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One vs. Two: The debate over how many embryos to transfer

02/25/2012

Belle


This has been weighing heavily on me recently and it seems no one wants to talk about it: Do we transfer one or two blastocysts? When transferring with blastocysts the chance of twins goes up considerably and this, frankly, terrified me.

My  emotional side  says transfer two. “YES. I can handle twins. Sure I have the pelvis of a 12-year-old boy, an unusually small cervix and some funky immune issues but look at all those wonderful twins out there! GIVE ME TWO BLASTOCYSTS!”

My reasonable and scientific side says transfer one.

NPR has a great article called “Taming the Twin Trend.” In it they say, “The downfalls [of twin pregnancy] are well-documented. The human uterus is designed to carry one baby. When it’s stuffed with two, any number of things can go wrong, and odds are good that the babies will be born prematurely.”

The article goes on to cite Barbara Collura, executive director of Resolve: The National Infertility Association, as saying, “…Most twins end up fine. But because 60% are born premature, many do not survive and others face a lifetime of problems: developmental, cognitive, respiratory, digestive, trouble with sight and hearing. Twins are far more likely to have cerebral palsy.”

No matter how you spin it, a twin pregnancy comes with risks. I have read about women with twins where everything worked out beautifully. I have read of women with twins where things have ended up complicated and scary.  And I have read of women with twins where things went terribly, horribly wrong.

My mom recently made a comment about one day having six grandchildren and I had to choke back tears, “Mom, it does not work that way. Having six embryos does not guarantee six babies. We are only a fraction of the way there. The embryos have to survive the thaw, and then they have to implant, and then my messed up body has to keep them… Or keep one of them, I mean! Only one!” I added that last comment as a partial joke and a careful opening to a conversation I so desperately want to have.

“You know, since we have six high quality blasts I’m considering transferring one at a time,” I said. “I don’t want twins. What are your thoughts?”

My question was met with silence and then some muttering about it is my choice but… “twins would be fun!”

Whenever I try to bring this subject up to family and fertile friends, I get the same thing. Twins would be fun! Twins are awesome! Even the nurses and my former RE said, “Twins mean you never have to do this again! Twins would be great!” What they do not say is that this only applies if my twins live.

I have not heard a single medical professional, fertile friend or family member discuss the risks of twins. My doctors have warned me about the risks of high order multiples, but never have they mentioned the risks associated with carrying and delivering twins. At times, I feel my doctors are actually pushing two embryos so THEIR rate of success per transfer increases.

Taming the Twin Trend says, “In recent years, guidelines set by the American Society for Reproductive Medicine (ASRM) have grown more conservative, and the rate of triplets and higher order multiples has plummeted. Yet the twins rate has remained stubbornly stable. The ASRM recommends using just one embryo for many women undergoing IVF. But many doctors may not push that forcefully. And Stillman [Robert Stillman, medical director at Shady Grove Fertility Center in Rockville, Md.] says those who try may have trouble convincing someone desperate to become a parent.”

Stillman goes on to say that he understands the urgency women feel to have a child, but it doesn’t change his message: “It’s safer to have one baby, and using one embryo in IVF has nearly the same success rate as two.”

Wait? What was that statistic? Using one embryo in IVF has nearly the same success rate as two. Really?

According to OneAtATime.org, “A study in 2005 showed that where younger women** received only a single blastocyst, their chances of a live birth remained almost identical (65.3%) compared with those after double blastocyst transfer (64.2%), when one fresh and one frozen cycle were included. However, there were only 7% multiple pregnancies in the single blastocyst transfer group, compared with 34% in the group who chose double blastocyst transfer.”

So why is it that when I bring this subject up I’m met with looks of disbelief or deaf ears? My body and heart long for a child as much as any other woman battling infertility. The emptiness I feel when I wake up in the morning is palpable. Yet my doctors, parents, and friends still hesitate when I consider one embryo vs. two.

So hear me out: either one of these six frozen embryos will or will not result in a baby. Transferring two at a time does nothing if they have chromosomal abnormalities, if my body rejects them, if they implant in a tube, etc. If these embryos are not going to stick then I will be doing another round of IVF whether I transfer one or two.

