michele evans (2)
TRANSCRIPT
Infertility, In Vitro Infertility, In Vitro Fertilization (IVF) and Fertilization (IVF) and
Genetic TestingGenetic Testing
Michele Evans, M.D.Michele Evans, M.D.
OutlineOutline
InfertilityInfertility Treatment optionsTreatment options
In Vitro FertilizationIn Vitro Fertilization
Genetic TestingGenetic Testing PreconceptionPreconception PreimplantationPreimplantation Prenatal Prenatal
ControversiesControversies
Normal FertilityNormal Fertility
0
0.2
0.4
0.6
0.8
1
1 2 3 4 5 6 7 8 9 10 11 12
Months of Follow Up
Cumulative Pregnancy
Rates
Hull, et al: Br Med J 1985:291;1693
Overview of InfertilityOverview of Infertility
Definition: 1 year of well-timed, unprotected Definition: 1 year of well-timed, unprotected intercourse without a pregnancyintercourse without a pregnancy
10-15% of population is infertile (subfertile)10-15% of population is infertile (subfertile)
FSH (+)
FSH=Follicle Stimulating Hormone
PhysiologyPhysiology
E2 (-)
E2=Estradiol
Developing follicle
Causes of Female InfertilityCauses of Female Infertility
OvaryOvary TubesTubes UterusUterus CervixCervix HormonesHormones ChromosomesChromosomes
Causes of Female Infertility - OvaryCauses of Female Infertility - Ovary
AGEAGE
Problems with ovulation Problems with ovulation
Premature ovarian failurePremature ovarian failure
Ovary - Female AgeOvary - Female Age
Women are born with their lifetime egg supplyWomen are born with their lifetime egg supply 4 million at 20 weeks gestation4 million at 20 weeks gestation 400,000 at birth400,000 at birth
100,000 eggs left at time of puberty100,000 eggs left at time of puberty Fertility initially declines at age Fertility initially declines at age 2727 Significant decline at age 37-38Significant decline at age 37-38 Rare pregnancies after age 44Rare pregnancies after age 44
Percentage of Married Women Percentage of Married Women Who are InfertileWho are Infertile
From 3 national U.S. surveysFrom 3 national U.S. surveys
Age (years)Age (years) InfertileInfertile
20-2420-24 7.07.0
25-2925-29 8.98.9
30-3430-34 14.614.6
35-3935-39 21.921.9
40-4440-44 28.728.7
Menken et al, Science 1989;23:1389
Ovarian Reserve TestingOvarian Reserve Testing
Day 3 FSH/EDay 3 FSH/E22 FSH (mIU/mL)FSH (mIU/mL) EE22 (pg/mL) (pg/mL)
NormalNormal <10<10 <100<100
BorderlineBorderline 10-2010-20 NANA
AbnormalAbnormal >20>20 >100>100
Clinical pregnancy per cycleClinical pregnancy per cycleas function of both FSH and ageas function of both FSH and age
Pearlstone et al, Fertil Steril 1992:58:674
Prevalence of genetically abnormal Prevalence of genetically abnormal oocytes in infertile womenoocytes in infertile women
Abnorm
al (%)
Ovary - OvulationOvary - Ovulation
HistoryHistory Regular menses (90%)Regular menses (90%) Premenstrual symptomsPremenstrual symptoms
Patient self-testingPatient self-testing BBT, urinary ovulation kits (LH)BBT, urinary ovulation kits (LH)
Laboratory testsLaboratory tests Mid-luteal serum progesterone > 10 ng/mLMid-luteal serum progesterone > 10 ng/mL Endometrial biopsyEndometrial biopsy
Ovary - Causes of AnovulationOvary - Causes of Anovulation
Hormone imbalanceHormone imbalance ObesityObesity AnorexiaAnorexia Significant stressSignificant stress Patients display:Patients display:
Irregular menstrual cyclesIrregular menstrual cycles Skipped cyclesSkipped cycles Minimal or absent premenstrual symptomsMinimal or absent premenstrual symptoms
Ovary – Premature Ovarian FailureOvary – Premature Ovarian Failure
Menopause prior to age 40Menopause prior to age 40 ↓↓EstrogenEstrogen ↑↑FSHFSH
CausesCauses AutoimmuneAutoimmune GeneticGenetic Idiopathic Idiopathic
1-2% pregnancy rate1-2% pregnancy rate
Causes of Female Infertility – Causes of Female Infertility – Fallopian TubesFallopian Tubes
Infection (chlamydia)Infection (chlamydia)
