Neca% FINDIKLI, Ph.D.
Director of IVF Laboratories
Bahceci Women’s Health Group, Turkey
Should Gene%c Tes%ng Be Applied Universally in IVF?
Gene%c Tes%ng in IVF
• Preconcep%on Gene%c Screening
• Preimplanta+on Gene+c Screening/Diagnosis
• Non Invasive Prenatal Gene%c Tes%ng
• Prenatal Diagnosis
• Newborn Screening
Indica%ons and ART outcome wrt. female age
Contribu%on of female age in infer%lity
≈90% of the oocytes are normal
≈10% of the oocytes are normal
Early Celavage and differentiation Gametogenesis
Errors in meiosis I & meiosis II
Errors in mitosis (postzygo+c)
Contribu%on of gene%c factors in infer%lity
Sunkara et al. 2011
OPU ICSI 2PN Day3 Day4 Day5
Embryo Selec+on
Enough +me for gene+c analysis
“The main aim was to preselect the embryos that will fail to implant or miscarry due to aneuploidy and hereby to increase the live birth rate”
… Assuming that there is no extra and nega%ve contribu%ons of in vitro culture, sampling and the diagnos%c error etc.
PGS-‐v1
EB
Day 0 or Day 1 or Day 3
FISH
3, 5, 9 ,12 crh.
From late 1990s – to late 2000s
Posi+ve effect
Gianaroli et al. 1999 Munne et al 1999 Gianaroli et al 2001a Gianaroli et al. 2001b Munne et al. 2003 Gianaroli et al. 2004 Munne et al. 2005 Munne et al 2006 Verlinsky et al. 2005 Colls et al. 2007
Garrisi et al. 2009 Rubio et al. 2009
No effect (small)
Werlin et al. 2003 Jansen et al. 2008
Mersereau et al. 2008 Scholcrab et al. 2009
No effect (Large)
St
aessen et al. 2004 Placeau et al. 2005
Nega+ve effect
Mastenbroek et al. 2007
Hardarson et al. 2008
PGS-‐v2
EB
Day 5 & 6
CCS
24 crh.
If FISH with 9 chromosomes was performed, %28.4 would be diagnosed as normal
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 SK 6,0%
8,5%
5,8%
3,5% 4,7% 4,3% 5,6%
6,9%
4,7% 4,5% 4,5% 4,5%
10,9%
8,2%
10,4%
16,8%
5,8%
10,0%
8,7%
14,7%
18,7%
14,9%
11,6%
Distribu+on of chromosomal abnormali+es
Cohort studies showing posi+ve effect
Schoolcrab et al. 2010 Schoolcrab et al. 2011 Rubio et al. 2013
RCTs
Yang et al. 2012 Forman et al. 2012 Scoc et al. 2013
Serious issues on study quality
Alloca%on concealment Lack of blinding
Large loss to follow-‐up No ITT analysis
…
Robberecht et al., 2010 Nega%ve Selec%on Placental Mosaicism Embryonic Mosaicism
Day 3
Day 5
“It may not be solely a macer of technology, but the problem do exist in the biology itself”
Northrop et al., 2010 58%
57%
Day 3 FISH à Day 5 aCGH
Northrop et al., 2010
Capalbo et al., 2013 Only 2 of the 50 (4%) aneuploid blastocysts analyzed in this study were mosaic diploid/aneuploid being at risk of misdiagnosis due to mosaicism when molecular analysis is carried out on few TE cells.
Day 5 aCGH à Day 5 FISH
Greco et al., 2015
Between May 2013 and July 2014, 3802 blastocysts were analyzed by means of aCGH.
Chromosomal mosaicism was detected in 181 blastocysts (4.8%).
Clinically recognizable error rate aber the transfer of comprehensive chromosomal screened euploid embryos is low
Werner et al., 2014
" Advanced Maternal Age (AMA)
" D
" Repeated Implanta+on Failure (RIF)
" Recurrent Spontaneous Abor+on (RSA)
" Severe male Factor Infer+lity (SMF)
We should keep in our mind that the focus on PGS is:
“On poor prognosis pa%ents with high risk of embryonic aneuploidy”
Between 2011 -‐ 2014, PGS cycles has an annual increase rate of >30%.
Nearly 8% of all IVF involved PGS.
A high por+on of pa+ents, the indica+on may solely be “beaer embryo selec+on”.
Brown., 2014
Kushnir et al. 2016
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 Preven%on.
10,3% 10,1%
19,0%
25,2%
54,7%
50,8%
60,3%
51,2%
35,8%
68,7%
50,8% 52,9%
44,7%
30,8%
61,6%
0,0%
10,0%
20,0%
30,0%
40,0%
50,0%
60,0%
70,0%
80,0%
90,0%
100,0%
25-‐29 30-‐34 35-‐39 >=40 aCGH
Pregnancy Outome According to Female Age
Cancella%on rate % BPR CPR
PR wrt. Female age
Aneuploidy wrt. Female age
Clinical scenarios
Day 3 DET
Day 5 ET
Normal Trisomy 13 Monosomy 4 (or mosaic?)
Day 5 CCS+ET
Deferred Day 5 FET aber CCS
Survival vs.
Receptvity
Minimizing mul%ple pregnancies?
Improving clinical outcome?
Minimizing drop out rate?
Decreasing the %me to achieve pregnancy?
Biological loss vs. Technical loss
Mastenbroek and Repping, 2014
" Do not forget evidence-‐based medicine
D" An adverse past and an uncertain future
" The trophectoderm is an area of chromosomal variability
" Data are missing for several indica%ons
" Indica%ng PGS-‐new for infrequent popula%ons
" Concerns about extended culture to the blastocyst stage
" Non-‐maleficence
Conclusion
Franco JG. 2015