At my clinic the cost for each FET is $2,200 plus medication. This pales in comparison to the price of even a short stay in the NICU or, god forbid, the emotional price of losing one or both babies. I realize that by transferring only one embryo at a time I may be in for multiple FETs, but I feel like this is a risk I’m willing to take.**

Mr. Husband and I had a long talk about this last night and decided that as long as our blastocysts are healthy and thrive after thawing, we will only transfer one, even if it is unpopular with the doctors. Even if my friends and family look disappointed because “twins are fun!” Even if it means waiting a little longer for my healthy, happy, take home baby.

* Let me be clear to my IRL friends that are not dealing with infertility and read this: these feelings about twins in no way lessen my desire for a child. Twins are simply a medical risk to the babies and myself that I’m not ready to take. 

** I am WELL aware that I have the luxury of time a more than other couples. I am 31, meaning I still have a few years before I hit that 35 point. If I start closing in on 35 and still don’t have my take-home baby, then my tune may change.

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40 Comments

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  1. February 25, 2012

    I’m so firmly in the ‘one at a time’ camp!! We never had any doubts that we would only have one transferred no matter what. As far as I can see there is so much evidence out there of the risk of twin pregnancies and equally that the chance of success with IVF is not significantly lower by transferring one embryo rather than two. And especially not when we are talking frozen embryos as in your case.

    I am of course quite biased by the fact that I’m from Scandinavia where I think they first started changing the practice in IVF from multiple to single embryo transfers. In Denmark for instance it has been law since 2007 that clinics can only transfer one embryo unless in specific circumstances. In Sweden they have been doing it for even longer I think. And over time their IVF success rates have not gone down overall. But the complications associated with many twin pregnancies has significantly been reduced.

  2. February 25, 2012

    We go through the same discussion pretty often. Esp when our first IVF failed, I got impatient and started bringing up the idea of transferring 2. But, in the end, I know that twins is NOT what we want, or what is best for my body. One it is.

  3. February 25, 2012

    Good for you for forging your own path, and making the right decision for you. Many times women aren’t provided with the “full picture” when faced with such, truly enormous, decisions. Doctors paint a pretty picture and leave out the details that show what’s hiding in the background. Thank you for sharing the knowledge that you have gathered as you weighed the decision!

  4. February 25, 2012

    I wrote a post tackling the same subject. The reality is, twins carry risk. My niece and nephew are fraternal twins and though happy and healthy today, were not initially that way. They spent quite a bit of time in NICU and even when they were released, there were a number of health problems that could have been overcome if they had been carried individually and to 39-40 weeks and their mother being able to nurse (she didn’t produce enough milk for two). It’s taken the family almost 3 yrs to stabilize (there was a 6 month period where no one was sleeping through the nights).

    I’m all for eSET. In Europe this the norm. But there’s still data that transferring two results in higher pregnancy rates. (Paper released last year in British medical journal) and considering this country require insurance companies to cover fertility treatments, we made the decision to risk it and transfer 2. That said, every woman I know IRL who is pregnant from IVF did eSET, while here I am with a miscarriage under my belt.

  5. February 25, 2012

    I was definitely in the same boat before our first FET. Our RE gave us all this info on multiple pregnancies and I was in tears reading it I was so so so scared. There was no way I was transferring two, I filled out our thaw instructions for one. Then we went to our first FET, and on thawing our first embryo was downgraded and they were suggesting two. Well to me that first one was as good as dead. We transferred two. That failed. Next one I didn’t even think about it, we transferred two. Then next one they were all crap, they suggested 3. We were so thrown off that we did it, but I spent my tww in absolute terror. With this fresh cycle, with 3 Failed ETs under our belt, I didn’t blink, we transferred 2. And my betas…..well we don’t know for sure but it certainly looks like twins. I am scared shitless. I do think that when it works – it just works. Go ahead and transfer one. It is scary enough to be pregnant after infertility, the thought of a perfect long healthy pregnancy with one baby is just perfect.

  6. February 25, 2012

    I’m so glad you wrote this post! I’ve never done IVF but when those fertility drugs come out and you’re always popping out more than one egg I WAS SCARED TO DEATH OF MULTIPLES. Even twins. And you’re right it seems like there are SO many ladies on these boards who seem like they’re jumping for joy with their twins and even triplets and they never discuss the risks they’ve just set themselves up for later in their pregnancies. I fully support the decision you’ve made to transfer only one, I’d like to think if I was in your position I’d be doing the same thing.

