Preimplantation genetic testing for aneuploidy: what technology should you use and what are the differences?

PURPOSE: The purpose of the review was to define the various diagnostic platforms currently available to perform preimplantation genetic testing for aneuploidy and describe in a clear and balanced manner the various strengths and weaknesses of these technologies. METHODS: A systematic literature review was conducted. We used the terms "preimplantation genetic testing," "preimplantation genetic diagnosis," "preimplantation genetic screening," "preimplantation genetic diagnosis for aneuploidy," "PGD," "PGS," and "PGD-A" to search through PubMed, ScienceDirect, and Google Scholar from the year 2000 to April 2016. Bibliographies of articles were also searched for relevant studies. When possible, larger randomized controlled trials were used. However, for some emerging data, only data from meeting abstracts were available. RESULTS: PGS is emerging as one of the most valuable tools to enhance pregnancy success with assisted reproductive technologies. While all of the current diagnostic platforms currently available have various advantages and disadvantages, some platforms, such as next-generation sequencing (NGS), are capable of evaluating far more data points than has been previously possible. The emerging complexity of different technologies, especially with the utilization of more sophisticated tools such as NGS, requires an understanding by clinicians in order to request the best test for their patients.. CONCLUSION: Ultimately, the choice of which diagnostic platform is utilized should be individualized to the needs of both the clinic and the patient. Such a decision must incorporate the risk tolerance of both the patient and provider, fiscal considerations, and other factors such as the ability to counsel patients on their testing results and how these may or may not impact clinical outcomes.

Fertility Preservation Through Oocyte Cryopreservation in a Patient with Ovarian Dysgerminocarcinoma: A Case Report.

BACKGROUND: This case evaluates a 20-year-old patient diagnosed with recurrent dysgerminoma who desired fertility preservation. CASE: A 20-year-old woman, GOPO, with a history of fertility-preserving right salpingo-oophorectomy and staging for dysgerminoma presented with interval change of a 5-cm left ovarian solid mass on ultrasound evaluation concerning for recurrent carcinoma. She underwent controlled ovarian hyperstimulation with injectable gonadotropins followed by transvaginal oocyte retrieval immediately followed by laparotomy, at which time ovarian dysgerminoma was confirmed. Completion total abdominal hysterectomy, left salpingo-oophorectomy, and exploratory surgery were performed. Forty-five oocytes were obtained, of which 37 mature oocytes were isolated and cryopreserved. The patient had an unremarkable postoperative course and was discharged home. CONCLUSION: Oncofertility preservation through oocyte cryopreservation may be considered a viable option for young women with ovarian cancer.

Two different microarray technologies for preimplantation genetic diagnosis and screening, due to reciprocal translocation imbalances, demonstrate equivalent euploidy and clinical pregnancy rates.

PURPOSE: To compare single nucleotide polymorphism (SNP) and comparative genomic hybridization (aCGH) microarray platforms to evaluate embryos for parental translocation imbalances and aneuploidy. METHODS: A retrospective review of preimplantation genetic diagnosis and screening (PGD/PGS) results of 498 embryos from 63 couples undergoing 75 in vitro fertilization cycles due to parental carriers of a reciprocal translocation. RESULTS: There was no significant difference between SNP and aCGH microarrays when comparing the prevalence of embryos that were euploid with no translocation imbalance, euploidy with a parental translocation imbalance or aneuploid with or without the parental chromosome imbalance. The clinical pregnancy rates were also equivalent for SNP (60 %) versus aCGH (65 %) microarrays. Of 498 diagnosed embryos, 45 % (226/498) were chromosomally normal without translocation errors or aneuploidy, 22 % (112/498) were euploid but had a parentally derived unbalanced chromosomal segregant, 8 % (42/498) harbored both a translocation imbalance and aneuploidy and 24 % (118/498) of embryos were genetically balanced for the parental reciprocal translocation but were aneuploid for other chromosomes. The overall clinical pregnancy rate per IVF cycle following SNP or aCGH microarray analysis was 61 % and was higher if the biopsy was done on blastocysts (65 %) versus cleavage stage embryos (59 %), although not statistically significant. CONCLUSIONS: SNP or aCGH microarray technologies demonstrate equivalent clinical findings that maximize the pregnancy potential in patients with known parental reciprocal chromosomal translocations.

