnancy, or if not that, at least an improvement in your menstrual regularity, especially if you are not normally regular. Remember. If what you’re doing is not working, try something different, including eventually going to see a good reproductive endocrinologist.

Now go and enjoy your holiday feasts, everyone. Merry Christmas!

It depends.

Inside a woman’s body, it doesn’t live long at all, if we’re referring to in the vaginal canal. Sperm that is in the vagina will leak out or die before a few hours. However, if the sperm makes it to the cervical mucus, then it can live for a day or two there. But some "top survivor" sperm will live even longer, beyond 4 days. Remember, we are talking about several millions of sperm, so they survive different durations. Because there are so many INDIVIDUAL sperm, the lifespan varies between the fastest to die and the slowest to die. It’s sort of like us asking the question "How many years can a car be driven before it needs a major repair" In general, that answer might be 1-5 years, but you can always have that one car that is still running after 10 years without a repair, even though that is an uncommon exception. So in a particular grouping of sperm, the wimpiest will die instantly, and each minute more die until after a few days, only the best survive. It’s not a scenario where the sperm all stay alive and then a biological alarm goes off and they all instantly die at the same time.

Inside the male’s body, the life span of sperm is 74 days. This means if a man does something bad for sperm (smokes marijuana or tobacco), then the sperm will be negatively affected for a long time.

Outside the body, sperm die very quickly (less than a few hours), unless of course, we are talking about sperm that is placed outside the body into a special laboratory environment. Then it can live several days. If that sperm is frozen properly, then it can live indefinitely until it is thawed.

US fertility rate at it’s highest in 35 years
For the first time in 35 years, the fertilty rate in the US has reached 2.1 babies per woman. This is called the replacement rate, because it is the rate at which a population is stable. Below that, the population will dwindle, as is happening in many countries in Europe. If the rate is above that,  the country’s population will increase. This article talks about many theories why 2006 was special, but with no mention of the benefits of fertility treatment. Anyway, we’re still glad to have been able to contribute our share to this good news.

 Muslims couples forbidden from doing fertility treatment
The Muslim clerical community has gone back and forth for years regarding the acceptability of different types of fertility treatment such as IUI and IVF. Most recently, they have gone back to saying no. In my practice, I’ve helped many Muslim couples have babies. In some, their treatment is standard. For some couples, they request that one of my female assistants insert the vaginal ultrasound, cover her up and THEN I come in the room to do the ultrasound. Of note, my billing manager is a devout Muslim and is very happy working here. On the other hand,  I once offered a clinical job to another woman who regretably had to turn down the opportunity after discussing with her Imam.

You can’t control whether you get pregnant or not.

What you CAN control to a big extent are your ODDS of getting pregnant. Understanding his simple distinction can go a long towards giving you a better grasp of your situation and hopefully a better sense of control on the whole big picture. For example, next month if you make the decision to stay celibate and never have sex, then you can effectively eliminate any chance of getting pregnant. The last time someone gave birth without ever having sex actually happened around this time of year. But unless you tell me that you were just paid a visit by three wise men from the East bearing gifts of gold, frankincence and myrrh, then this probably isn’t going to happen to you.

Taking this further, if you end up having sex randomly twice this month, then you might have a chance of having a baby, but it will be low. Furthermore, if you have sex at an exact day, planned by using ovulation tests and past temperature charts, or better yet, if you have sex every two days for the whole month, then your chances get even better.

Now, taking this further, if you can somehow quadruple your egg production and then on the day of ovulation (or better yet, near the HOUR of ovulation) arrange to have 20 million of your husbands live sperm delivered right to the doorstep of where your eggs should be waiting, then your odds get better yet.

Ultimately, if you instead arrange to have your eggs found and retrieved, directly fertilized and then transplanted back into a hormonally-enriched uterus, then your odds are the best.