  7. Kat #
    February 25, 2012

    I’m really surprised your doctors haven’t gone over the risks of twins. My RE laid it all out during our IVF consult and said he only transfers one embryo for women my age provided their good quality. Before that I was one of the “Twins are fun!” people. But I really didn’t know what the risks are. It’s kind of amazing more people don’t. It’s also amazing that everyone else is all “Twins are fun” when you’re the one who has to carry, birth, and raise them. Good for you for sticking with what is best for you and good luck with your next transfer.

  8. February 25, 2012

    I also heard that NPR piece on the radio just before our IVF. I’m pretty shocked by your doctor’s reaction. Mine were very firm that, based on my age, they only wanted to transfer one embryo because of the risks that come with multiples (including twins). Now they did end up transferring two because they were the only ones that didn’t arrest, and they had only reached morula stage by Day 5. Only one stuck though. As much as I wanted to be pregnant, I was relieved it was not with twins. I’m not really shocked by other people’s reactions (these are the same people to tell us to “relax” and we’ll get pregnant). They just aren’t informed that while “twins are fun”, they also bring a lot of risk to themselves and mommy. You’ve done your homework, and you know what’s best for you and your family. So don’t doubt yourself. Wishing the best for you and your embryo!

  9. Jay #
    February 25, 2012

    I think that you are making the sensible choice. With the murky threat of autoimmunity over your head, you are best off with just carrying a singleton pregnancy. Is your doc planning any immune supressives, just to be on the safe side? Prednisone is fairly safe and may increase your chances. IVIG is safe-ish, but maybe effective, but super expensive. Intralipids are safe, inexpensive but kind of questionable as to whether they work.

  10. February 25, 2012

    Wonderful, informative, clearly written post! Thank you so much for writing this. Our RE will only transfer 1 at a time, but may do 2 if desired… he explained the risk that twins bring and is adamant about 1 at a time. Whereas in my mind I’m thinking “twins are fun” or “let’s get more bang for our buck”… I will be sharing this post with my husband because you’ve said what my RE said … but I just wasn’t ready to hear him. Thank you!

  11. February 25, 2012

    This is the first post I’ve read on your blog (found you from ICLW) but it sounds clear that you only want to transfer one, that you’ve seriously considered the issue and that you would like validation. I’m just starting IVF and I was in the 2 camp, but your post made me seriously reconsider! It’s so much easier to think about the odds of getting pregnant (which you mentioned don’t change much) rather than the additional risks later on. And with FET only costing $2,200…it makes a lot of sense. My RE’s transfer # is almost exactly 2. I wonder what his response would be if I only wanted to do 1 (or if that would even be allowed in the “guaranteed success” plan that I am doing).

    Thanks for the post! I can’t wait to hear how everything works out!

  12. February 25, 2012

    To those who just pop out babies I think the idea of multiples are fun, but to those of us who have seen so much in the ALI community and been through so many procedures it is much less appealing. Sometimes I think I wish I would get pregnant with twins so I could just be done and not worry about doing this again, but I agree with how scary a multiple pregnancy could be.

    You guys are doing what you feel is right for you. Screw the doctors. This is your body and your life. I’m glad you came to the decision you did because it sounds like you feel good about it.

  13. February 25, 2012

    Actually, our RE recommends transferring only one embryo if they are high enough quality simply because of the risks associated with twin pregnancies. Personally, I’m scared to death of twins. Eek. If you feel twins are too high of a risk, just transfer one. 🙂

  14. 35life #
    February 25, 2012

    My sister is tiny and they transferred two and they both took. She made it to like 37 weeks I think, which was fantastic. A natural birth was always the plan but then she ended up with preeclampsia and a necessary c-section. So in that sense it was scary. Nephew spent a night or two in NICU and had some tummy issues over the first several months where they had to change formulas many times to get it right, but other than that my niece and nephew are turning 4 next month and are perfectly fine and healthy.

    It’s such a hard decision to make. We transferred three both times due to my age, embryo quality and the fact that we never have enough left to freeze. So far a no-go but we’ll see what next time holds for us. Good luck!!