EndometriosisEndometriosis
Tubal ligation (female sterilization)Tubal ligation (female sterilization)
Female Infertility - UterusFemale Infertility - Uterus
UterusUterus FibroidsFibroids PolypsPolyps
Mullerian (congenital) defectsMullerian (congenital) defects AbsentAbsent Bicornuate/SeptumBicornuate/Septum
Asherman’s syndromeAsherman’s syndrome
Female InfertilityFemale Infertility
Uterine muscle tumorUterine muscle tumor
Benign (>95%)Benign (>95%)
25-30% of women25-30% of women
Female Infertility - UterusFemale Infertility - Uterus
UterusUterus TumorsTumors
FibroidsFibroids PolypsPolyps
Mullerian defects (congenital)Mullerian defects (congenital) Absent uterusAbsent uterus Bicornuate/septateBicornuate/septate
Asherman’s syndromeAsherman’s syndrome
Female Infertility - UterusFemale Infertility - Uterus
UterusUterus TumorsTumors
FibroidsFibroids PolypsPolyps
Mullerian defects (congenital)Mullerian defects (congenital) Absent uterusAbsent uterus Bicornuate/septateBicornuate/septate
Asherman’s syndromeAsherman’s syndrome
Female Infertility - CervixFemale Infertility - Cervix
CervixCervix Post-surgicalPost-surgical
StenosisStenosis Mucus changesMucus changes
Female Infertility - HormonesFemale Infertility - Hormones
Endocrine abnormality (hormones)Endocrine abnormality (hormones) ThyroidThyroid ProlactinProlactin Polycystic ovary syndrome (PCOS)Polycystic ovary syndrome (PCOS)
Estrogen, insulinEstrogen, insulin
Hypothalamic hypogonadismHypothalamic hypogonadism StressStress Exercise (ballet dancer)Exercise (ballet dancer)
Other Causes of Female InfertilityOther Causes of Female Infertility
OthersOthers Chromosome abnormalitiesChromosome abnormalities
Turner’s syndrome (XO)Turner’s syndrome (XO) Androgen Insensitivity (XY)Androgen Insensitivity (XY)
Male pseudohermaphroditeMale pseudohermaphrodite Female phenotypeFemale phenotype Blind vaginal canalBlind vaginal canal Inguinal hernia (50%)Inguinal hernia (50%)
Causes of Male InfertilityCauses of Male Infertility
Abnormality in sperm productionAbnormality in sperm production
Abnormality in sperm functionAbnormality in sperm function
Obstruction in the ductal systemObstruction in the ductal system
Sperm: Semen AnalysisSperm: Semen Analysis
Volume: Volume: >> 2 mL 2 mL Concentration: Concentration: >> 20,000,000 per mL 20,000,000 per mL Motility: Motility: >> 50% 50% Normal morphology: Normal morphology: >> 40% normal 40% normal
Krueger strict criteria: Krueger strict criteria: >> 14% normal 14% normal Best predictor of fertilizing ability Best predictor of fertilizing ability
SpermSperm
How many are needed for fertilization?How many are needed for fertilization? Natural conceptionNatural conception
20,000,00020,000,000
Intra-uterine inseminationIntra-uterine insemination 1,000,0001,000,000
In-vitro fertilization (IVF)In-vitro fertilization (IVF) 10,00010,000
Intra-cytoplasmic sperm injection (ICSI)Intra-cytoplasmic sperm injection (ICSI) 11
FertilizationFertilization
Binding to zona Binding to zona pellucidapellucida
Penetration of oocytePenetration of oocyte Decondensation and Decondensation and
aster formationaster formation Pronucleus Pronucleus
formationformation
Causes of Male InfertilityCauses of Male Infertility
Abnormality in sperm productionAbnormality in sperm production
Abnormality in sperm functionAbnormality in sperm function
Obstruction in the ductal systemObstruction in the ductal system
Abnormalities of Sperm ProductionAbnormalities of Sperm Production
GeneticGenetic Y chromosome microdeletionsY chromosome microdeletions
Damage to testes – anatomicalDamage to testes – anatomical CryptorchidismCryptorchidism VaricoceleVaricocele
InfectionInfection Mumps orchitisMumps orchitis
GonadotoxinsGonadotoxins
Abnormalities of Sperm FunctionAbnormalities of Sperm Function
