Search

Objective To determine the rate of utilization, factors influencing the decision-making process, and patient satisfaction with preimplantation genetic diagnosis for monogenic disorders (PGT-M). Design Survey study. Setting Academic center. Patient(s) Genetically at-risk patients seen for PGT-M consultation between January 2010 and 2018. Intervention(s) Electronic survey including demographics, genetic history, consultation experience, decision-making process, and satisfaction with PGT-M process. Main Outcome Measure(s) Rate of utilization of PGT-M, importance of decision-making factors, and satisfaction with PGT-M process. Result(s) Among survey respondents (n = 49), the rate of utilization of PGT-M after consultation was 89.8%. Ninety-three percent of participants decided whether to pursue PGT-M within 3 months of consultation. Factors that were considered most important to this decision-making process included information provided at consultation, accuracy of test results after PGT-M, avoidance of suffering of an affected child, and ability to avoid termination of an affected pregnancy. Key barriers to utilization included financial burden and overall complexity of the in vitro fertilization (IVF)/PGT-M process. Of those utilizing PGT-M (n = 44), 72.1% had at least one live birth or were pregnant during the study period. Satisfaction with PGT-M was high, and most couples would use IVF/PGT-M for a future pregnancy (84.1%). Participants with a live birth were more satisfied with the PGT-M process than those who had no live birth. Conclusion(s) Most patients seeking consultation for PGT-M were likely to pursue this technology despite financial burden and complexity of the process. Exploring factors that influence patient decision-making regarding PGT-M is important for tailoring the consultation and optimizing the overall experience.

Objective To determine some of the unresolved questions related to chromosome anomalies in early human embryos, such are the detection of any advanced maternal age effect; the complete assessment of mosaicism, which requires analysis of all cells; and the relationship with embryonic dysmorphism. Fluorescence in situ hybridization has been used in this study to answer these issues. Design Fluorescence in situ hybridization analysis of human embryos using simultaneously probes for three or five chromosomes. Five hundred twenty-four cleavage-stage human embryos obtained by IVF were analyzed by fluorescence in situ hybridization. Embryos were allocated into three groups according to morphological and developmental characteristics (arrested; slow and/or fragmented; morphologically and developmentally normal). The embryos also were analyzed according to maternal age. Results Dysmorphic embryos had higher rates of polyploidy and diploid mosaicism. Aneuploidy increased with maternal age in nonarrested embryos. Preimplantation genetic diagnosis successfully detected these abnormalities. Conclusion This study demonstrates that, in morphologically and developmentally normal human embryos, cleavage-stage aneuploidy significantly increases with maternal age. The results suggest that implantation failure in older women largely could be due to aneuploidy.

Recent advancements in reproductive genetics have resulted in the availability of an extraordinary amount of new and detailed information for patients and providers. Whereas this information can inform many who are facing difficult clinical decisions, it can also introduce complex and uncertain choices. Expanded carrier screening and preimplantation genetic diagnosis for aneuploidy are important examples of new genetic techniques that are now widely used in reproductive medicine. This paper will explore these techniques through a medical-legal prism to better understand the opportunities and obligations incumbent on both patients and providers in this new age of genetic diagnosis.

Objective To report a rare case of somatic mosaicism with a germline component of campomelic dysplasia in a woman undergoing in vitro fertilization with preimplantation genetic diagnosis (IVF-PGD). Design Case report. Setting Clinic. Patient(s) A 28-year old G2P0110 and her 34-year old husband had two previous pregnancies complicated by fetal campomelic dysplasia with suspected germline mosaic mutation. The couple, both phenotypically normal, underwent IVF-PGD to reduce their chances of transmission. None of the embryos could initially be determined to be disease free, because all embryos shared either a maternal or a paternal short tandem repeat haplotype with the products of conception from her last pregnancy. Intervention(s) Peripheral-blood cytogenomic single-nucleotide polymorphism (SNP) microarray to identify the carrier of the mutation, and IVF-PGD to identify the disease-free embryo. Main Outcome Measure(s) Disease-free embryo. Result(s) Only one of the five euploid embryos was identified as disease free. Conclusion(s) A woman with suspected germline mosaicism for campomelic dysplasia was found to be a somatic mosaic with a germline component via a peripheral blood SNP microarray test. This identified her solitary disease-free embryo, which was transferred to her uterus but did not result in a viable pregnancy.

Objective To assess the impact of multiple blastocyst biopsy and vitrification-warming procedures on clinical outcomes. Design Retrospective study. Setting Private fertility clinic. Patient(s) Preimplantation genetic diagnosis (PGD) patients undergoing comprehensive chromosome screening, including monogenic disorder and chromosome rearrangement cases. Intervention(s) Warming and transfer of euploid blastocysts biopsied and vitrified-warmed once (group 1 [G1, control]; n=2,130), biopsied once but vitrified-warmed twice (group 2 [G2]; n=34), or biopsied and vitrified-warmed twice (group 3 [G3]; n=29). Main Outcome Measure(s) Thaw (for transfer) survival rate and clinical pregnancy rate (CPR). Result(s) The thaw survival rates were 98.4% for G1, 97.3% for G2, and 93.3% for G3, with once biopsied and vitrified-warmed embryos being significantly higher than twice biopsied and vitrified-warmed embryos (G1 vs. G3; P =.032). There was a slight reduction in CPR with an additional vitrification-warming (G1 54.3% vs. G2 47.1%) and larger reduction with an additional embryo biopsy (G2 47.1% vs. G3 31.0%), but neither difference was statistically significant. However, the combined effect of both additional biopsy and vitrification-warming resulted in a significantly reduced CPR (G1 54.3% vs. G3 31.0%; P =.013). Conclusion(s) This study indicates that blastocysts biopsied and vitrified-warmed twice have reduced clinical outcomes compared with blastocysts biopsied and vitrified-warmed once. PGD patients should be advised that performing a second biopsy and vitrification-warming in cases of failure to obtain a result from initial biopsy will reduce the chance of pregnancy. Patients with inherited disorders may elect to proceed with the second biopsy and vitrification to avoid transfer of embryos with the genetic condition.

