Clinical experience and acceptability of the etonogestrel subdermal contraceptive implant

Use of etonogestrel subcutaneous implant in Sardinia, Italy: women's compliance and satisfaction

PURPOSE OF THE ARTICLE

The main aim of the study was to analyze the population of women who used etonogestrel implant, the reason that led them to this type of contraception, and the degree of compliance with it. Materials and methods: We carried out a retrospective study on women who had etonogestrel subcutaneous implant placed (n°47) over a 6-year period (2015-2021). We submitted the women a series of questions by telephone questionnaire (range 10-72 months after placements, mean 40 months) that investigated the comorbidities and side effects related to etonogestrel implant.

MATERIALS AND METHODS

We carried out a retrospective study on women who had etonogestrel subcutaneous implant placed (n°47) over a 6-year period (2015-2021). We submitted the women a series of questions by telephone questionnaire (range 10-72 months after placements, mean 40 months) that investigated the comorbidities and side effects related to etonogestrel implant.

RESULTS

The average age of placement of etonogestrel implant was 33.8 ± 3.45 years. As regards level of education, 16/47 (34%) of the women had a university degree, 21/47 (44%) had a high school diploma and 10/47 (21%) had a secondary school diploma. The 12/47 (25%) of the women were, at the time of the counselling, unemployed and only 8% did not use in the past contraceptive methods other than etonogestrel implant. The 92% of women choose etonogestrel implant because it offered safe, comfortable and long-lasting contraception. Among the main side effects evaluated, we reported spotting in 24 out of 47 (51%), headache in 4 out of 47 (8.5%). The 85% of the women recommended etonogestrel implant to their friends as a contraceptive method, with an approval rating for the implant, expressed a rating from 1 to 10 with the mean that was 7.79, the median 8.

CONCLUSIONS

Our results are of interest because they derive from a region of Italy in which the Long acting reversible contraception (LARC) is strongly underused. Etonogestrel implant was a safe and effective, long-acting, reversible hormonal contraception (LARC) and majority of women recommended the etonogestrel implant to their friends as a contraceptive method.

Non-oral routes, novel formulations and devices of contraceptives: An update

Family planning enables society to prevent unintended pregnancies and helps in attaining desired spacing between the pregnancies. It is done with the use of contraceptive methods and infertility treatments. The use of contraceptives serves to ease maternal ill-health and reduce pregnancy-related deaths and helps to decrease the number of unsafe abortions and HIV transmission from mothers to newborns. The most popular contraception method is a daily dose of combined oral contraceptives pills. However, poor compliance and various adverse effects are common problems of oral contraceptives that considerably reduce their long-term use. Thus, several non-oral contraceptive options have been developed for better compliance, reduced side effects and improved therapeutic efficacy. This review presented the non-oral contraceptive formulations given by different routes such as transdermal, nasal, subcutaneous, intramuscular, intrauterine and vaginal routes. These formulations delivering contraceptives, mainly through devices, include transdermal patches and microneedles, nasal sprays, intrauterine devices and intrauterine systems, vaginal rings, contraceptive implants and contraceptive injections, which are unique in their specific advantages and drawbacks.

Safety and Benefits of Contraceptives Implants: A Systematic Review

Progestin-only contraceptive implants provide long-acting, highly effective reversible contraception. We searched the medical publications in PubMed, CENTRAL, and EMBASE for relevant articles on hormonal implants published in English between 1990 and 2021. Levonorgestrel (LNG) 6-capsule subdermal implants represented the first effective system approved for reversible contraception. The etonogestrel (ENG) single rod dispositive has been widely employed in clinical practice, since it is a highly effective and safe contraceptive method. Abnormal menstrual bleeding is a common ENG side effect, representing the main reason for its premature discontinuation. Emerging evidence demonstrated that it is possible to extend the use of the ENG implant beyond the three-year period for which it is approved. The ENG implant could be an effective and discrete alternative to the IUD in young girls, such as post-partum/post-abortion. Implants should be inserted by trained skilled clinicians who previously provide adequate counselling about their contraceptive effect, benefits, and any possible adverse events. More studies are needed to validate the extended use of the ENG implant for up to 5 years.

