About Infertility

Causes of Infertility

    Infertility Overview

    Symptoms

    Female Infertility

    Male Infertility

    Risk Factors

    More Relevant Information

Infertility Evaluations and When to Seek Treatment

    Exams and Tests

    Treatment for female infertility

    Treatment for male infertility

Assisted Reproductive Technologies (ART)

    Treatment Overview

    Other Treatment Choices

    Medications

    Medication Choices

10 Questions to ask your Doctor

Links to additional resources

 

Causes of Infertility

Infertility can be caused by problems with either the man's or woman's reproductive system, or both. Some conditions are hormonal in nature, and others are structural problems in the reproductive organs that require surgical repair.

Half of all couples tested for a cause of infertility are affected by a problem with the woman's fallopian tubes or uterus or her ability to ovulate. About one-third find that their infertility is caused by problems in the male reproductive tract. Some couples find that both partners have problems that are contributing to their infertility.1

In 10% of infertile couples, no cause is found despite thorough testing

Overall, 40% of female infertility is caused by a problem with the ability to ovulate, and another 40% is due to fallopian tube or other pelvic problems.

Half of all couples tested for a cause of infertility are affected by a problem with the woman's fallopian tubes or uterus or her ability to ovulate. About one-third find that their infertility is caused by problems in the male reproductive tract. Some couples find that both partners have problems that are contributing to their infertility.

In 5% of infertile couples, infertility is caused by unusual problems, such as DES exposure.

Rates of infertility and miscarriage increase with age. A woman's fertility peaks in her late 20s and gradually begins to decline in her early 30s. A more pronounced drop in fertility and increase in miscarriage risk begins around her mid-30s, primarily due to the aging egg supply.

Infertility Overview

 

Infertility is defined as a couple's inability to become pregnant after 1 year of sex without using birth control. When considering whether you may have an infertility problem, however, bear in mind that "normal fertility" is defined as the ability to naturally conceive within 2 years' time.

Of all couples who have not conceived after 1 year, about half will go on to conceive naturally in the following year.1 If you are a younger couple, this is encouraging news. However, if you are 35 or older, another year may be too long to wait before seeking testing and treatment.

A woman's fertility declines from her mid-30s into her 40s, as her egg supply ages. At the same time, her risk of miscarriage increases. Although a man's sperm count decreases with age, male fertility is not known to be greatly affected by age.

 

Symptoms

Infertility does not cause physical symptoms. Infertility is a general term for a couple's inability to start a pregnancy after 1 year of having sex 2 to 3 times a week without using birth control methods.

For women younger than 30, some health professionals will diagnose a couple with infertility and offer treatment only after 3 years of trying to become pregnant.1 For women over 35, some health professionals encourage beginning testing and treatment after 6 months of trying to become pregnant.

More Relevant Information

You can be considered infertile if you have not been able to conceive after 1 year of sex without using birth control. However, an infertility diagnosis does not mean that you are incapable of pregnancy.

  • About 50% of couples who do not conceive within 1 year will naturally become pregnant during the following year.1
  • Of all couples diagnosed as infertile, 35% of those who do not seek treatment will become pregnant.1
  • Infertile couples whose fertility test results are normal are diagnosed with "unexplained infertility." Of all couples with unexplained infertility who do not seek treatment, about 35% will naturally become pregnant within 3 years, and 45% do so within 7 years.3

Major factors that affect your chances of conceiving with or without treatment include age, how long you have been trying to conceive, and the cause of infertility.

  • Female fertility normally decreases with age. The older a woman is (particularly over age 35), the less likely she is to become pregnant and the more likely she is to miscarry. This is primarily due to the aging of her egg supply. A woman who is over 40 and fails to ovulate despite medication, or who does not respond to in vitro fertilization therapy, is encouraged to use donor eggs.
  • A couple's chances of conceiving are greatest within their first 3 years of trying. Pregnancy is considered unlikely without treatment after 3 years of sex without birth control use.1

If a clear cause of infertility can be determined and if there is a promising treatment for that cause, pregnancy is more likely. Treatment for unexplained infertility is less likely to be successful. However, medications or assisted reproductive techniques may still be effective.

