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Thursday, July 24, 2014

how many embryos should you transfer?


this is a very personal question. it is one that couples going through IVF have to ask themselves. the right answer is different for each couple. some people look at the ASRM guidelines to make their decision while others consider multiple factors when making their decision including: age, diagnosis, doctor's recommendation, desired family size and past success with IVF transfers.

i've been asked this question many times by both infertiles and well-meaning acquaintances who have not had to make this difficult choice but have their opinions about how many embryos someone in our position should transfer.

after my transfer, i had two sweet friends on instagram ask why we made the decision to transfer only one embryo. it is a great question. so i decided to delve into this topic a bit deeper in this blog post. so this post is for you @leeleekoontz and @andressahorne and anyone else who's pondered this very question.

"how many embryos should we transfer"? 

here are the questions that we asked ourselves…in our particular situation.

1. what is our ultimate goal? 
for us, it is to give birth to a healthy child. and that answer might not be the same for everyone. notice, i didn't say that our goal is to get pregnant or to achieve IVF success.

2. if we transfer more than one embryo, what are the benefits?
we'd have a higher chance of success achieving a pregnancy on that particular transfer cycle.

3. what are the risks associated with transferring more than one embryo?
the biggest risk is getting pregnant with multiples. while i know many people who have had twins with relatively no issues, i also know people who've had devastating experiences carrying multiple pregnancies. case in point, a fellow blogger Holly…she suffered the heartbreaking loss of her twins and my friend D lost one twin and her other baby had serious health challenges.

below is a list of common complications associated with multiples:
preterm labor/delivery
low birth weight
intrauterine growth restriction (IUGR)
preeclampsia
gestational diabetes
placental abruption
fetal demise/loss
cesarean

4. what is the worse case scenario with transferring two embryos? 
getting pregnant with both embryos and having one of those embryos split. triplet pregnancy. see risks above if we attempt to carry all three babies to term. and we'd also be at a huge risk for twin-to-twin transfusion syndrome because two of the babies would share the same sack and the other would not.

or we'd be faced with the option to terminate one of the pregnancies to reduce the risks to mother and the remaining babies. this is a heartbreaking decision to have to make after going through infertility. but sadly, it is one that is frequently made, quietly and in private, by couples who chose to transfer multiple embryos.

5. do you believe that each normal embryo has a chance of successfully implanting whether transferred individually or with other embryos?
for us, the answer is yes. so the only benefit we could find to transferring two at a time is saving money on future transfers down the road. if the choice is fail, try again, fail try again and it will cost more money in transfers. or try transferring multiple embryos at once and risk all of the things mentioned above… it is a no brainer for us….

one embryo.

how did y'all make this decision for yourselves?


48 comments:

jAllen said...

After our first IVF we had a grade 1 and a Grade 2 blast. My RE recommended transfering both. I insisted on single transfers and had 2 BFNs. When we think about the cost of that second transfer, I compate it to the potential costs of carrying and raising twins. Not even a drop in the bucket.

The Granberrys said...

I'm so glad you shared this! I have always wondered how couples come to make the decision on how many embryos, and it's definitely something that I've thought about it my "what ifs".

Cristy said...

This is a very informative post. Thank you for taking the time to write it!

We weighed similar options. For us, we had 3 failed rounds with good quality embryos. The diagnosis was implantation issues. Based on that, out limited finances and that our emotional reserves were spent, we decided to transfer two. Yes, there are risks with multiples, something I truly didn't appreciate at the time. But for us, that was the best decision.

That said, I wish I had known more about this going into IVF. And I certainly would have considered a eSET if finances weren't an issue/there was insurance coverage.

Mrs Green Grass said...

I just went with "what everyone else does" which seemed to be transferring 2. My husband and I reasoned that we were okay with having twins. But at our first ultrasound, there were FOUR heartbeats. We had an extremely difficult pregnancy both before or after we reduced the pregnancy to our singleton. I was very open throughout the process and so many parts were deeply scarring. There are absolutely cases where transferring multiple embryos is advisable, but I strongly believe that most couples should be counseled to transfer one. You can read my post on eSET if you want more detail.

Thanks for this post Jessah! I think it's an important discussion.

Ms DanL said...

