Educational Objectives Current IVF Practice

2/23/2015

Update from the IVF Lab: Preimplantation Genetic Testing

Janet McLaren Bouknight, MD Reproductive Endocrinology and Infertility Department 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

1 2/23/2015

Current IVF Practice

150,000 cycles

65,000 livebirths

Current IVF Practice

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

2 2/23/2015

Current IVF Practice: Improved Lab Conditions

3 2/23/2015

Current IVF Practice: Extended Embryo Culture Day 3: Cleavage Stage Day 5: Blastocyst Stage

• 8‐cells • 200‐300 cells • 30% implantation rate • 50% implantation rate  Increased live birth rates seen in “good prognosis” patients who undergo a Day 5 transfer

Current IVF Practice: Extended Embryo Culture

• Supports blastocyst transfer for “good prognosis” patients • Opportunity to consider single embryo transfer • May be associated with a small increased risk of monozygotic twinning

4 2/23/2015

Current IVF Practice: Embryo Cryopreservation Cycles • Improvements in freezing techniques (vitrification) have increased success of cryopreserved embryos. • IiIncreasing apprecitiiation tha t the endometrial environment created by ovarian hyperstimulation may not be the most favorable for implantation

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

Current IVF Practice: Embryo Cryopreservation Cycles

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

Maheshwari Fertil Steril 2012; 98(2): 368

5 2/23/2015

Preimplantation Genetic Diagnosis PGD

Preimplantation Genetic 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 Fibrosis Huntingtons Hemophilia Sickle Cell Anemia Myotonic dystrophy Β‐Thalassemia Spinal Muscular Atrophy Tuberous sclerosus NF1 Ocular Albinism FAP

Preimplantation Genetic 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 preimplantation genetic 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

6 2/23/2015

PGD: Current practice

• Biopsy is typically done on blastocyst (day 5)

Trophectoderm (placental)

Inner cell Biopsy mass (fetal) Zona pellucida • Sample of cells are taken from the trophectoderm • Embryo is frozen • After results, embryo is selected for frozen transfer

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) . • Gray areas: • Adult‐onset disease • Cancer‐causing genes • HLA‐matching for sibling

Preimplantation Genetic Screening PGS

7 2/23/2015

Preimplantation Genetic 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 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).

8 2/23/2015

PGS: Technique

• Initial aneuploidy screening was done with FISH • Fluorochrome‐tagged DNA probe 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

9 2/23/2015

CCS Outcomes

Euploid eSET • 61% preg rate * • No twins

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

Forman Fertil Steril 2013; 100(1):100

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

* *

Forman Fertil Steril 2013; 100(1):100

eSET Nationwide

15% of cycles in < 35 years

10 2/23/2015

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

11 2/23/2015

SART IVF Predictor: 25yo with PCOS

2 months later Frozen Embryo Transfer: $2500

SART IVF Predictor: 38yo unexplained

2 months later Frozen Embryo Transfer: $2500