How TCM treats Infertility | Full Guide

How TCM treats Infertility | Full Guide

What is infertility and how TCM can help?

Infertility is considered an inability to conceive in a sexually active couple who are trying to get pregnant for one year. About 8-12% of the couples in the world are facing problems with infertility, and in this modern times the per cent is getting bigger, and 20% of the cases are due to both male and female factor. By the theory of Traditional Chinese Medicine (TCM), infertility occurs due to disrupted vital balance and blockages in the Qi energy and Blood circulation flow.

TCM can be utilised in infertility consultations as an alternative as well as supplement to other medical methods. In this context, it benefits from the fact that the unusual reception of TCM in the West has integrated aspects of psychological diagnosis and care, in addition to the therapeutic application of acupuncture/moxibustion and Chinese medicinals, into a special treatment concept.

The philosophy in TCM is that you are able to treat infertility issues and conceive naturally when you are more balanced physically, mentally and emotionally. Using TCM, I guide my patients to achieve in their overall well-being rather than focusing on infertility definitions or tiny details of implantation.

How prevalent is infertility worldwide?

In Germany, about 15% of all couples have problems with fertility[1]. In the United States, about 10 percent of women (6.1 million) in the United States ages 15-44 have difficulty getting pregnant or staying pregnant, according to the Centers for Disease Control and Prevention (CDC) report dated Apr 1, 2019. That is an incredible number to start with. It is becoming evident that fertility problems will increase further in the coming years because women, those with a higher level of education in particular, are delaying the question of having a child until the time that biomedicine tends to associate with approaching menopause. In my country, about 15 percent of couples in Singapore do not get pregnant successfully within 12 months of trying to conceive (or TTC). The good news is, TCM is generally accepted in my country and people have been turning to it for infertility treatments.

What are the causes of Infertility?

  • Ovulatory and hormonal disorders (including polycystic ovarian syndrome, premature ovary failure).

  • Unexplained.

  • Endometriosis.

  • Blocked or damaged fallopian tubes (including previous infections of the reproductive organs, PID/STD, scars from previous surgery).

  • Male factor (including low sperm count, poor morphology and poor motility).

Other uncommon causes of infertility/subfertility:

  • Scarring of the uterus or birth defects.

  • Hostile cervical mucus.

  • Antibodies that attack sperm, thyroid disorders.

What are the risk factors of infertility/subfertility?

  • Age – a woman’s chances of becoming pregnant decline dramatically with age.
  • Emotional factors, such as depression and stress.

  • Occupational and environmental risks, such as prolonged exposure to radiation, certain chemicals, high temperatures, microwave emissions, etc.

  • Alcohol intake and smoking.

  • Obesity or being underweight

How TCM treats infertility

From the perspective of TCM, all viscera, bowels, and channels participate in this process. Only their harmonious cooperation ensures that fertility disorders are prevented.

The factors associated with infertility can be very complicated and TCM can help to treat some of them.

Basically, infertility is very closely related to the kidney essence from the view of TCM. In TCM, the kidney governs not only the urinary system but also the reproductive and endocrine systems.

For a female to have a normal and healthy menstrual cycle leading to successful pregnancy, it would only occur when kidney Qi is abundant as well as there is sufficiency of both essence and blood. Any factors that affect the kidney essence will fail to conceive a fetus.

TCM involved in the treatment of infertility relies upon a carefully differential and personalized diagnosis (Chinese syndrome differentiation), in combination with herbal formulas or acupuncture to resolve underlying patterns of disharmony in an individual. The Chinese syndrome differentiation involves the analysis and synthesis of the clinical data obtained by four examination methods, that is, inspection, listening and olfactory, inquiry and unique pulse-taking to further investigate the nature of the disease.

TCM Theory Part 1: YinYang阴阳

TCM theory is based on a number of philosophical constitutions including the theory of Yin-Yang and Qi-blood, the Five Elements, Meridian system, Zang Fu organ theory, and others. The theory approaches human health from macroscopic and integrated parts of view due to the lack of modern molecular knowledge. It is an early form of integrated medicine and system biology.

The basic concept of TCM has originated from the theory of Yin-Yang. Yin-Yang represents two opposite yet complementary entities, which kept balancing to reach homeostasis. Imbalance of Yin and Yang off a boundary triggers off diseases and accounts for their progression. The current chaotic concept is consistent with this theory.