I think you can see the point. Choices you make, whether on the type of treatment you get in a certain month, the frequency of sex, what you eat, how much stress you have, how healthy you make yourself all can have some bearing on your odds of getting pregnant. The unfortunate thing to accept is that you can do all the right things to maximize your odds, but still not get pregnant in a given month. In basketball, your team can work hard moving the ball around and making passes to get the ball set up for a super easy shot and still fail to score because that easy shot is missed. On the other hand, you can also just fling the ball from half-court without a prayer of it going on, and most of the time it won’t, BUT, once in a blue moon, it WILL. In the first case, even if you miss the easy shot one time, as long you continue to do the right thing to set up easy shots subsequent months, eventually one will go in.

So if you have been reading this site from the beginning, you now know two important basics of fertility strategy.

• Try something.
• If time goes by and that particular something is not working, try something different.
• When trying something different, focus on doing things that are expected to improve your odds. If your odds were truly improved by your new action, then eventually it will work.
• If it doesn’t work, then it means that your odds weren’t truly improved enough by your particular choice of different action, so then try something else!

This is the basic outline of our gameplan. There are many specific ways of how we can medically and naturally increase those odds, but those are lessons for another day.

The phones ring madly here. Theres no escaping it. We have stubbornly clung to the policy of having a team approach to answering the phone (usually with about five people), rather than having a single receptionist or voicemail handle most of the calls. Patients especially love it, because our staff is entirely cross trained, so unless it’s a very specific billing question that only our financial expert can handle, most callers can get their problem solved by the person who answers. Some days, if it gets too overwhelming, we might have to rely more and more on that dreaded voicemail (or just as likely, hire more people), but for now, we’re holding strong. Not all calls are from our established patients or from prospective patients. So because we answer most of our calls, we have to deal with the occasional telemarketer asking if we’re happy with our long-distance plan or teenage prankster asking how he can donate his sperm. Sometimes, we get legitimate calls from women who are already pregnant and find us because I’m listed in their insurance plan as being a board-certified OB/Gyn. We have to explain to them that we don’t deliver babies. There have been times I’ve walked by the nursing station and happen to overhear one of my staff patiently helping these types of callers by assisting them in finding an obstetrician. She even went to the trouble of looking up the phone number of an OB and giving them our inside opinion on how much we like that particular OB. I curiously asked my staff member what that call was about and she told me, almost apologetically, adding she probably shouldn’t have spent so much time helping someone who was not our responsibility to help. It was a typical hectic day and she acted guilty as if she was caught slacking off at a time when we were swamped. Shyly, she added "I know we were busy, but she sounded so lost. She was so happy after I helped her that she said she really wished she could come see us for her pregnancy." I’m not sure if my staff member was expecting to be reprimanded, but instead, I praised her action. This was just one of the instances in which maybe it cost one of our established patients a bit of inconvenience in having her call going to voicemail and being responded to 15 minutes later rather than get her issue solved instantly, but in return, a good deed was done and I got further (unneeded) reinforcement on just why I was so proud of the caring girls who work with me. Now if you are expecting me to make this a great story by adding the twist that the pregnant caller whom she helped wound up sending us five of her friends as patients, I wish I could, but it hasn’t happend that way to our knowledge. Oh well. =)

I believe in choosing my daily actions so as to make the world better.
I believe in judging people by their actions, not their words.
I believe in the value of thinking first rather than just emotionally reacting to a situation.
I believe in diligently expanding my knowledge and sharpening my skills, so that I can be more empowered to positively impact the world.
I believe that most people allow their world view to be almost entirely shaped by their childhood, their teachers and by the media. This is mostly not good.
I believe God put us on earth to show love for others through our actions.
I believe that it is possible to have love and compassion for those who seek to harm us, while at the same time, taking wise steps to prevent them from hurting us or our loved ones.
I believe that we can’t always control our feelings, but we CAN control our actions.
I believe there are more wonders in the world, big and small, than we will ever be able to explore in several lifetimes.

My medical students often ask me how I decide what to post about. Usually, it’s just whatever pops into my head. Other times, like today, it’s on things that I have to explain over and over again to many different people. I realized that if something is inherently so confusing as to have the need to clarify it repeatedly, then it would do the world some good to put it down in words for everyone to read at their leisure.