A systematic review on clinical effectiveness, side-effect profile and meta-analysis on continuation rate of etonogestrel contraceptive implant

Background

Unintended pregnancies (UIP) have a significant impact on health of women and the health budget of countries. Contraception is an effective way to prevent UIPs. The study objective was to collate evidence on clinical effectiveness of etonogestrel subdermal implant (ESI), continuation rate and side effect profile among eligible women of reproductive age group, as compared to levonorgestrel intrauterine system (LNG-IUS), copper intrauterine device (Cu-IUD) and depot medroxy progesterone acetate injections; other types of contraceptive implants were excluded as comparators.

Methods

The protocol of the systematic review was registered in Prospero (registration number: CRD42018116580). MEDLINE via PubMed, Cochrane library and web of science were the electronic databases searched. A search strategy was formulated and studies from 1998 to 2019 were included. Clinical trial registries and grey literature search was done. Critical assessment of included studies was done using appropriate tools. A qualitative synthesis of included studies was done and a meta-analysis was conducted in RevMan software for continuation rates of ESI as compared to other long acting reversible contraceptives (LARC) e.g. LNG IUS and Cu-IUD.

Results

The search yielded 23,545 studies. After excluding 467 duplicates, 23,078 titles were screened and 51 studies were included for the review. Eight of the 15 studies reporting clinical effectiveness reported 100% effectiveness and overall pearl index ranged from 0 to 1.4. One-year continuation rates ranged from 57–97%; 44–95% at the end of second year and 25–78% by 3 years of use. Abnormal menstruation was the most commonly reported side effect. There was no significant difference in bone mineral density at 1 year follow-up. The meta-analyses showed that odds ratio (OR) of 1-year continuation rate was 1.55 (1.36, 1.76) for LNG-IUS vs. ESI and 1.34 (1.13, 1.58) for copper-IUD vs. ESI; showing that continuation rates at the end of one-year were higher in LNG-IUS and copper-IUD as compared to ESI.

Conclusion

ESI is clinically effective and safe contraceptive method to use, yet 1-year continuation rates are lower as compared to LNG-IUS and copper-IUD, mostly attributed to the disturbances in the menstruation.

There might be blood: a scoping review on women's responses to contraceptive-induced menstrual bleeding changes

INTRODUCTION

Concern about side effects and health issues are common reasons for contraceptive non-use or discontinuation. Contraceptive-induced menstrual bleeding changes (CIMBCs) are linked to these concerns. Research on women's responses to CIMBCs has not been mapped or summarized in a systematic scoping review.

METHODS

We conducted a systematic scoping review of data on women's responses to CIMBCs in peer-reviewed, English-language publications in the last 15 years. Investigator dyads abstracted information from relevant studies on pre-specified and emergent themes using a standardized form. We held an expert consultation to obtain critical input. We provide recommendations for researchers, contraceptive counselors, and product developers.

RESULTS

We identified 100 relevant studies. All world regions were represented (except Antarctica), including Africa (11%), the Americas (32%), Asia (7%), Europe (20%), and Oceania (6%). We summarize findings pertinent to five thematic areas: women's responses to contraceptive-induced non-standard bleeding patterns; CIMBCs influence on non-use, dissatisfaction or discontinuation; conceptual linkages between CIMBCs and health; women's responses to menstrual suppression; and other emergent themes. Women's preferences for non-monthly bleeding patterns ranged widely, though amenorrhea appears most acceptable in the Americas and Europe. Multiple studies reported CIMBCs as top reasons for contraceptive dissatisfaction and discontinuation; others suggested disruption of regular bleeding patterns was associated with non-use. CIMBCs in some contexts were perceived as linked with a wide range of health concerns; e.g., some women perceived amenorrhea to cause a buildup of "dirty" or "blocked" blood, in turn perceived as causing blood clots, fibroids, emotional disturbances, weight gain, infertility, or death. Multiple studies addressed how CIMBCs (or menstruation) impacted daily activities, including participation in domestic, work, school, sports, or religious life; sexual or emotional relationships; and other domains.

CONCLUSIONS

Substantial variability exists around how women respond to CIMBCs; these responses are shaped by individual and social influences. Despite variation in responses across contexts and sub-populations, CIMBCs can impact multiple aspects of women's lives. Women's responses to CIMBCs should be recognized as a key issue in contraceptive research, counseling, and product development, but may be underappreciated, despite likely - and potentially substantial - impacts on contraceptive discontinuation and unmet need for modern contraception.