 

Female Infertility

Problems with the fallopian tubes are a leading cause of infertility in women. Tubal blockage may be caused by:

  • Previous infection (most often a sexually transmitted disease; sometimes associated with a ruptured appendix).
  • Tubal ligation for sterilization or other types of surgery.
  • Endometriosis, a common cause of infertility.
  • Scarring of fallopian tubes associated with previous pelvic surgery (for ovarian cysts or uterine surgery for fibroids).

Problems with a woman's uterus and/or cervix may be caused by:

  • Abnormalities of the uterus present from birth.
  • Previous surgery or a procedure, such as a cervical cone biopsy or a dilation and curettage (D&C), which may decrease fertility if these procedures have damaged the cervix or uterine lining (rare).
  • Exposure to certain drugs before birth, such as DES, which may cause deformities of the uterus, resulting in infertility.
  • Abnormalities in a woman's cervical mucus, which may affect the movement of sperm through the vagina and cervix.
  • Antibodies to sperm present in a woman's cervical mucus, which may kill the sperm or affect their ability to move normally and result in infertility.

It can be difficult and complicated to determine the cause of ovulation problems. Possible causes may include:

  • Hormonal imbalances. 70% of all women with ovulation problems have hormonal imbalances related to polycystic ovary syndrome (PCOS).1 Other ovulation problems can originate in the ovaries, or in the pituitary gland and hypothalamus, which produce hormones that regulate the menstrual cycle. These hormones are vital to normal ovulation.
  • Structural problems. Abnormalities in the structure of the ovaries (such as ovarian cysts) or structural problems in other reproductive organs can cause changes in a woman's ovulation schedule.
  • General medical problems. Medical problems that affect the metabolism (such as thyroid problems), serious illness, emotional stress, low weight, or excessive exercise can affect a woman's ovulation schedule.
  • Cancer treatment. Exposure to certain kinds of chemotherapy or radiation can damage the egg supply in the ovaries

 

Male Infertility

The most common cause of male infertility is low sperm count. Absence of sperm in the semen is less common, affecting only 1% of all men and 10% to 15% of infertile men.1

Causes of sperm count problems include:

  • Hormonal problems in the testicles or pituitary gland. The pituitary gland releases hormones that stimulate the testicles to produce testosterone.
  • Testicular injury or failure, either present at birth (congenital) or associated with radiation or toxic chemical exposure.
  • Cancer treatment with certain kinds of chemotherapy or radiation.
  • Antibodies that attack sperm, which also may be present in semen. Sperm antibodies sometimes develop when a man's sperm has been exposed to his immune system (outside of the testicles). This may happen after a vasectomy, an infection, or injury to the testicles.2
  • Drug use (some prescription medications, and marijuana and tobacco use).
  • Structural problems. These include:
    • A varicocele in the testicles.
    • Blocked ejaculation due to a surgical vasectomy.
    • Absence of a vas deferens (a birth defect that may be associated with the cystic fibrosis genes).
    • Retrograde ejaculation (the ejaculation of semen into the bladder rather than out through the penis).
  • Chromosomal problems (such as Klinefelter's syndrome).

Risk Factors

Infertility has many causes that involve either the woman's, the man's, or both partners' reproductive systems. Some factors that increase your risk of infertility are within your control; other are not.

Risk factors you cannot control include:

  • Aging. Rates of infertility (not due to surgical sterilization) in women increase with age and are about:3
    • 7% in women ages 20 to 24.
    • 9% in women ages 25 to 29.
    • 15% in women ages 30 to 34.
    • 22% in women ages 35 to 39.
    • 29% in women ages 40 to 44.
  • Problems with the male or female reproductive system that were present at birth (congenital birth defects).
  • Exposure to DES (diethylstilbestrol) before birth.
  • Moderate or severe endometriosis, the growth of uterine lining (endometrial) cells in other parts of the abdominal cavity (such as the ovaries or fallopian tubes, the outer surface of the uterus, the bowels, or other abdominal organs).
  • Exposure to very high levels of environmental toxins, certain drugs, or high doses of radiation (including cancer chemotherapy or radiation).
  • History of a sexually transmitted disease (such as gonorrhea or chlamydia) that has damaged the reproductive system.