  15. February 25, 2012

    Good call, belle. One word for you : triplets. There are at least four women on my clinics discussion boards that had two transferred , one divided, and now they have TRIPLETS. Our clinic is very anti transferring two & will never transfer 3. Ever. If you want two, it’s compulsory to have counselling first. The pregnancy rates do not give not have a statistically significant difference , but the risks are huge .

    It is a lot more strain on your body, something you’ve already discussed. And you’re so right balancing up the costs. There are also women who lose one twin during the pregnancy , & I think when you’re talking about emotional complexity that must be so confounding.

    Best of luck.

  16. February 25, 2012

    I agree with the other commenters that mentioned their surprise that your doctors haven’t discussed the risk of twins. Our RE strongly suggested transferring 1, and we didn’t hesitate to agree. BUT…if I had known how difficult a fresh IVF cycle was and that we’d be transferring on day 3, with 0 frozen embryos, I might have chosen differently for our last cycle. Or maybe not, I don’t know. It’s definitely something we’ve been discussing lately, and we’re going to run the idea by our doctor on Monday. The research does seem to concur that twins are harder on a women’s body, and the pregnancy is riskier for them, but most do turn out okay. It’s certainly not an easy decision.

    On a related note…I’m so excited that your FET is coming soon!

  17. February 25, 2012

    Twins are always more fun when they’re someone else’s. It’s a lot easier to be excited when you’re not the one worrying yourself sick over being able to carry them both to term with as few complications as possible.

    But I have to say, if we get to IVF, we’re still far enough away from it that I’ll be too old to primly ask for ‘one, please,’ as opposed to if we were doing it today. I’ll be harpy-screaming ‘MORE!!’ I’m sure.

  18. February 25, 2012

    I totally totally agree. Everyone says “twins are fun” when they aren’t faced with the reality of the risks of twins. I’m pretty scared that I might have twins going on right now (won’t know until next week), and the risks freak me out. But what makes me even more scared is the chance of triplets, and how much harder that is on the body even than twins (and I had three possible eggs!).

    Good luck on your FET – I think you’re making the right choice!!!

  19. February 25, 2012

    If you feel more comfortable with just one, stick with that. Listen to your heart on these things. Carrying multiples is scary and you will have control over it. Hugs!

  20. February 25, 2012

    Ummm..my internal mind is sounding like a robot saying ” Talk.to. C.O.U.S.I.N..Who.was.infertile. Who.had.twins.Twins.were.premature.Twins.weighed.two and three pounds.” Now this is me talking “Girrlll…our first cousin is 40 years old with three year old twins who couldn’t conceive after fertility treatments.Who loves her twins dearly (and you know how damn cute they are) but is EXHAUSTED and all that stuff but wouldn’t trade it for the world but still…you have some options. You also have a wonderful person in your own family to discuss this with that went through it and shares the same genes.” Oh, and by the way…she is also having some wierd eye thing going on that I quickly reminded the fam of your uvetisis (sp?) So..CALL HER!!

  21. February 26, 2012

    I have twins. It was a difficult, difficult pregnancy. They made it to almost 36 weeks. I am tremendously, enormously lucky. Each day with them is a miracle.

    Do what’s in your heart.

  22. February 26, 2012

    We are about to transfer two good quality blast on Wednesday, and I too am a little worried about twins. Not that I wouldn’t love two babies but the possibility of compications, and the financial aspect is very scary. Financial reasons force us to transfer two at a time. It was hard enough for us to come up with the finances for this cycle, so we feel the need to increase the chances of pregnancy as much as possible. Good luck to you! If you would like to hear ivf success stories please visit http://www.ivfsuccessstories.info.

  23. February 27, 2012

    Getting this far and then adding more risk isn’t my cup of tea. Give me the safest healthiest way to give me a baby.

    I hope you two are excited and happy with whatever decision you make!

  24. liz77 #
    February 27, 2012

    Yo. I was all about 1 at a time. My RE (who I otherwise loved) BEGGED me to transfer 2 on my 2nd (and successful) cycle. I came close to caving – my husband was on board with 2, and it’s so stressful & emotional – but then we were talking abt the potential for splitting and she told us about a patient who transferred 2 and ended up with FIVE. (1 split once, the other twice.) Obviously very, very rare but still. No thank you. One please!!!