Objective To assess the characteristics of IVF cycles for which preimplantation genetic diagnosis (PGD) was used and to evaluate indications for PGD and treatment outcomes associated with this procedure as compared with cycles without PGD with the data from the U.S. National ART Surveillance System. Design Retrospective cohort study. Setting None. Patient(s) Fresh autologous cycles that involved transfer of at least one embryo at blastocyst when available. Intervention(s) None. Main Outcome Measure(s) PGD indications and age-specific reproductive outcomes. Result(s) There were a total of 97,069 non-PGD cycles and 9,833 PGD cycles: 55.6% were performed for aneuploidy screening (PGD Aneuploidy), 29.1% for other reasons (PGD Other), and 15.3% for genetic testing (PGD Genetic). In comparison to non-PGD cycles, PGD Aneuploidy cycles showed a decreased odds of miscarriage among women 35–37 years (adjusted odds ratio [aOR] 0.62; 95% CI, 0.45–0.87) and women >37 years (aOR 0.55; 95% CI, 0.43–0.70); and an increased odds of clinical pregnancy (aOR 1.18; 95% CI, 1.05–1.34), live-birth delivery (aOR 1.43; 95% CI, 1.26–1.62), and multiple-birth delivery (aOR 1.98; 95% CI, 1.52–2.57) among women >37 years. Conclusion(s) Aneuploidy screening was the most common indication for PGD. Use of PGD was not observed to be associated with an increased odds of clinical pregnancy or live birth for women 35 years, but an increased odds of a live-birth and a multiple live-birth delivery among women >37 years.

Objective To develop an expanded pan-ethnic preconception carrier genetic screening test for use in assisted reproductive technology (ART) patients and donors. Design Retrospective analysis of results obtained from 2,570 analyses. Setting Reproductive genetic laboratory. Patient(s) The 2,570 samples comprised 1,170 individuals from the gamete donor programs; 1,124 individuals corresponding to the partner of the patient receiving the donated gamete; and 276 individuals from 138 couples seeking ART using their own gametes. Intervention(s) None. Main Outcome Measure(s) Next-generation sequencing of 549 recessive and X-linked genes involved in severe childhood phenotypes reinforced with five complementary tests covering high prevalent mutations not detected by next-generation sequencing. Result(s) Preclinical validation included 48 DNA samples carrying known mutations for 27 genes, resulting in a sensitivity of 99%. In the clinical dataset, 2,161 samples (84%) tested positive, with an average carrier burden of 2.3 per sample. Five percent of the couples using their own gametes were found to have pathogenic variants conferring high risk for six different diseases. These high-risk couples and patients received genetic counseling and recommendations for preimplantation genetic diagnosis. For patients receiving gamete donation, we applied a genetic testing and blinded matching system to avoid high-risk combinations regardless of their carrier burden. For female donors, 1.94% were positive for X-linked conditions; they received genetic counselling and were discarded. Conclusion(s) We have developed a comprehensive carrier genetic screening test that, combined with our matching system and genetic counseling, constitutes a powerful tool to avoid more than 600 mendelian diseases in the offspring of patients undergoing ART.

Preimplantation genetic testing for monogenic diseases for adult-onset conditions is ethically permissible for a range of conditions including when the condition is serious and no safe, effective interventions are available. The Committee strongly recommends that a genetic counselor experienced with PGT-M counsel patients considering such procedures. This document replaces the document titled "Use of preimplantation genetic diagnosis for serious adult-onset conditions: a committee opinion," last published in Fertil Steril 2013;100;54-7.

In vitro fertilization (IVF) began in Melbourne in 1970 when Carl Wood founded a research group at the Queen Victoria Hospital. The group reported the first biochemical pregnancy from a transferred IVF embryo in 1973. The group included the Royal Women's Hospital Melbourne, and they were the first to report confirmation of the British group's pregnancies with the use of IVF in natural cycles in 1980. The group then split, and the Monash group pursued fertility drug–induced multiple follicle growth in controlled ovulatory cycles and demonstrated for the first time that they could achieve multiple pregnancies in 1980–1981. This became the basis of a sustainable procedure for treating infertile patients. Successful embryo freezing and thawing methods resulted in pregnancies for the first time and were adopted to cryopreserve excess embryos produced after superovulation. Embryo donation methods were devised for anovulatory patients and were the first reported use of oocyte in vitro maturation techniques (IVM) for polycystic ovarian syndrome patients. Sperm microinjection techniques were pioneered for enabling fertilization for severely infertile men, and micromanipulative techniques were published for embryo biopsy for potential use in preimplantation genetic diagnosis (PGD) for patients with inheritable genetic diseases. The latter research programs were hampered by creation of restrictive embryo research laws in the State of Victoria, handicapping their timely clinical applications. Work on cryopreservation of ovarian tissue for cancer patients enabled clinical application of this for patients at risk of loss of fertility. Vitrification was developed as an alternative to freezing for oocytes and embryos, and this has now replaced the original slow cooling methods. Blastocyst culture systems were devised and optimized to improve IVF success and PGD.