We followed our RE's recommendation of transferring just one embryo. We are thankful to have had success with this one embryo who is now days away from joining us on the outside.

I think it's important to know what's best for your family and to consider potential outcomes thoughtfully.

I can haz babyz? said...

You made a very educated decision!! I'm rooting that the beautiful embryo your transferred is snuggling in for the next 9 months :)

--Mindy

Anh said...

With my first transfer, we did two - it was a no brainer, everyone seemed to be doing two, my doctor told me to do it, nurses urged me to do it,....until it didn't work. I remember beating myself up wondering why two good embryos just didn't take.

Then when the next transfer came around, I listened to my gut and just did one. I felt I wanted to give my all to just one embryo, I wanted my body, soul and mind focus on growing that one special baby. Well, that ONE embryo became my little boy. In hindsight, I don't know why I had ever even tried two, it's just too risky. With the IVF process being so stressful and worrisome, carrying two babies would have been too much.

I'm glad you decided on what you thought was best for you. I have a good feeling about this cycle for you!

Megan Swanek said...

We transferred 3 on day 3 last month and I had a BFN. My doctor used guidelines and although 2 were recommended and three was not, he said he was okay doing it because it was day three (as opposed to five) and just one wasn't worth freezing. Gearing up for my next cycle soon. Here's my blog: http://www.fertilityauthority.com/content/made-of-stars

Holly said...

Oh man, even after EVERYTHING, I still struggle with this. I agree with you that if you go the extra mile to have them genetically tested, 1 is the best/safest route. In our case, we have quite a few on ice that haven't been tested...our track record is 2/7. I can't bare to think of doing 1. at. a time. when I know several could be irregular...but then if I happened to have 2 implant I would be horrified too. I wish we would have tested, even though its more $. I still dont' know what we will end up doing when I go back-transfer 2, hope for 1? Sigh! Good discussion and <3 to you in the wait!

Weylin said...

Sometimes the decision could also be affected by whether the transfer is of a blastocyst and the ability to do PGD/CCS screening. In Singapore, PGD/CCS is an option, unless you have a blood-related condition. I had a friend who opted for Selective Embryo Transfer because she is relatively young (31), it took and two months later there was no heartbeat. Of course, now she is regretting not putting in two. I have done a transfer of two in the past, because it was a three day transfer, and in the end, neither took. As you mentioned, it's a personal decision based on weighed probabilities and priorities.

Endo_Life said...

For me I didn't get a choice. In the UK there are guidelines that clinics have to follow dependant on age and a few other factors. As I was 34 when we had the transfer I was only allowed one. I am very lucky that I achieved pregnancy. Plus for me as my daughter was born 9 weeks early I am glad I only had one transferred as who knows what could have happened if I had been pg with two!

Brittnie said...

Way to think it through and go with your gut intuition. Not always easy when emotions are so high during such a process.

We transferred two embryos, and got pregnant with twins, but lost one twin early on (around 6 weeks) as the heartbeat just kept getting slower and slower and eventually stopped. It was hard, but I think God knew that my body needed to (like you said) give its all to one embryo. I am also a smaller size person and twins probably would have been way too hard on my body. If we are ever in the position to do a transfer again, we will most likely only transfer one.

Praying for you!!

Elena Ridley said...

We only did one and will continue to only do one. I don't want to risk mine or my babies health because just because I want to he pregnant.

Anonymous said...

It was a "no brainer" for us to transfer two. We lost a previous pregnancy that we achieved through IUI + injectables due to Turner's Syndrome. When we reached the point of needing IVF to achieve a subsequent pregnancy, we did PGS on our embryos and discovered 2/7 had chromosomal issues - one had the same Turner's Syndrome diagnosis. We discussed the issue of "how many" with two doctors at our clinic and got mixed answers. Our primary RE said one is best, but it was up to us. The other RE said she could justify either one or two. After doing my own research, I found the statistics to support the "one is best" movement to be incredibly misleading. There are studies that suggest transferring two embryos still provides the highest success rates and that a twin pregnancy is no more dangerous than having two consecutive single gestation pregnancies. Additionally, doctors in favor of double embryo transfers argue that twin pregnancies conceived using ART are at an advantage over natural twin pregnancies due to the close monitoring and early knowledge of the multiple gestation. Like you, we want a healthy baby or babies, otherwise we wouldn't have gone through the added expense and complication of PGS testing. But I'm also not buying into the propaganda of "one is best," knowing clinics are being pressured by outside forces to drive down their twinning rates.

