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Coming Soon…

*From the Conception Booklet by the Jocelyn Center in Sydney Australia. www.fertility.com.au
© Copyright Natural Fertility Management Pty Ltd, 2004

Some of the children walked up to the stage; others limped or ambled proudly using walkers or braces. Several confined to wheelchairs muscled their way through the crowded rehearsal hall up the ramp to take their places center stage.

As the syncopated beat of Stomp spilled into the uncoordinated bodies of children banging sticks to the music, I stared up at the unfinished ceiling of the gymnasium and my heart ached. I turned my gaze toward the audience watching a small group of children move their arms and legs a beat behind the music while laughing and conversing with heavy tongues and slurred speech.

Then I caught a glimpse of an autistic child sitting apart from the rest wearing a helmet and a protective vest unable to cope with the enormity of sights, sounds, and physical closeness. His personal teacher sat beside him. Several of the Special Education assistants moved their bodies to the music initially appearing upbeat and jubilant but a closer look exposed a desperate resignation. For many of these children it was a long haul to self-sufficiency and for others, dependency on a private caregiver would be a lifelong reality.

Pioneering nutritional scientific research points to the sobering truth: the incidence of children with brain disorders is escalating disproportionate to the success of improved awareness and diagnostic tools. Increasing evidence of nutrient deficiency during key developmental stages strongly suggests a correlation between inadequate diets and neurodevelopmental difficulties. Now I looked back into the crowd and surveyed the scene: children with neural tube defects, Down’s syndrome, autism, cerebral palsy, and mental retardation. My gut twisted with this thought: what if many or most of these conditions are influenced by more than genetics or chance and are preventable with proper nutrition?

Several months later I found myself – a seasoned Montessori educator turned nutritional researcher and therapist – boarding a plane to London. It was finally time to meet my long-distance mentor, Professor Michael Crawford, the Director of the Institute of Brain Chemistry and Human Nutrition and world-renowned nutritional scientist. Professor Crawford and I had been corresponding for several years.

Classroom meets laboratory? Perhaps. But my quest to correlate a child’s individual breakfast and lunch fare to the hard science of nutrients and brain function turned out to be infinitely more involved than simply observing the dietary improvements for my three-year-old students. My relationship with Professor Crawford became a stewardship as he directed me to the province of brain growth and development in utero and the paramount importance of the nutritional status of the mother-to-be. Childless and bursting with maternal hormones, the more I learned about preconceptual and prenatal nutrition, the more I wanted to make every fertilized egg, embryo, fetus, and newborn my own.

With medical dictionary in hand, volumes of research, and tutelage from Professor Crawford (whom I now call Michael and friend) I was increasingly astonished at the mounting evidence. Nutrients are integral in the physiological pie of creation and nutritional scientists continue to publish data that suggest nutritional disorders cripple early cell division sometimes leaving the brains of our children behind.

Many of the devastating insults during brain development occur during the first three weeks of gestation when the neural tube is about the size and shape of this “C.” Health professionals and government agencies stress the importance of the nutrient, folate, or folic acid, prior to conception and throughout pregnancy. But folate is not the lone nutrient in the preconceptual wilderness. To work, it relies on both vitamin B12 for neural protein synthesis to build new cells and on zinc the transcriber of the genetic code (DNA) and nature’s premier antioxidant.

Deficiencies of folate or its accessory nutrients retard DNA growth which impacts the formation of the neural tube. Failure of fusion can lead to a cleft palate, cerebral palsy, or malformation of the spine, commonly called spina bifida. Where this tiny “C” fuses together is the stem of the primitive brain.

Anencephaly which occurs once in one thousand births, is a neural tube defect that halts brain growth. Twenty-five percent of these babies are stillborn. The remainder live long enough to wear knitted skull caps to cover their gaping craniums, awaiting imminent death.

The grey area between profound deformity, mental retardation, autism, Down’s syndrome, dyslexia, and attention deficit hyperactivity disorder (ADHD) is difficult to pinpoint but is increasingly emboldened by highly sophisticated magnetic resonance imaging (MRI) that determines the location and timing of injury to the brain. Dr. Patrica M. Rodier of The University of Rochester School of Medicine has identified an environmental-induced, embryological origin for autism at the time of closure of the neural tube where the cranial nerve motor nuclei is forming – laying down lines of communication between the left and right hemispheres of the future brain. Imperfect connections between regions means reduced signalling between the brain’s feeling right side and thinking left side. This would reduce a person’s consciousness of their feelings, as in autism, and account for impulsiveness, compulsiveness, and diminished social skills that traditionally accompany autism. Other skills can become hyper-developed, such as instances of musical, mathematical, and artistic savants.