Antisperm antibodiesAntisperm antibodies Genital tract inflammationGenital tract inflammation
prostatitisprostatitis
VaricoceleVaricocele Failure of acrosome reactionFailure of acrosome reaction Problems with sperm binding/penetrationProblems with sperm binding/penetration
Obstructions in Ductal SystemObstructions in Ductal System
VasectomyVasectomy
Congenital bilateral absence of the vas deferensCongenital bilateral absence of the vas deferens
Epididymis/ejaculatory ductsEpididymis/ejaculatory ducts Congenital or acquiredCongenital or acquired
Male Infertility - LifestyleMale Infertility - Lifestyle
TobaccoTobacco MarijuanaMarijuana AlcoholAlcohol CocaineCocaine Steroids (can be permanent)Steroids (can be permanent) HeatHeat ExerciseExercise
Infertility: Initial EvaluationInfertility: Initial Evaluation
EggsEggs OvulationOvulation Egg qualityEgg quality
SpermSperm PresencePresence QualityQuality
Gamete transport/ImplantationGamete transport/Implantation HysterosalpingogramHysterosalpingogram
Unexplained InfertilityUnexplained Infertility
Work-up is negativeWork-up is negative
15-20 % of couples15-20 % of couples
TreatmentsTreatments
Observation (improve timing)Observation (improve timing) Clomiphene citrate + intrauterine insemination Clomiphene citrate + intrauterine insemination
(IUI)(IUI) FSH + IUIFSH + IUI IVFIVF Egg donationEgg donation
Clomiphene Citrate (Clomid)Clomiphene Citrate (Clomid)
Anti-estrogenAnti-estrogen
↑ ↑ FSHFSH
↑ ↑ egg productionegg production
$$
Estrogen AntagonistEstrogen Antagonist
FSH (+)
FSH=Follicle Stimulating Hormone
PhysiologyPhysiology
E2 (-)
E2=Estradiol
Developing follicle
Clomid
ART: Treatment OptionsART: Treatment Options
Clomiphene citrate + IUIClomiphene citrate + IUI Prospective randomized trialProspective randomized trial Patients with unexplained infertilityPatients with unexplained infertility
ObservationObservation CC + IUICC + IUI
CyclesCycles 150150 148148
PregnanciesPregnancies 55 1414
FecundityFecundity 0.0330.033 0.0950.095
Deaton et al, Fertil Steril 1990;54:1083
FSH +IUIFSH +IUI
Daily injections Daily injections
Goal is to make multiple follicles (eggs)Goal is to make multiple follicles (eggs)
$$$$
FSH (+)
FSH=Follicle Stimulating Hormone
PhysiologyPhysiology
E2 (-)
E2=Estradiol
Developing follicle
Infertility Treatment OptionsInfertility Treatment Options
IUI, FSH or FSH + IUIIUI, FSH or FSH + IUI Patients with unexplained infertilityPatients with unexplained infertility
Serhall et al, Fertil Steril 1988;49:602
TreatmentTreatment CyclesCycles PregnancyPregnancy Pregnancy per Pregnancy per cyclecycle
IUIIUI 3030 11 2.7%2.7%
FSHFSH 4949 33 6.1%6.1%
FSH+IUIFSH+IUI 3434 99 26.4%26.4%
In Vitro Fertilization - HistoryIn Vitro Fertilization - History
1978 – First “test tube” baby was born in England 1978 – First “test tube” baby was born in England
1981 – IVF in U.S.1981 – IVF in U.S.
Started with GIFT and ZIFTStarted with GIFT and ZIFT
2004 - >98% IVF with transfer of embryo to uterus2004 - >98% IVF with transfer of embryo to uterus
Who Needs IVF?Who Needs IVF?
Failed other treatmentsFailed other treatments Tubal damageTubal damage Significant male factorSignificant male factor Absent uterusAbsent uterus Carriers of genetic diseasesCarriers of genetic diseases Cancer patients?Cancer patients?
Egg RetrievalEgg Retrieval
FertilizationFertilization
2 Pronuclei (2PN)2 Pronuclei (2PN)
1 day after egg retrieval1 day after egg retrieval
Embryo TransferEmbryo Transfer
Special IVF ProceduresSpecial IVF Procedures
Assisted hatchingAssisted hatching Intracytoplasmic sperm injection (ICSI)Intracytoplasmic sperm injection (ICSI) Preimplantation genetic diagnosis (PGD)Preimplantation genetic diagnosis (PGD) FreezingFreezing Egg donationEgg donation SurrogacySurrogacy
How Many Embryos are How Many Embryos are Transferred?Transferred?
