Infertility, In Vitro Infertility, In Vitro Fertilization (IVF) Fertilization (IVF)

and Genetic and Genetic TestingTesting

Susan Sarajari, M.D., Susan Sarajari, M.D., Ph.DPh.D..

History of InfertilityHistory of Infertility

First written document dealing with First written document dealing with infertility may be found in the Kahoun infertility may be found in the Kahoun papyrus (oldest Egyptian medical text), papyrus (oldest Egyptian medical text), dated to 2200-1950 BCdated to 2200-1950 BC

The early attribution of infertility to The early attribution of infertility to women persisted for centuries and was women persisted for centuries and was often considered divine punishmentoften considered divine punishment

The only solution to infertility was prayer – The only solution to infertility was prayer – to Egyptian Isis, Phoenician Astarte, Greek to Egyptian Isis, Phoenician Astarte, Greek Aphrodite, or Roman VenusAphrodite, or Roman Venus

The role of the human male in The role of the human male in reproduction was not understood in past reproduction was not understood in past civilizations and is still veiled in mystery civilizations and is still veiled in mystery for many of the primitive tribesfor many of the primitive tribes

Overview of InfertilityOverview of Infertility

Definition: 1 year of well-timed, Definition: 1 year of well-timed, unprotected intercourse without unprotected intercourse without a pregnancya pregnancy

10-15% of population is infertile 10-15% of population is infertile

15-20 % of couples have 15-20 % of couples have unexplained infertility (work-up unexplained infertility (work-up is negative)is negative)

Causes of InfertilityCauses of Infertility

Female Reproductive Female Reproductive OrgansOrgans

FSH (+)

FSH=Follicle Stimulating Hormone

PhysiologyPhysiology

E2 (-)

E2=Estradiol

Developing follicle

Ovary - Female AgeOvary - Female Age

Women are born with their lifetime Women are born with their lifetime egg supplyegg 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 27Fertility initially declines at age 27 Significant decline at age 37-38Significant decline at age 37-38 Rare pregnancies after age 44Rare pregnancies after age 44

Causes of Female Causes of Female InfertilityInfertility OvaryOvary TubesTubes UterusUterus CervixCervix HormonesHormones ChromosomesChromosomes

Causes of Female Infertility Causes of Female Infertility - Ovary- Ovary

AgeAge

Problems with ovulation Problems with ovulation

Premature ovarian failurePremature ovarian failure

Percentage of Married Percentage of Married Women Who are InfertileWomen Who are InfertileFrom 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

Fertility and age: natural Fertility and age: natural populationspopulations

Marital fertilityrates in naturalpopulations(no contraception)as a functionof age of wife

Science 1986;23:1389

FSH (+)

FSH=Follicle Stimulating Hormone

Effects of Aging on the Ovary

E2 (-)

E2=Estradiol

Why does fertility decline Why does fertility decline with increasing maternal with increasing maternal

age?age? Decline in the Decline in the numbernumber of eggs of eggs

Every month there is loss of a Every month there is loss of a group of eggsgroup of eggs

Decline in the Decline in the qualityquality of eggs of eggs As the egg ages, errors in the As the egg ages, errors in the

dividing embryo increasedividing embryo increase These errors may result in These errors may result in

aneuploidy (an incorrect aneuploidy (an incorrect number of chromosomes)number of chromosomes)

Prevalence of genetically Prevalence of genetically abnormal oocytes in abnormal oocytes in

infertile womeninfertile women

% Abnormal

Ovary - Causes of Ovary - Causes of AnovulationAnovulation

Hormone imbalanceHormone imbalance ObesityObesity AnorexiaAnorexia Significant stressSignificant stress Patients display:Patients display:

Irregular menstrual cyclesIrregular menstrual cycles Skipped cyclesSkipped cycles Minimal or absent premenstrual Minimal or absent premenstrual

symptomssymptoms

Ovary – Premature Ovarian Ovary – Premature Ovarian FailureFailure

Menopause prior to age 40Menopause prior to age 40 Decreased EstrogenDecreased Estrogen Increased FSHIncreased FSH

CausesCauses AutoimmuneAutoimmune GeneticGenetic Idiopathic Idiopathic

1-2% pregnancy rate1-2% pregnancy rate

Causes of Female Infertility Causes of Female Infertility – Fallopian Tubes– Fallopian Tubes