For instance, relatively dominant Yang can be linked to inflammation caused by pathogenic infection and manifested in high fever, sweating, reddish complexion and rapid pulse. On the contrary, relatively dominant Yin can be linked to insufficient immunity or poor blood circulation and manifested in cold symptoms such as lassitude, floating, whitish complexion, cold limbs and slow and weak pulse. In general, how to maintain the perpetual dynamic equilibrium of Yin and Yang in individuals is the critical task for a TCM practitioner for the sake of maintaining the health condition of patients.

TCM Theory Part 2: Qi 气(Energy)

In addition to Yin and Yang, Qi and blood are also important concepts in TCM. The scientific definition of ‘Qi’ and ‘blood’ is not well defined in today’s biochemical and molecular microscopic terms.

Qi is considered as a vital energy that flows through the human body and universe. This could include magnetic electronic force or biochemical process. It is the most indispensable energy that makes up the vitality of the body and maintains life activities. The physiological function of Qi is linked to the energy of the body to protect from the invasion of various pathogens and produce and propel body fluids and blood to different viscera and organs regularly.

Blood includes the blood circulation inside the blood vessels, stasis of blood vessels in different tissues and platelet activities, and so on. Qi and blood are coupled just like Yang and Yin. Chinese medicine is based on the concept of Qi, blood, Yin, and Yang. By understanding the meaning of each concept and the way they relate to each other, one will be able to appreciate the treatment rendered in TCM.

Lack of Qi 气虚
Any state of qi vacuity is usually rooted in the spleen or lung, since the lung directs the qi and the spleen, by its moving and transforming activity, is the source of qi. Lack of qi manifests in shortness of breath, fatigue, a weak voice, lack of appetite and strength, and sometimes diarrhea and spontaneous sweating. The pulse is weak and vacuous, the tongue pale with a whitish fur.

Qi Stagnation 气滞
Qi can wane in its movement and cause stagnations. Frequently, the decisive is an insufficient regulatory function in the liver. These stagnations can be felt as palpable abdominal “knots” that change their location and can even disappear altogether. They are accompanied by painful, pulling feelings of tension and pressure in the entire abdominal region, with irritability, emotional instability, and periods of mental depression.

TCM Theory Part 3:  Blood 血

A direct translation of xue as “blood” does not do justice to the Chinese understanding of the function and attributes of blood. Rather, blood is the material form of qi, and it nourishes and moistens the body. With the help of the spleen, the blood of the body xue shui (blood-water 血水) is formed from ying qi (constructive qi阳气) and bodily fluids; spleen qi also contains it in the blood vessels. The blood is stored in the liver, especially in the muscles (uterus!). The liver thereby also regulates the volume of blood.

The menstrual blood, on the other hand, the jing shui (menstrual water 经水), is produced from kidney water and is transformed with the help of the heart, liver, and spleen. Kidney water or kidney yin is hence the foundation for the formation of menstrual blood. The kidney is the storehouse of prenatal jing and yuan qi (original qi).

Kidney is also the source of menstrual blood and of sexual maturity, the so-called tian gui天癸. Tian means heaven, and gui is the 10th heavenly stem from the old Chinese calendrical system that ordered the macrocosm. It is associated with the element water. This “heavenly water” is present in the human body from birth on, but only manifests with sexual maturity. In the man, the tian gui regulates the transformation of blood into semen; in the woman, it starts the menstrual period and provides for the moistening of the vagina. Thus, girls begin menstruating at the age of 14 because this is when the heavenly water has arrived. The ren mai(任脉) opens and fills with qi, the chong mai(冲脉) fills with blood, and the girl is ready to conceive.

Lack of Blood (blood deficiency 血虚)

General lack of blood causes insufficient nourishment of the mucous membranes of the uterus and ultimately also of the embryo. Fertilisation of the egg is not complete because the endometrium is insufficiently formed. A lack of liver blood in particular supplies the uterus with an insufficient amount of blood, the menstrual period is scant, and the cycle can become irregular or even cease altogether. A weak menstrual period with rather pale blood and in general a longer cycle are typical of this pattern. Such women are pale, they feel tired, without energy, often dizzy, and generally rather depressed. Often, the vision is also impaired and her skin is dry.