How to recognize PCOS: results of a web-based survey at IVF-worldwide.com.

This retrospective evaluation of a web-based survey posted from 1 to 30 September 2010 was to determine which diagnostic tools physicians are currently utilizing to diagnose polycystic ovary syndrome (PCOS). Responses from 262 IVF centres in 68 countries are included in the study. Providers used various diagnostic criteria to diagnose PCOS, including the Rotterdam criteria (82%), National Institutes of Health criteria (8%), Androgen Excess Society 2006 criteria (3%) and other classification systems (7%). Many providers utilized diagnostic tools not necessarily included in traditional classification systems: 58% of respondents evaluated LH/FSH ratio in addition to androgen concentrations to define patients with PCOS; physicians also commonly obtain measurement of anti-Müllerian hormone (22%) and impaired glucose tolerance (74%) in diagnosing PCOS. Many respondents (64%) felt that polycystic-appearing ovaries on ultrasound with anovulation and a normal serum prolactin should be adequate criteria to diagnose PCOS. In conclusion, while the majority of centres (82%) uses the Rotterdam criteria to diagnose PCOS, other criteria and diagnostic tools are commonly used in evaluating patients with suspected PCOS. This study highlights the need for continual re-evaluation of PCOS diagnostic criteria with an ultimate goal of developing a consensus definition for the disorder in the future.

Fertility management in the PCOS population: results of a web-based survey at IVF-worldwide.com.

PURPOSE: To identify the leading treatment strategies for infertile women with PCOS on an international scale. METHODS: A retrospective evaluation using the results of a web-based survey, (IVF-Worldwide ( www.IVF-worldwide.com ), posted from 1 to 30 September 2010 was performed. Binomial confidence intervals for proportions were calculated by the modified Wald method with significance defined as P < 0.05 using a DataStar software package (DataStar, Waltham, MA, USA). Incomplete surveys were excluded from the analysis. RESULTS: The results from 262 centers in 68 nations were obtained. Clomiphene citrate was the clear first choice, 68 %, for PCOS treatment in the respondent group. Eighty-eight percent of respondents utilized ultrasound follicular monitoring when conducting ovulation induction with oral medications. A significant (p < 0.05) proportion of respondents (66 %) did use some BMI cutoff beyond which IVF treatment was not offered. The preferred IVF protocols for PCOS patients were gonadotropin releasing hormone (GnRH) antagonist, 46 %, and GnRH agonist, 51 %. There was heterogeneity of responses observed regarding the management of a patient at very high risk of OHSS. CONCLUSIONS: While some advances, such as the use of GnRH antagonist regimen in IVF cycles, were relatively underutilized, the survey gives an unfiltered snapshot at the practice patterns of a large number of clinics. Results from this survey may be used by researchers and professional organizations to improve the clinical care of PCOS women suffering with infertility.

Update on preimplantation genetic testing for aneuploidy and outcomes of embryos with mosaic results.