Infection (chlamydia)Infection (chlamydia)

EndometriosisEndometriosis

Tubal ligation (female sterilization)Tubal ligation (female sterilization)

Open TubesOpen Tubes

Blocked TubesBlocked Tubes

Female Infertility - Female Infertility - UterusUterus

UterusUterus FibroidsFibroids PolypsPolyps

Female InfertilityFemale Infertility

Uterine muscle Uterine muscle tumortumor

Benign (>95%)Benign (>95%)

25-30% of women25-30% of women

Normal Shape of UterusNormal Shape of Uterus

Fibroid UterusFibroid Uterus

Female Infertility - Female Infertility - UterusUterus

Mullerian defects (congenital)Mullerian defects (congenital)

Absent uterusAbsent uterusBicornuate/septateBicornuate/septate

Mullerian DefectMullerian Defect

Treatment with Treatment with HysteroscopyHysteroscopy

Treatment with Treatment with LaparoscopyLaparoscopy

Female Infertility - Female Infertility - CervixCervix

CervixCervixPost-surgicalPost-surgical

StenosisStenosisMucus changesMucus changes

Female Infertility - Female Infertility - HormonesHormones

Endocrine abnormality Endocrine abnormality (hormones)(hormones) ThyroidThyroid ProlactinProlactin Polycystic ovary syndrome (PCOS)Polycystic ovary syndrome (PCOS)

Estrogen, insulinEstrogen, insulin Hypothalamic hypogonadismHypothalamic hypogonadism

StressStress Exercise (athlete)Exercise (athlete)

Other Causes of Female Other Causes of Female InfertilityInfertility

Chromosome abnormalitiesChromosome abnormalitiesTurner’s syndrome (XO)Turner’s syndrome (XO)Androgen Insensitivity (XY)Androgen Insensitivity (XY)

Male pseudohermaphroditeMale pseudohermaphroditeFemale phenotypeFemale phenotypeBlind vaginal canalBlind vaginal canalInguinal hernia (50%)Inguinal hernia (50%)

Sperm Are Also Sperm Are Also Required!!Required!!

Male Reproductive Male Reproductive OrgansOrgans

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

Normal Sperm Normal Sperm MorphologyMorphology

Abnormal MorphologyAbnormal Morphology

Abnormal MorphologyAbnormal Morphology

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 Intra-cytoplasmic sperm injection

(ICSI)(ICSI) 11

Abnormalities of Sperm Abnormalities of Sperm ProductionProduction

GeneticGenetic Y chromosome microdeletionsY chromosome microdeletions

Damage to testes – anatomicalDamage to testes – anatomical CryptorchidismCryptorchidism VaricoceleVaricocele

InfectionInfection Mumps orchitisMumps orchitis

GonadotoxinsGonadotoxins

Abnormalities of Sperm Abnormalities of Sperm FunctionFunction

Antisperm antibodiesAntisperm antibodies Genital tract inflammationGenital tract inflammation

ProstatitisProstatitis VaricoceleVaricocele Failure of acrosome reactionFailure of acrosome reaction Problems with sperm Problems with sperm

binding/penetrationbinding/penetration

Obstructions in Ductal Obstructions in Ductal SystemSystem

VasectomyVasectomy

Congenital bilateral absence of Congenital bilateral absence of the vas deferensthe vas deferens

Epididymis/ejaculatory ductsEpididymis/ejaculatory ducts Congenital or acquiredCongenital or acquired

Male Infertility - Male Infertility - LifestyleLifestyle

TobaccoTobacco MarijuanaMarijuana AlcoholAlcohol CocaineCocaine Steroids (can be Steroids (can be

permanent)permanent) HeatHeat ExerciseExercise

Infertility: Initial Infertility: Initial EvaluationEvaluation

EggsEggs Ovulation (Progesterone)Ovulation (Progesterone) Egg quality (FSH, Estradiol)Egg quality (FSH, Estradiol)

SpermSperm PresencePresence QualityQuality

Gamete transport/ImplantationGamete transport/Implantation HysterosalpingogramHysterosalpingogram