Related to age and embryo qualityRelated to age and embryo quality <35 = 2<35 = 2 35-37 = 2-335-37 = 2-3 38-40 = 3-438-40 = 3-4 >40 = up to 5>40 = up to 5
For patients with 2 or more failed IVF cycles, or a poor For patients with 2 or more failed IVF cycles, or a poor prognosis, can add more based on clinical judgementprognosis, can add more based on clinical judgement
IVF Success Rates - 2000IVF Success Rates - 2000
U.S. Fertility Centers (SART/CDC)U.S. Fertility Centers (SART/CDC) Female ageFemale age
<35 – 33%<35 – 33% 35-37 – 27%35-37 – 27% 38-40 – 18.6%38-40 – 18.6% >40 – 7.8%>40 – 7.8%
IVF Statistics - 2000IVF Statistics - 2000
65.1% singletons (16,533)65.1% singletons (16,533)
30.8% twins (7,817)30.8% twins (7,817)
3.9% triplets (1,000)3.9% triplets (1,000)
0.2% higher order multiples (44)0.2% higher order multiples (44)
Twin PregnancyTwin Pregnancy
IVF and Multiple PregnancyIVF and Multiple Pregnancy
Maternal complicationsMaternal complications Fetal complicationsFetal complications CostCost ““Selective reduction”Selective reduction” Single embryo transfer vs. success ratesSingle embryo transfer vs. success rates
IVF Statistics - 2000IVF Statistics - 2000
383 U.S. programs offer IVF383 U.S. programs offer IVF
99,989 cycles of ART treatment99,989 cycles of ART treatment
7,581 donor oocyte cycles7,581 donor oocyte cycles
25,394 deliveries (birth of 35,345 neonates)25,394 deliveries (birth of 35,345 neonates)
Current status of ART in the USACurrent status of ART in the USA
SART registry, 1998
Pregnancy and live birth ratesfor ART cyclesusing fresh,non-donor eggs,by age of woman
Cost of IVFCost of IVF
IVF cycle + medications = $10,000-15,000IVF cycle + medications = $10,000-15,000 Assisted hatching = $500Assisted hatching = $500 ICSI = $1,500ICSI = $1,500 Freezing = $650Freezing = $650 Storage = $360 Storage = $360 Egg Donor = $5,000Egg Donor = $5,000 Surrogate = $10,000-15,000Surrogate = $10,000-15,000
Egg DonationEgg Donation
Egg donationEgg donation
IVF for twoIVF for two
DonorDonor Standard controlled Standard controlled
ovarian hyperstimulationovarian hyperstimulation Egg retrievalEgg retrieval
RecipientRecipient Embryo transferEmbryo transfer
Current status of ART in the Current status of ART in the USAUSA
SART registry, 1998
Live birth rates per transferfor fresh embryos from own anddonor eggs, by age of recipient
Egg DonationEgg Donation
Grade A: The Market for a Yale Woman’s Grade A: The Market for a Yale Woman’s EggsEggs When a Yale undergraduate explored becoming an egg When a Yale undergraduate explored becoming an egg donor for a wealthy couple willing to pay top dollar to the donor for a wealthy couple willing to pay top dollar to the right candidate, she didn't realize how unsettling the right candidate, she didn't realize how unsettling the process of candidacy would prove to beprocess of candidacy would prove to be
by Jessica Cohen by Jessica Cohen
Egg DonationEgg Donation
October 23, 1999October 23, 1999 Selling Fashion Models' Eggs Online Raises Ethics IssuesSelling Fashion Models' Eggs Online Raises Ethics Issues By CAREY GOLDBERG By CAREY GOLDBERG
CAMBRIDGE, Mass. -- To the horror and disgust of CAMBRIDGE, Mass. -- To the horror and disgust of mainstream infertility groups, a longtime fashion photographer mainstream infertility groups, a longtime fashion photographer has begun offering up models as egg donors to the highest has begun offering up models as egg donors to the highest bidders, auctioning their ova via the Internet to would-be parents bidders, auctioning their ova via the Internet to would-be parents willing to pay up to $150,000 in hopes of having a beautiful willing to pay up to $150,000 in hopes of having a beautiful child. child.