Uptake of long-acting, reversible contraception in three remote Aboriginal communities: a population-based study

OBJECTIVE

To assess the use, effectiveness and acceptance of prescribed contraception in three remote Western Australian Aboriginal communities.

PARTICIPANTS AND DESIGN

Mixed method study, including retrospective file review of contraception methods for 566 regular female Aboriginal patients, 1 November 2010 - 1 September 2014, and semi-structured interviews with 20 Aboriginal women.

SETTING

Primary care clinics in three remote Aboriginal communities.

MAIN OUTCOME MEASURES

Number of episodes of contraceptive use, effectiveness and continuation rates of prescribed contraceptive use; personal experiences, attitudes towards and beliefs about contraception options.

RESULTS

34% of women had used contraception, ranging from 15% of women aged younger than 15 years to 55% of women aged 15-19 years. The most common forms of contraception at the census date were long-acting reversible contraceptives (LARCs): 77% of women using contraception had an etonogestrel implant and 7% had depot medroxyprogesterone. Etonogestrel continuation rates at 1, 2 and 3 years were 87% (95% CI, 81-92%), 72% (95% CI, 64-78%) and 51% (95% CI, 41-60%) respectively. Medroxyprogesterone depot continuation at one year was only 14% (95% CI, 8-22%). Social acceptance of the etonogestrel implant was high; no concerns were raised about stigma or unwanted attention related to implant use.

CONCLUSION

The high uptake of LARCs in these communities is consistent with international recommendations about contraception use. High acceptability was reflected in excellent continuation rates. Service delivery models that use community engagement and capacity building are recommended for broadening the focus of sexual health beyond sexually transmitted disease detection and management, giving priority to the reproductive rights and unmet needs of Aboriginal women.

Microbial transformation of contraceptive drug etonogestrel into new metabolites with Cunninghamella blakesleeana and Cunninghamella echinulata

Biotransformation of a steroidal contraceptive drug, etonogestrel (1), (13-ethyl-17β-hydroxy-11-methylene-18,19-dinor-17α-pregn-4-en-20-yn-3-one) was investigated with Cunninghamella blakesleeana and C. echinulata. Five metabolites 2-6 were obtained on incubation of 1 with Cunninghamella blakesleeana, and three metabolites, 2, 4, and 6 were isolated from the transformation of 1 with C. echinulata. Among them, metabolites 2-4 were identified as new compounds. Their structures were deduced as 6β-hydroxy-11,22-epoxy-etonogestrel (2), 11,22-epoxy-etonogestrel (3), 10β-hydroxy-etonogestrel (4), 6β-hydroxy-etonogestrel (5), and 14α-hydroxy-etonogestrel (6). Compounds 1-6 were evaluated for various biological activities. Interestingly, compound 5 was found to be active against β-glucuronidase enzyme with IC₅₀ value of 13.97±0.12μM, in comparison to standard compound, d-saccharic acid 1,4-lactone (IC₅₀=45.75±2.16μM). Intestinal bacteria produce β-glucuronidase. Increased activity of β-glucuronidase is responsible for the hydrolyses of glucuronic acid conjugates of estrogen and other toxic substances in the colon, which plays a key role in the etiology of colon cancer. Inhibition of β-glucoronidase enzyme therefore has a therapeutic significance. Compounds 1-6 were also found to be non cytotoxic against 3T3 mouse fibroblast cell lines.

Global trends in use of long-acting reversible and permanent methods of contraception: Seeking a balance

The global trend shows that the use of permanent contraception to prevent unintended pregnancy is high. Although the trend also shows a rise in the use of long-acting reversible methods, these are still underutilized despite having contraceptive as well as non-contraceptive benefits. Lack of knowledge among women, dependence on the provider for information, and provider bias for permanent contraception are cited as reasons for this reduced uptake. Training of healthcare providers and increased patient awareness about the effectiveness of long-acting reversible contraceptive methods will increase their uptake and help prevent unintended pregnancies.

Sociodemographic profiles and use-dynamics of Jadelle (levonorgestrel) implants in Jos, Nigeria

Background:

Contraceptive implants (including Jadelle) are highly effective, safe, and easy to use and have a long duration of action. They do not interfere with intercourse with immediate return to fertility after removal. However, disruption of the menstrual bleeding pattern is almost inevitable and coercive prescription may be a problem because insertion and removal of implants are provider dependent. The objective of this study was to determine the sociodemographic profiles of acceptors of Jadelle and the reasons for discontinuation in Jos, Nigeria.