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

Infertility TreatmentsInfertility Treatments

Improve Timing of IntercourseImprove Timing of Intercourse Intrauterine insemination (IUI)Intrauterine insemination (IUI)

Clomiphene citrate (Clomid) + IUIClomiphene citrate (Clomid) + IUI FSH + IUIFSH + IUI

In Vitro Fertilization (IVF)In Vitro Fertilization (IVF) ““Standard” IVFStandard” IVF Egg donation + IVF Egg donation + IVF Egg Freezing + IVFEgg Freezing + IVF

Infertility Treatment Infertility Treatment OptionsOptions

IUI, FSH or FSH + IUIIUI, FSH or FSH + IUI Patients with unexplained infertilityPatients with unexplained infertility

Serhall et al, Fertil Steril 1988;49:602

TreatmeTreatmentnt

CyclesCycles PregnancPregnancyy

Pregnancy Pregnancy per cycleper cycle

IUIIUI 3030 11 2.7%2.7%

FSHFSH 4949 33 6.1%6.1%

FSH+IUIFSH+IUI 3434 99 26.4%26.4%

FSH (+)

FSH=Follicle Stimulating Hormone

How Does Clomid Work To Increase How Does Clomid Work To Increase Egg Number?Egg Number?

E2 (-)

E2=Estradiol

Developing follicle

Clomid

FSH (+)

FSH=Follicle Stimulating Hormone

How Does Recombinant FSH Work How Does Recombinant FSH Work To Increase Egg Number?To Increase Egg Number?

E2 (-)

E2=Estradiol

Developing follicle

Intrauterine Intrauterine Insemination (IUI)Insemination (IUI)

Goal is to Maximize the Chance of Fertilization• Increase Number of Eggs• Position Sperm Closer to Eggs

In Vitro FertilizationIn Vitro Fertilization

Historical Historical PerspectivePerspective

1978 Louise Joy Brown, first IVF baby 1978 Louise Joy Brown, first IVF baby 1981 Elizabeth Carr, first IVF baby in USA1981 Elizabeth Carr, first IVF baby in USA 1983 First birth after egg donation1983 First birth after egg donation 1985 First birth from cryopreserved embryo1985 First birth from cryopreserved embryo 1985 Transvaginal ultrasound for follicle 1985 Transvaginal ultrasound for follicle

monitoringmonitoring 1990 First report of births after PGD1990 First report of births after PGD 1990 First report of egg donation to older 1990 First report of egg donation to older

mothersmothers 1992 First human birth after ICSI1992 First human birth after ICSI

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 Family BalancingFamily Balancing Cancer patientsCancer patients Non-traditional LifestylesNon-traditional Lifestyles

IVF Statistics - 2005IVF Statistics - 2005

422 U.S. programs offer IVF422 U.S. programs offer IVF

134,260 cycles of ART treatment134,260 cycles of ART treatment

9,649 donor oocyte cycles9,649 donor oocyte cycles

38,910 deliveries (birth of 52,041 38,910 deliveries (birth of 52,041 neonates)neonates)

CDC 2005 National Report

In Vitro Fertilization In Vitro Fertilization (IVF)(IVF)

Egg Egg RetrievalRetrieval

Egg RetrievalEgg Retrieval

FertilizationFertilization

FertilizationFertilization

2 Pronuclei (2PN)2 Pronuclei (2PN)

1 day after egg 1 day after egg retrievalretrieval

Embryo TransferEmbryo Transfer

Embryo TransferEmbryo Transfer

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 For patients with 2 or more failed IVF cycles, or a poor prognosis, can add more cycles, or a poor prognosis, can add more based on clinical judgementbased on clinical judgement

What Happens to the Other What Happens to the Other Embryos?Embryos?