Objective To report live birth rates (LBR) and total aneuploidy rates in a series of patients with balanced translocations who pursued in vitro fertilization (IVF)–preimplantation genetic diagnosis (PGD) cycles. Design Retrospective cohort analysis. Setting Genetic testing reference laboratory. Patient(s) Seventy-four couples who underwent IVF-PGD due to a parental translocation. Intervention(s) IVF cycles and embryo biopsies were performed by referring clinics. Biopsy samples were sent to a single reference lab for PGD for the translocation plus 24-chromosome aneuploidy screening with the use of a single-nucleotide polymorphism (SNP) microarray. Main Outcome Measure(s) LBR per biopsy cycle, aneuploidy rate, embryo transfer (ET) rate, miscarriage rate. Result(s) The LBR per IVF biopsy cycle was 38%. LBR for patients reaching ET was 52%. Clinical miscarriage rate was 10%. Despite a mean age of 33.8 years and mean of 7 embryos biopsied, there was a 30% chance for no chromosomally normal embryos. Maternal age >35 years, day 3 biopsy, and having fewer than five embryos available for biopsy increased the risk of no ET. Conclusion(s) IVF-PGD for translocation and aneuploidy screening had good clinical outcomes. Patients carrying a balanced translocation who are considering IVF-PGD should be aware of the high risk of no ET, particularly in women ≥35 years old.

To examine whether embryo biopsy for preimplantation genetic diagnosis (PGD) influences neonatal outcomes.Prospective follow-up cohort.Tertiary university-affiliated medical center.242 children born after PGD, 242 children born after intracytoplasmic sperm injection (ICSI) (158 singletons and 42 twins pairs in each group), and 733 children born after a spontaneous conception (SC) (493 singletons, 120 twins pairs), matched for maternal age, parity, and body mass index.None.Gestational age, birth weight, prematurity (37 and34 weeks), low birth weight (2,500 g, very low birth weight,1,500 g), and intrauterine growth restriction (10th percentile for gestational age).For singletons, the mean birth weight was higher after SC compared with ICSI but not compared with PGD. Mean gestational ages were lower after PGD and ICSI compared with SC. The low birth weight and intrauterine growth restriction rates were 4.4%, 12.0%, and 5.7% and 5.1%, 9.5%, and 5.5% for PGD, ICSI, and SC, respectively. Similar results were found when controlled for the number of embryos transferred and cryopreservation. The results for twins exhibited similar but less statistically significant trends. Polar body and blastomere biopsies provided similar outcomes.Embryo biopsy itself did not cause intrauterine growth restriction or low birth weight compared with SC, despite lower gestational ages with PGD. The worsened outcomes in ICSI compared with PGD pregnancies may be due to the infertility itself.

To evaluate the clinical outcomes in carriers of complex chromosomal rearrangements (CCRs).Case series.An institute for reproductive and stem cell engineering.Seven couples with CCRs.Assisted reproduction with preimplantation genetic diagnosis (PGD).PGD results, embryo rating, pregnancy outcomes.In cases 1, 2, 3, 4, 5, and 6, each woman underwent one cycle of PGD. Case 7 underwent two PGD cycles. We obtained 51 blastocysts from seven couples with CCR, of which 47 were eligible for biopsy; only 3 (5.9%) were normal/balanced, and 2 (3.9%) conceptions resulted. One healthy baby girl was born (the other was not yet born at the time of publication). Karyotyping revealed that the healthy baby girl was 46,XX. Although the patient with both a balanced translocation and a CCR (case 7) had 12 embryos available for biopsy, all were chromosomally unbalanced. It is interesting that 22 (57.9%) of the total 38 blastocysts were of high quality for type A CCRs, and 2 (15.4%) of the total 13 blastocysts were of high quality for type B CCR at day 6 after fertilization.The chances of identifying normal/balanced blastocysts in patients with CCR are6%; the chances of a pregnancy are4%. Greater complexity CCRs result in fewer transplantable embryos. Moreover, CCRs of greater complexity have a lower rate of high quality blastocysts than CCRs of less complexity.

Defining the actual incidence and prevalence of mosaicism in human blastocysts still remains a difficult task. The small amount of evidence generated by animal and human studies does not support the existence of mechanisms involved in developmental arrest, clonal depletion, or aneuploidy rescue for abnormal cells in euploid/aneuploid embryos during preimplantation development. However, studies in humans are mainly descriptive and lack functional evidence. Understanding the biological mechanisms that beset preimplantation differentiation holds the potential to reveal the role of aneuploidies and gene dosage imbalances in cell fate decision, providing important clues on the origin and evolution of embryonic mosaicism. The evidence on human blastocysts suggests that a mosaic euploid/aneuploid configuration is detected in around 5% of embryos. This figure supports the extremely low level of mosaicism reported in natural and IVF pregnancies. Similarly, the clinical management of patterns consistent with the presence of mosaicism in a trophectoderm biopsy during preimplantation genetic diagnosis cycles (PGD-A) is still a controversial issue. Despite the facts that some contemporary comprehensive chromosomal screening platforms can detect mosaic samples in cell mixture models with variable accuracy and many reproductive genetics laboratories are now routinely including embryonic mosaicism on their genetic reports, a diagnosis of certainty for mosaicism in PGD-A cycles is conceptually impracticable. Indeed, several technical and biological sources of errors clearly exist when trying to estimate mosaicism from a single trophectoderm biopsy in PGD-A cycles and must be understood to adequately guide patients during clinical care.