TCM Theory Part 4: Jing 精 (Essence)

Jing, qi, and xue are vital substances that are essential for reproduction. Their unimpeded circulation guarantees theharmonious progression of all body functions.

The vital essence jing consists of two components:

  1. First, the congenital prenatal potential, the constitution so to speak, that was inherited from the parents.

  2. Second, it consists of the acquired jing, which a person can increase or at least maintain throughout the course of his or her life.

In accordance with the laws of nature, jing runs out towards the end of life. The amount of prenatal jing that a person is born with is predestined by fate. We can try to use it sparingly and continuously replenish the store in the kidney with acquired jing by a correct lifestyle (yang sheng 养身, “nurturing/ cultivating life”). In addition to proper diet, lifestyle, and breathing and movement exercises, the preservation of jing also includes advice on sexuality.

Jing is stored in the kidney. When it is strong, it enables women to still bear children after their 40th birthday.

Lack of Jing 精亏

Weak jing leads to weak, sickly children, delayed puberty, and partly to underdeveloped primary and secondary sexual characteristics. In women, we often find not only menstrual irregularities, but also eggs of lower quality, which can then be fertilized only with difficulty and often produce weak embryos. In the man, a lack of jing causes low-quality sperm or a reduced sperm count. Generally speaking, a lack of kidney jing has a complicating effect on reproduction.

What are some of the latest TCM research regarding infertility?

TCM has a long history of treating infertility in both women and men, and reports of successful cases have made a significant part of chinese gynecology/obstetrics textbooks. Recently clinical research studies have further supported that Chinese medicine is a useful tool for improving natural pregnancy and live birth rates by treating infertility in both women and men. When used in conjunction with assisted reproductive technology, TCM treatment increases the number of oocytes retrieved; improves the quality of eggs and sperms; enhances the chances of clinical pregnancy and live birth rates; and minimises the symptoms caused by IVF treatment. Furthermore, TCM treatment reduces the chances of miscarriages, and relieves some of the symptoms associated with pregnancy with no adverse effects.

Increased number of oocytes retrieved during IVF

In a recent case study, infertile female patients undergoing IVF treatment were divided into two groups: (1) a treatment group with a minimum of two sessions of acupuncture 5 to 7 days prior to and on the day of embryo transfer, and (2) a control group without acupuncture treatment. Amazingly, it was reported that after only a few sessions of acupuncture, the treatment group showed an increased number of oocytes retrieved, and a significantly lower number of first trimester miscarriages, although both groups showed similar fertilization rates, pregnancy or implantation rates, and endometrial thickness on the day of HCG administration[2].

Increased pregnancy rate

In a similar but much bigger clinical trial (160 participants), acupuncture was given before and after embryo transfer in 80 patients and a similar-sized control group without any supportive therapy. The clinical pregnancy rate was 42.5% in the acupuncture group but only 26.3% in the control group, indicating the usefulness of acupuncture treatment for improving pregnancy rate after assisted reproductive technology[3].

Increased pregnancy rate and reduced ectopic pregnancy and miscarriages rates

In another larger clinical study, the acupuncture treatment significantly enhanced the pregnancy and live birth rates and decreased the ectopic pregnancy and miscarriage rates both in IVF poor responders (with elevated FSH and longer history of infertility) and in IVF patients with good prognosis[4].

Reduced the dosage of gonadotropins injections during IVF

In a randomized controlled double-blind cross-over study the efficacy of acupuncture as an adjunct to IVF was evaluated. A significantly lower amount of gonadotropins was required when IVF was combined with standard acupuncture. Most importantly a 70% pregnancy rate was achieved with standard acupuncture and IVF, compared to 25% pregnancy rate with IVF only[5].

Improved follicle development, uterine blood supply and endometrium thickness

In a controlled clinical study infertile patients were treated with Clomiphene either alone or in combination with herbal medicine, and were followed up for one year. Although no significant differences were found in ovulation rate, pregnant rate and miscarriage rate, the Chinese medicine group showed significant improvement in menstruation, follicle development, uterine blood supply, and endometrium thickness compared with the group treated with clomiphene alone. Patients in both groups showed similar minimal side effects which did not need medical intervention. The results indicate that herbal medicine is superior to Clomiphene in restoring regular menstruation, improving uterine blood circulation and may thus improve pregnancy rates[6].

