Comprehensive
Study of Association of Śukravikŗtīkara Hetus in Male Infertility
INTRODUCTION:
Scholar: Dr. Sachin Kulkarni,
Associate Professor, Bharati Vidyapeeth (Deemed to be University), College of Ayurved, Pune
Guide: Dr. Mrs. Yashashree Joshi
Professor, Bharati Vidyapeeth (Deemed To be University), College of Ayurved, Pune
Carakācārya
has enlightened the importance of fertility in Vājīkaraņa chapter. A person
without a child is like a tree just with one branch devoid of fruits and
shadows with an unwanted smell[1]. Love,
strength, happiness, excellence, wide spread influence, vastness of kinsmen,
fame, utility to the world and pleasure are dependent upon children & to
achieve all these fertility is required[2]. Nowadays numbers of patients of
infertility are increasing due to various reasons. Infertility, the inability
to conceive a child is an emerging public health priority. According to
National Family Health Survey (NFHS-3) fertility is decreasing day by day[3]. In Indian society most of the time,
females are blamed for infertility however infertility due to abnormalities in
male partner is also equally important[4].
Epidemiology:
Infertility has been a concern
through ages and is also a significant clinical problem today, which affects
8-12% of couples worldwide. Approximately 40-50% cases are due to "male
factor" of all infertility[5]. Moreover, the fertility rate
in men younger than age 30 years has also decreased worldwide by 15%.[6] As per the WHO, the overall
prevalence of primary infertility ranges between 3.9% and 16.8%[7].Over 25% of infertility cases in India has no detectable cause &
can be considered as unexplained infertility[8]
Etio-pathology of male
infertility:
European
Association of Urologists has mentioned various diagnosis of male infertility. Male
infertility is classified as Idiopathic (48.5%), Idiopathic abnormal semen
analysis (26.4%), Varicocele(12.4%), Infection (6.6%), Immunologic factor (3.1%),
other abnormalities (3.0%), Acquired factor (2.6%), Congenital anomaly (2.1%), coital
factor (1.7%), Endocrine abnormality (0.6%).[9]In
this report idiopathic causes or diagnosis has major share in the list. In the latest
report in 2014 also, it is found that 30 – 40 % of cases are of idiopathic male
infertility[10].Idiopathic
is an adjective used primarily in medicine, meaning arising spontaneously or
from an obscure or unknown cause. It shows that there are some factors which cause
infertility but are currently unknown to the medical fraternity.
W.H.O.
multi-centric studies of infertility in India revealed that 40 percent of women
and 73 percent of men had no demonstrable cause of infertility[11].
The
known risk factors for male infertility are smoking, tobacco chewing, alcohol
consumption, over usage or misuse of drugs such as chemotherapy or the anabolic
steroids, wearing tight undergarments, working near hot places, taking
extremely hot and long baths etc. These factors are already proved & hence
care about these factors is advised in preventive andrology. There is need to enlighten
more risk factors if any, in the light of Āyurveda theories.
Strength of Āyurveda
approach:
Āyurveda
concepts can play a key role to understand the cause of infertility. According
to Āyurveda, Ŗtu, Kşetra, Ambu and Bīja i.e. Śukra & Śoņita are the factors
responsible for conception. All these factors should be in the state of
normalcy for proper conception and normal development of fetus. Abnormalities in one or all above mentioned
factors may lead to infertility[12].
Various
Śukravikŗtīs are mentioned in Āyurveda classics. Amongst all of them Śukra Duşţī,
Śukra Kşaya, Śukra Rodha, Śukra Apravŗttī are commonly seen in today’s society.
It is need of hour to study Hetus of Śukravikŗtī in detail; so that appropriate
treatment of the same can be done. After the review of the previous works, it
was found that focus was on interventional studies than core work on
pathogenesis considering the relation between Hetu of male infertility. Though work
on disease management is important but study on etio-pathogenesis is also
equally important. Hence comprehensive study of Hetus of Śukravikŗtī in male
infertility was planned for this study.
Hypothesis:
Śukravikŗtīkara Hetus
mentioned in Bŗhattrayī are associated with male infertility
AIM AND OBJECTIVES:
Aim:
To
study the association of Śukravikŗtīkara Hetus in male infertility
Objectives:
1.