Egg Donation - Ethical IssuesEgg Donation - Ethical Issues
Egg Donor Egg Donor Known or anonymousKnown or anonymous How many times to donate?How many times to donate?
RecipientRecipient How old is too old?How old is too old?
Pregnancy in the Sixth Decade of Pregnancy in the Sixth Decade of LifeLife
USC experience: 1991-2000USC experience: 1991-2000
77 recipients of egg donation77 recipients of egg donation
Mean age 52.8 + 2.9 yearsMean age 52.8 + 2.9 years
Paulson, Tourgeman, Boostanfar et al, JAMA 2002:228;2320.
Pregnancy in the Sixth Decade of Pregnancy in the Sixth Decade of LifeLife
Medical screeningMedical screening EKG and treadmillEKG and treadmill Mammogram, PapMammogram, Pap Chest x-rayChest x-ray Glucose tolerance testGlucose tolerance test Complete blood countComplete blood count Blood chemistry with cholesterolBlood chemistry with cholesterol
Pregnancy in the Sixth Decade of Pregnancy in the Sixth Decade of Life: Pregnancy OutcomeLife: Pregnancy Outcome
Of the 77 women, 42 (54.5%) had live birthsOf the 77 women, 42 (54.5%) had live births
45 deliveries in 42 women45 deliveries in 42 women
Pregnancy in the Sixth Decade of Pregnancy in the Sixth Decade of Life: Pregnancy OutcomeLife: Pregnancy Outcome
45 Live births45 Live births 78% Cesarean delivery78% Cesarean delivery
31 Singletons31 Singletons 68% Cesarean delivery68% Cesarean delivery 6% Vacuum assisted6% Vacuum assisted 26% NSVD26% NSVD
14 Multiple gestations14 Multiple gestations 100% Cesarean delivery100% Cesarean delivery
Pregnancy in the Sixth Decade of Pregnancy in the Sixth Decade of Life: Obstetric ComplicationsLife: Obstetric Complications
35% Pre-eclampsia35% Pre-eclampsia 25% mild25% mild 10% severe10% severe
Background incidenceBackground incidence 3-5% in young women3-5% in young women 10% in women over age 4010% in women over age 40
Pregnancy in the Sixth Decade of Pregnancy in the Sixth Decade of Life: Life:
Obstetric ComplicationsObstetric Complications 20% gestational diabetes20% gestational diabetes
17.5% diet controlled17.5% diet controlled 2.5% insulin2.5% insulin
Background incidenceBackground incidence 5% overall, increasing with age5% overall, increasing with age
<20 years of age: 3.7%<20 years of age: 3.7% 20-30 years of age: 7.5%20-30 years of age: 7.5% >30 years of age: 13.8%>30 years of age: 13.8%
Is 55 a “physiological limit”?Is 55 a “physiological limit”?
Marked increase in pre-eclampsiaMarked increase in pre-eclampsia
Increase in diabetesIncrease in diabetes
How old is too old?How old is too old?
Genetic TestingGenetic Testing
PreconceptionPreconception
PreimplantationPreimplantation
PrenatalPrenatal
PostnatalPostnatal
Preconception CounselingPreconception Counseling
Offered to all womenOffered to all women Prenatal vitamins – 400 micrograms folic acid/dayPrenatal vitamins – 400 micrograms folic acid/day Rubella immunityRubella immunity Varicella immunityVaricella immunity Rh statusRh status HIVHIV Hepatitis B screenHepatitis B screen Cystic Fibrosis screeningCystic Fibrosis screening
Preconception CounselingPreconception Counseling
Offered to certain ethnic groupsOffered to certain ethnic groups Mediterranean – thalassemiaMediterranean – thalassemia African-American – sickle-cell anemiaAfrican-American – sickle-cell anemia Caucasian/Hispanic – cystic fibrosisCaucasian/Hispanic – cystic fibrosis Ashkenazi Jews – 7 autosomal recessive disordersAshkenazi Jews – 7 autosomal recessive disorders
Gaucher disease (1/13), Tay-Sachs (1/30), Familial Gaucher disease (1/13), Tay-Sachs (1/30), Familial dysautonomia (1/30), Canavan disease (1/40), Fanconi dysautonomia (1/30), Canavan disease (1/40), Fanconi anemia (1/89), Niemann-Pick disease (1/90), Bloom anemia (1/89), Niemann-Pick disease (1/90), Bloom syndrome (1/100)syndrome (1/100)
Prenatal TestingPrenatal Testing
UltrasoundsUltrasounds
Serum screensSerum screens
Chorionic villus sampling (CVS)Chorionic villus sampling (CVS)