A cell adhesion molecule from the developing embryo and evidence of a relationship between families of children with neural tube defects has been identified in Down’s syndrome. This common thread in evidence leads us to a new scientific paradigm: nutrigenomics – the study of nutrients and their “system fingerprints” in gene expression. Though genetics provides the template for central nervous system and brain design, nutrients play a tremendous role in the enzymatic activity responsible for healthy cell proliferation. Johan Hultdin has identified a “folate trap” created by a nutritional disorder involving vitamin B6 and B12 in Down’s syndrome. Enzymatic activity for vitamin B6 is located on chromosome 21, where extra duplication (trisomy) is the hallmark of Down’s syndrome.

The small intestines develop shortly after the neural tube. Poor cellular formation of the lining can result in malabsorption of vital nutrients needed for fetal brain growth and connectivity. Impaired absorption of vitamin B12 could interfere with nerve mylenization and result in impaired nervous system development. Much of the data related to innate gut immune abnormalities and food intolerances in children with neurodevelopmental difficulties point us in the direction of a strong brain-gut interrelation.

Evidence of the power and impact of nutritional deficiency on neurological development in utero has amassed thousands of articles in scientific literature. The fetal brain grows at a prodigious rate of 250,000 neurons per minute depending on energy from the maternal thyroid which is fueled by iodine. Endemic cretinism, severe mental retardation associated with deaf mutism, is astonishingly preventable with maternal dietary iodine prior to conception.

Maternal deficiencies of vital nutrients are conclusive in the cord blood of premature and low birth weight babies. These little ones are at high risk for permanent neurological impairment at a time when perinatal fatty acids, particularly docosahexaenoic acid (DHA), fosters rapid brain growth and refines neural circuitry and signaling. The recent in-vitro fertilized embryos of the now famous California octuplets whose median birth weight is two pounds replays this risk as a sequel to the 1998 Houston octuplets involving one death and two children developing cerebral palsy.

Lesson’s learned? In today’s fast food-a-rama, nutrients are pummeled and synthesized beyond the cells recognition resulting in fake nourishment for real-life developing brains. Restoring nutritional potency into our diets by eating seeds, nuts, whole grains (germ and bran in tact) legumes, fruits, vegetables and protein from grass-fed animals and wild fish is paramount during preconception and gestation to provide the best opportunities for a successful pregnancy.

And whether our cells are “slightly used” or “over the hill” research points us in the same direction as we try to sustain mental health and reduce the risk of cognitive decline including Alzheimer’s disease.

Would the lives of the disabled performers in the production of Stomp have been any different if their preconceptional diets contained more whole/real food nutrition? No one knows for sure. But nutritional investigators all over the world are living up to the universal challenge proposed by Albert Einstein; “The important thing is not to stop questioning.”

Copyright © 2009 Jan Katzen-Luchenta AMI CFP

CLICK HERE to see the posters

Jorge Chavarro, M.D., and Walter Willett, M.D., of the Harvard School of Public Health, and colleagues, “followed a cohort of 17,544 women without a history of infertility for 8 years as they tried to become pregnant or became pregnant. A dietary score based on factors previously related to lower ovulatory disorder infertility (higher consumption of monounsaturated rather than trans fats, vegetable rather than animal protein sources, low glycemic carbohydrates, high fat dairy, multivitamins, and iron from plants and supplements) and other lifestyle information was prospectively related to the incidence of infertility.”¹

The researchers noted, high fertility scores were related to consuming more high-fat dairy products versus low-fat products.

Drs. Chavarro and Willett are co-authors of the book The Fertility Diet: Groundbreaking Research Reveals Natural Ways to Boost Ovulation & Improve Your Chances of Getting Pregnant.