Laura Rahel said...

I think I would choose one all the way. I didn't realize all the health problems/risks associated with multiples via IVF, but I wouldn't want to risk having all of the embryos take and having several babies at once anyways. I think one baby the first time around is the easiest way to keep everyone sane and healthy. Twins would be amazing, but not if it comes at the cost of their or my health or my sanity!

Amie said...

I often think oh two at one time would be great but then the risks outweigh that by far. I think you made a great decision :)

shay said...

We did 2 each time for all 3x we did the process. We just wanted the best odds and figured if it was in God's plan to have both take, then it was.

Our 3rd transfer, we became pregnant with twins, but lost one at 7 weeks. As heartbreaking as that was, we are very grateful that there is still one left that is growing and healthy (God-willing).

I think it's a personal decision for every couple and that there are no right or wrong choices!

Joahn Fauchier said...
This comment has been removed by the author.
Just T said...

I personally agree with the choice of transferring one embryo. Although our ivfs didn't work and we ultimately got pregnant with iui, I am scared to death of carrying twins. It has been a challenge since day one. Don't get me wrong, I love my girls, but it is not a choice I would have purposely made for the exact reasons you list in your post today.

FIngers crossed!!

waiting and wishing said...

We transferred two both times we did ivf. Since I was healthy, young (28) and wanted at least 2-3 children it was recommended that we transfer two given we were fully prepared to have twins because selective reduction was off the table for us. After a lot of thought we decided to go with two. My body handled twins like a champ, and I never had any real complications- but it was a delicate dance to make sure I was as healthy as possible throughout my entire pregnancy. With that said, we will likely transfer remaining embryos singularly. It's a hard decision, and one that is so personal! Hoping to hear great news from you soon!

Abby G said...

Hi Jessah, My husband and I have our first FET schedule for August 7 and we just came to our final decision a couple days ago. After 2 months of talking and praying about it, we too decided on just doing one embryo. Although we want the best chance for IVF success, we didn't want to risk my heath and the health of our babies to get there. We have 5 healthy embryos, all with normal PGS testing results. Thank you for this post, as it sounds almost identical to our reasoning and shows me I'm not the only one transferring 1 embryo in this crazy IVF world! Praying for you guys. :)

Amanda said...

Like you said there are SO many factors at play. If IVF had turned out like I thought it would, if I'd had 8-10 blasts, I was prepared to transfer 1 embryo. But when it hit the fan, things changed. We decided on two AGAINST my doctor's suggestion of three... that's how bad things were looking. And now, I'm thinking about transferring four for the next FET... it sounds straight up crazy to hear, but it all comes down to quality, to past history, etc.

If I was doing donor eggs, and they were tested normal, I'd do one too!

futureMom said...

Hi Jessah! This is a topic that is on my mind a lot. In fact, we have been working on coming to a decision and I think for many of the reasons that you have listed, we are going to transfer one this time. While I would LOVE to get pregnant fast, as you said, getting pregnant is not the ultimate goal. It is to have a healthy baby, and there are risks for multiples, such as premature labour to just name one, that could end so badly. Also, even if the babies were healthy, we need to consider that we would suddenly need a new car, different stroller, and let's face it probably a new house to accommodate our new family size. I am not exaggerating because my "house" is 750 square feet, it is tiny so twins would put us over the edge with this living space. If I could wave a magic wand and get healthy twins, I could probably figure out the car, stroller, and house size issues, but it is the pregnancy complications that scare me the most. Even the "healthy" twins that I come across, the moms have told me tales about how they were in the NICU and they nearly didn't make it, etc. so that is worrisome. I know I will be so devastated to get a negative after just transferring one, and I may wonder if two would have worked, but I don't think it even compares to the devastation of having something go wrong with a twin pregnancy. I think after all our wavering we are going to opt for doing PGS and putting in just one, and hope for the best. I think we have really gone through the same thought process as you, initially thinking of how great and cool and fun it would be to have twins, but then to reconsider after more carefully thinking the whole thing through and weighing the risks of each option.
Transferring one can work. As an example, I transferred 2 poor quality own egg embryos (PGS tested!) and I got a BFN. Then we tried again and out of 6 tested embryos only had one normal one to transfer, so we did a single embryo transfer and got our miracle baby, Joseph. I think at that time if we HAD two embryos, we would have put them both in, but we only had one, and we were amazed that it actually worked. My RE also said that putting in two does not double your chances of it working, but it does increase your risk of having multiples.
I'm hoping for the best for you, as you wait for your beta. Stick and grow, little embie!! Good luck!