To study the effect of Śukravikŗtīkara Hetus on pathogenesis of male
infertility on literary basis
2.
To validate the observations of literary study with the data generated
from survey study
METHODOLOGY:
Study design:
This
is an observational case-control study comparing presence of Śukravikŗtīkara Hetus in
patients of male infertility and fertile men.
The
methods adopted for this study has been divided into 4 steps. In first step literature
study has been carried out regarding Śukra, Śukravikŗtī, and male infertility. Case
Record Form (CRF) has been designed in second step. Then in next step actual survey
has been carried out. In this survey study
patients were examined with the help of CRF and investigations of semen in
laboratory and by Śukra Parīkşā by Āyurveda Methods. In the fourth step data
was organized and analyzed with the help of statistical methods in purview of
aim and objectives. Observations were noted and results were drawn.
1.
Literature
Study:
Detailed review of
literature has been done as per following points
a.
Hand-search:
Extensive review of Bŗhattrayī with the necessary part of commentaries, text
books on anatomy, physiology, pathology and medicines and other allied
literature was done. Scattered references of Śukravikŗtīkara Hetus like
Śukraghna, Avŗşya, Punstopaghātakara and male infertility have been compiled.
b.
Electronic
search: Software’s like AyuSoft, Ayuta Nidan
and various database websites like AYUSH portal, Dharaonline portal was
extensively reviewed for keywords related to Śukra, Śukravikŗtī and male infertility.
The appropriate data have been collected.
c.
Research
Papers: 177 research papers &previous
works done for MD & PhD in Āyurveda related to causes and pathogenesis of
male infertility, abnormalities in semen, spermatogenesis, sexual inadequacy,
Oligospermia, Azoospermia, Premature Ejaculation and Śukra Duşţī, Śukra Kşaya have
been reviewed through print and electronic media.
d.
Expert
Guidance: Ten experts in the field of Āyurveda,
research and infertility have been consulted and their guidance regarding
carrying out this work has been taken. After completion of survey, guidance of
two experts has been taken for analysis and interpretation of the data
generated from survey.
2.
Development of Case Record Form
(CRF): A draft CRF was developed on
the basis of the data collected from literary study. It was pretested on 5
patients. Then it was finalized after required modifications.
The variables used for data collection
are as follows:
·
Demographic: Age, BMI, Occupation, Nature of work, Type of work,
Education, Socio-economic status, Religion
·
Daśavidha Parīkşā: Prakŗtī, Vikŗtī, Sāra, Saṃhanana, Pramāņa, Sātmya, Satva, Āhāraśakti (Abhyavaraņa & Jaraņa),Vyāyāmaśakti, Vaya, Agni
·
Hot/cold water bath, Sleep etc
·
Diet related: Madhura Sevana, Amla Sevana, Lavaņa Sevana, Kaţu Sevana,
Tikta Sevana, Kaşāya Sevana, Viruddhānna, Paryuşita, Hotel food, Junk Food, Bakery
Items, Consumption of water, Tea, Coffee, Milk, Meals timings
·
Mala Related: Mala, Mūtra, Sveda Pravŗittī
·
Addictions: Smoking, Tobacco, Alcohol, Other
·
Mānasa Related: Cintā,
Krodha, Bhaya, Śoka, Other
·
Maithuna Related: H/O Masturbation, relation with wife, Diva Maithuna,
Duration between food & coitus, Freq. of coitus
·
Semen Analysis: Abstinence, Volume, Appearance, Leqification Time,
Viscosity, (Ph) Reaction, Fructose, Sperm count, Motility (% and grades), Pus
cells, RBC, abnormal forms.ŚukraParīkşā by Āyurveda method.
Operational
Definitions:
The
operational definitions which are used for this were included in the thesis. A
few of them are mentioned in Table-1.
