This document discusses integrated fixed-film activated sludge (IFAS) systems for biological wastewater treatment. IFAS systems combine suspended and attached growth in aeration tanks by adding media. Three studies showed IFAS improved nutrient removal at full-scale plants. A lab study found IFAS effective for industrial wastewater. An IFAS-MBR system had better removal and less fouling than MBR alone. Pilot and full-scale IFAS successfully achieved nitritation-anammox for nitrogen removal. Overall, IFAS is cost-effective for retrofitting plants to increase capacity or improve effluent quality.