  25. February 28, 2012

    Hey girl, sorry for the late post but I just wanted to share what my RE told me at our IVF consult. She gave us the age groups of women and the respective embryo transfer their clinic goes by. Two of the groups are: under 35 (transfer 1 embryo) and 35-37 (2-3 embryos). I hope this helps a little.

  26. February 28, 2012

    Oh, I’m SOOO glad I came across your blog today!! I soaked up every word you wrote as I’m home, resting on the couch after our day 5 transfer. I literally JUST posted my questions on our decision to only transfer one as we had the same thoughts on how much fun twins could be. But… the risks…

    Thank you for writing this!! I feel a little lighter after reading it! Good for you and hubby for making the decision you feel is best for you. Stick with it and know that you know what is best for your body, not your mom, your friends, etc.

    I’m now following along and will be cheering you on during your journey.

    • February 28, 2012

      Hey Lora! Glad you found me, too! The one or two debate is a TOUGH call. It was super interesting to read all the comments to this post – my readers outside of the U.S. were consistently one embryo always, while some of my state-side readers were very much of the two embryo mindset. Either way, it is a super personal choice and I’m glad I could help you feel more comfortable with your decision. I’ll be following your journey now, too. Cheers!

  27. March 3, 2012

    My husband does not want twins. I WOULD be OK with them…you know, “get them both at the same time” (we only want two). However – I know the risks are too numerous. I know this is something we are going to have to take into serious consideration. As an infertile couple, I personally do not have any health issues (other than a blocked tube) the reason we are doing IVF is because we are dealing, mainly, with male factor…so – honestly I do have the thought that “maybe my body can handle twins” BUT even if my body COULD…the question is – can WE…as in, financially can we? And – like you said (and I read that article, too…) what DOES happen if two are implanted and issues arise and both are lost?
    But – I do lean towards wanting two. Again – my husband does not. IF it happens naturally then we will learn to live with twins. sigh. I just don’t know!

  28. June 2, 2012

    I am in the program and I am also remniag nuetral and optimistic. I have seen an equal amount of negative as I have positive with the clinic. However the negatives are about the actual visit not the procedure or success rates. I do notice that mainly patients 35 plus benefit from this clinic and I am under than range so I hope the Mini-IVF works for me. I think people should give them a fair chance based on results not too much of the bedside manner, after all I am not concerned with someone that getting a call back right away about a question, mine is did the IVF work? As long as they are pleasant and not make the situation any more stressful than it is then hey, works for me. They are not magicians, they are simply a staff of qualified medically trained team trying to give us all what we went there for A BABY. Just stay positive, it will all work out, I am holding on to hope and I hope you can too.

    • June 2, 2012

      I agree! Are you also at Bl.ue.grass Fert.ility KY? If so, I’d love to meet up with you for coffee sometime. It’s a lonely world for infertiles around here, too!

  29. Jane #
    January 15, 2013

    HI, I stumbled upon this page whilst trying to decide on the 1vs2 embryo transfer. First of all I’d like to know if anyone is still following this post and if any of you now have babies, if so did you transfer 1or2?
    I have had a biochemical pregnancy & 1 failed frozen embryo transfer (with a single blastocyst).
    I am now due to have another FET on 24th January 2013, as I am 39 and this will probably be my final attempt, I am now debating whether to transfer 1 or 2 embryos. If I was younger then I’d probably go for only 1, but since I’ve already twice had embryos that didn’t implant I feel transferring 2 will give me a better chance, but understand there is more risk.
    I’m not against having twins if thats the end outcome but I am afraid of all the risks that goes with it!
    Discuss please, I’m so confused. I know in the end only I can decide but it helps to hear other views. Thanks

    • January 15, 2013

      Hey Jane, I’m going to email you with some more information, but I did end up transferring two during my third and final transfer. It was a tough call but seemed the best option given the circumstances. I’ll shoot you an email in a second with more info…

      • Sara #
        June 9, 2013

        Hi Belle,
        I need to decide today whether or not to transfer one or two 5 day blastocysts. My FET is scheduled for tomorrow. I am 43 years old and the 2 embryos I have were PGD tested. My heart is telling me to put in 2. I want to up my chances of having one as much as possible and 2 would be a blessing at this point. This has been such a long journey… 18 months of waiting, medication, 2 miscarriages, multiple IUIs and 3 IVF egg extractions to get the 2 genetically healthy good embryos. Although my heart says 2, I worry about the risks involved and wonder if one is a more sensible choice. If you or anyone out there reads this today, and can share their thoughts I’d appreciate it. I need all the insight I can get to make this difficult decision. Thanks for listening.