Table -1: Operational
Definitions
Variables
|
Operational
Definitions
|
Āhāra
related Hetu
|
|
Ati Madhura, Ati Amla, Lavaņa, Kaţu,Tikta,
Kaşāya Rasa Sevana
|
Consumption of food having that
particular tastes, combined or separate, for more than 60 Annakāla/month
(67%) in moderate quantity.
|
Viruddha Anna
Sevana, Vidāhi Anna Sevana, Kşāra Sevana,
Rūkşa Anna Sevana
|
Consumption of such food, combined or
separate, for more than 60 Annakāla/month (67%) in moderate quantity.
|
Maithuna
related Hetu
|
|
Ati Maithuna
|
Intercourse for >3times/week is
considered as Ati Maithuna irrespective of season.
|
H/O. masturbation>3times/week is
considered Shukra Vega Udirana.
|
|
Divā Maithuna
|
Day time intercourse is considered as Divā
Maithuna
|
Ajīrņe Maithuna
|
Interval between consumption of
food(lunch/dinner) and intercourse if less than 2 hours, it is considered as
Ajīrņe Maithuna
|
Mānasa related Hetu
|
|
Cintā, Śoka, Bhaya, Krodha
|
It is considered positive if patient
gives answer ‘Yes’ for more than 60 percent questions related to
Physcological condition.
|
Śukra
Parīkşā
|
|
Colour (Sphaţikābha/ Vivarņa)
|
Colour of the sample if matches with the alum cube (as standard) then
it is considered as normal. Yellowish white or greenish white or any
other colour is considered as Vivarņa type of Śukra Duşţī.
|
Consistency of the sample is observed
to access the Dravatā, It is done by tilting the test tube containing sample.
Liqification time 20 to 40 min is considered as normal. If Liqification time
is > 40 min. it is considered as Granthibhùta.
|
|
Snigdhatā / Picchilatā
|
It is done by pouring the sample with
dropper; if it falls drop by drop then it is considered as normal. If thread is
formed it is considered as abnormal.(Picchila)
|
Mādhurya
|
If fructose is present in semen analysis,
it is considered as normal
|
Madhu Gandha
|
Seminal odour is considered as normal
|
Kşīņa Śukra
|
If volume of the semen is less than 1.5
ml it is considered as Kşīņa Śukra
|
Tanu Śukra
|
If Liqification time is less than 30
min. and sperm count is less than 20 million/ml
|
Phenila
|
Bubbles in semen are generated with
aquarium bubbler for 30 seconds. If size of froth increases more than 1 cm
and froth remains for 5 min., it is considered as Phenila type of Śukra Duşţī.
|
Anya Dhātu Saṃşiśţha
|
In semen sample if R.B.C. or epithelial
cells are found it is considered as Anya Dhātu Saṃşŗiśţa Śukra Duşţī
|
3.
Survey
study:
Settings:
Bharati
Vidyapeeth Medical Foundation’s Ayurved Hospital, Pune; Pune based infertility
clinics & Glo –Vision Pathology Lab,
Pune.
Groups:
For the comparison, it was designed as Case &
Control type study. Fertile males were taken as control and named as Group-I.
Male patients who were suffering from infertility with
known diagnosis in modern medicine were
grouped under Group-II. Patients of male infertility without known
diagnosis in modern medicine i.e. functional or unexplained infertility were
considered under Group-III.
Ethical Clearance:
As
per the ICMR guidelines for Ethical Research, the proposal of this study was
presented before ‘Institutional Ethics Committee’ (IEC), BVDU, College of Ayurved,
Pune and work was started after IEC approval. (Dated: 06/01/2011)
Sample size:
Sample
size was 90. 60 patients of infertility were divided into two groups as 30
patients of infertility with known cause (Gr.-II) & 30 patients of
unexplained infertility (Gr.-III). 30 healthy fertile individuals have been
taken as control group (Gr.-I)
Inclusion Criteria:
Married
male patients of age group between 25 to 50 years, and whose female partners
are normal as far as fertility is concerned, were included in the study. For
control group fertile healthy individuals of same age group have been included.
Exclusion Criteria:
Patients
who were suffering from major systemic & chronic disorders were excluded
from the study.
Study
Population:
Total
195 patients were screened. Out of these 103 (Cases & Control) patients
befitted the study criteria. 90 patients out of these were enrolled in the
study after their informed consent. Random
numbering & bar-coding method was adopted to assure the two layer
confidentiality of the participants.
Survey Study:
Included
patients were examined with the help of CRF. The information was noted in the
form. Then patients were posted for semen analysis.
Semen
Examination:
All
patients were given clear oral instructions regarding Standard Operating
Procedures (SOP)of collection of sample. Semen examination was carried out in
the lab as per standard method. For examination of Śukra by Āyurveda method
criteria was finalized on the basis of the methods adopted by the scholars in
the previous research works.[13],[14]
Analysis:
The
data collected from the survey study was compiled, tabulated and analyzed in
the view of aim and objectives of study by using Odds Ratio (OR) for specific Hetu
& Chi-Square test for categorical variables. This data was cross checked
with the help of observations of literary study.