Preimplantation genetic testing for aneuploidy (PGT-A) is used as a frequent add-on for in-vitro fertilization (IVF) to improve clinical outcomes. The purpose is to select a euploid embryo following chromosomal testing on embryo biopsies. The current practice includes comprehensive chromosome screening (CCS) technology applied on trophectoderm (TE) biopsies. Despite its widespread use, PGT-A remains a controversial topic mainly because all of the RCTs comprised only good prognosis patients with 2 or more blastocysts available; hence the results are not generalizable to all groups of patients. Furthermore, with the introduction of the highly-sensitive platforms into clinical practice (i.e. next-generation sequencing [NGS]), a result consistent with intermediate copy number surfaced and is termed "Mosaic," consistent with a mixture of euploid and aneuploid cells within the biopsy sample. The optimal disposition and management of embryos with mosaic results is still an open question, as many 'mosaics' generated healthy live births with no identifiable congenital anomalies. The present article provides a complete and comprehensive up-to-date review on PGT-A. It discusses in detail the findings of all the published RCTs on PGT-A with CCS, comments on the subject of "mosaicism" and its current management, and describes the latest technique of non-invasive PGT-A.

In vitro fertilization: four decades of reflections and promises.

BACKGROUND: In 2010, Robert Edwards was awarded the Nobel Prize in Medicine for his pioneering work in the development of in vitro fertilization, a field that has touched millions of lives across the globe. Edwards dedicated his career to helping couples overcome infertility. He first established principles of early embryo development that served as the foundation for his later work. In the 1960s, he achieved the first human fertilized oocyte in vitro while at the Johns Hopkins Hospital. He then continued his work at Cambridge University. In 1978, the world witnessed the birth of the first "test tube baby". This achievement is a landmark not only in the reproductive sciences but also in the history of mankind's technological evolution. SCOPE OF REVIEW: This article outlines the development and progression of IVF from its infancy to the refined and broadly utilized technology offered to patients today. We describe the evolution of the field and the current state of IVF, including its current technological and social challenges. MAJOR CONCLUSIONS: We congratulate Professor Edwards for his well-deserved recognition as Nobel Laureate in Medicine. GENERAL SIGNIFICANCE: This article is a tribute to Edwards for his exceptional accomplishments in this specific and rewarding field of modern medicine.

The impact of luteal phase support on endometrial estrogen and progesterone receptor expression: a randomized control trial.

BACKGROUND: To assess the impact of luteal phase support on the expression of estrogen receptor (ER) alpha and progesterone receptors B (PR-B) on the endometrium of oocyte donors undergoing controlled ovarian hyperstimulation (COH). METHODS: A prospective, randomized study was conducted in women undergoing controlled ovarian hyperstimulation for oocyte donation. Participants were randomized to receive no luteal support, vaginal progesterone alone, or vaginal progesterone plus orally administered 17 Beta estradiol. Endometrial biopsies were obtained at 4 time points in the luteal phase and evaluated by tissue microarray for expression of ER alpha and PR-B. RESULTS: One-hundred and eight endometrial tissue samples were obtained from 12 patients. No differences were found in expression of ER alpha and PR-B among all the specimens with the exception of one sample value. CONCLUSIONS: The administration of progesterone during the luteal phase of COH for oocyte donor cycles, either with or without estrogen, does not significantly affect the endometrial expression of ER alpha and PR.

Intergenerational gestational surrogacy in a patient with ovarian dysgerminocarcinoma.

A 20-year-old woman was diagnosed with an ovarian dysgerminoma on the right ovary and underwent fertility-preserving right salpingo-oophorectomy and staging. Eight months later she was found to have a left ovarian solid mass. She underwent controlled ovarian hyperstimulation and oocyte cryopreservation before total abdominal hysterectomy, left salpingo-oophorectomy, and exploratory surgery were performed. The patient was optimally debulked, with no recurrent cancer to date. Thirty-six oocytes were mature and cryopreserved using vitrification. Now, the patient's mother has undergone embryo transfer that resulted in a clinical pregnancy, acting as a gestational carrier, for her daughter. To our knowledge, this is the first case describing the uterine transfer of embryos into a gestational carrier where the embryos were generated using oocytes obtained through controlled ovarian hyperstimulation in the context of active ovarian cancer. In the appropriate clinical setting, women desiring future fertility with a diagnosis of ovarian cancer without the option of ovarian-sparing surgery may be candidates for controlled ovarian hyperstimulation for the purposes of fertility preservation, especially if altruistic gestational carriers are available and willing.