Freeze EmbryosFreeze Embryos Donate For Research/Stem CellsDonate For Research/Stem Cells Embryo AdoptionEmbryo Adoption DiscardDiscard

Special IVF ProceduresSpecial IVF Procedures

Assisted hatchingAssisted hatching Intracytoplasmic sperm injection Intracytoplasmic sperm injection

(ICSI)(ICSI) Preimplantation genetic Preimplantation genetic

diagnosis (PGD)diagnosis (PGD) FreezingFreezing Egg donationEgg donation SurrogacySurrogacy

Assisted HatchingAssisted Hatching

Intracytoplasmic Sperm Injection

(ICSI)

IVF Success Rates - 2005IVF Success Rates - 2005

U.S. Fertility Centers U.S. Fertility Centers (SART/CDC)(SART/CDC)

Female ageFemale age <35 – 37% (43%)<35 – 37% (43%) 35-37 – 30% (36%)35-37 – 30% (36%) 38-40 – 20% (27%)38-40 – 20% (27%) >40 – 11% (18%)>40 – 11% (18%)

IVF Statistics - 2005IVF Statistics - 2005

65.1% singletons 65.1% singletons

32.9% twins 32.9% twins

4.4% triplets or more 4.4% triplets or more

Singleton PregnancySingleton Pregnancy

Twin PregnancyTwin Pregnancy

Triplet PregnancyTriplet Pregnancy

Egg DonationEgg Donation

Egg Egg donationdonation

IVF for twoIVF for two Known/Known/

anonymous donor anonymous donor

<35 years old<35 years old

DonorDonor Standard Standard

controlled controlled ovarian ovarian hyperstimulationhyperstimulation

Egg retrievalEgg retrieval

RecipientRecipient Embryo transferEmbryo transfer

Who are candidates to be an egg donor ?

21-35 years old (older if a friend or 21-35 years old (older if a friend or relative)relative)

FSH <10FSH <10 Negative donorNegative donor Good health and genetic historyGood health and genetic history Preferably prior egg donation Preferably prior egg donation

experienceexperience How many eggs were produced?How many eggs were produced? Did pregnancy result?Did pregnancy result?

Who are candidates for egg Who are candidates for egg donation ?donation ?

Premature ovarian failurePremature ovarian failure Ovarian insufficiency (e.g. Ovarian insufficiency (e.g.

FSH>15 )FSH>15 ) Physiologic menopausePhysiologic menopause Maternal age over 43Maternal age over 43 History of poor egg/embryo History of poor egg/embryo

quality or multiple IVF failuresquality or multiple IVF failures

Egg DonationEgg Donation October 23, 1999October 23, 1999 Selling Fashion Models' Eggs Online Selling Fashion Models' Eggs Online

Raises Ethics IssuesRaises Ethics Issues By CAREY GOLDBERG By CAREY GOLDBERG

CAMBRIDGE, Mass. -- To the horror and disgust CAMBRIDGE, Mass. -- To the horror and disgust of mainstream infertility groups, a longtime of mainstream infertility groups, a longtime fashion photographer has begun offering up fashion photographer has begun offering up models as egg donors to the highest bidders, models as egg donors to the highest bidders, auctioning their ova via the Internet to would-auctioning their ova via the Internet to would-be parents willing to pay up to $150,000 in be parents willing to pay up to $150,000 in hopes of having a beautiful child. hopes of having a beautiful child.

Egg DonationEgg Donation

Grade A: The Market for a Yale Grade A: The Market for a Yale Woman’s EggsWoman’s Eggs When a Yale undergraduate explored When a Yale undergraduate explored becoming an egg donor for a wealthy becoming an egg donor for a wealthy couple willing to pay top dollar to the couple willing to pay top dollar to the right candidate, she didn't realize how right candidate, she didn't realize how unsettling the process of candidacy unsettling the process of candidacy would prove to bewould prove to be

by Jessica Cohen by Jessica Cohen

Gestational Surrogacy:Gestational Surrogacy:IndicationsIndications

Absent uterus; congenital or Absent uterus; congenital or iatrogeniciatrogenic

Abnormal uterusAbnormal uterus

Medical contraindication to pregnancyMedical contraindication to pregnancy

Recurrent pregnancy wastageRecurrent pregnancy wastage

Repeated IVF failures with good Repeated IVF failures with good embryosembryos

Gestational CarriersGestational Carriers

Friends or relativesFriends or relatives AgenciesAgencies Age less importantAge less important Previous delivery and Previous delivery and

parentingparenting Benign obstetrical historyBenign obstetrical history Major psychological Major psychological

evaluationevaluation Screening similar to Screening similar to

recipientsrecipients

Initial screening-Egg and Initial screening-Egg and Sperm Donors (Known and Sperm Donors (Known and