ADSchill said...

Like you said, this is a personal question. The first time around I had no reservations about transferring two and those turning into twins...which I later lost at 20 weeks. There is no concrete answer as to why, but I do know that I had slightly high BP which is not good with one baby, let alone two.

When it came to my next FET, I spoke with some specialists who said even though my loss may have had nothing to do with my having two, they were solid in their advice to transfer one only.

After much deliberation, I agreed that a singleton was healthiest. Plus I was scared to carry one, so two would have been even more stressful.

I believe the decision has many things to consider and it's dependent on the couple's/individual's situation and past history. Overall...I would encourage a SET over multiple transfer. Especially the first go-round. You don't know at that point how your body will take to an embryo via IVF...it's better to start small and give yourself the best chance at a full-term pregnancy.

I miss my twins. I wish I could have kept them, but I am sure that my decision the second time around was the best one I could make(even though in the end I never had a choice as I had only one to survive the thaw).

Krystal Sullivan said...

Our first IVF, we transferred two. We had to change my trigger at the last minute due to possible OHSS, which reduced my chances of pregnancy from 60% to 30%. So after talking to my husband, we transferred two. They both stuck. But as you know, I lost them both. Our doctors cannot say for sure if the pregnancy was complicated because of multiple gestation. So for this FET, we transferred one even though our RE urged us to do two. My OB and MFM pushed us to only transfer one, and that is what we went with. This one stuck as well! I have read studies that say transferring two increases success, but also have read studies that say that transferring two simply increases your chances of multiples and not pregnancy. In other words, you are either going to get pregnant or you aren't and it doesn't matter how many embryos you transfer. But I think this decision is so hard to make and it really is a personal decision that is made on a case to case basis. I think you made the best decision you could make after weighing all the pros and cons. Best of luck!

Lisa {Amateur Nester} said...

This is such a tough decision. With my first IVF, I was in tears over the choice, especially since I had like, 5 minutes to decide. We ended up doing 2 and had a chemical. Our 1st FET we only had one embryo and that failed. Now I'm waiting our beta on Sunday on our 2nd fresh cycle. This time, transferring 3 was a no brainer for us.

Anonymous said...

Do you have any cites to these studies? I'm currently undergoing my first ivf stim and trying to decide what I'll do if I even have an option after allsis said and done.

Hope said...

It was a no-brainer for me because I never had more than one to transfer! Even if I had, I'd have considered two only if they were low quality. There are people who feel comfortable (medically, emotionally, financially) with having twins after years of infertility traumas and expenses. I'm not one.

There was one other factor. As an only child myself (and fine with that fact), I've never felt strongly about having two or more kids. One would be a miracle.

Anyway, I'm glad that this decision was easy and that you both agreed!

AMY MICHELE said...

We are about to face this same decision. I think it all goes to how well your body handled with whole process and how healthy the embryo's are. I can't answer what I would do until we are in that position and know the grade of each embryo's.

While I am contemplating one or two - our question goes to what to do with the others. I'm a huge fan of freezing the remaining embryos. We have also thought about donating them.

No matter what anyone says its up to you to make the decision on how many you use. I think overall it's a hard process and we all tend to make our own choices.

Excited for you!!! Great post.

<3, Amy

Anonymous said...

On our second attempt, we were left with only 3 embryos... We planned on two and I knew the third would not make it to blast... I decided I couldn't leave it to just stop griwing in it's own and decided lastin to just transfer all 3 knowing only one was a good embryo. We had two implant and lost one the first week, but our shinning star stuck and he's now a beautiful 6 month old boy... I still believe he was the good embryo.. No way or knowing though.. It's a personal decision and only you can know what's right in your own situation.. I would do the same if we can ever afford to try for a sibling.

Waiting for my miracle said...