Description of the parasite Wucheria bancrofti microfilariae identified in follicular fluid following transvaginal oocyte retrieval.

INTRODUCTION: This case study presents an unusual finding of filarial infection within follicular fluid obtained during an in vitro fertilization (IVF) oocyte retrieval procedure. CASE: A 41 year-old G4P1030 immigrant from western Africa underwent in vitro fertilization (IVF). At the time of inspection of the follicular fluid obtained at oocyte retrieval, mobile worm-like organisms were observed and identified as Wuchereria bancrofti microfilariae (filariasis). The patient successfully underwent treatment for filariasis and Onchocerciasis co-infection. Following treatment, the patient underwent embryo transfer that failed to result in a pregnancy. DISCUSSION: Recent years have seen an increase in international travel and immigration. Therefore, practitioners must become familiar not only with illnesses that are endemic to their geographic region but also diseases that are more common in remote regions of the world. The infertility evaluation and treatment offers physicians a unique opportunity to identify and initiate treatment for diseases that might otherwise go undiagnosed.

Does route of hysterectomy affect outcome in obese and nonobese women?

OBJECTIVE: Our objective was to compare the surgical outcomes of obese women having hysterectomy according to the route (abdominal, vaginal, or laparoscopic) of the procedure. METHODS: A chart review of 293 hysterectomy procedures was performed. Data were collected including operative and anesthesia time, estimated blood loss, change in hematocrit, hospital stay, complications, conversion to laparotomy, transfusion, and body mass index. An analysis of variance and a Newman-Keuls Multiple Comparison test were performed. RESULTS: Obese women experienced a significant decrease in hospital days (2.5 versus 4.2) and reported blood loss (204 mL versus 455 mL) in the laparoscopic hysterectomy and vaginal hysterectomy groups compared with the abdominal hysterectomy group. No significant difference was found in obese women between laparoscopic and abdominal hysterectomy for time spent in surgery and under anesthesia. For obese and normal weight women, vaginal hysterectomy offered the shortest surgery, anesthesia times, and hospital stays. CONCLUSIONS: For normal and obese women, vaginal hysterectomy offered the shortest hospital stay and surgery time. In obese patients for whom vaginal hysterectomy is not possible, laparoscopic hysterectomy should be considered before abdominal hysterectomy, because the laparoscopic route reduced hospital time and blood loss.

Takotsubo cardiomyopathy in pregnancy.

BACKGROUND: Takotsubo cardiomyopathy is a cardiac condition associated with the acute onset of chest pain, abnormalities in cardiac enzymes and electrocardiogram, and a distinct pattern of left ventricular dysfunction on echocardiography. This case evaluates an obstetric patient diagnosed with Takotsubo cardiomyopathy during her 23rd week of pregnancy. CASE: A woman (G3P2002) at 23 weeks in an intrauterine pregnancy was admitted with chest pain. ST-segment elevation was noted on electrocardiogram with elevated cardiac enzymes. Subsequent tracings showed resolution of ST elevation with conservative management. Echocardiography was consistent with Takotsubo cardiomyopathy. She delivered through spontaneous vaginal delivery at term after a complete resolution of her cardiomyopathy. CONCLUSION: Although uncommon, physicians who manage cardiac complications should be familiar with the diagnosis and management of Takotsubo cardiomyopathy.

Fertility preservation for social and oncofertility indications.

The desire to reproduce is a base human instinct. However, for many individuals, the chances of being able to have a genetic child are compromised by a number of factors. For some, therapies aimed at treating serious medical illness, such as cancer; result in a deleterious impact on the function of eggs and sperm in the future thus compromising future fertility. In women, a predictable decrease in egg quality and quantity occurs with advancing maternal age. Therefore, women who choose to delay childbearing until their late 30s or early 40s may experience fertility difficulties that would not have been present earlier in life. Currently, technologies exist that allow individuals to have an "insurance policy" to preserve eggs or sperm prior to being exposed to agents, including time or specific toxic agents to the ovaries or sperm, that may decrease fertility potential. This article attempts to summarize the current state of the art technologies regarding fertility preservation for both social and oncofertility indications.