AmniocentesisAmniocentesis
Prenatal Tests - UltrasoundPrenatal Tests - Ultrasound
Nuchal translucency screeningNuchal translucency screening
Performed between 10-13 weeks gestationPerformed between 10-13 weeks gestation
Screen for Down SyndromeScreen for Down Syndrome
Prenatal Tests - UltrasoundPrenatal Tests - Ultrasound
Second trimester ultrasoundSecond trimester ultrasound Detailed examDetailed exam Down Syndrome, other trisomiesDown Syndrome, other trisomies Cardiac, renal, spinal, limb, brain deformitiesCardiac, renal, spinal, limb, brain deformities Cleft lip/palateCleft lip/palate
Ultrasound AbnormalitiesUltrasound Abnormalities
Ultrasound AbnormalitiesUltrasound Abnormalities
Prenatal Tests - SerumPrenatal Tests - Serum
15-20 weeks gestation15-20 weeks gestation
Quad ScreenQuad Screen Tests for AFP, hCG, uE3 and inhibin ATests for AFP, hCG, uE3 and inhibin A Neural tube defects, Down syndrome and Neural tube defects, Down syndrome and
trisomy 18trisomy 18 Readjusts age-related risksReadjusts age-related risks
Prenatal TestsPrenatal Tests
Who is offered further testing?Who is offered further testing? Advanced maternal ageAdvanced maternal age Previous child or pregnancy with birth defectPrevious child or pregnancy with birth defect Suggestive screening test resultsSuggestive screening test results Family historyFamily history
Prenatal Tests – CVSPrenatal Tests – CVS
Chorionic Villus SamplingChorionic Villus Sampling 11-13 weeks gestation11-13 weeks gestation Catheter/needle biopsy of placental cellsCatheter/needle biopsy of placental cells Performed through cervix or abdomenPerformed through cervix or abdomen Can tests for aneuploidy and enzyme defectsCan tests for aneuploidy and enzyme defects 1-2% miscarriage rate1-2% miscarriage rate Digit/limb deficiencies (10 weeks)Digit/limb deficiencies (10 weeks)
Prenatal Tests - AmniocentesisPrenatal Tests - Amniocentesis
Performed at 15-18 weeks gestationPerformed at 15-18 weeks gestation 10 cc amniotic fluid10 cc amniotic fluid Living cells from fetus in amniotic fluidLiving cells from fetus in amniotic fluid Cells grown in lab for 1-2 weeksCells grown in lab for 1-2 weeks Results in 3 weeksResults in 3 weeks
Postnatal TestingPostnatal Testing
Most done during first day of lifeMost done during first day of life Heel stickHeel stick CaliforniaCalifornia
GalactosemiaGalactosemia Hypothyroidism (congenital) Hypothyroidism (congenital) Phenylketonuria (PKU) Phenylketonuria (PKU) Sickle Cell Disease (SCD) and Hemoglobinopathies Sickle Cell Disease (SCD) and Hemoglobinopathies
Postnatal Screening – Tandem Mass Postnatal Screening – Tandem Mass SpectrometySpectromety
Fatty Acid Oxidation Disorders Carnitine/Acylcarnitine Translocase Deficiency (Translocase)
Carnitine Palmitoyl Transferase Deficiency Type I (CPT-I)2
3-Hydroxy Long Chain Acyl-CoA Dehydrogenase Deficiency (LCHAD)2,4-Dienoyl-CoA Reductase Deficiency2
Medium Chain Acyl-CoA Dehydrogenase Deficiency (MCAD)Multiple Acyl-CoA Dehydrogenase Deficiency (MADD or Glutaric Acidemia-Type II)Neonatal Carnitine Palmitoyl Transferase Deficiency-Type II(CPT-II)Short Chain Acyl-CoA Dehydrogenase Deficiency (SCAD)Short Chain Hydroxy Acyl-CoA Dehydrogenase Deficiency (SCHAD)Trifunctional Protein Deficiency (TFP Deficiency)Very Long Chain Acyl-CoA Dehydrogenase Deficiency (VLCAD)
Organic Acid Disorders 3-Hydroxy-3-Methylglutaryl-CoA Lyase Deficiency (HMG)
Glutaric Acidemia-Type I (GA I)Isobutyryl-CoA Dehydrogenase DeficiencyIsovaleric Acidemia (IVA) Acute onset Chronic2-Methylbutryl-CoA Dehydrogenase Deficiency3-Methylcrotonyl-CoA Carboxylase Deficiency (3MCC Deficiency)3-Methylglutaconyl-CoA Hydratase DeficiencyMethylmalonic Acidemias Methylmalonyl-CoA Mutase Deficiency 0 Methylmalonyl-CoA Mutase Deficiency + Some Adenosylcobalamin Synthesis Defects Maternal Vitamin B12 DeficiencyMitochondrial Acetoacetyl-CoA Thiolase Deficiency (3-Ketothiolase Def.)Propionic Acidemia (PA) Acute onset Late onsetMultiple-CoA Carboxylase DeficiencyMalonic Aciduria