Materials and Methods:

This was a 6-year retrospective chart review carried out at the Jos University Teaching Hospital.

Results:

About 1401 women accepted Jadelle with a mean (±standard deviation) of 33.4 ± 5.9 years. About 88% of the women were Christians and almost three-quarters (73.5%) had at least secondary school education. The means of parity and number of children still alive at the time of accepting Jadelle were 4.1 and 3.8, respectively. Half of the women (49.5%) were breastfeeding and over half (55.9%) had future fertility desires at the time of commencing Jadelle. About 82% had previously used other contraceptives (mostly short-acting methods such as injectables, pills, and condoms), with only 18% starting Jadelle as the first-ever contraceptive method. About 90% of the women had regular menstrual cycles. The major reason for discontinuation of Jadelle was desire for pregnancy although menstrual pattern disruption was the most common reason for removal in the first 6 months of use.

Conclusion:

The main reason for discontinuation of Jadelle was to have more children although menstrual pattern disruptions accounted for earlier discontinuation.

Long-Acting Reversible Contraceptives for Incarcerated Women: Feasibility and Safety of On-Site Provision

CONTEXT

Many incarcerated women have an unmet need for contraception. Providing access to long-acting reversible contraceptive (LARC) methods--IUDs and implants--before release is one strategy to meet this need and potentially prepare them for reentry to the community, but the safety and feasibility of providing these methods in this setting have not been described.

METHODS

A retrospective descriptive study of all LARC insertions at the San Francisco County Jail in 2009-2014 was conducted. Data from community clinic and jail clinic databases were assessed to examine baseline characteristics of LARC initiators, complications from insertion, method continuation, and pregnancy and reincarceration rates. Correlates of method discontinuation were assessed in multivariate logistic regression analyses.

RESULTS

Eighty-seven LARC devices were inserted during the study period--53 IUDs and 34 implants. There were no cases of pelvic inflammatory disease or other insertion complications in IUD users and no serious complications in implant users. Median duration of known use was 11.4 months for IUDs and 12.9 months for implants. Women who discontinued a LARC method most commonly cited a desire to get pregnant (32%). Black women were more likely than whites to discontinue use (odds ratio, 4.4).

CONCLUSIONS

It is safe and feasible to provide LARC methods to incarcerated women. Correctional facilities should consider increasing access to all available contraceptives, including LARC methods, in a noncoercive manner as a strategy to reduce reproductive health disparities among marginalized women at high risk of unplanned pregnancies.

Nexplanon: the new implant for long-term contraception. A comprehensive descriptive review

Nexplanon(®) is a new long-term reversible contraception method. The current review is aimed to analyze the published data concerning the contraceptive effectiveness of Nexplanon(®) and its effects on reproductive function. Pharmacological properties and technical procedures of insertion and removal, as well as the efficacy and safety data available, were discussed. Possible strategies for treating Nexplanon(®)-related bleeding were also described. With regard to the future research and the future scientific developments of contraceptive implants, the possible use of Nexplanon(®) wide-ranging for the symptomatic treatment of endometriosis and premenstrual syndrome (PMS) were considered. Finally, it was defined in which women the use of Nexplanon(®) is indicated and in which it is contra-indicated.

Contraceptive features preferred by women at high risk of unintended pregnancy

CONTEXT

Available contraceptives are not meeting many women's needs, as is evident by high levels of typical-use failure, method switching and discontinuation. To improve women's satisfaction with contraceptive methods, determining what features they prefer and how these preferences are satisfied by available methods and methods under development is crucial.

METHODS

The importance of 18 contraceptive method features was rated by 574 women seeking abortions--a group at high risk of having unprotected intercourse and unintended pregnancies--at six clinics across the United States in 2010. For each available and potential method, the number of features present was assessed, and the percentage of these that were "extremely important" to women was calculated.