Urgent medical decision making regarding a Jehovah's Witness minor: a case report and discussion.

BACKGROUND: Physicians strive to respect the autonomy of patients. The emergent care of Jehovah's Witnesses, however, leaves health care providers struggling with ethical and legal questions. These are further compounded when the patient in question is a minor. CASE: A girl aged 15 years presented with anemia, a large ovarian mass, massive hemoperitoneum, and parents who were devout Jehovah's Witnesses who refused administration of blood products. Following discussion of the patient's condition and treatment options with the patient, her family, members of the treatment team, and consultants, the patient was transferred to a hospital that offered a blood conservation program for surgical patients. The patient received surgical management without the need for blood transfusion. Her surgeons, however, reserved the legal right to give blood if an emergent need arose despite the lack of parental consent. CONCLUSION: Society grants considerable legal latitude in dealing with Jehovah's Witness minors, and physicians must be aware of the legal and ethical parameters surrounding the care of such patients.

Future Implications of Human Embryonic Testing and Modification: Great Medicine or GATTACA?

The past several decades have seen tremendous advances in the field of medical genetics. Currently, the application of genetic testing on human embryos determines if embryos harbor a lethal condition or a serious genetic disease. The purpose of this sort of testing is not to "improve" the offspring of a couple. Rather, current testing strategies focus on helping couples to have a healthy family in an efficient manner. Newly emerging technologies have opened the door to test embryos for an exponentially growing number of traits. Additionally, recent reports describe the actual modification of human embryonic DNA. The implications from the application of this technology are many and have the potential to fundamentally change the social paradigm of the human experience. Embryonic testing and modification does have the potential to accomplish good and is not inherently amoral. However, thoughtful consideration should be given by scientists, legislators, and the general population on how to apply this technology in a manner that is both appropriate and equitable and does not result in further social stratification and polarization, both within individual nations and the global community.

Clinical applications of preimplantation genetic testing.

Genetic diagnostic technologies are rapidly changing the way medicine is practiced. Preimplantation genetic testing is a well established application of genetic testing within the context of in vitro fertilization cycles. It involves obtaining a cell(s) from a developing embryo in culture, which is then subjected to genetic diagnostic analysis; the resulting information is used to guide which embryos are transferred into the uterus. The potential applications and use of this technology have increased in recent years. Experts agree that preimplantation genetic diagnosis is clinically appropriate for many known genetic disorders. However, some applications of such testing, such as preimplantation genetic screening for aneuploidy, remain controversial. Clinical data suggest that preimplantation genetic screening may be useful, but further studies are needed to quantify the size of the effect and who would benefit most.

Blastocoel fluid from differentiated blastocysts harbors embryonic genomic material capable of a whole-genome deoxyribonucleic acid amplification and comprehensive chromosome microarray analysis.