Anonymous)Anonymous) Medical History (especially past history of Medical History (especially past history of

donation in the case of egg donors so donation in the case of egg donors so protocol and outcome can be reviewed)protocol and outcome can be reviewed)

Physical and Clinical AssessmentPhysical and Clinical Assessment Genetic Testing (as required based on Genetic Testing (as required based on

Ethnic background and Family and Medical Ethnic background and Family and Medical History)History)

Serologic (lab) Testing, STD tests, Drug Serologic (lab) Testing, STD tests, Drug ScreeningScreening

Sexual partners of donors are screened for Sexual partners of donors are screened for infectious diseases when donors are being infectious diseases when donors are being evaluated for eligibility evaluated for eligibility

Screening results for donors are good for 6 Screening results for donors are good for 6 months onlymonths only

Anonymous Egg Anonymous Egg DonationDonation

Psychocologic EvaluationPsychocologic Evaluation

Personality Profile administered and Personality Profile administered and evaluatedevaluated

by psychologist (PhD) or licensed socialby psychologist (PhD) or licensed socialworker trained to work with donors worker trained to work with donors

withwithregards to donor's ability to "meet theregards to donor's ability to "meet thedemands of the egg donor role“. Report demands of the egg donor role“. Report

sent tosent toMD's office.MD's office.

Legal ContractLegal Contract Sent to MD's office stating that the Egg Sent to MD's office stating that the Egg Donation Agreement has been Donation Agreement has been "executed by all parties“."executed by all parties“.

Known Egg/Sperm Known Egg/Sperm DonorsDonors

Screenings set up through a specific Screenings set up through a specific agency agency

Links known donors with psychologists Links known donors with psychologists and lawyers trained to perform above and lawyers trained to perform above assessments and execute necessary legal assessments and execute necessary legal contractscontracts

Psych and legal assessment and clearance Psych and legal assessment and clearance are especially important between known are especially important between known donors and recipients in which family donors and recipients in which family relations or friendships may cloud the relations or friendships may cloud the boundaries and guidelines necessary for a boundaries and guidelines necessary for a successful donor relationship and processsuccessful donor relationship and process

Danger to motherDanger to mother

Decreased life expectancy of Decreased life expectancy of parentsparents

Quality of parentingQuality of parenting

Is 55 a “physiological limit”?Is 55 a “physiological limit”?

How old is too old?How old is too old?

Pregnancy in the Sixth Pregnancy in the Sixth Decade of LifeDecade of Life

USC experience: 1991-2000

77 recipients of egg donation Mean age 52.8 + 2.9 years

Of the 77 women, 42 (54.5%) had Of the 77 women, 42 (54.5%) had live birthslive births

45 deliveries in 42 women45 deliveries in 42 womenPaulson, Tourgeman, Boostanfar et al, JAMA 2002:228;2320.

Pregnancy in the Sixth Pregnancy in the Sixth Decade of Life: Obstetric Decade of Life: Obstetric

ComplicationsComplications Pre-eclampsiaPre-eclampsia

35%35% Background Incidence 3-10% Background Incidence 3-10%

Gestational DiabetesGestational Diabetes 20%20% Background Incidence 5% Background Incidence 5%

Pregnancy in the 6th Pregnancy in the 6th decade of life:decade of life:

ConclusionConclusion

There does not appear to be There does not appear to be any definitive medical reason any definitive medical reason for excluding these women for excluding these women from attempting pregnancy on from attempting pregnancy on the basis of age alonethe basis of age alone

Genetic TestingGenetic Testing

PreconceptionPreconception

PreimplantationPreimplantation

PrenatalPrenatal

PostnatalPostnatal

Preimplantation Genetic Preimplantation Genetic Diagnosis (PGD)Diagnosis (PGD)

Can test embryos for genetic abnormalities Can test embryos for genetic abnormalities prior to implantationprior to implantation

Has been successfully used in diagnosing Has been successfully used in diagnosing and preventing inherited genetic diseases and preventing inherited genetic diseases like Cystic Fibrosis, Tay Sach’s, like Cystic Fibrosis, Tay Sach’s, Thalassemia, Sickle Cell Anemia and may Thalassemia, Sickle Cell Anemia and may be potentially used to screen for cancer be potentially used to screen for cancer mutations.mutations.