Amino Acid Disorders Argininemia
Argininosuccinic Aciduria (ASA Lyase Deficiency) Acute onset Late onsetCarbamoylphosphate Synthetase Deficiency (CPS Def.)2
Citrullinemia (ASA Synthetase Deficiency) Acute onset Late onsetHomocystinuriaHypermethioninemiaHyperammonemia, Hyperornithinemia, Homocitrullinemia Syndrome (HHH)2
Hyperornithinemia with Gyral Atrophy2
Maple Syrup Urine Disease (MSUD) Classical MSUD Intermediate MSUD5-Oxoprolinuria (pyroglutamic Aciduria)2
Phenylketonuria (PKU) Classical PKU Hyperphenylalaninemia Biopterin Cofactor Deficiencies (4)TyrosinemiaTransient Neonatal Tyrosinemia Tyrosinemia Type I (Tyr I)2
Tyrosinemia Type II (Tyr II) Tyrosimenia Type III (Tyr III)
Other Abnormal Profiles Hyperalimentation
Liver DiseaseMedium Chain Triglyceride (MCT) Oil AdministrationPresence of EDTA Antigoagulants in blood specimenTreatment with Benzoate, Pyvalic Acid, or Valproic AcidCarnitine Uptake Deficiency2
Preimplantation Genetic Diagnosis Preimplantation Genetic Diagnosis (PGD)(PGD)
Can test embryos for genetic abnormalities prior Can test embryos for genetic abnormalities prior to implantationto implantation
Uses single cell (blastomere) at 8-cell stageUses single cell (blastomere) at 8-cell stage
PGD – Clinical IndicationsPGD – Clinical Indications
Single gene defectsSingle gene defects Balanced translocationsBalanced translocations Advanced maternal age (aneuploidy)Advanced maternal age (aneuploidy) Repetitive IVF failureRepetitive IVF failure Recurrent pregnancy lossRecurrent pregnancy loss Embryo selectionEmbryo selection
Fluorescence in situ hybridization (FISH)Fluorescence in situ hybridization (FISH) Aneuploidy/translocations and sexing (5-9 Aneuploidy/translocations and sexing (5-9
chromosomes)chromosomes) PCRPCR
specific single gene disordersspecific single gene disorders
PGD
•Achondroplasia •ADPKD1 •ADPKD2 •Adrenoleukodystroph •Age-related aneuploidies •Alpha-thalassemia •Alpha-1-antitrypsin •Alport disease •Amyloid precursor protein (APP) mutation •ARPKD •Becker muscular dystrophy •Beta-thalassemia •Charcot Marie Tooth disease •Chromosomal translocations •Congenital adrenal hyperplasia •Cystic fibrosis •Down syndrome •Duchenne muscular dystophy •Dystonia •Epidermolysis bullosa •Familial dysautonomia •Fanconi anemia •FAP •Fragile X syndrome •Gaucher disease •Hemophilia A and B •HLA genotyping •HSNF5 mutation
•Huntington disease •Hypophosphatasia •Incontinentia pigmenti •Kell disease •Klinefelter syndrome •LCHAD •Lesch Nyhan syndrome •Marfan syndrome •Multiple epiphysial dysplasia •Myotonic dystophy •Myotubular myopathy •NF1 and NF2 •Norrie disease •Osteogenesis imperfecta •OTC deficiency •P53 mutations •PKU •Retinitis pigmentosa •SCA6 •Sickle cell anemia •Sonic hedgehog mutations •Spinal muscular atrophy (SMA) •Tay-Sachs disease •Tuberous sclerosis •Turner syndrome •Von Hippel Lindau •X-linked hydrocephaly •X-linked hyper IgM syndrome
PGD for Single Gene Disorders - PGD for Single Gene Disorders - AdvantagesAdvantages
Safer than elective terminationSafer than elective termination More psychologically acceptable for couplesMore psychologically acceptable for couples Provides couples with another optionProvides couples with another option
AdoptionAdoption SterilizationSterilization Donor gametesDonor gametes
PGDPGD
Pre-implantation genetic Pre-implantation genetic diagnosis (PGD)diagnosis (PGD) has been has been successfully used in successfully used in diagnosing and preventing diagnosing and preventing inherited genetic diseases inherited genetic diseases like Cystic Fibrosis, Tay like Cystic Fibrosis, Tay Sach’s, Thalassemia, Sickle Sach’s, Thalassemia, Sickle Cell Anemia and may be Cell Anemia and may be potentially used to screen potentially used to screen for cancer mutations.for cancer mutations.