OBJECTIVE: To obtain embryonic molecular karyotypes from genomic DNA (deoxyribonucleic acid) isolated from blastocoel fluid (BF) and to compare these karyotypes with the karyotypes from the remaining inner cell mass (ICM) and trophectoderm (TE) of the blastocyst. DESIGN: Prospective cohort study. SETTING: Academic center and preimplantation genetics laboratory. PATIENT(S): Ninety-six donated cryopreserved embryos. INTERVENTION(S): Embryo biopsy, BF aspiration, DNA analysis using a comparative genomic hybridization microarray (aCGH). MAIN OUTCOME MEASURE(S): The aCGH of a single blastomere, BF-DNA, and ICM-TE. RESULT(S): The BF-DNA samples resulted in a successful aCGH in 63% of cases. Discordance in karyotypes was found between the BF-DNA and the ICM-TE in 52% of cases. A total of 70% of aneusomic (mosaicism), cleavage-stage embryos differentiated into euploid blastocysts. Probabilities for diagnostic accuracy were calculated and demonstrated the following: sensitivity of 0.88 (95% confidence interval [CI]: 0.62-0.98); specificity of 0.55 (95% CI: 0.39-0.70); positive predictive value of 0.41 (95% CI: 0.25-0.60); negative predictive value of 0.92 (95% CI: 0.75-0.99). CONCLUSION(S): Genomic DNA from the BF can be amplified and characterized by comprehensive chromosome microarrays. The results demonstrated that aneusomic cleavage-stage embryos differentiated into euploid blastocysts, possibly using a mechanism that marginalizes aneuploid nuclei into the blastocoel cavity. In addition, owing to the high discordance between the karyotypes obtained from the BF-DNA and the ICM-TE, using BF-DNA for preimplantation genetic testing is not yet advised.

Fertility preservation in the age of assisted reproductive technologies.

The desire to reproduce is one of the strongest human instincts. Many men and women in our society may experience situations that compromise their future fertility. The past several decades have seen an explosion of technologies that have changed the historical limitations regarding fertility preservation. This review offers an overview of the state of the art within fertility preservation including surgical and medical interventions and therapies that necessitate the need for cryopreservation of eggs, sperm, and embryos. The review also addresses the psychological consequences of banking/not banking materials among patients in need of fertility preservation, particularly in the oncofertility context.

Efficient differentiation of steroidogenic and germ-like cells from epigenetically-related iPSCs derived from ovarian granulosa cells.

To explore restoration of ovarian function using epigenetically-related, induced pluripotent stem cells (iPSCs), we functionally evaluated the epigenetic memory of novel iPSC lines, derived from mouse and human ovarian granulosa cells (GCs) using c-Myc, Klf4, Sox2 and Oct4 retroviral vectors. The stem cell identity of the mouse and human GC-derived iPSCs (mGriPSCs, hGriPSCs) was verified by demonstrating embryonic stem cell (ESC) antigen expression using immunocytochemistry and RT-PCR analysis, as well as formation of embryoid bodies (EBs) and teratomas that are capable of differentiating into cells from all three germ layers. GriPSCs' gene expression profiles associate more closely with those of ESCs than of the originating GCs as demonstrated by genome-wide analysis of mRNA and microRNA. A comparative analysis of EBs generated from three different mouse cell lines (mGriPSCs; fibroblast-derived iPSC, mFiPSCs; G4 embryonic stem cells, G4 mESCs) revealed that differentiated mGriPSC-EBs synthesize 10-fold more estradiol (E2) than either differentiated FiPSC- or mESC-EBs under identical culture conditions. By contrast, mESC-EBs primarily synthesize progesterone (P4) and FiPSC-EBs produce neither E2 nor P4. Differentiated mGriPSC-EBs also express ovarian markers (AMHR, FSHR, Cyp19a1, ER and Inha) as well as markers of early gametogenesis (Mvh, Dazl, Gdf9, Boule and Zp1) more frequently than EBs of the other cell lines. These results provide evidence of preferential homotypic differentiation of mGriPSCs into ovarian cell types. Collectively, our data support the hypothesis that generating iPSCs from the desired tissue type may prove advantageous due to the iPSCs' epigenetic memory.

Classic and cutting-edge strategies for the management of early pregnancy loss.

There are few conditions in medicine associated with more heartache to patients than recurrent pregnancy loss (RPL). The management of early RPL is a formidable clinical challenge for physicians. Great strides have been made in characterizing the incidence and diversity of this heterogeneous disorder, and a definite cause of pregnancy loss can be established in more than half of couples after a thorough evaluation. In this review, current data are evaluated and a clear roadmap is provided for the evaluation and treatment of RPL.