OBSERVATIONS
AND RESULTS:
Literature Study: After
the thorough study various Śukravikŗtīkara Hetus
have been complied. They are classified under –
§ Āhāriya
Hetus: Ati Amla Sevana, Ati Kaţu Rasa Sevana, Rūkşa Āhāra Sevana etc.
§ Vihāriya
Hetus: Atimaithuna, Duşţayoni Maithuna, Ayoni Maithuna, Tirayak Yoni Maithuna,
Jāgaraņa etc
§ Mānasa
Hetus: Cintā, Krodha, Bhaya, Śoka, Irşya
§ Other
Hetus: As a Upadrava of Sahaja Arśa, Kşatakşīņa, Duşivişa
§ Auşadha
etc like Kşāra Sevana, Yavakshāra Sevana
Causes
of Male Infertility: Sperm Factors, Environmental Factors, Social Factors,
Stress Factors. The details have been expounded in the thesis.
Survey Study: Observations
in the survey study were organized, analyzed, evaluated. These observations are mentioned in detail in
the thesis.
Method
of Statistical analysis:
Ø This
study is case – control type study. Possible causative factors in patients of
infertility compared to fertile male were observed in this study.
Ø Proportion
of outcome (Infertility) to exposure (specific Hetu) was studied using Odds
Ratio (OR)
Ø Gr.-II
& Gr.-III are of infertile males. Both these groups has clubbed for the
purpose of comparing infertile males versus fertile males.
Ø Interpretation
of OR:
OR > 1- Exposure is associated with
higher odds of outcome (significant)
OR = 1- Exposure does not affect odds
of outcome
OR < 1- Exposure associated with
lower odds of outcome
Factors
which are found significant are noted in the Table- 2. There are various
factors which are not found significant in the study, are mentioned in the
thesis.
Table
-2: Observations of the Survey study
|
|||||
Variables
|
Fertile
Gr. I
n=30(%*)
|
Infertile
(Known Cause)
Gr. II
n=30 (%*)
|
Infertile
(Unknown Cause)
Gr. III
n=30 (%*)
|
Odds Ratio
|
95%
CI
|
Āhāra
related Hetu
|
|||||
Amla Rasa
|
17 (57)
|
17 (57)
|
18 (60)
|
1.07
|
0.44 –2.60
|
Lavaņa Rasa
|
16 (53)
|
20 (67)
|
19 (63)
|
1.63
|
0.67 – 3.97
|
Kaţu Rasa
|
15 (50)
|
21 (70)
|
22 (73)
|
2.53
|
1.02
– 6.28
|
Tikta Rasa
|
08 (27)
|
10 (33)
|
08 (27)
|
1.18
|
0.44 – 3.14
|
Viruddha Anna
Sevana
|
21 (70)
|
23 (77)
|
21 (70)
|
1.18
|
0.45–3.10
|
Vidāhi Anna
Sevana
|
16 (53)
|
18 (60)
|
18 (60)
|
1.31
|
0.54 – 3.18
|
Kşāra Sevana
|
16 (53)
|
20 (67)
|
19 (63)
|
1.21
|
0.49 – 3.00
|
Rūkşa Anna Sevana
|
14 (47)
|
22 (73)
|
19 (63)
|
2.47
|
1.00
– 6.07
|
Maithuna
related Hetu
|
|||||
Ati Maithuna
|
22 (73)
|
24 (80)
|
24 (80)
|
1.45
|
0.52 – 4.06
|
H/O Śukra Vegodiraņa
|
12 (40)
|
18 (60)
|
17 (57)
|
2.10
|
0.86 – 5.13
|
Divā Maithuna
|
10 (33)
|
11 (37)
|
11 (37)
|
1.16
|
0.46 – 2.91
|
Ajīrņe Maithuna
|
22 (73)
|
24 (80)
|
23 (77)
|
1.31
|
0.48 – 3.63
|
Mānasa related Hetu
|
|||||
Cintā
|
20(67)
|
29 (97)
|
28 (93)
|
9.50
|
2.37-38.03
|
Śoka
|
14 (47)
|
19 (63)
|
18 (60)
|
1.34
|
0.54 – 3.33
|
Bhaya
|
14 (47)
|
27 (90)
|
23 (77)
|
5.71
|
2.13
–15.34
|
Krodha
|
21 (70)
|
23 (77)
|
23 (77)
|
1.41
|
0.53 - 3.77
|
(*percentage
is rounded to nearest whole number)
The observations of semen analysis and
Śukra Parīkşā are noted in Table -3
Table
-3: Semen
Analysis
|
|||
Variables
|
Fertile
Gr. I
n=30(%*)
|
Infertile
(Known Cause)
Gr. II
n=30 (%*)
|
Infertile
(Unknown
Cause)
Gr.