        • June 9, 2013

          Hey Sara,
          This is such a personal choice and a really really hard one to boot! I can share my story and hope it might help you – I was AVIDLY against two embryos up until my last cycle. We had also had a miscarriage (Trisomy 15) and been at this for a long time. We were also at the point of desperation, and running out of money, so we opted to transfer two day 5 blastocysts that looked “perfect” (no PGD). I was scared to death of twins and the risks, but my heart said do two so we did. I’m not 37 weeks pregnant with a singleton. Transferring two was truly the best choice for my little family at the time. My advice is if you would view two as a blessing and are at a point in your life where caring for two would be feasible, than follow your heart. You and your husband will know best. Best of luck and please pop by and let me know how things go. I’ll be keeping you in my thoughts.

  30. October 10, 2013

    Hitting dr google to help me find some opinions on the 1 vs 2 blasto’s I found you blog… A little excited to see you have been successful!

    I’m just recovering from a d&c last week, our 2nd single blasto had a heartbeat @7weeks but not @8weeks

    This is year6 on our quest to become pregnant & 5th miscarrage

    So undecided what to do about 1 vs 2 a lot being driven by $$ but those higher risks scare the crappers out of me!

  31. lucy #
    November 9, 2013

    I had IVF in November 2012 and had two embryos put back in (not blastos). I was overjoyed to find at my 7 week scan to find out I was expecting twins. Two weeks later I had a scare and was scanned again only to find I was in fact expecting triplets. Again I was overjoyed. I felt blessed and so special that both embryos had taken and one had split. I am 38 and have one child through my first IVF cycle but then suffered two failures. I thought that was me done my family complete. How I was wrong! I continued to bleed from 12 weeks and was scanned every two weeks and nothing was ever found to be wrong. I read up on everything to do with multiple pregnancies so knew they were tricky but I am a sturdy girl and thought I could handle it. Unfortunately at 21 weeks 5 days I suddenly went into premature labour and had to give birth to my babies, all perfect girls. Nothing could be done to save them as they were too young so we had to wait for them to take their last breath. From start to finish it was over within 2 hours. It was horrific and I wouldn’t wish what we went through on anyone. At the post mortem they told us that there was nothing wrong with the babies or me it was just a risk of a multiple pregnancy. Having said all this my friend was pregnant with twins and carried to 38 weeks and gave birth to 7lb babies. She doesn’t realise how lucky she is in having such a healthy pregnancy and babies.

    We have just had IVF again transferring one embryo which unfortunately didn’t work. However disappointed I am, I have no regrets about not transferring two. We just couldn’t take the risk again. I thought twins/triplets would be fun well now I am unfortunately and sadly a lot more wiser. Just my view. Thanks for reading and thanks for the blog.

  32. sphyaw #
    February 2, 2014

    i am glad i read your post, i am ttc again with FET, just failed with a SET, and i was a bit wavered on putting in2 thawed embryos in my next attempt althou i am sure i cannot deal with another multi birth loss. i was pregnant with twins and had 1 live birth and 1 stillborn 1.5 years ago. occasionally the emo of losing one of my twins still overwhelms me and i have to succumb. your post helped to strengthen i am on the right path with SET.

  33. Cheryl #
    September 27, 2015

    We transferred 2 and became pregnant with twins. We were over the moon and when we heard the term ‘high-risk pregnancy’ said casually, we just didn’t take it seriously. I was put on bed rest at 23 weeks and at 24 weeks and 3 days went into premature labour. One of our boys died from a bleed in his brain after 3 days. My surviving son spent 103 days in NICU and thankfully has no prolonged health issues. We will never be the same.

    • September 27, 2015

      Oh Cheryl, I am so sorry for your loss and trauma. There are no words. Thank you for sharing and weighing in on this debate. It is SUCH a hard choice to make when faced with desperation for a child. I think all our stories will help others make the right choice for their family when the time comes. Sending you love and light.

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