In both our IVF attempts, we did a fresh cycle. I didn't have many embryos progressing, none left to be frozen. We decided how many to transfer based on our doctor and the embryologist recommendations. On our first try we transferred 2, 1 good and 1 not so good quality. It was a failed attempt.
On our 2nd IVF we transferred 4. 1 great, 2 good and 1 not so good. Those were all that they were. The embryologist and the doctor both agreed that based on my previous attempts there was a "problem" with the quality of my follicles anyway, so to become pregnant with more than twins was almost impossible. In this case, only 1 of them implanted, but we'd lost the baby on the 5th week anyway. Currently, I'm in the middle of one miscarriage that it just won't be resolved.
Our goal was also to have a healthy baby home, but we are not against a twin pregnancy. I guess we haven't heard as many horror stories as you. And also for us there is the financial factor to be considered. IVF is a real struggle, and if we could have 2 babies in one attempt, it would be better.

acoursetothefinishline said...

Interesting question. Our doctor recommended one but we (obviously) went with two. Why? Well, because at the time I said I'd rather have twins than none. I was nervous about possible complications of a twin pregnancy, but also had a feeling and faith in my body that should we get pregnant with twins, we would be ok. That didn't stop me from being nervous or counting every week until we hit viability and beyond, but I probably would have done that with one baby as well. I find anoymous's comment very interesting about the research - the part about early knowledge and monitoring does make sense.

Mrs B. said...

Australia has a strict one embryo policy. If you're under 35 you have to get special permission to transfer two. We got the permission and got to transfer day. My embryos were good quality and the embryologist talked us out of it. Did we want to risk a healthy child through a multiple pregnancy? Risk preterm labour and a multitude of issues because of our desire to have twins. We decided to only transfer one. I regretted that decision as soon as we left the clinic. Lo and behold we went to our first scan and were pregnant with twins anyway! The embryo split. I can't imagine our reaction had I been pregnant with triplets.
My twin pregnancy was hard. Mae had the risks and monitoring associated with having identical twins (luckily all was good on that part). I had preeclampsia and cholestasis. I went into preterm labour at 28 weeks and was hospitalised until 34 when my water broke. I had a c section. All in all it was a difficult pregnancy.

If you transfer two embryos you need to be prepared for a twin pregnancy. And hey, if you transfer one you might still end up with two anyway!

Anonymous said...

On my fourth & last attempt at ivf, because of my age (36) and embryo history, we transferred 3 on day 3. We only had 4. The 4th left in lab demised & to our SHOCK 2 of the 3 transferred took. One split. I am pregnant with triplets, 28 wks. It is a blessing, but it has been very difficult. I had hyperesmis, was hospitilized & have been on bedrest since 22 wks. I just thought 'the odds of multiples in my case are so low.' You just never know. We couldn't reduce personally. In retrospect, I would've transferred one. But...hindsight is always 20/20.

Anonymous said...

To anonymous who asked for studies/articles regarding # of embryos to transfer, here are some that I used to make my decision:

http://sogc.org/wp-content/uploads/2013/01/gui241CPG1004E.pdf

http://www.dailymail.co.uk/health/article-2085367/One-embryo-rule-reduces-chances-IVF-success-women-better-prospects-getting-pregnant.html

http://www.slate.com/articles/double_x/doublex/2011/08/in_defense_of_ivf_twins.2.html

The number of articles supporting SETs far outweigh those for DETs (just do a Google search and it'll return hundreds of results). As previously stated, it's a VERY personal decision based on economics, statistics, age and health risk factors. However you come to your decision, there is no right or wrong answer.

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Mrs B. said...

I definitely think you've been mislead somewhere. A twin pregnancy is definitely more dangerous then two consecutive single pregnancies. It is found out about earlier but it is classified as high risk. I wouldn't quote that to a twin mum either. I am in a Facebook group of mothers with twins and most of us delivered early due to complications like preeclampsia. Myself included.

Anonymous said...