Risk factors you can control include:

  • Polycystic ovary syndrome, which is related to a hormone imbalance that interferes with normal ovulation. When weight loss with diet and exercise do not stimulate ovulation (or is not necessary), medication often helps.
  • Tobacco or marijuana use, which reduces sperm counts and female fertility.
  • Drinking more than 2 to 4 alcoholic beverages daily for several months, which decreases male fertility and causes injury to sperm.
  • Frequent (daily) or infrequent (every 10 to 14 days) ejaculation, either of which can temporarily lower sperm count.
  • Frequency of intercourse some experts say that the ideal frequency and timing is every 36 hours during the time a woman ovulates.4 However, others say that given a normal sperm count, daily sex during the fertile period may lower sperm count, but it does increase the overall chance of pregnancy.5
  • Increased temperature in a man's scrotal area, which can damage sperm (common causes are hot tub use and high fever).
  • Exercising intensely for months or years, which may affect a man's sperm count and prevent a woman's ovulation.

Prior surgical sterilization, such as vasectomy or tubal ligation. Surgical sterilization reversal may be successful, depending on the procedure used and how much time has passed since original surgery.

More Relevant Information

You can be considered infertile if you have not been able to conceive after 1 year of sex without using birth control. However, an infertility diagnosis does not mean that you are incapable of pregnancy.

  • About 50% of couples who do not conceive within 1 year will naturally become pregnant during the following year.1
  • Of all couples diagnosed as infertile, 35% of those who do not seek treatment will become pregnant.1
  • Infertile couples whose fertility test results are normal are diagnosed with "unexplained infertility." Of all couples with unexplained infertility who do not seek treatment, about 35% will naturally become pregnant within 3 years, and 45% do so within 7 years.3

Major factors that affect your chances of conceiving with or without treatment include age, how long you have been trying to conceive, and the cause of infertility.

  • Female fertility normally decreases with age. The older a woman is (particularly over age 35), the less likely she is to become pregnant and the more likely she is to miscarry. This is primarily due to the aging of her egg supply. A woman who is over 40 and fails to ovulate despite medication, or who does not respond to in vitro fertilization therapy, is encouraged to use donor eggs.
  • A couple's chances of conceiving are greatest within their first 3 years of trying. Pregnancy is considered unlikely without treatment after 3 years of sex without birth control use.1

If a clear cause of infertility can be determined and if there is a promising treatment for that cause, pregnancy is more likely. Treatment for unexplained infertility is less likely to be successful. However, medications or assisted reproductive techniques may still be effective.

 

Infertility Evaluations and When to Seek Treatment

Consult with your health professional about infertility concerns if you:

  • Want children but have been unable to become pregnant after 1 year of having sex without using birth control.
  • Are a woman older than 35 who has been unable to become pregnant after about 6 months of sex without using birth control.
  • Have had three or more miscarriages in a row.

Consider medical testing for a cause of infertility if you:

  • Have noticed a physical problem (such as an absence of ejaculation or ovulation, or menstruation irregularities) or have a history of repeat miscarriages or pelvic inflammatory disease.
  • Are in your mid-30s or older and have been unable to conceive after 6 months of regular sex.
  • Are in your 20s to early 30s and have been unable to conceive after a year or more of regular sex.

Initial testing for a couple's cause of infertility evaluates both partners' lifestyle habits and health. Among other general health factors, your health professional will focus on sperm and egg production, checking sperm counts and ability to ovulate. If no cause is found, you can decide whether to proceed with further testing.

  

Exams and Tests

 

Testing for a cause of infertility usually starts with simple tests for both partners. In addition to an interview and physical examinations, your initial tests will check semen quality and both partners' hormone levels in the blood. Hormone imbalances can be a sign of ovulation or sperm production problems that can be treated.

If your initial test results show no cause of infertility, your doctor may recommend checking fallopian tube function. Depending on your age and other risk factors, you may then be offered further testing or begin treatment with superovulation, intrauterine insemination, or both.

 

Common initial tests for infertility

Who is tested?

Type of test

The woman

  • Charting basal body temperature (BBT) at home to identify ovulation phases, often for a few menstrual cycles before considering medical testing. A home ovulation test kit can help to confirm that ovulation is within 12 to 36 hours, based on luteinizing hormone (LH) levels in urine.

  • Pap test to assess the health of the cervix

  • Rubella test to check for rubella immunity; a woman without immunity requires a rubella immunization to protect her fetus from possible infection.