RESULTS

The three contraceptive features deemed extremely important by the largest proportions of women were effectiveness (84%), lack of side effects (78%) and affordability (76%). For 91% of women, no method had all of the features they thought were extremely important. The ring and the sponge had the highest percentage of features that women deemed extremely important (67% each). Some streamlined modes of access and new contraceptive technologies have the potential to satisfy women's preferences. For example, an over-the-counter pill would have 71% of extremely important features, and an over-the-counter pericoital pill, 68%; currently available prescription pills have 60%.

CONCLUSION

The contraceptive features women want are largely absent from currently available methods. Developing and promoting methods that are more aligned with women's preferences presumably could help increase satisfaction and thereby encourage consistent and effective use.

Pharmacokinetics of the etonogestrel contraceptive implant in obese women

OBJECTIVE

We sought to examine the pharmacokinetics and acceptability of the etonogestrel contraceptive implant in obese women.

STUDY DESIGN

We developed and validated a plasma etonogestrel concentration assay and enrolled 13 obese (body mass index ≥30) women and 4 normal-weight (body mass index <25) women, who ensured comparability with historical controls. Etonogestrel concentrations were measured at 50-hour intervals through 300 hours postinsertion, then at 3 and 6 months to establish a pharmacokinetic curve.

RESULTS

All obese participants were African American, while all normal-weight participants were white. Across time, the plasma etonogestrel concentrations in obese women were lower than published values for normal-weight women and 31-63% lower than in the normal-weight study cohort, although these differences were not statistically significant. The implant device was found highly acceptable among obese women.

CONCLUSION

Obese women have lower plasma etonogestrel concentration than normal-weight women in the first 6 months after implant insertion. These findings should not be interpreted as decreased contraceptive effectiveness without additional considerations.

Continuation and satisfaction of reversible contraception

OBJECTIVE

To estimate 12-month satisfaction and continuation rates of intrauterine device (IUD) and implant users enrolled in the Contraceptive CHOICE Project and compare these measures with women using the oral contraceptive pills (OCPs).

METHODS

We analyzed 12-month data from the first 5,087 participants enrolled in a prospective cohort study of women in the St. Louis region offered contraception at no cost for 3 years. The primary purpose of CHOICE is to promote the use of long-acting reversible contraception (IUDs and implants) and to reduce unintended pregnancies in our region. This analysis includes those participants who received their baseline contraceptive method within 3 months of enrollment and who reached the 12-month follow-up telephone survey time point (n=4,167).

RESULTS

Sixty-eight percent of our participants chose a long-acting reversible contraception method (45% levonorgestrel intrauterine system, 10% copper IUD, and 13% subdermal implant), 23% chose combined hormonal methods (11% OCPs, 10% vaginal ring, and 2% transdermal patch), and 8% chose depot medroxyprogesterone acetate. Long-acting reversible contraception users had higher 12-month continuation rates (86%) than OCP users (55%). The two IUDs had the highest 12-month continuation rates: levonorgestrel intrauterine system (88%) and copper IUD (84%). Women using the implant also had very high rates of continuation at 1 year (83%). Satisfaction mirrored continuation: more than 80% of users were satisfied with the IUD compared with 54% satisfied with OCPs.

CONCLUSION

IUDs and the subdermal implant have the highest rates of satisfaction and 12-month continuation. Given that long-acting reversible contraception methods have the highest contraceptive efficacy, these methods should be the first-line contraceptive methods offered to patients.

Contraceptive failure in the United States

This review provides an update of previous estimates of first-year probabilities of contraceptive failure for all methods of contraception available in the United States. Estimates are provided of probabilities of failure during typical use (which includes both incorrect and inconsistent use) and during perfect use (correct and consistent use). The difference between these two probabilities reveals the consequences of imperfect use; it depends both on how unforgiving of imperfect use a method is and on how hard it is to use that method perfectly. These revisions reflect new research on contraceptive failure both during perfect use and during typical use.

Examining the efficacy, safety, and patient acceptability of the etonogestrel implantable contraceptive

Contraceptive implants provide long-acting, highly effective reversible contraception. The etonogestrel implant (ENG implant) is a single rod implant that offers three years of efficacy. The ENG implant was designed to provide contraceptive efficacy by inhibiting ovulation and Pearl Index scores reported for this method are similar to other long-acting reversible contraception as well as similar to sterilization. The implant has been shown to be safe during breast feeding and may improve symptoms of dysmenorrhea and endometriosis. Irregular bleeding patterns can be expected with the device's use and should be addressed in order to decrease rates of discontinuation.