III
n=30
(%*)
|
Semen
Analysis
|
|||
Oligospermia
|
-
|
23 (77)
|
-
|
Asthenozoospermia
|
-
|
06 (20)
|
-
|
Azoospermia
|
-
|
01 (03)
|
-
|
Abnormal forms of sperm
|
-
|
02 (07)
|
-
|
Śukra
Parīkşā
|
|||
Abnormal Colour
|
|||
Yellowish White
|
-
|
03 (10)
|
04
(13)
|
Greenish White
|
-
|
03 (10)
|
02
(07)
|
Abnormal Snigdhatā (Picchilatā)
|
-
|
04 (13)
|
01
(03)
|
Abnormal Rasa
(Fructose Absent)
|
-
|
02 (07)
|
01
(03)
|
Abnormal Gandha
|
-
|
01 (03)
|
04(13)
|
DISCUSSION:
It is revealed in this study thatvarious Śukravikŗtīkara
Hetus mentioned in Āyurveda classics are
found associated with male infertility.
Āhāriya Hetu:
Kaţu Rasa Sevana:
It is found in
the survey that consumption of Kaţu Rasa is found in50 % cases in Gr. I, 70 %
in Gr. II & 73 % cases in Gr. III.
This difference is found to be significantly associated with infertility
after applying odds ratio test (OR - 2.53). Kaţu Rasa due to its Kaţu Vipāka
reduces fertility. Due to its Uşņa property it dries up the Drava Bhāva in the
body leading to reduction in Saumya property of Śukra. Eventually it causes Śukra
Duşţī. The effect of Kaţu Rasa is long lasting& fatal. It is so fatal that
it can be transformed into next generation[15].
Amla
(OR-1.07), Lavaņa (OR-1.63), Tikta Rasa (OR-1.18) are also found associated
with the infertility in this study, but its lower values are less than 1 at 95%
confidence interval.
Ati Rūkşa Āhāra Sevana:
In
this study it is revealed that 47 % cases in Gr. I, 73 % in Gr. II & 63 %
cases in Gr. III consumes of Rūkşa Āhāra. This is found associated with infertility
after application of Odds Ratio (2.47). Rūkşa Guņa vitiates Vāta and reduces
Kapha Doşa. It dries up the Dhātus by Śoşana of the Dravāṃśa.
As this Rūkşa Guņa is opposite to that of the Śuddha Śukra Guņas like Snigdha,
Picchila etc. Ati Rūkşa Sevana causes Śukra Duşţī and also reduces the sexual
strength. Rūkşa Dravyas are consists of Vāyu & Agni Mahābhūta. These are
opposite to the qualities of Śukra. It dries up the Dhātus, reduces Bala and
Varņa of the Śarīra[16].It
finally leads to Viśuşka and Kşīņa Retas. The Rūkşa Guņa along with Uşņa Guņa
causes Āśu Śukra Duşţī.
Vihāriya Hetu:
Ati Maithuna:
In
the survey it is observed that 73 % patients in Gr-I, 80% in Gr.II & III
are indulging excessive sexual intercourse. It is found associated significantly.
(OR-1.45). Season wise frequency of Maithuna has been specified in Āyurveda
classics[17].
In this survey it is found that, patients are not aware of such rules. Excessive
indulgence in sexual intercourse directly leads to Śukra Kşaya[18].
As Ativyavāya leads to Śukra and Oja Kşaya which are the Sneha of the body,
leads to the aggravation or vitiation of Vāta Doşa. This further leads to
Pratiloma Gati Kşaya of the remaining Dhātus, which may further hampers the Śukrotpatti.