Improved pregnancy rate in patients with PCOS

Chinese herbal medicine was used to treat 76 infertile women with polycystic ovarian symdrome (PCOS) and 31 matched patients were treated with Clomiphene. The herbal group showed an improved menstruation with a pregnancy rate of 65.7% whereas the Clomiphene group did not show any effect on the menstruation. The pregnancy rate was only 25%[7].

Improved symptoms in patients with endometriosis

A study recruited 53 infertile women with endometriosis and treated them using Chinese herbal medicine. A significant relief of the symptoms related to endometriosis (such as dysmenorrheal and menstrual disorder) was found after 3.5 months treatment. Twenty two of the ovarian chocolate cysts became smaller and 16 disappeared. The pregnancy rate was 45%[8].

Improved sperm quality in men

In a prospective controlled and blind study, nineteen patients with semen abnormalities in concentration, morphology and/or progressive motility without apparent cause were randomized into two groups and submitted to acupuncture and moxa treatment at the therapeutic (Study Group) and the indifferent points (Control Group), respectively, for 10 weeks. The patients of the Study Group presented a significant increase in the percentage of normal-form sperm compared to the Control Group[9].

Improved fertilisation rates in ICSI treatment

Twenty two patients with idiopathic male infertility who failed previous intracytoplasmic sperm injection (ICSI) treatment were treated with acupuncture twice weekly for 8 weeks before embarking on another ICSI treatment. Fast sperm motility was significantly improved, and the percentage of sperm with normal morphology significantly increased. Most importantly, the fertilisation rates were significantly increased compared with the previous ICSI treatment [10].

Reduced nausea in first trimester pregnant women

A study reported that nerve stimulation therapy (acupuncture) is effective in reducing nausea and vomiting and promoting weight gain in symptomatic women in the first trimester of pregnancy[11].

Improved insomnia in pregnant women

In a recent prospective quasi-randomised controlled clinical study, 30 pregnant women were allocated at random into two groups: control (without acupuncture), and acupuncture group. The acupuncture group showed a significant reduction in insomnia compare with the control group [12].

Potentially helpful in preventing miscarriages 

Twenty patients with early symptoms of threatened miscarriage (such as vaginal bleeding, abdominal cramps) in the 7-8th week of gestation were treated with a classical herbal formula combined with psychological consultation. In 16 patients the symptoms disappeared, indicating the use of herbal medicine in threatened miscarriages[13].

How I treat fertility issues with TCM

Whether you are having trouble getting pregnant, have had pregnancy loss or complications, or haven’t even started trying, boosting fertility naturally is an important step to have a healthy pregnancy and a healthy baby.

Usually TCM can achieve good results by diagnosing Chinese pattern identification with biomedical pathology. For example, a female patient whose infertility is accompanied by problems such as endometriosis, PCOS, luteal phase defect (LPD), or dysfunctional uterine bleeding can become pregnant when treated with TCM.

We are unique individuals

Just as we are intricately different, our fertility challenges are also different. TCM has a very unique way of treat infertility. Every treatment plan is customised and no treatment prescription is identical. I could have three different women with the same Western medical diagnosis of PCOS, and they will all be treated differently. This is one big distinction between Western and Eastern Medicine. 

During my consultation, I don’t just talk to them about menstrual cycles and ovulation, I talk also about your sleep, diet, energy levels, sex drives, lifestyle factors, emotional states, stress and bowel movements. TCM takes into account every aspect of every patient – body, mind and spirit- as there is so much more into infertility than just plain physiology.

TCM + Western

I don’t usually ask my patients to discontinue your Western medications and take TCM only. A patient with PCOS, for example, can supplement TCM treatment with Clomifen/hCG or Metformin, to profit from the advantages of both methods. Of course, I will explain in details with the patient to manage expectations.

For endometriosis patients, if they are still not pregnant after 3-6months of TCM treatment, laparoscopy is advised. Afterwards, we continue treatment with TCM because the pregnancy rate 6 months after laparoscopy is relatively high. This results either from the stimulation of ovulation or from the additional softening of adhesions and tissue growths, as a result of which the function of the ovaries and fallopian tubes is supported.

I have to emphasise that patients after a laparoscopy should not go without additional treatment. This would reduce the possibility of a pregnancy because these patients often suffer also from lack of ovulation, LPD, luteinized unruptured follicle syndrome (LUFS), or immune problems. Moreover, endometriosis relapses are common.