Implanon users are less likely to be satisfied with their contraception after 6 months than IUD users

BACKGROUND

The study was conducted to perform a direct comparison of the satisfaction of intrauterine device (IUD) users and Implanon users after 6 months.

STUDY DESIGN

Women were recruited to this study in the contraception clinics of Southern Health and Family Planning Victoria. Each woman completed a questionnaire at the time of starting her contraception with either an IUD or Implanon. Women were sent a follow-up questionnaire after 6 months to assess their satisfaction with their chosen method of contraception.

RESULTS

A total of 439 participants were recruited for this non randomized cohort study; 211 choosing an IUD and 228 choosing to use Implanon. The main reason patients in both groups chose their contraceptive method was recommendation by the doctor. Follow-up was achieved in over 84% in both groups. More than 50% of women in both groups reported at least one side effect. The most commonly reported side effect in both groups was abnormal bleeding and this was also the most common reason for having the contraceptive device removed. The IUD users reported a higher rate of satisfaction with their chosen method of contraception, although there was no difference between groups in the removal rate or whether the women would recommend the contraception to others.

CONCLUSIONS

IUD users reported a higher level of satisfaction than did Implanon users at 6 months. Side effects in women using IUDs and Implanon are common. The range of likely side effects should be included in counseling women about long-term reversible contraception.

Effect of etonogestrel contraceptive implant (Implanon) on portal blood flow and liver functions

BACKGROUND

This study was conducted to evaluate changes in portal blood flow and liver functions among women using Implanon for 2 years.

STUDY DESIGN

Fifty healthy Implanon users were enrolled in this longitudinal study and followed up for 24 months. Portal blood flow, assessed by color Doppler; prothrombin time and concentration; serum albumin; bilirubin; gamma-glutamyl transferase (GGT); alanine aminotransferase (ALT); and aspartate aminotransferase (AST) were measured before and 24 months after insertion.

RESULTS

After 24 months of Implanon insertion, there were no significant changes in portal blood flow, serum albumin, prothrombin time or concentration. However, there was a significant increase in serum levels of total and unconjugated bilirubin and GGT and a significant decrease in ALT and AST levels. All levels, however, remained within the normal range of values.

CONCLUSIONS

Implanon use for 2 years does not seem to influence portal hemodynamics. Changes in serum levels of bilirubin, GGT, ALT and AST are unlikely to be of clinical significance.

Implanon: a new contraceptive implant

Women who cannot use hormonal contraception containing estrogen have a variety of progestin-only contraceptive methods from which to choose. Implanon is a new single-rod progestin-only contraceptive implant that is easily inserted and can remain in place for up to 3 years. It is highly effective with a rapid onset of action and an equally rapid return of fertility once removed. Counseling is important to help women decide if this method is appropriate for their needs.

Side effects and acceptability of Implanon: a pilot study conducted in eastern Turkey

OBJECTIVE

To assess side effects during the first 6 months of use of Implanon.

DESIGN AND METHODS

The study was conducted in eastern Turkey between June 2004 and May 2005. Forty-one healthy women, aged 18-40 years who chose to use Implanon participated in the study. The implant was inserted between days 1 and 5 of the menstrual cycle. Findings were recorded before and during 6 months following insertion. Statistical analyses were performed using SPSS package programme including paired samples t-test.

RESULTS

No pregnancy occurred during the study. Ninety days after initiation of therapy, three of the 41 patients (7.3%) had regular periods, 14 (34.1%) were amenorrhoeic and the remaining 24 (58.5%) had some type of abnormal bleeding. Dysmenorrhoea affected significantly less women (1/41, i.e. 2.4%) than before treatment (17/41, i.e. 41.5%), but mastalgia increased significantly as it was reported by five previously unaffected participants (12.2%). Mood changes appeared in seven patients (17.1%) and acne in 11 of them (26.8%). The circulating levels of protein C, total cholesterol and oestradiol dropped significantly. Endometrial thickness decreased significantly. At completion of the study period, removal of the implant was requested by eight of the 41 patients (19.5%) because of irregular bleeding (six women), depressive symptoms requiring treatment (one woman) or weight gain (one woman).

CONCLUSIONS

Mainly because of irregular bleeding, the discontinuation rate of Implanon at 6 months among the women in this region is high (19.5%).