Objective To report laboratory and clinical outcomes in preimplantation genetic diagnosis for aneuploidies (PGD-A) cycles for women 44 to 47 years old. Design Multicenter, longitudinal, observational study. Setting In vitro fertilization (IVF) centers. Patient(s) One hundred and thirty-seven women aged 44.7 ± 0.7 years (range: 44.0–46.7) undergoing 150 PGD-A cycles during April 2013 to January 2016. Intervention(s) Quantitative polymerase chain reaction–based PGD-A on trophectoderm biopsies and cryopreserved euploid single-embryo transfer (SET). Main Outcomes Measure(s) Primary outcome measure: delivery rate per cycle; secondary outcome measures: miscarriage rate, and the rate and reasons for cycle cancelation with subanalyses for female age and number of metaphase 2 oocytes retrieved. Result(s) In 102 (68.0%) of 150 cycles blastocyst development was obtained, but only 21 (14.0%) were euploid blastocysts. The overall euploidy rate was 11.8% (22 of 187). Twenty-one SET procedures were performed, resulting in 13 clinical pregnancies, of which 1 miscarried and 12 delivered. The delivery rate was 57.1% per transfer, 8.0% per cycle, and 8.8% per patient. The logistic regression analysis found that only female age (odds ratio 0.78) and number of metaphase 2 oocytes retrieved (odds ratio 1.25) statistically significantly correlated with the likelihood of delivery. The delivery rate per cycle was 10.6% (11 of 104) in patients aged 44.0 to 44.9 years and 2.6% in patients aged 45.0 to 45.9 years (n = 1 of 38). No euploid blastocysts were found for patients older than 45.0 years. Conclusion(s) Extensive counseling based on biological and clinical data should be provided to women older than 43 years who are requesting IVF because of their very low odds of success and high risk for embryonic aneuploidies. Nevertheless, the low miscarriage and good delivery rates reported in this study in women with good ovarian reserve aged 44 should encourage the use of PGD-A in this population.

PGD for adult-onset conditions is ethically justified when the condition is serious and no safe, effective interventions are available. It is ethically allowed for conditions of lesser severity or penetrance. The Committee strongly recommends that an experienced genetic counselor play a major role in counseling patients considering such procedures.

Biomarkers can be employed for screening for fetal genetic disorders, identifying individuals at sufficiently high risk for a confirmatory invasive procedure. In this article we discuss prenatal genetic aneuploidy screening. Maternal serum analytes and ultrasound have long been routinely offered, providing detection rates of 80% to 93% for trisomy 21; however, an invasive procedure (false-positive) must be performed in 5% of pregnancies screened. Recovering fetal cells from maternal blood initially proved inconsistent, but new methods recovering trophoblasts offer promise for detecting disorders using a single fetal cell, analogous to preimplantation genetic diagnosis. Current emphasis is focused predominantly on cell-free fetal DNA, which accounts for 5% to 10% of total cell-free DNA in maternal blood. Analysis of maternal blood results in detection rates of over 99% for fetal trisomy 21, and also very high rates for trisomy 18 and sex chromosomal abnormalities. Such detection rates are substantively higher than with maternal serum analytes, and are accompanied by a much lower (1%) false-positive rate.

Increasing percentages of children are being born to older fathers. This has resulted in concerns about the potential adverse effects of advanced paternal age. To help clinicians counsel couples, a systemic review was performed to attempt to address questions that these couples may ask: Should routine sperm testing be performed in older males? Should preimplantation genetic diagnosis (PGD) be performed? How do providers counsel patients about risk? Should young males freeze sperm if they plan to delay paternity? Using the terms "advanced paternal age", "semen testing", "preimplantation genetic diagnosis/screening", and "cryopreservation", a comprehensive search was performed in PubMed and the Cochrane Library, and numerous international societal guidelines were reviewed. In total, 42 articles or guidelines were reviewed. There were no limits placed on the timing of the articles. Thirty articles were found to be relevant and beneficial to answering the above questions. Each question was answered separately by the supporting literature. While primary research exists to support the role of semen testing, PGD/preimplantation genetic screening, and sperm banking in males who may be affected by advancing age, comprehensive studies on the possible clinical benefit of these interventions have yet to be performed. As a result, societal guidelines have yet to incorporate distinct best-practice guidelines on advanced paternal age.

Chromosome deletions and duplications-copy number variations (CNVs)-are a major contribution to the genome variability and can be either pathogenic or not. A particular class, the microdeletions and microduplications, which alter5 Mb, have been extensively associated with developmental delay and intellectual disability. Although their prevalence in pregnancies and newborn is relatively low, their estimates in preimplantation embryos are poorly defined. The introduction of novel technologies for preimplantation genetic diagnosis of aneuploidies (PGD-A) caused new possibilities and challenges associated with diagnosis of subchromosomal CNVs. Both technical aspects of performing genomewide microarray or next generation sequencing analysis on single cells and interpretation issues are subject of debate. The latter include the reliability of detection of CNVs from embryonic biopsies, their clinical classification based on reproductive outcomes, as well as how before and after test counseling should be organized. It is also important to consider that the current resolution of these technologies from single cells is usually10 Mb, thus ruling out the possibility to diagnose the most important recurrent microdeletion and microduplication syndromes. Furthermore, at present we face with a lack of well-designed studies addressing the actual resolution and accuracy of CNVs detection in PGD-A and no reference databases is available to evaluate their pathogenicity. Accordingly, it seems reasonable at the moment to avoid the reporting of subchromosomal CNVs in PGD-A. However, although these issues require proper handling, they should not lead us away from providing an improved preimplantation genetic diagnosis.

Chromosomal rearrangements have long been known to significantly impact fertility and miscarriage risk. Advancements in molecular diagnostics are challenging contemporary clinicians and patients in accurately characterizing the reproductive risk of a given abnormality. Initial attempts at preimplantation genetic diagnosis were limited by the inability to simultaneously evaluate aneuploidy and missed up to 70% of aneuploidy in chromosomes unrelated to the rearrangement. Contemporary platforms are more accurate and less susceptible to technical errors. These techniques also offer the ability to improve outcomes through diagnosis of uniparental disomy and may soon be able to consistently distinguish between normal and balanced translocation karyotypes. Although an accurate projection of the anticipated number of unbalanced embryos is not possible at present, confirmation of normal/balanced status results in high pregnancy rates (PRs) and diagnostic accuracy.