Read the full article here

1. Obstetrics & Gynecology. 110(5):1050-1058, November 2007.
Chavarro, Jorge E. MD, ScD 1,2; Rich-Edwards, Janet W. MPH, ScD 2,3,4; Rosner, Bernard A. PhD 2,5; Willett, Walter C. MD, DrPH 1,2,4

Epidural pain relief is an increasingly popular choice for Australian women in the labor ward. Up to one-third of all birthing women have an epidural¹, and it is especially common amongst women having their first babies². For women giving birth by cesarean section, epidurals are certainly a great alternative to general anesthetic, allowing women to see their baby being born, and to hold and breastfeed at an early stage: however their use as a part of a normal vaginal birth is more questionable³.

There are several types of epidural used in Australian hospitals. In a conventional epidural, a dose of local anesthetic injected through the lower back into the epidural space, around the spinal cord. This numbs the nerves which bring sensation from the uterus and birth canal. Unfortunately, the local anesthetic also numbs the nerves which control the pelvic muscles and legs, so with this type of epidural, a woman usually cannot move her legs and, unless the epidural has worn off, cannot push her baby out, in the second stage of labor.

More recent forms of epidurals use a lower dose of local anesthetic, usually combined with an opiate, such as pethidine, morphine or fentanyl (sublimaze). With this low-dose or combination epidural, most women can move around with support; however the chance of a woman being able to give birth without forceps is still low⁴. Another form of epidural, popular in the US, is the CSE, or combined spinal-epidural, where a one-off dose of opiate, with or without local anesthetic, is injected into the spinal space, very close to the end of the spinal cord. This gives pain relief for around 2 hours, and if further pain relief is needed, it is given as an epidural. These forms of “walking epidural” may seem advantageous, but being attached to a CTG machine to monitor the baby, and hooked up to a drip which is also a requirement when an epidural is in place, can make walking impossible.

Many women have a good experience with epidurals. Sometimes the relief from pain can allow a woman to rest and relax sufficiently to go on and have a good birth experience. However deciding to use an epidural for pain relief can also lead to a “cascade of intervention”, where an otherwise normal birth becomes highly medicalized, and a woman feels that she loses her control and autonomy. Often the decision to accept an epidural is made without an awareness of these, and other, significant risks to both mother and baby.

Although the drugs used in epidurals are injected around the spinal cord, substantial amounts enter the mother’s blood stream, and pass through the placenta into the baby’s circulation. Most of the side effects of epidurals are due to these “systemic”, or whole-body effects.

One of the most commonly recognized side effects is a drop in blood pressure. Up to one woman in 8 will have this side effect to some degree⁵, and for this reason, extra fluids are usually given through a drip to prevent problems. A drop in the mother’s blood pressure will affect how much of her blood is pumped to the placenta, and can lead to less oxygen being available to the baby.

An epidural will often slow a woman’s labor, and she is three times more likely to be given an oxytocin drip to speed things up^{6 7}. The second stage of labor is particularly slowed, leading to a three times increased chance of forceps⁸. Women having their first baby are particularly affected; choosing an epidural can reduce their chance of a normal delivery to less than 50%⁹.

This slowing of labor is at least partly related to the effect of the epidural on a woman’s pelvic floor muscles. These muscles guide the baby’s head so that it enters the birth canal in the best position. When these muscles are not working, dystocia, or poor progress, may result, leading to the need for high forceps to turn the baby, or a cesarean section. Having an epidural doubles a woman’s chance of having a caesarean section for dystocia¹⁰.

When forceps are used, or if there is a concern that the second stage is too long, a woman may be given an episiotomy, where the perineum, or tissues between the vaginal entrance and anus, are cut to enlarge the outlet and hurry the birth. Stitches are needed and it may be painful to sit until the episiotomy has healed, in 2 to 4 weeks.

As well as numbing the uterus, an epidural will numb the bladder, and a woman may not be able to pass urine, in which case she will be catheterised. This involves a tube being passed up from the urethra to drain the bladder, which can feel uncomfortable or embarrassing.

Other side effects of epidurals vary a little depending on the particular drugs used. Pruritis, or generalized itching of the skin, is common when opiate drugs are given. It may be more or less intense and affects at least ¼ of women^{11 12}: morphine or diamorphine are most likely to cause this. Morphine also causes oral herpes in 15% of women¹³.

All opiate drugs can cause nausea and vomiting, although this is less likely with an epidural (around
30%¹⁴) than when these drugs are given into the muscle or bloodstream, where larger doses are needed. Up to 1/3 of women with an epidural will experience shivering¹⁵, which is related to effects on the bodies heat-regulating system.