Hi Jessah. First, I'm so very happy for you that this cycle is going so well - such great news. The question of how many embryos to transfer is such a difficult and personal one. After three failed IVF attempts (transferring one), we decided to transfer two. This resulted in two very healthy twin boys who are now 14 months. I totally understand that we were 'lucky' and acknowledge that twin pregnancies can be very complicated. Our RE's mantra was one healthy baby at a time which I also appreciate. Although I adore having twins and feel so incredibly grateful, it was very difficult in the beginning and it was quite an adjustment emotionally, financially, physically, etc. having two babies at once. You seem like such a thoughtful and wise person, so I'm sure you'll make the right decision for you. I wish you all the very best and hope this is all getting you one step to the family you so deserve.

Sunflower said...

For my own egg IVF cycle I put it two. I only had two embies and given my age and crappy eggs they did a Day 2 transfer! One almost took - had a chemical :-( For DE cycle I only did one - the first time the embies were not great quality even with DE they suggested two but I was too scared. Next time it was a great embie and my clinic only recommends one. Plus being a single Mom, I preferred just one. Hope your TWW is flying by fast :-)

Lyndsey Davis said...

I've done one (not by choice but because we only had one genetic frozen embryo), two and three in 5 rounds. The only time I got pregnant was when we did three. Then I miscarried. So I still go with the more the merrier but then again that didn't work really either.

Breathe Gently said...

We will always do SET's. Every time. I know too many people/stories of high risk multiples coming from double transfers, particularly when they're 5-day blasts being transferred.

Our first SET failed, which was really disappointing, obviously. But when it came time the next stim cycle, we didn't even consider more than one. A healthy singleton baby is what our end goal was. Our clinic in Australia thoroughly supports SET only, unless you've had multiple failed cycles or are 40+.

It's a very personal choice, but I'm really happy with our decision to have/continue to have SET's in future. xx

Lisamarie said...

I'm glad you did what's best for you! Please provide another update soon, doll!!! Thinking about you and wishing you all the best!

SmallTownFamily said...

We used the same train of thought you did. Plus, we know that this baby is genetically sound. :)

Anonymous said...

I get really sick of hearing twin moms talk about how they regret transferring two embryos and how they had a high risk pregnancy full of complications. I feel like a lot of them want you to learn from their mistake or something. Just as with singleton pregnancies, things can go wrong and there is a wide spectrum of success and horror stories. Please stop guilt tripping women out of transferring two or more embryos. Leave the decision up to them!

Anonymous said...

I'm surprised no one's mentioned the argument that embryos are not babies. An embryo is the CHANCE at life but it's far from a guarantee. I see it in some of your personal stories where 3 embryos were transferred and no take-home baby (I'm so sorry). Surely if someone transfers more than one embryo, they understand there is a CHANCE of a high risk multiple pregnancy, but there is also a CHANCE the cycle could just as well end in failure. Again, I would emphasize education on the issue and letting the person decide for themselves without criticism.

Amber said...

I'm so glad I find this blog. We've been TTC for 2.5 years (I'm 35, husband is 39). We were diagnosed as unexplained.. I've had 6 iuis and 2 miscarriages. They found out after my second mc in nov that I am neg beta 3 integrins. So I was put on lupron depot feb 2014-May 2014. I just had my first iui cycle post lupron and it's neg. :(
We are ready and willing to move to Ivf. However, I'm nervous.. It feels very "final straw". Whereas the iuis seem to work (minus that I've mc twice). I would love to hear from ladies who are or were in a similar boat..

Anonymous said...

We went with our RE's recommendation, which was two, but this has a lot to do with our DX as well as the laws here prohibiting letting the embryos develop and transferring the best (German-speaking Europe, if you are wondering where). After three failed transfers of two embryos each, we are finally expecting twins. I am frightened of something going wrong, but it would be the same case were it a singleton. We are just taking it day by day, week by week and praying for the best. In the end, there is a lot, which is out of one's control, regardless of the number of babies.

Anonymous said...

We decided to transfer two, 5 day blasts. I had previously had 2 early miscarriages and we felt two would give us the best odds of having a baby not just becoming pregnant. We had some complications leading up to the transfer so we froze our best quality eggs and used the lower grade for the fresh transfer. To our amazement both took and i am pregnant with twins. I am only 9 weeks so it is still early but i am so excited and thrilled, both have healthy strong heart beats. While i am terrified something might go wrong, something can always go wrong with any pregnancy. Twins do have a slightly higher risk of complications but with technology and close monitoring this risk continues to decrease. Wishing everyone the best during their IVF journeys!!

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