Objective To characterize nuclear and mitochondrial DNA (mtDNA) in spent culture media from normally developing blastocysts to determine whether it could be used for noninvasive genetic assessment. Design Prospective embryo cohort study. Setting Academic center and private in vitro fertilization (IVF) clinic. Patient(s) Seventy patients undergoing intracytoplasmic sperm injection (ICSI) and 227 blastocysts. Intervention(s) Culture media assessment, artificial blastocoele fluid collapse and DNA analysis using digital polymerase chain reaction (dPCR), long-range PCR, quantitative PCR (qPCR), and DNA fingerprinting. Main Outcome Measure(s) Presence of nuclear and mtDNA in three different commercial culture media from Vitrolife and Irvine Scientific, spent embryo media assessment at the cleavage and blastocyst stages of development, and analysis of the internal media controls for each patient that had been exposed to identical conditions as embryo media but did not come into contact with embryos. Result(s) Higher levels of nuclear and mtDNA were observed in the culture media that had been exposed to embryos compared with the internal media controls. Nuclear DNA (∼4 copies) and mtDNA (∼600 copies) could be detected in spent media, and the levels increased at the blastocyst stage. No increase in DNA was detected after artificial blastocoele fluid collapse. Mixed sex chromosome DNA was detected. This originated from contamination in the culture media and from maternal (cumulus) cells. Due to the limited amount of template, the presence of embryonic nuclear DNA could not be confirmed by DNA fingerprinting analysis. Conclusion(s) Currently DNA from culture media cannot be used for genetic assessment because embryo-associated structures release DNA into the culture medium and the DNA is of mixed origin.

Objective To evaluate the effect of laser polar-body biopsy (PBB) for preimplantation genetic diagnosis on embryo quality. Study design Retrospective case-control analysis. The quality of 145 embryos after PBB was compared to 276 embryos of the same group of women without biopsy. Setting University-based tertiary-care medical center. Patient(s) Women with inherited genetics disease. Intervention(s) Laser PBB of IVF embryos for genetic diagnosis. Main Outcome Measure(s) The study and control embryos were compared for fertilization rate, pronuclear grading, and cleavage-stage parameters on days 1, 2, and 3 after oocyte retrieval. Result(s) The study embryos demonstrated higher rates of cleavage arrest (3.6% vs. 0.7%), higher rate of significant fragmentation on day 2 (9.5% vs. 3.0%), and lower rate of good cleavage embryos on day 2 (69.1% vs. 78.4%) compared with control embryos. On day 3, the study embryos had lower cleavage rates (six or more blastomeres; 56.5% vs. 74.5%), higher fragmentation (11.7% vs. 3.9%), higher rate of embryos presenting inferior cleavage pattern (57.2% vs. 38.5%), and lower mean blastomere number (5.8 ± 2.1 vs. 6.6 ± 1.9) compared with control embryos. Conclusion(s) Polar-body biopsy may have a negative effect on embryo quality.

Objective To assess effectiveness of preimplantation genetic screening (PGS) in fresh IVF cycles. Design Reanalysis of retrospective US national data. Setting Not applicable. Patient(s) A total of 5,471 fresh autologous IVF cycles with PGS and 97,069 cycles without PGS, reported in 2011–2012 to the Centers for Disease Control and Prevention. Intervention(s) Not applicable. Main Outcome Measure(s) Cycles that reached ET, miscarriage rates, live birth rates per cycle and per transfer. Result(s) More PGS than non-PGS cycles reached ET (64.2% vs. 62.3%), suggesting favorable patient selection bias for patients using PGS. Nevertheless, live births rates per cycle start (25.2% vs. 28.8%) and per ET (39.3% vs. 46.2%) were significantly better in non-PGS cycles, whereas miscarriage rates were similar (13.7% vs. 13.9%). With a maternal age >37 years significantly more cycles in the PGS group reached ET (53.1% vs. 41.9%), suggesting a significant selection bias for more favorable patients in the PGS population. This bias rather than the PGS procedure may partially explain the observed improved live birth rate per cycle (17.7% vs. 12.7%) and lower miscarriage rate (16.8% vs. 26.0%) in the older PGS group. Conclusion(s) Overall, PGS decreased chances of live birth in association with IVF. National improvements in live birth and miscarriage rates reported with PGS in older women are likely the consequence of favorable patient selection biases.

Objective To apply a comprehensive chromosomal screening through short comparative genomic hybridization (CGH) in the preimplantation genetic diagnosis (PGD) of translocations. Design Clinical research study. Setting A PGD laboratory and two IVF clinics. Patient(s) Three Robertsonian translocation carriers, two reciprocal translocation carriers, and a double-translocation carrier. Intervention(s) After using the short-CGH approach in the reanalysis of two unbalanced embryos, discarded from a PGD for a reciprocal translocation carrier, the same method was applied in the PGD of day-3 embryos of translocation carriers. Main Outcome Measure(s) Ability of short CGH to detect partial chromosomal abnormalities in unbalanced embryos, translocation segregation proportions, and proportion of embryos carrying chromosomal abnormalities not related to the translocations. Result(s) The short-CGH technique detected errors resulting from the meiotic segregation of the chromosomes involved in the translocations and other abnormalities affecting the remaining chromosomes. Alternate segregation was detected most frequently among Robertsonian translocation cases, whereas unbalanced chromosome segregations were found predominantly in reciprocal ones. Aneuploidy and structural chromosome errors were found more frequently in Robertsonian than in reciprocal translocation carriers. Application of short-CGH PGD achieved pregnancy in two cases. Conclusion(s) Short CGH is a reliable approach for PGD of translocations, as it is capable of detecting partial chromosome errors caused by unbalanced segregations simultaneously to the screening of all chromosomes, and it may improve the results after PGD for translocation carriers.

