3 bouknight - uab · 2/23/2015 1 update from the ivf lab: preimplantationgenetic testing janet...

2/23/2015

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Update from the IVF Lab:Preimplantation Genetic Testing

Janet McLaren Bouknight, MDReproductive Endocrinology and InfertilityDepartment of Obstetrics & Gynecology

Educational Objectives

• Gain familiarity with the procedures and pregnancy outcomes of current in vitro fertilization practices.

• Understand the application of Preimplantation Genetic Diagnosis (PGD) for single‐gene disorders.

• Appreciate the role of Preimplantation Genetic Screening (PGS) in maximizing IVF cycle efficiency and encouraging elective single embryo transfer.

Current IVF Practice

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150,000 cycles

65,000 livebirths


All SART Clinics 2012 <35 35‐37 38‐40 41‐42 >42

Pregnancy Rate 47% 38% 30% 20% 9%

Live Birth Rate 41% 31% 22% 12% 4%

# embryos transfer 1.9 2.0 2.4 2.9 2.9


% Twins 30% 25% 20% 13% 9%

• What are the advanced that have contributed to an increase in success in the IVF Lab?

• Improved lab conditions

• Extended embryo culture

• Improvements in embryo cryopreservation

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Current IVF Practice:Improved Lab Conditions



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Current IVF Practice:Extended Embryo Culture

Day 5: Blastocyst StageDay 3: Cleavage Stage

• 8‐cells• 30% implantation rate

• 200‐300 cells• 50% implantation rate

Increased live birth rates seen in “good prognosis” patients who undergo a Day 5 transfer



• Supports blastocyst transfer for “good prognosis” patients

• Opportunity to consider single embryo transfer

• May be associated with a small increased risk of monozygotic twinning

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Current IVF Practice:Embryo Cryopreservation Cycles

• Improvements in freezing techniques (vitrification) have increased success of cryopreserved embryos.

I i i ti th t• Increasing appreciation that the endometrial environment created by ovarian hyperstimulationmay not be the most favorable for implantation

Kalra Obstet Gynecol 2011; 118(4): 863Wu JARG 2014; 31(3):275Maheshwari Fertil Steril 2012; 98(2): 368



Maheshwari Fertil Steril 2012; 98(2): 368

Cryo transfers may provide better obstetrical and perinatal outcomes than fresh transfers.

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Preimplantation Genetic DiagnosisPGD

PreimplantationGenetic Diagnosis (PGD)• Allows patients who are carriers of or affected by genetic conditions select unaffected embryos for transfer prior to becoming pregnant

• Decreases chance of sick child/neonatal loss

• Avoids difficult decision to terminate pregnancy

• Single‐gene disorders

Cystic FibrosisSickle Cell AnemiaSpinal Muscular AtrophyOcular Albinism

HuntingtonsMyotonic dystrophyTuberous sclerosus

HemophiliaΒ‐ThalassemiaNF1FAP

PreimplantationGenetic Diagnosis (PGD)• First pregnancies from PGD reported in 1990

• 2 cases, both X‐linked: adrenoleukodystrophy and x‐linked mental retardation.

• Y chromosome‐specific sequence amplified from embryo biopsy and only female embryos transferred

• As of 2008 66% of IVF centers offer preimplantationgenetic testing (PGT)

• PGT was used in 4% of all non‐donor IVF cycles

• Majority of genetic testing is sent out, not done in house

• Natera, Reprogenetics, LabCorp, Genesis

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PGD: Current practice

• Biopsy is typically done on blastocyst (day 5)

Trophectoderm(placental)

• Sample of cells are taken from the trophectoderm

• Embryo is frozen

• After results, embryo is selected for frozen transfer

Inner cell mass (fetal)

Zona pellucida

Biopsy

PGD: Additional Concerns

• Aneuploidy screening is commonly performed in conjunction with PGD testing.

• Cost: $5000 for lab to test biopsies, + IVF charges ($12 000 $15 000)($12,000‐$15,000).

• Gray areas:• Adult‐onset disease

• Cancer‐causing genes

• HLA‐matching for sibling

Preimplantation Genetic ScreeningPGS

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PreimplantationGenetic Screening (PGS)

• Goal = to identify the embryo(s) that will lead to a live birth:

• Morphology

• Metabolomics/secretome

• Cytokinetics/time‐lapse imaging

• Genetic Screening

• Significant percentage of human embryos are aneuploid

• PGS identifies euploid embryos for transfer

Embryo Aneuploidy and Age

2701 patients / 3,392 cycles 15,169 embryo biopsy results

20‐80% based on age

Franasiak Fertil Steril 2014; 101:656

PGS: Target population

• Initially targeted toward populations at higher risk for aneuploid embryos:

• Advanced Reproductive Age

• Recurrent Pregnancy LossRecurrent Pregnancy Loss

• Multiple failed IVF cycles

• Increasing appreciation of technique for “good prognosis” patients to increase the efficiency of IVF.

• Increases patient and provide willingness to consider an elective single embryo transfer (eSET).

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PGS: Technique

• Initial aneuploidy screening

was done with FISH

• Fluorochrome‐tagged DNA

probe binds to DNA targetprobe binds to DNA target

• 5‐8 probes can be used (13, 18, 21, X, Y)

• Detects chromosome number and large deletions

• Multiple clinical trials did not show a benefit of FISH‐based PGS; actually decreased live birth rates

• Incomplete detection, mosaicism at cleavage‐stage

PGS: New Techniques

• Newer platforms allow for Comprehensive Chromosomal Screening (CCS)

• All 24 chromosomes

• Finer resolution

• Current methods:

• Single nucleotide polymorphisms (SNP) microarrays

• Array comparative genomic hybridization (aCGH)

• Quantitative real‐time PCR (qPCR)

• aCGH and qPCR will not detect balanced rearrangements and polyploidy

PGS: CCS Outcomes

• BEST Trial (2013)• RCT of N = 205 couples with female partner ≤42yo

• Normal ovarian reserve testing

• Randomized if ≥ 2 blasts on day 5

1) PGS CCS with transfer of single euploid blast

OR

2) No screening and transfer of two untested blasts

Forman Fertil Steril 2013; 100(1):100

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CCS Outcomes

Euploid eSET• 61% preg rate• No twins

*

Forman Fertil Steril2013; 100(1):100

2 blast transfer• 65% preg rate• 46% twins• 2% triplets

CCS OutcomesAll single embryo transfer: PGS/CCS vs Untested, by age

Forman Fertil Steril 2013; 100(1):100

* *

eSET Nationwide

15% of cycles in < 35 years

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Outcome in <35yo eligible for eSET

Conclusions

• Continued advances in laboratory and clinical practices that improve the IVF outcomes of our patients.

• PGD is a treatment available to those with genetic disease that is only increasing in accuracy and efficiency.

• PGS = Game Changer

• Screening with CCS appears to increase live birth rates and reduce multiples

• Route to eSET

UAB IVF Team

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SART IVF Predictor: 25yo with PCOS

2 months laterFrozen Embryo Transfer: $2500

SART IVF Predictor: 38yo unexplained

2 months laterFrozen Embryo Transfer: $2500

3 bouknight - uab · 2/23/2015 1 update from the ivf lab: preimplantationgenetic testing janet...

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