When an epidural has been in place for more than 5 hours, a woman’s body temperature may begin to rise¹⁶. This will lead to an increase in both her own and her baby’s heart rate, which is detectable on the CTG monitor. Fetal tachycardia, or fast heart rate can be a sign of distress, and the elevated temperature can also be a sign of infection such as chorioamnionitis, which affects the uterus and baby. This can lead to such interventions as cesarean section for possible distress or infection, or, at the least, investigations of the baby after birth such as blood and spinal fluid samples, and several days of separation, observation, and possibly antibiotics, until the results are available¹⁷.

Less common side effects for a woman having an epidural are; accidental puncture of the dura, or spinal cord coverings, which can cause a prolonged and sometimes severe headache (1 in 100)¹⁸ ongoing numb patches, which usually clear after 3 months(1 in 550)¹⁹; and weakness and loss of sensation in the areas affected by the epidural, (4-18 in 10,000) also usually resolving by 3 months²⁰.

More serious but rare side effects include permanent nerve damage; convulsions and heart and breathing difficulties (1 in 20,000)²¹ and death attributable to epidural. (1 in 200,000)²² When opiates are used, a woman may experience difficulty in breathing which comes on 6 to 12 hours later²³.

There is a noticeable lack of research and information about the effects of epidurals on babies²⁴. Drugs used in epidurals can reach levels at least as high as those in the mother²⁵, and because of the baby’s immature liver, these drugs take a long time- sometimes days- to be cleared from the baby’s body²⁶. Although findings are not consistent, possible problems, such as rapid breathing in the first few hours²⁷ and
vulnerability to low blood sugar²⁸ suggest that these drugs have measurable effects on the newborn baby.

As well as these effects, babies can suffer from the interventions associated with epidural use; for example babies born by cesarean section have a higher risk of breathing difficulties²⁹. When monitoring of the heart rate by CTG is difficult, babies may have a small electrode screwed into their scalp, which may not only be unpleasant, but occasionally can lead to infection.

There are also suggestions that babies born after epidurals may have difficulties with breastfeeding^{30 31} which may be a drug effect, or may relate to more subtle changes. Studies suggest that epidurals interfere with the release of oxytocin³² which, as well as causing the let-down effect in breastfeeding, encourages bonding between a mother and her young³³.

Epidural research, much of it conducted by the anaesthetists who administer epidurals, has unfortunately focused more on the pro’s and con’s of different drug combinations than on possible serious side-effects³⁴. There have been, for example, no rigorous studies showing whether epidurals affect the successful establishment of breastfeeding³⁵.

Several studies have found subtle but definite changes in the behavior of newborn babies after epidural^{36 37 38} with one study showing that behavioral abnormalities persisted for at least six weeks³⁹. Other studies have shown that, after an epidural, mothers spent less time with their newborn babies⁴⁰, and described their babies at one month as more difficult to care for⁴¹.

While an epidural is certainly the most effective form of pain relief available, it is worth considering that ultimate satisfaction with the experience of giving birth may not be related to lack of pain. In fact, a UK survey which asked about satisfaction a year after the birth found that despite having the lowest self-rating for pain in labour (29 points out of 100), women who had given birth with an epidural were the most likely to be dissatisfied with their experience a year later⁴².

Some of this dissatisfaction was linked to long labours and forceps births, both of which may be a consequence of having an epidural. Women who had no pain relief reported the most pain (70 points out of 100) but had high rates of satisfaction.

Pain in childbirth is real, but epidural pain relief may not be the best solution. Talk about other options with your care-givers and friends. With good support, and the use of movement, breathing and sound, most women can give themselves, and their babies, the gift of a birth without drugs.