Both the man and the woman

  • Medical history and physical examination

  • Chlamydia test, since untreated chlamydia can cause female infertility and can infect a newborn at birth

  • HIV, syphilis, and hepatitis B and C tests, since these infections can be passed on to a fetus or newborn, with serious consequences

The man

  • Semen analysis to check the amount and quality of semen and sperm and for signs of infection. Abnormal test results are usually confirmed with another semen analysis, then followed with testosterone and FSH tests.

The man or the woman

Hormone tests, to check for a woman's ability to ovulate or a man's ability to produce sperm. These may include:

  • Luteinizing hormone (LH). Abnormal LH levels can be a sign of female ovulation problems or male testosterone production problems.

  • Progesterone. Low progesterone levels can be a sign of ovulation problems.

  • Follicle-stimulating hormone (FSH), sometimes followed by a more specific clomiphene challenge test of the egg supply. High FSH levels may be a sign of low egg supply, or ovarian reserve; low FSH levels can prevent ovulation or, in men, sperm production.

  • Thyroid-stimulating hormone (TSH). Abnormal thyroid function can affect the menstrual cycle and ovulation.

  • Prolactin. High prolactin can be a sign of a pituitary problem, which can cause infertility.

  • Testosterone. Low testosterone in men can cause sperm production problems, while high levels in women can cause irregular menstrual periods.

No test provides absolute proof that the ovaries are releasing eggs. However, basal body temperature charting, LH, and progesterone testing can provide strong evidence of ovulation.

 

 

If the above tests are normal (sperm is within normal ranges and ovulation is regular), one of the following tests is often done next.

Who is tested?

Type of test

The woman

  • Pelvic ultrasound to study egg follicle development

  • Hysterosalpingogram (via the vagina) to check the uterus and fallopian tubes for signs of damage or structural problems

  • Hysteroscopy (via the vagina) to examine the uterus, sometimes done instead of a hysterosalpingogram

  • Laparoscopy (through an incision) to look for and possibly repair conditions such as uterine fibroids, scarring from pelvic inflammatory disease, or endometriosis that can prevent pregnancy

  • Endometrial biopsy (via the vagina) to assess uterine health, and to see whether the uterine lining (endometrium) is going through the stages of change that occur during a normal menstrual cycle

 

If initial testing reveals no cause of infertility or if infertility treatment has been unsuccessful, one or more of the following tests are sometimes used.

 

Who is tested?

Type of test

Both the man and the woman

  • Sperm antibody test to see whether the man's or woman's body is producing antibodies that impair his sperm, possibly preventing pregnancy

  • Sperm penetration tests to see how well the sperm can travel to and/or penetrate an egg

 

If initial testing reveals no cause of infertility or if infertility treatment has been unsuccessful, one or more of the following tests are occasionally used

 

Who is tested?

Type of test

The woman

  • Postcoital test of a sample of cervical mucus, for cervical mucus quality and sperm function after sex (the value of this test is uncertain)

The man

  • Testicular biopsy (through an incision, rarely used) to see whether a low sperm count is linked to a sperm production problem in the testicles

Both the man and the woman

  • Genetic testing to see whether a genetic problem is contributing to infertility and/or to assess for possible genetic disorders that a parent could pass on to a child. Many, but not all, genetic conditions can currently be identified.

  • Culture of semen and cervical mucus to check for infection that should be treated before trying to start a pregnancy

 

 

Treatment for female infertility

  • Ovulation problems are usually treated with medications (clomiphene, GnRH, gonadotropins, and bromocriptine) that stimulate the body to produce and release eggs. Clomiphene (Clomid, Serophene) is typically the first-choice medication for stimulating ovulation. However, treatments vary according to the cause. For example, initial treatment of women with polycystic ovary syndrome (PCOS) often focuses on weight loss and metabolism.
  • Fallopian tube damage (including tubal ligation) and structural ovary or fallopian tube problems can sometimes be corrected with tubal surgery.
  • A blocked fallopian tube can be bypassed by collecting eggs from the ovaries for in vitro fertilization and placement of fertilized eggs in the uterus.
  • Endometriosis, the growth of uterine lining (endometrial) cells in other parts of the abdominal cavity, may be treated using laparoscopic surgery to remove endometrial tissue growth.
  • Cervical problems (such as a narrow cervical opening or presence of sperm antibodies) can be bypassed with intrauterine insemination.
  • If initial treatments are not successful, assisted reproductive technology (ART) treatments are available, such as in vitro fertilization or gamete or zygote intrafallopian transfer (GIFT or ZIFT). These procedures require eggs and sperm of good quality, so some couples use donor eggs or sperm. Other couples choose adoption.