Objective To report the first case of cri du chat syndrome after preimplantation genetic diagnosis (PGD) for reciprocal translocation. Design Case report. Setting In vitro fertilization center in a university affiliated hospital. Patient(s) A woman carrying a t(11;22)(q23;q11.2) translocation. Intervention(s) Preimplantation genetic diagnosis was performed, and the woman became pregnant. Main Outcome Measure(s) Successful PGD for reciprocal translocation and diagnosis of Cri du chat syndrome for the baby. Result(s) A male baby was born at 36 weeks' gestation. However, the baby presented with a high-pitched, cat-like cry. Cytogenetic study revealed a rare case of cri du chat syndrome associated with t(11;22)(q23;q11.2) translocation. Conclusion(s) Chromosomal abnormalities, including the rare cru du chat syndrome, may occur after fluorescent in situ hybridization–based preimplantation genetic diagnosis.

Objective To report a case of bilateral ovarian fibromas and ovarian leiomyomas in a young patient with Gorlin syndrome and to highlight issues of fertility preservation, ovarian conservation, and preimplantation genetic diagnosis in this population. Design Case report. Setting University hospital. Patient(s) A 15-year-old female patient with Gorlin syndrome and bilateral ovarian masses. Intervention(s) Ultrasound, magnetic resonance imaging, hormone analysis, and laparotomy with resection of ovarian fibromas. Main Outcome Measure(s) Preservation of ovarian function, pathologic diagnosis. Result(s) Our patient represented an adolescent case of bilateral ovarian fibromas and leiomyomas in Gorlin syndrome presenting with menstrual irregularities. She was managed surgically with resection of the lesions and conservation of normal ovarian tissue. Conclusion(s) In Gorlin syndrome, ovarian fibromas are a common clinical manifestation. Patients with ovarian involvement may present with complex gynecologic needs and may have decreased fertility potential. Careful surgical management, follow-up, and counseling on options for future fertility should be offered to all patients.

Objective To investigate whether egg retrieval at ≥36.5 hours improves IVF outcomes in women aged ≥40 years. Design Retrospective cohort study. Setting Academic medical center. Patient(s) First-attempt autologous IVF cycles without preimplantation genetic diagnosis, IUI conversion, or intentional delayed egg retrieval were included (n = 3,231). Cycles were stratified by age and hCG exposure ( Intervention(s) None. Main Outcome Measure(s) Oocyte yield, maturity, fertilization, embryo quality, implantation, clinical pregnancy, and live birth were analyzed, controlling for age and gonadotropins. Stimulation type, hMG use, stimulation days, day-3 FSH level, and diagnosis were evaluated as potential confounders. Multivariable regression analyses were performed and Wald tests for trend calculated. Result(s) No consistent differences in oocyte yield, maturity, fertilization, or embryo quality were detected. No absolute differences in outcomes were noted among group comparisons. However, as age increased, significant trends toward improved implantation, clinical pregnancy, and live birth were detected at ≥36.5 hours. Conclusion(s) Extending exposure to hCG for ≥36.5 hours may be beneficial in patients aged ≥40 years. A prospective, randomized study is warranted to determine whether retrieval time merits revision for patients of advanced age, as well as the age cutoffs at which such protocols should be applied.

Over the past 30 years, controlled ovarian hyperstimulation, cryopreservation, intracytoplasmic sperm injection, improved embryologic technology, vaginal egg retrieval, donor gametes, and surrogacy have gotten us where we are. For future progress, we must have group thinking, widely available assisted reproductive technologies, the ability to identify fertilized eggs with newborn potential, an understanding of oligospermia, better preimplantation genetic diagnosis, somatic reproduction, and exogenesis.

Objective To develop and validate a whole genome amplification and single nucleotide polymorphism (SNP) microarray protocol for accurate single cell 24 chromosome aneuploidy screening. Design Prospective, randomized, and blinded study. Setting Academic reproductive medicine center. Patient(s) Multiple euploid and aneuploid cell lines were obtained from a public repository and blastomeres were obtained after biopsy of cleavage stage embryos from 78 patients undergoing IVF. Main Outcome Measure(s) Accuracy of copy number assignment and consistency of individual SNPs, whole chromosomes, and single cell aneuploidy status were determined. Intervention(s) None. Result(s) Single cells extracted from karyotypically defined cell lines provided 99.2% accuracy for individual SNPs, 99.8% accuracy for whole chromosomes, and 98.6% accuracy when applying a quality control threshold for the overall assignment of aneuploidy status. The concurrence for more than 80 million SNPs in 335 single blastomeres was 96.5%. Conclusion(s) We have established and validated a SNP microarray-based single cell aneuploidy screening technology. Clinical validation studies are underway to determine the predictive value of this methodology.

Objective To overcome problems associated with the use of triplet repeat primed polymerase chain reaction (TP-PCR) in preimplantation genetic diagnosis (PGD) of myotonic dystrophy type 1 (DM1). Design Clinical research study. Setting UCL Centre for PGD and Centre for Reproductive and Genetic Health. Patient(s) Seven couples undergoing PGD for DM1. Intervention(s) A modified TP-PCR protocol (mTP-PCR) for the reliable detection of both expanded and nonexpanded alleles in DMPK was optimized using single lymphocytes. Four cycles of PGD were performed with TP-PCR for diagnosis and a further 10 cycles with mTP-PCR. Main Outcome Measure(s) Amplification efficiency, allele dropout, diagnosis rate, and delivery rate. Result(s) Preliminary testing showed that the TP-PCR amplification efficiency was higher using lymphocytes versus buccal cells. Single lymphocytes gave very high amplification efficiencies for both protocols (99% to 100%). There were no false-positive or false-negative results for 148 single lymphocytes tested with mTP-PCR compared with 9% (5 out of 54) false-positive results with TP-PCR, indicating the improved accuracy of the modified protocol. In embryos, the diagnosis rate was 95.6% with mTP-PCR and 75% with TP-PCR. Conclusion(s) For PGD of DM1, mTP-PCR is recommended. It may also be applied as a rapid screen for DMPK expansions in individuals with symptoms of DM1, relatives of known mutation carriers, or in prenatal diagnosis.