Thus Ati Maihuna leads to Śukra Kşaya and eventually causes infertility.
Mānasa Hetu:
Stress
developed due to Cintā (worry), Śoka (grief), Krodha (anger), Bhaya
(fear), Irşya (jealousy) is one
of the leading causes of infertility. It was observed in the survey study that Cintā & Bhaya induced stress has
been found in maximum patients. These
Mānasa Hetus are responsible for Śukra Kşaya[19].
Cintā, Bhaya, Śoka & Krodha
was found significant in infertility after applying Odds Ratio. Cintā (9.50)
followed by Bhaya (5.71) are found more significant at 95% Confidence
Interval than Śoka & Krodha. In
today’s competitive world everybody has stress. Stress is found in fertile
group also as far as this study is concerned, but the stress found in infertile
cases was of severe type (hampering their daily routine), whereas in fertile
group it was moderate type.
Much
research in the field of medicine has focused on the change of sperm quality in
men exposed to stress induced by fear, anxiety, worries etc. Collodel G stated
that stress is an additional risk factor for idiopathic infertility[20].
Krodha,
Śoka, Bhaya & Cintā lead to vitiation of Pitta and Vāta, which causes Rasa-Rakta Duşţī. Duşita Rakta gets
lodged in Śukravaha Srotas that result in Śukravaha Srotoduşţī, which finally
leads to Śukra Vikŗtī[21].
Śukra Vikŗtī
Lakşaņa:
Mukhaśoşa(10%) followed by Gātrasāda(7%) and Timīradarśana
(7%) in Gr.-I, Maithuna Aśakti(20%) followed by Mukhaśoşa (17%) in Gr.-II, and
Mukhaśoşa (20%) followed by Maithuna Aśakti (13%) Daurbalya (13%) Gātrasāda (13%)
in Gr.-III were found in the survey study.
Semen Analysis:
In the survey it was found in Gr. II, that 77%
cases were suffering from Oligospermia, 20% patients were of Asthenozoospermia,
1 patient (3%) was of Azospermia and 2 patients(7%) were of abnormal forms of
sperm.
As per Āyurveda Śukra Parikşā it was found in the
study that yellowish white colour of semen in 10% cases in Gr.-II, & 13% in
Gr.-III whereas greenish white colour of semen in 10%cases in Gr.-II& 7% in
Gr.-III. Dravatā was normal in all the cases. Picchilatā was found in 13% cases
in Gr.-II & 3% in Gr.-III. Madhura
Rasa was found absent in 7% cases in Gr.-II & 3% in Gr.-III. Madhu Gandha
was absent in only 1 patient (3%) in Gr.-II & 4 patients (13%) in Gr.-III
In a Nut Shell:
1.
Literary review shows that Śukravikŗtīkara Hetus mentioned in Āyurveda classics are linked with
pathogenesis of male infertility.
2.
As per this survey
study consumption of Ati Amla (1.07), Lavaņa(1.63), Kaţu(2.53), Tikta Rasa(1.18),
Viruddha Āhāra(1.18), Rūkşa Āhāra (2.47), Kşāra Sevana (1.21)is found
associated in Śukravikŗtī.
3.
Vihāriya Hetus like Ati
Maithuna (1.45), Ajīrņe Maithuna (1.31), Divā Maithuna (1.16), Śukra Vegodiraņa
(2.10) are found associated with male infertility in this survey study.
4.
Stress developed due
to Cintā (9.50), Śoka (1.34), Bhaya(5.71), Krodha (1.41) are leading causes of
infertility. It was observed in the survey study that Cintā induced stress has
been found in maximum patients followed by Bhaya induced stress.
5.
This study shows that
Āhāriya & Vihāriya Hetus along with Cintā, & Bhaya are contributing factor
for development of infertility.
6.
This study shows that
infertility should be considered as a psychosomatic entirety.
7.
Amongst all above
Hetus, Cintā (9.50) & Bhaya (5.71), Kaţu (2.53) & Rūkşa Āhāra Sevana(2.47)
are found significant at 95% Confidence Interval.
CONCLUSION:
Cintā
(9.50) & Bhaya (5.71) along with Kaţu (2.53) & Rūkşa (2.47) Āhāra Sevana
are associated with male infertility.
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