In order to closely time and control the success of an ART procedure, doctors commonly control the ovaries with hormone treatment before harvesting eggs. First, a hormone is used to "shut down" the pituitary gland, which puts the ovaries in a menopauselike state (menopausal symptoms are common). This is called pituitary down-regulation with a GnRH analogue. Then, ovulation-stimulating gonadotropins are used to trigger ovulation on a schedule. This process is also used before some insemination procedures.

Some procedures can be used both to diagnose and treat an infertility problem. For example, flushing the fallopian tubes for a hysterosalpingography can sometimes clear a blockage.

Treatment for male infertility

  • Low sperm counts can be treated by collecting and concentrating healthy sperm for insemination or assisted reproductive technology (ART) treatment.
  • Semen without sperm can be treated by using either mature or immature sperm surgically removed from the testicles. Conception is then attempted by injecting a sperm into an egg (intracytoplasmic sperm injection) and transferring the fertilized egg into the uterus or a fallopian tube.
  • If semen is ejaculated into the bladder (retrograde ejaculation) instead of out through the penis, sperm can be recovered from the bladder, washed, and used for insemination.
  • Structural problems can be treated surgically, increasing the chances of natural conception. Surgery can sometimes reverse a vasectomy, repair an enlarged vein in the scrotum (varicocele repair), or correct blockages in or absence of the vas deferens.
  • Sperm production problems caused by hormonal imbalances (affecting about 2% of infertile men) can be treated with medication or hormones that help the hypothalamus and pituitary gland start normal sperm production.7 Treatments include hormones and medications such as GnRH, gonadotropins, and bromocriptine.
  • When no healthy sperm are available using the above means, some couples use donor sperm combined with insemination or assisted reproductive technology. Other couples choose adoption.

Assisted Reproductive Technologies (ART)

Assisted reproductive technologies (ART) are procedures to remove eggs from a woman's ovaries (or use donor eggs) and fertilize them with sperm outside the body. One or more fertilized eggs are then transferred to the woman's uterus or fallopian tubes. ART is most successfully used to treat infertility caused by problems with fallopian tubes, ovulation, and sperm, as well as endometriosis and unexplained infertility.15 These expensive and complex procedures are typically used only after more conservative treatment methods have failed.

In order to closely time and control the success of an ART procedure, doctors commonly control the ovaries with hormone treatment. First, a hormone is used to "shut down" the pituitary gland, which in turn stops the ovaries from making eggs (menopausal symptoms are common). This is called pituitary down-regulation with a GnRH analogue. Then, ovulation-stimulating medications are used to trigger ovulation on a schedule. This process is also used before some insemination procedures. For more information, see the Medications section of this topic.

 

Treatment Overview

The ultimate goal of infertility treatment is a healthy pregnancy and the birth of one healthy infant. (A multiple pregnancy increases risks of complications for a mother and her fetuses.)

Just as there are many causes of infertility, there are many types of treatment using hormones, surgery, and assisted reproductive technology (ART). In general, female infertility problems are more easily treated than male infertility problems. Some infertility problems have more effective treatments that others, and no treatment can guarantee a healthy pregnancy.

Other Treatment Choices

Insemination procedures include artificial insemination (AI) and intrauterine insemination (IUI).

Assisted reproductive technologies include:

  • In vitro fertilization (IVF), mixing eggs with sperm outside the body; one or more fertilized eggs are then transferred to the uterus using a thin flexible tube (catheter) inserted through the cervix.
  • Intracytoplasmic sperm injection (ICSI), injecting a sperm into an egg, which is then transferred to the uterus using a catheter inserted through the cervix.
  • Gamete or zygote intrafallopian transfer (GIFT or ZIFT). GIFT is the transfer of eggs and sperm into a fallopian tube through a small abdominal incision. ZIFT is the in vitro fertilization of an egg, which is transferred to a fallopian tube through a small abdominal incision.

For couples with sperm-related infertility, ICSI can be used to achieve the fertilization stage of the in vitro fertilization process.