Three different terms that are used in overlapping fashion are cyst, egg and follicle. The EGG is that all-important biological specimen that contains half a woman’s genetic information. In my simplified view of human reproduction, a woman randomly shuffles all her DNA (the stuff that influences her body to develop blue eyes, a cute little nose and a fondness for puppies) and packages exactly half of it into each egg. The goal then, is for the egg to unite with one of her husband’s sperm, which very coincidentally contains half of HIS genetic information. The final product is a baby, a tiny person with genetic information from both parents. We can’t see eggs on ultrasound, because eggs are smaller than a speck of dust. What we CAN see are FOLLICLES. Imagine a follicle to be like a water balloon with a speck of magic dust (the egg) inside it. A woman is born with about a million of these packed inside her ovaries. Each month after she reaches puberty, some of these follicles start to fill up with water like expanding water balloons. Most will grow just a little and then fizzle out. However, the biggest one, which gets crowned with the title of THE DOMINANT FOLLICLE will grow from microscopic size up to about 20mm, roughly half the diameter of a golf ball. Once it reaches that size, it should burst and let the egg fly out. Under ideal conditions, the egg gets slurped up into the Fallopian tubes where it can hopefully meet a nice eligible sperm and then off they go into the uterus to implant.

So when doing ultrasounds, I’ll often report to my patients, "Great news! You are growing two eggs in each ovary for a total of four, giving you four chances at pregnancy this month! Right now they are still a few days away from being ready." When they ask how I know that, I answer "Based on the measurements." This is where the patients naturally assume that by measurement, I am talking about the size of the eggs. But as you probably realize know after having paid attention to what I just wrote, I’m actually talking about the size of the follicles.

Now that we have clarified the relationship between an egg and a follicle, where does the term CYST come into all this? A cyst can be defined as a CLOSED SAC, sometimes filled with a substance like fluid, air or blood.. So actually, follicles are cysts. They happen to be GOOD cysts as opposed to bad cysts. So medically, CYST is the term we use to generically refer to many different sac-like structures, not just dust-filled water balloons. Cysts can be found in many places like in breasts, under the skin, in the cervix or in the brain. Furthermore, ovarian cysts can be the good kind (follicle) or bad kinds, such as endometriomas which are harmful cysts filled with fluid that looks like chocolate syrup.

Now here’s the tricky part. A follicle and a simple cyst look identical on ultrasound. So using just one single ultrasound, nobody can say for sure whether we see a good follicle or some other type of cystic structure. However, if you look again on ultrasound three days later and see that the water balloon has grown from 14mm to 19mm, then you get a pretty good idea that it is a growing follicle. If instead, your repeat ultrasound shows nothing, then it turns out that it was most likely a cyst which has gone away on its own.

The typical protocol for patients who are taking strong fertility drugs is to do a cyst check prior to starting the stimulation medications. This is an ultrasound done on about day #3 of the cycle. What we want to see is nothing. What we don’t want to see, but sometimes do, are cysts and if they are big enough, it tells us that this is not a good month to do a cycle, so we postpone things.

Finally, let’s go back to the idea of how it’s normal each month for a single healthy water balloon to grow to a mature size and ovulate its precious contents. Remember, I alluded to this being the dominant contender out of several contestants which start the race, meaning most women will start growing a lot of potential follicles each month, but without medications, they should just ovulate one (or occasionally two). The other follicles should quickly all fizzle out and not even grow to a visible size. However, there are some women with a common medical condition in which the ovulation process goes haywire. Instead of one dominant follicle emerging and the others all shrinking to nothingness, what happens is that a whole bunch of the follicles keep growing, but none really make it to mature size. So instead of seeing one large 20mm water balloon and nothing else, you see a whole bunch of 12mm follicles stagnated in their growth. Some of you have probably already guessed that this condition in which multiple small ungrowing non-ovulating follicles are seen in the ovary is called POLY-CYSTIC OVARY SYNDROME, but that’s a story for another day.