PGDPGD
After a cycle of in- After a cycle of in- vitro fertilization, vitro fertilization, biopsy of a single cell biopsy of a single cell can be performed from can be performed from an 8 cell embryo an 8 cell embryo obtained after 3 days obtained after 3 days of culture in the of culture in the laboratory.laboratory.
PGD – Timing of BiopsyPGD – Timing of Biopsy
<67 hours post-retrieval<67 hours post-retrieval
Implantation rates Implantation rates significantly lower if >70 significantly lower if >70 hourshours
Probably represents Probably represents technical issues with technical issues with compacting embryocompacting embryo
PGDPGD
The genetic material of The genetic material of this single cell can be this single cell can be amplified by PCR and amplified by PCR and the chromosomal the chromosomal mutation or an mutation or an aneuploidy can be aneuploidy can be identified in the identified in the embryo that underwent embryo that underwent a biopsy.a biopsy.
PGDPGD
The embryos would The embryos would continue to grow for 2 continue to grow for 2 more days in the more days in the laboratory, awaiting genetic laboratory, awaiting genetic analysis, and confirmation analysis, and confirmation of which embryos were of which embryos were unaffected with the unaffected with the mutation or aneuploidy.mutation or aneuploidy.
PGDPGD
The unaffected embryos The unaffected embryos are then transferred to the are then transferred to the uterus at the blastocyst uterus at the blastocyst stage on day 5 of embryo stage on day 5 of embryo culture and subsequently a culture and subsequently a child would be born child would be born unaffected from the unaffected from the screened genetic disease.screened genetic disease.
PGD – Female EmbryoPGD – Female Embryo
Uses fluorescence in-situ Uses fluorescence in-situ hybridization (FISH) hybridization (FISH) technique to identify XXtechnique to identify XX
Sex-linked diseasesSex-linked diseases
““Family balancing”Family balancing”
Prenatal vs. Preimplantation Prenatal vs. Preimplantation DiagnosisDiagnosis
PNDPND PGD PGD
CellsCells >100,000 >100,000 11
Time Time 2 weeks2 weeks 6-10 hrs6-10 hrs
AccuracyAccuracy 99%99% 90%90%
Who Would Benefit From PGD?Who Would Benefit From PGD?
Couples with a history of --Couples with a history of -- Abnormal numbers of chromosomesAbnormal numbers of chromosomes Single gene disordersSingle gene disorders Balanced translocationsBalanced translocations
Couples who --Couples who -- Desire an offspring of a certain sex Desire an offspring of a certain sex
Future considerationsFuture considerations
Cytoplasmic transferCytoplasmic transfer Donation of enucleated oocytesDonation of enucleated oocytes
Oocyte cryopreservationOocyte cryopreservation ““Pausing the biological clock”Pausing the biological clock”
Reproduction without gametesReproduction without gametes Use of nuclear material from somatic cellsUse of nuclear material from somatic cells Donated or synthetic cytoplasmDonated or synthetic cytoplasm Reconstituted oocytesReconstituted oocytes
CasesCases
Sperm donorSperm donor Female coupleFemale couple Huntington’s diseaseHuntington’s disease Surrogacy – Baby “M”Surrogacy – Baby “M” Single womanSingle woman Sex-linked diseaseSex-linked disease Family balancingFamily balancing ““Wrongful death” of discarded embryoWrongful death” of discarded embryo