Objective: To investigate the preference for preimplantation genetic diagnosis (PGD) as an alternative to prenatal diagnosis (PND) in a large group of couples representing a wide array of genetic disorders. We also investigated the couple's familiarity with PGD and presented time trade-off scenarios for PGD versus PND, as PGD treatment is regularly accompanied by waiting lists. Design: Questionnaire study. Setting: Patient organizations representing genetic disorders. Patient(s): A total of 210 couples carrying genetic disorders. Main Outcome Measure(s): Preference for PGD or PND and familiarity with PGD in carrier couples. Result(s): Fifteen organizations representing 38 genetic disorders agreed to participate. Nine hundred eighty-three couples responded. In total 210 couples were in their reproductive years (women 18-40 years) and had a desire to conceive. Ninety couples (42%) had never heard of PGD. After they were informed, 127 couples (60%) wanted to have diagnostic testing (PND or PGD) performed. Ninety-four (74%) of these couples preferred testing with PGD. When no waiting list was used 102 couples (80%) preferred PGD. With a 2-year waiting list for PGD, 58 couples (46%) would opt for PGD. Conclusion(s): Many carrier couples are unaware of the existence of PGD. When informed, most couples prefer PGD more than PND. The preference for PGD decreases with longer waiting lists. (Fertil Steril (R) 2010;94:1239-43. (C) 2010 by American Society for Reproductive Medicine.)

Preimplantation genetic diagnosis has been proposed as a method to improve assisted reproduction technology outcomes, but different techniques have produced conflicting results. The use of appropriate techniques may provide positive outcomes.

Objective To compare the genomic profiles of blastocoel fluid (BF), inner cell mass (ICM), and trophectoderm (TE) cells derived from the same blastocyst. Design Prospective study. Setting Academic and in vitro fertilization units. Patient(s) Sixteen donated cryopreserved embryos at blastocyst stage. Intervention(s) BF, TE, and ICM cells were retrieved from each blastocyst for chromosome analysis by means of next-generation sequencing (NGS). Main Outcome Measure(s) Aneuploidy screening and assessment of mosaicism in BF, TE and ICM samples with subsequent comparison of genomic profiles between the three blastocyst compartments. Result(s) Out of 16 blastocysts, 10 BF samples and 14 TE and ICM samples provided reliable NGS data for comprehensive chromosome analysis. Only 40.0% of BF-DNA karyotypes were fully concordant with TE or ICM, compared with 85.7% concordance between TE and ICM. In addition, BF-DNA was burdened with mosaic aneuploidies and the total number of affected chromosomes in BF was significantly higher compared with the TE and ICM. Conclusion(s) BF-DNA can be successfully amplified and subjected to NGS, but owing to increased discordance with ICM and TE, BF does not adequately represent the status of the rest of the embryo. To overcome biologic and technical challenges associated with BF sampling and processing, blastocentesis would require improvement in both laboratory protocols and aneuploidy calling algorithms. Therefore, TE biopsy remains the most effective way to predict embryonic karyotype, and the use of BF as a single source of DNA for preimplantation genetic screening is not yet advised.

Objective To determine if preimplantation genetic diagnosis (PGD) for translocation carriers with three or more pregnancy losses reduces loss rates. Design Retrospective review of data. Setting Preimplantation genetic diagnosis laboratory servicing IVF groups. Patient(s) Patients (n = 192) undergoing PGD for either a reciprocal translocation or Robertsonian translocation who had three or more previous pregnancy losses. Intervention(s) Preimplantation genetic diagnosis for translocations. Main Outcome Measure(s) Pregnancy loss rate, pregnancy success rate defined as delivery of at least one child or an ongoing pregnancy in the third trimester, and length of time to success. Result(s) Pregnancy loss rate was significantly reduced to 13% post-PGD compared with 88.5% in previous non-PGD pregnancies and to 35% to 64% from naturally conceived pregnancies as reported in the literature. Pregnancy success rate was 87%. Conception occurred after an average of 1.4 cycles or Conclusion(s) Individuals with translocations who have experienced three or more losses benefit from PGD by realizing a significant reduction in loss rate and improvement in rate of success of pregnancy. Length of time to conceive is also dramatically reduced compared with data in the literature for similar populations not undergoing PGD.

Objective To establish the exact rates of chromosomal mosaicism in morphologically normal rhesus macaque embryos by determining the chromosomal complement of all blastomeres. Design Retrospective rhesus monkey IVF study. Setting Academic laboratory and primate research center. Patient(s) Young fertile rhesus macaque females. Intervention(s) Morphologically normal in vitro–produced rhesus macaque embryos were dissociated and cytogenetically assessed using a five-color fluorescent in situ hybridization assay developed for rhesus macaque chromosomes homologous to human chromosomes 13, 16, 18, X, and Y. Main Outcome Measure(s) The incidence and extent of chromosomal mosaicism in rhesus macaque preimplantation embryos. Result(s) Seventy-seven preimplantation embryos, displaying normal morphology and development, from 17 young rhesus macaque females were analyzed. Overall, 39 embryos (50.6%) were normal, 14 embryos (18.2%) were completely abnormal, and 24 embryos (31.2%) were mosaic. Of the 226 blastomeres analyzed in the mosaic group, 110 blastomeres (48.7%) were normal. Conclusion(s) The observed rate of mosaicism in good-quality rhesus embryos resembles previously documented frequencies in poor-quality human preimplantation embryos. A high incidence of mosaicism may limit the diagnostic accuracy of preimplantation genetic diagnosis.