References

1. Perinatal Statistics, Queensland 1996. Queensland Health 1998. At the present time, national figures for epidural use are not collected.
2. Dr Steve Chester, Head of Anaesthetics Dept, Royal Women’s Hospital, Melbourne. Around 45% of primiparous women at RWH have an epidural. Personal Communication
3. World Health Organisation. Care in Normal birth: A Practical Guide..P 16. WHO 1996
4. Russell R, Reynolds F. Epidural infusion of low-dose bupivicaine and opioid in labour. Does reducing the motor block increase the spontaneous delivery rate? Anaesthesia 1996; 51(5): 266-273
5. Webb RJ, Kantor GS. Obstetrical epidural anaesthesia in a rural Canadian hospital. Can J Anaesth 1991; 39:390-393
6. Ramin SM, Gambling DR, Lucas MJ et al. Randomized trial of epidural versus intravenous analgesia during labor. Obstet Gynecol 1995; 86(5): 783-789
7. Howell CJ. Epidural vs non-epidural analgesia in labour. [Revised 6 May 1994] In: Keirse MJNG, Renfrew MJ, Neilson JP, Crowther C. (eds) Pregnancy and Childbirth Module. In: The Cochrane Pregnancy and Childbirth Database. (database on disc and CD-ROM ) The Cochrane Collaboration; Issue 2, Oxford: Update Software 1995 (Available from BMJ publishing group, London)
8. Thorp JA, Hu DH, Albin RM, et al. The effect of intrapartum epidural analgesia on nulliparous labor; a randomized, controlled, prospective trial. Am J Obstet Gynecol 1993; 169(4): 851-858
9. Paterson Catherine, Banfield Philip. Epidural analgesia and maternal satisfaction. BMJ 1991 v302: 1079
10. Thorp JA, Meyer BA, Cohen GR et al. Epidural analgesia in labor and cesarean section for dystocia. Obstet Gynecol Surv 1994; 49(5): 362-369
11. Lirzin JD, Jacquintot P, Dailland P, et al. Controlled trial of extradural bupivicaine with fentanyl, morphine or placebo for pain relief in labour. Br J Anaesth 1989; 62: 641-644
12. Caldwell LE, Rosen MA, Shnider SM. Subarachnoid morphine and fentanyl for labor analgesia. Efficacy and adverse effects. Reg Anesth 1994;19:2-8
13. John Paull, Faculty of Anaesthetists, Melbourne. Quoted in: “The perfect epidural for labour is proving elusive” New Zealand Doctor. 21 Oct 1991
14. as above
15. Buggy D, Gardiner J. The space blanket and shivering during extradural analgesia in labour. Acta-Anaesthesiol-Scand 1995; 39(4): 551-553
16. Camann WR, Hortvet LA, Hughes N, et al. Maternal temperature regulation during extradural analgesia for labour. Br J Anaesth 1991;67:565-568.
17. Kennell J, Klaus M, McGrath S, et al. Continuous emotional support during labor in a US hospital. JAMA 1991;265:2197-220
18. Stride PC, Cooper GM. Dural taps revisited: a 20 year survey from Birmingham Maternity Hospital. Anaesthesia 1993; 48(3):247-255
19. Epidurals for pain relief in labour: Informed choice leaflet for women. MIDIRS and the NHS centre for Reviews and dissemination 1997.
20. Epidural pain relief during labour; Informed choice for professionals. MIDIRS and the NHS centre for Reviews and dissemination 1997.
21. see 13
22. see 13
23. Rawal N, Arner S et al Ventilatory effects of extradural diamorphine.Br J Anaesthesia 1982;54:239
24. Howell CJ, Chalmers I. A review of prospectively controlled comparisons of epidural with non-epidural forms of pain relief during labour. Int J Obstet Anaesth 1992;1:93-110
25. Fernando R, Bonello E et al. Placental and maternal plasma concentrations of fentanyl and bupivicaine after ambulatory combined spinal epidural (CSE) analgesia during labour. Int J Obstet Anaesth 1995;4:178-179
26. Caldwell J, Wakile LA, Notarianni LJ et al. Maternal and neonatal disposition of pethidine in child birth- a study using quantitative gas chromatography-mass spectrometry. Lif Sci 1978;22:589-96
27. Bratteby LE, Andersson L, Swanstrom S. Effect of obstetrical regional analgesia on the change in respiratory frequency in the newborn. Br J Anaesth 1979; 51:41S-45S
28. Swanstrom S, Bratteby LE. Metabolic effects of obstetric regional analgesia and of asphyxia in the newborn infant during the first two hours after birth I. Arterial blood glucose concentrations. Acta Paediatr Scand 1981; 70:791-800
29. Enkin M, Keirse M, Renfrew M, Neilson J. A Guide to Effective Care in Pregnancy and Childbirth. P 287 Oxford University Press 1995
30. Smith A. Pilot study investigating the effect of pethidine epidurals on breastfeeding. Breastfeeding Review, Nursing Mothers Association of Australia. V5 no1 May 1997.
31. Walker M. Do labor medications affect breastfeeding? J Human Lactation 1997;13(2) 131-137
32. Goodfellow CF, Hull MGR, Swaab DF et al. Oxytocin deficiency at delivery with epidural analgesia. Br J Obstet Gynaecol 1983; 90:214-219
33. Insel TR, Shapiro LE. Oxytocin receptors and maternal behavior. In Oxytocin in Maternal Sexual and Social Behaviors. Annals of the New York Academy of Sciences, 1992 Vol 652. Ed CA Pedersen, JD Caldwell, GF Jirikowski and TR Insel pp 122-141 New York, New York Academy of Science
34. Howell CJ, Chalmers I A review of prospectively controlled comparisons of epidural with non-epidural forms of pain relief during labour. Int J Obstet Anaesth 1992 1: 93-110
35. See 31
36. Scanlon JW, Brown WU, Weiss JB Alper MD. Neurobehavioral responses of newborn infants after maternal epidural anesthesia. Anesthesiology, 1974; 40: 121-128
37. Morikawa S, Ishikawa I, Kamatsuki H, et al. Neurobehavior and mental development of newborn infants delivered under epidural analgesia with bupivicaine. Nippon Sanka 1990; 42: 1495-1502
38. Lester BM, Heidelise A, Brazelton TB. Regional obstetric anesthesia and newborn behavior: a synthesis toward synergistic effects.Child Dev 1982; 53;687-692
39. Rosenblatt DB, Belsey EM, Lieberman BA et al. The influence of maternal analgesia on neonatal behaviour II epidural bupivicaine. Br J Obstet Gynecol 1981 24;649-670
40. Seposki C, Lester B, Ostenheimer GW, Brazelton, TB. The effects of maternal epidural anesthesia on neonatal behavior during the first month. Dev Med Child Neurol 1992:34;1072-1080
41. Murray AD, Dolby RM, Nation RL, Thomas DB.Effects of epidural anesthesia on newborns and their mothers. Child Dev 1981; 82:71-82
42. Morgan BM, Bulpitt CJ, Clifton P, Lewis PJ. Analgesia and satisfaction in childbirth (the Queen Charlotte’s 1000 mother survey) Lancet 1982; 2 (Oct 9) 808-810