Good results can also be achieved with TCM in the treatment of male infertility patients in whom sperm density is less than 20 million/mL and sperm activity is reduced. This is suitable for patients who want to conceive naturally or IVF treatment. Either way you need healthy sperms for treatment to be successful.

Tongue and Pulse Diagnosis

Many are puzzled with tongue and pulse diagnosis. Actually they are not as mystified as it seems. When I feel your radial artery through my fingers, I am actually paying attention to the rate and rhythm of the pulse, as well as its qualities. How the blood flows within the blood vessels, and how fast it flows, indicates the person’s health and vitality.

Tongue provides another glimpse into the overall state of an individual’s health. The tongue is the only visible internal muscle in the body. Its colour, size, shape as well as the thickness of the coating, colour of the coating, reflect a lot about one’s health. 

Unexplained Infertility

There are so many patients diagnosed with ‘Unexplained Infertility’. However, when these patients arrive in my clinic, I find so many misalignments from a TCM perspective, physically and emotionally.This is why being so negative about your own pregnancy chances are so detrimental to your own body and if you don’t believe in your body and fertility, chances are it is going to be hard getting pregnant.

I strongly encourage to take 3-6 months to get your fertility health back in order before you pro-actively try to conceive. This is to allow a strong and healthy foundation for pregnancy. 

However, if time is not on your side, acupuncture and Chinese Medicine can help increase your chances of conceiving and having a healthy pregnancy.

Can I take TCM if I am visiting a Fertility Clinic?

Definitely you can.

I always ask my patients to see fertility clinic as a step on their path and suggest you to take it as an opportunity to gather as much medical information about your current baseline reproductive health as possible. Don’t view it as something stressful and negative. Along the way, always remember that you are in charge of your health and pay attention to your intuition when it is time to make important decisions.

Be Positive

Create a positive state of mind before attending your first appointment. As what we are educated in medical schools, typically compare your results are compared against the “norm”. But you are a dynamic individual, capable of change and you body has an innate way of healing itself. NEVER consider any diagnosis to be the final word. Evaluation is always an educated guess, based on statistical averages and numbers. Every woman is unique, and many babies are born despite unfavourable diagnoses.

When you hear about ‘low quality eggs’, always remember that eggs are cells that develop over the course of a year. From a TCM perspective, you can have a profound impact on your eggs’ health in their last 90-120 days, while they are growing and proliferating, by making positive changes in your life and diet.

Be in control of your health

If you have already been visiting a fertiliy clinic for some time and found it difficult, try to reframe your visit with these thoughts in mind: It was an opportunity to collect baseline information about your reproductive health. Advice are there to guide you but you can only be guided if you are comfortable and by listening to your intuition. 
(adsbygoogle = window.adsbygoogle || []).push({});

What happens in your first visit?

  • Your first consultation usually takes an hour – or longer, so make sure you give yourself enough time. 
  • We will first look through all the reports you currently have and a thorough case history is usually taken during your first session. (so it is important that you bring all your relevant reports)
  • We will usually discuss your full medical history, including details of your menstrual cycle. 
  • Tongue and pulse diagnosis will also be carried out. 
  •  We will discuss the healthiest ways to boost infertility and prepare your body for pregnancy and conception using TCM. 
  • We will also review your current health and health history (and if available, any recent blood tests) to come up with individualized recommendations based on balancing your body naturally through TCM diagnosis.
  • For couples, we review the health of both partners and identify specific recommendations to support each partner.
  • We will then review your current diet and nutritional supplements and I will make recommendations if needed.
  • Your treatment plan will then be discussed and agreed. 
  • We discuss infertility awareness techniques and the best timing to increase your chances to conceive using TCM theories.
  • Acupuncture is often given in the first session. 
  • You may feel a tingling sensation or a slight ache when the needles are inserted but it shouldn’t be painful. 
  • Let me know if you feel uncomfortable during the acupuncture session. You may feel drowsy or fatigued following your session, so aim to go home and relax afterwards if possible.

What treatments can you expect

When you visit us for the first time, you will be introduced to fertility acupuncture and TCM herbal prescriptions, used alone or in conjunction with in vitro fertilization (IVF), intrauterine insemination (IUI), assisted reproductive technology (ART), or other conception modalities advised by a Doctor or other Health Care Professionals. 