Objective To develop and validate a new strategy to distinguish between balanced/euploid carrier and noncarrier embryos in preimplantation genetic diagnosis (PGD) cycles for reciprocal translocations and to successfully achieve a live birth after selective transfer of a noncarrier embryo. Design Retrospective and prospective study. Setting In vitro fertilization (IVF) units. Patient(s) Eleven patients undergoing mate pair sequencing for identification of translocation breakpoints, followed by clinical PGD cycles. Intervention(s) Embryo biopsy with 24-chromosome testing to determine carrier status of balanced/euploid embryos. Main Outcome Measure(s) Definition of translocation breakpoints and polymerase chain reaction (PCR) diagnostic primers, correct diagnosis of euploid embryos for carrier status, and a live birth with a normal karyotype after transfer of a noncarrier embryo. Result(s) In 9 of 11 patients (82%), translocation breakpoints were successfully identified. In four patients with a term PGD pregnancy established with a balanced/euploid embryo of unknown carrier status, the correct carrier status was retrospectively determined, matching with the cytogenetic karyotype of the resulting newborns. In a prospective PGD cycle undertaken by a patient with a 46,XY,t(7;14)(q22;q24.3) translocation, the four balanced/euploid embryos identified comprised three carriers and one noncarrier. Transfer of the noncarrier embryo resulted in birth of a healthy girl who was subsequently confirmed with a normal 46,XX karyotype. Conclusion(s) The combination of mate pair sequencing and PCR breakpoint analysis of balanced reciprocal translocation derivatives is a novel, reliable, and accurate strategy for distinguishing between carrier and noncarrier balanced/euploid embryos. The method has potential application in clinical PGD cycles for patients with reciprocal translocations or other structural rearrangements.

Objective To report a simple and efficient fluorescence in situ hybridization (FISH) method for preimplantation genetic diagnosis (PGD). Design Technique and method. Setting A hospital in vitro fertilization (IVF) laboratory. Patient(s) Women undergoing IVF or intracytoplasmic sperm injection (ICSI). Intervention(s) None. Main Outcome Measure(s) The intensity and clarity of signals, technical difficulty, the percentage of successfully treated blastomeres, and blastomere integrity after FISH. Result(s) This paraformaldehyde fixation technique simplified the process of fixation of blastomeres for PGD without losing blastomeres during fixation. A total of 35 blastomeres derived from 10 arrested embryos or abnormally fertilized eggs (one pronucleus or three pronuclei) were used for three-dimensional (3D) FISH staining. Signals in all blastomeres were obtained successfully by this method. Approximately 0.1 μL of DNA probe was enough for the detection of the signals in each blastomere, less than the volume (1 μL) used in the conventional FISH. Conclusion(s) The 3D-FISH technique for PGD is easy to learn, less damaging to blastomeres, and loses no blastomeres during fixation. It is efficient, feasible, and economic, which allows more patients to benefit from this technique.

Objective To determine opinions and attitudes of the German general population toward the treatment methods of reproductive medicine: egg donation, surrogate mothering, and reproductive cloning. Design Representative survey. Setting German general population: face-to-face interviews at home with 2,110 persons, aged 18–50 years. Patient(s) Patients were not included. Intervention(s) No interventions took place. Main Outcome Measure(s) Approval and disapproval of treatment methods of reproductive medicine and preimplantation genetic diagnosis were assessed by questionnaires regarding medical, age, reasons, or general. Result(s) Overall, the diverse treatment methods of reproductive medicine found comparable rates of approval and disapproval. Legalization of egg donation was approved by a slight majority (50.8%), particularly for medical reasons (35.9%). Surrogate mothering found lower overall rates of approval (43.7%), 28.5% supported an admission for medical reasons. Reproductive cloning was rejected by the vast majority (82.9%). Attitudes to reproductive medicine were affected by age and the individual reproductive experiences. Conclusion(s) New techniques in reproductive medicine and their development provide hope and health promises for affected couples but also entail long-term risks and ethical issues. Balancing the individual's right to a reproductive autonomy and choice and ethical standards will constitute a future challenge for society. Results demonstrate considerable uncertainty and information deficits in the community.

Objective To explore the knowledge and attitudes toward preimplantation genetic diagnosis (PGD) of women who have been personally affected by hereditary breast and ovarian cancer. Design A 33-item quantitative survey covering five domains, including demographics, knowledge and attitudes about PGD, usage of PGD, and informational needs. Setting Attendees of a national conference for individuals and families affected by hereditary breast and ovarian cancer participated in the survey. Patient(s) Not applicable. Intervention(s) Not applicable. Main Outcome Measure(s) Frequencies and proportions were summarized for all variables, and Fisher's exact tests were conducted to test association between two discrete variables. Result(s) Of the women surveyed, only 32% had ever heard of PGD before taking the survey. None of the women surveyed had actually used PGD, and 44% believed they would not use it in the future. However, 57% of attendees believed that PGD was an acceptable option for high-risk individuals, and 74% believed that high-risk individuals should be given information about PGD. Conclusion(s) Health care professionals who serve cancer patients should consider incorporating information about PGD into patient education. Further research is needed to survey physicians and genetic counselors about their knowledge and opinions of PGD.