 

Medications

Medication or hormone treatments are often the first steps in infertility treatment. They are typically less expensive and less risky than invasive procedures, and are used to:

  • Increase sperm counts in men with abnormal hormone levels.
  • Stimulate ovulation in women who are not ovulating regularly or at all.
  • Stimulate superovulation before an assisted reproductive technology (ART) or insemination procedure. Superovulation is used to increase the number of eggs that are collected for ART or that are present when sperm are inseminated.

In order to closely time and control the success of an ART procedure, doctors commonly control the ovaries with hormone treatment. First, a hormone is used to "shut down" the pituitary, which puts the ovaries in a menopauselike state (menopausal symptoms are common). This is called pituitary down-regulation with a GnRH analogue. Then ovulation-stimulating gonadotropins are used to trigger ovulation on a schedule. This process is also used before some insemination procedures.

 

 

Medication Choices

Clomiphene citrate (Clomid) stimulates the release of hormones that trigger ovulation. Clomiphene is typically the first choice of treatment for unexplained lack of ovulation because of its ease of use?it's taken orally rather than injected, doesn't cause severe side effects, and doesn't require daily monitoring.

If clomiphene does not restore ovulation, other medication or hormone treatments can be used, providing that their side effects are closely monitored:

  • Metformin (for nonovulating women with polycystic ovary syndrome) can correct insulin resistance and elevated male hormone levels, often starting egg production and regular menstrual cycles. If that isn't successful, metformin tends to increase the likelihood that clomiphene will stimulate ovulation.13
  • Gonadotropin-releasing hormone (GnRH) analogue, either an "agonist" or an "antagonist." A GnRH analogue is used to stop ovulation by "shutting down" the pituitary gland. A gonadotropin treatment is then used to stimulate ovulation on a certain day. This is done to improve the chances that an ART or insemination procedure will succeed.
  • Gonadotropin treatment with human menopausal gonadotropin (hMG) or recombinant human follicle-stimulating hormone (rFSH), and human chorionic gonadotropin (hCG) (for women and men with low levels of reproductive hormones) stimulates egg or sperm production.
  • Gonadotropin-releasing hormone (GnRH) (for women and men with low levels of naturally produced gonadotropins) increases the body's production of hormones needed for egg and sperm production.

Bromocriptine and cabergoline (for women and men) reduces abnormally high prolactin levels; high prolactin can interfere with egg and sperm production.

10 Questions to ask your Doctor: 

1. What are the underlying issues causing my (our) infertility? 

2. If male factor infertility is an issue, can intracytoplasmic sperm injection (ICSI) be used to fertilize my eggs, instead of other interventions which might take longer?

3. If "ovarian reserve" is the issue, what my chances are of getting pregnant with my own eggs. 

4. If surgery of any kind is being recommended (such as surgery for endometriosis or surgery for blocked fallopian tubes), could that surgery be bypassed, going straight to IVF, to save time?

5. If "superovulation" with clomiphene or gonadotropins is being recommended, how many cycles will we need to complete before going to IVF?

6. What is our risk of having twins, triplets, quadruplets or more, with superovulation cycles?  How will I be monitored so that I do not risk having multiples?  What criteria are used to "cancel" a cycle?

7. If I require IVF, am I a candidate for a Single Embryo Transfer?  Does this center have a high implantation rate, so that I can have a reasonable chance at becoming pregnant with a Single Embryo Transfer? 

8. How does the center determine which embryos to freeze for possible use at a later date? Are embryos sometimes lost during the thawing process? 

9. If I decide to use frozen embryos, what are the advantages? (Ask about the decreased costs with a frozen cycle and ask about "cumulative results" of fresh + frozen cycles.)

10. What are the total costs associated with the treatments proposed, including medications? (Medication benefit coverage may be separate from medical benefit coverage.)

 

Links to additional resources 

Society For Assisted Reproductive Technology              www.sart.org

Center for Disease Control and Prevention                     www.cdc.gov

Freedom Fertility                                                                    www.freedomfertility.com

American Society for Reproductive Medicine:                   www.reproductivefacts.org

National Infertility Association:                                            www.resolve.org

Fertile Hope:                                                                           www.fertilehope.org

Needy Meds:                                                                           www.needymeds.org

Livestrong:                                                                              www.livestrong.org

 

 

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