This paper may be copied and circulated, as long as the author is acknowledged.
Sarah Buckley, Brisbane, Australia. Nov 1998
The author can be contacted @ sarahjbuckley@uqconnect.net

The kit includes:

• a copy of the book, “Natural Fertility” by Francesca Naish
• a workbook to learn the methods
• an educational CD with instructions and relaxation suggestions
• a fertility thermometer
• a personal lunar calendar
• and a time machine for adjusting your personal lunar calculations to different time zones when traveling.

To purchase the kit, click here.

• Cost for a new visit to reproductive endocrine fertility specialist: $200-400
• Cost for pelvic ultrasound to evaluate uterus and ovaries: $150-500
• Cost of fertility related blood tests: $200-400\r\nCost for semen analysis – sperm test: $50-300
• Costs for a hysterosalpingogram (HSG – dye test of tubes): $800-1200

*Many (or all) of these tests & office visits are often covered by health insurance plans.

Costs of Basic Fertility Treatments (USA)

• Clomid medication cost: $10-100
• Monitored Clomid cycle cost (bloods and ultrasound x 2-3): $500-1600
• Intrauterine insemination, IUI cost, artificial insemination cost: $300-900
• Monitored injectable FSH cycle cost (bloods & ultrasound x 3-4): $900-3000
• Cost of injectable fertility drugs for an injectable FSH cycle: $1000 – 3500

Cost of Advanced Fertility Treatments – IVF and Donor Egg Costs

• IVF, In Vitro Fertilization costs (all inclusive): $11,000 (national average)
• In Vitro fertilization plus ICSI costs (all inclusive): $12,500 (national average)
• Cost of injectable fertility meds for an IVF cycle: $1500-4500
• Cost of IVF with donor eggs (includes all agency, donor & legal fees, etc.): $28,000 (national average)
• Cost of injectable fertility drugs for a donor egg cycle: $1500-4000