Preimplantation genetic diagnosis

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Brian Wilkerson
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1 Preimplantation genetic diagnosis Borut Peterlin Clinical institute of medical genetics, University Medical Centre Ljubljana

2 Outline of the presentation Primary prevention of genetic diseases Motivation of couples Indications Approaches Experience: international/cimg Conclusion

3 Prevention of genetic diseases Primary prevention Secondary prevention Tertiary prevention Genotype i.e. BRCA1 Reproductive choices Prenatal diagnosis PGD Disease Breast cancer Complications Metastasis

4 PGD is alternative to prenatal diagnosis to avoid physical and psychological trauma of pregnancy termination

5 Motivation of patients for PGD van Rij % couples interested Positive predictors Previous termination of pregnancy (medical) Lack of alternative (moral) Infertility Negative predictors Born child with a disease No effect Mode of inheritance Gravity of disease

6 Outline of the lecture Primary prevention of genetic diseases Motivation of couples Indications Approaches Experience: international/cimg Conclusion

7 Indications for PGD High risk è PGDiagnosis Mendelian disorders + Adult onset disorders Chromosomal disorders Low risk è PGScreening Maternal age Recurrent spontaneous abortions Recurrent failure of IVF Increase of IVF success Mozaicism

9 Indications for PGD (2) Selection of HLA-matched embryo Avoid poor obstetric outcomes - blood group incompatibility in couple Social sexing

10 Exclusion criteria Genetic test not possible to perform Age of women over 38 Contra-indications for IVF/ICSI Genetic disease risk for pregnancy Reduced ovarian reserve Low quality of embryos Psychological problems

11 Outline of the lecture Primary prevention of genetic diseases Motivation of couples Indications Approaches Experience: international/cimg Organization of the procedure Future

12 Approaches to PGD day 3 day 1-2 day 1 day 2 Polar body biopsy Cleavege-stage embryo (3 days) biopsy Blastocyst biopsy day 4 day 5 day 7 day 6

13 Polar body biopsy Advantages - Embryo undisturbed - Legal limitations - Early diagnosis Limitations -monogenic disorders -maternal contribution

14 Cleavege-stage embryo (3 days) biopsy Advantages - Maternal & paternal genome Limitations - Mosacisim - Contamination

15 Chromosomal mosaicism in human preimplantation embryos Diploid 22% Mosaic Diploid-aneuploid 59% Aneuploid 15% Abnormal 4%

16 Blastocyst biopsy Advantages Maternal and paternal contribution Extraembrionic tissue embryo intact More genetic material (several cells) Limitations Extraembrionic tissue Vitrification

17 Alport syndrome X X Y

18 PGS -FISH

19 Harper 2012

21 Testing for Mendelian disorders Jiang 2012

22 Next-generation sequencing in PGD Treff 2013

23 Outline of the lecture Primary prevention of genetic diseases Motivation of couples Indications Approaches Experience: international/cimg Conclusion

24 Realty of PGD 10 oocytes 8 successfully fertilized 6 8 cells embryos No result No mutation Mutation Bad morphology 2 embryos for transfer

25 ESHRE data No. cycles Chromosomal 4253 (15,4%) 774 (14%) Mendelian 4733 (17%) 1363 (24%) X-linked 1167 (4,2%) 96 (1,9%) PGS (61%) 3401 (60%) Social sexing 671 (2,4%) 5 (0,1%) Born 4386 (16%/cycle) 1005(18%/cycle)

26 ESHRE data (2) Goossens 2012

27 CIMG data(1) No. cycles 150 Chromosomal 52 (35%) Mendelian 59(39%) X-linked 10 (7%) PGS 29 (19%) Social sexing 0 Born 17+5

28 CIMG data(2) Age of women (avarage) 33 No. oocytes/cycle 9.3 No. fertilized/ cycle 5.2 Embryo-transfer 60% Pregnany/cycle 23% Pregnancy/ET 31%

29 Genetic counseling Genetic nature of disease & Risk estimation, Other reproductive options (prenatal diagnosis, donation of germ cells, adoption) Description of genetic testing (purpose, reliability) Expected no. of embryos with/without mutation Prenatal diagnosis after PGD Basic facts about IVF procedure (hormonal stimulation &risk, natural selection...) Limitations (other mutations, influence on development ) Description of the protocol and realistic time milestones

30 Outline of the presentation Primary prevention of genetic diseases Motivation of couples Indications Approaches Experience: international/cimg Conclusion

31 Conclusion PGD is an established option for prenatal diagnosis New technologies improve PGD performance but also bring new challanges

Preimplantation Genetic Testing

Protocol Preimplantation Genetic Testing (40205) Medical Benefit Effective Date: 01/01/14 Next Review Date: 09/14 Preauthorization No Review Dates: 09/11, 09/12, 09/13 The following Protocol contains medical