Acupuncture and Chinese Medical Herbs are contraindication-free, and can greatly enhance the potential for conception. Acupuncture treatments help to release energy blockages in women who tend to be physically and emotionally struggling with becoming pregnant, and who may have endometriosis, fibroid tumors, PMS symptoms, irregular cycles, polycystic ovarian syndrome (PCOS) and other disorders or factors which are causative of infertility.

Your treatment is completely individualized based on your body’s needs. We address health issues that may get in the way of fertility as well we address any other health issues for your overall health and well-being. This holistic treatment plan is designed to help you be your healthiest possible.

Treatment includes:

  • acupuncture and Herbal Chinese Medicine

  • guidance on the best nutritional supplements for healthy fertility and healthy pregnancy

  • guidance on fertility-boosting foods

For patients undergoing IUI/IVF/FET Treatments, acupuncture can boost your reproductive procedures. Research has shown that acupuncture is safe and effective to improve IUI and IVF/FET outcomes.

Acupuncture can:

  • improves the quality and thickness of the uterine lining

  • increases blood flow to the uterus and ovaries

  • decreases chance of miscarriage

  • decreases side effects of medications

  • reduces stress

Based on your body constitution and condition, I will discuss with you when will be a good time to begin acupuncture prior and during your IVF cycle.

 Book a consultation today to find out more how TCM can help your fertility journey.

Edmund graduated with a First Class Hons in Biomedical Sciences and Traditional Chinese Medicine from Nanyang Technological University, before taking a Masters in Gynaecology(TCM) in Liaoning, China. 

He has successfully treated patients with unexplained infertility, Polycystic Ovarian Syndrome(PCOS) and endometriosis and helped them conceive naturally with Traditional Chinese Medicine.

Related Posts

[1] Thöne C, Rabe T. Wir Wollen ein Kind! Unfruchtbarkeit: Ursachen und Behandlung. Munich: dtv; 1996.
[2] Khorram N.M., et al. The effect of acupuncture on outcome of in vitro fertilization. Fertility and Sterility 2005;84: S364.
[3] Paulus WE, et al. Influence of acupuncture on the pregnancy rate in patients who undergo assisted reproduction therapy. Fertility & Sterility 2002;77(4):721-4.
[4] Magarelli P.C., et al. Acupuncture and good prognosis IVF patients: Synergy. Fertility and Sterility 2004;82:S80-81.
[5] Quintero R, et al. A randomized, controlled, double-blind, cross-over study evaluating acupuncture as an adjunct to IVF. Fertility and Sterility 2004;81:11-12.
[6] Xia YW, et al. Therapeutic effect of Chinese herbal medicines for nourishing blood and reinforcing shen in treating patients with anovulatory sterility of shendeficiency type and its influence on the hemodynamics in ovarian and uterine arteries. Chinese Journal of Integrated Traditional & Western Medicine 2004;24(4):299-302.
[7] Hua L, et al. Clinical study of yishen jianpi yangxue tongli therapy in treating polycystic ovary syndrome. Chinese Journal of Integrated Traditional & Western Medicine 2003;23(11):819-22.
[8] Zhu WX and Cheng XA. Clinical study of the treatment of endometriosis with promoting blood circulation and stasis removing method. Chinese Journal of Integrated Traditional & Western Medicine 1993;13(1):16-8.
[9] Gurfinkel E, et al. Effects of acupuncture and moxa treatment in patients with semen abnormalities. Asian Journal of Andrology 2003;5(4):345-8.
[10] Zhang M, et al. Influence of acupuncture on idiopathic male infertility in assisted reproductive technology. Journal of Huazhong University of Science and Technology. Medical Sciences 2002;22(3):228-30.
[11] Rosen T, et al. A randomized controlled trial of nerve stimulation for relief of nausea and vomiting in pregnancy. Obstetrics & Gynecology 2003;102(1):129-35.
[12] da Silva JB, et al. Acupuncture for insomnia in pregnancy–a prospective, quasirandomised, controlled study. Acupuncture in Medicine 2005;23(2):52-61.
[13] Sun F et al. Miscarriage prevention tea affects plasma beta-endorphin concentrations in women with early threatened abortions. American Journal of Chinese Medicine 1999;27(2):277-82. 

Leave a Comment