Uses single cell (blastomere) at 8-cell stageUses single cell (blastomere) at 8-cell stage

PGD

First clinical application described by Handyside, Winston, and Hughes in 1990

By 2003, estimated >1000 PGD-defined live births (ESHRE Task Force, 2003)

Which Embryo is Which Embryo is Disease-Free?Disease-Free?

PGD – Clinical PGD – Clinical IndicationsIndications

Single gene defectsSingle gene defects Balanced translocationsBalanced translocations Advanced maternal age Advanced maternal age

(aneuploidy)(aneuploidy) Repetitive IVF failureRepetitive IVF failure Recurrent pregnancy lossRecurrent pregnancy loss Embryo selectionEmbryo selection

•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

Day 3 EmbryoDay 3 Embryo

Pre-Implantation Genetic Testing Pre-Implantation Genetic Testing StageStage

PGD – Timing of BiopsyPGD – Timing of Biopsy

Biopsy of a Biopsy of a single cell can be single cell can be performed from performed from an 8-cell embryo an 8-cell embryo after 3 days of after 3 days of culture in the culture in the laboratorylaboratory

Fluorescence in situ Fluorescence in situ hybridization (FISH)hybridization (FISH) Aneuploidy/translocations and Aneuploidy/translocations and

determining gender (5-10 determining gender (5-10 chromosomes)chromosomes)

Polymerase chain reaction (PCR)Polymerase chain reaction (PCR) Specific single gene disordersSpecific single gene disorders

PGD

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 laboratory, awaiting genetic analysis.genetic analysis.

The unaffected embryos The unaffected embryos are then transferred to are then transferred to the uterus at the the uterus at the blastocyst stage on day 5 blastocyst stage on day 5 of embryo culture and of embryo culture and subsequently a child subsequently a child would be born unaffected would be born unaffected from the screened genetic from the screened genetic disease.disease.

PGD Chromosome Panels

Five Chromosome PGD13, 18, 21, X, Y13, 18, 21, X, Y

Ten Chromosome PGDTen Chromosome PGD8, 9, 13, 15, 16, 18, 21, 8, 9, 13, 15, 16, 18, 21, 22, X, Y22, X, Y

Five Chromosome PGDFive Chromosome PGD

Five Chromosome PGDFive Chromosome PGD

Ten Chromosome PGDTen Chromosome PGD

8 Red9 Blue15 Orange16 Aqua22 Green

Prenatal vs. Prenatal vs. Preimplantation DiagnosisPreimplantation Diagnosis

PNDPND PGD PGD

CellsCells >100,000 >100,000 11

Time Time 2 weeks2 weeks 6-10 hrs6-10 hrs

AccuracyAccuracy 99%99% 99%99%

CostCost Covered Covered ~$5,000 ~$5,000

PGDPGD

Gender Selection:Gender Selection:

A Big Controversy!A Big Controversy!

Future considerationsFuture considerations

Oocyte cryopreservationOocyte cryopreservation ““Pausing the biological clock”Pausing the biological clock”

Cytoplasmic transferCytoplasmic transfer Donation of enucleated oocytesDonation of enucleated oocytes

Reproduction without gametesReproduction without gametes Use of nuclear material from Use of nuclear material from

somatic cellssomatic cells Donated or synthetic cytoplasmDonated or synthetic cytoplasm Reconstituted oocytesReconstituted oocytes

Clinical Applications of Egg Freezing

Oocyte cryopreservation could be a Oocyte cryopreservation could be a clinical tool for:clinical tool for:

Women at risk of losing ovarian Women at risk of losing ovarian functionfunction

Women desiring fertility preservation Women desiring fertility preservation (e.g. delayed maternity)(e.g. delayed maternity)

Eliminating ethical concerns of Eliminating ethical concerns of embryo cryopreservationembryo cryopreservation

Solving the dilemma of abandoned Solving the dilemma of abandoned frozen embryos in the IVF laboratoryfrozen embryos in the IVF laboratory

Oocyte CryopreservationOocyte Cryopreservation

•Slow-freeze Technique

•Vitrification (Rapid Freeze) Technique

Oocyte Freezing: Where do we stand?

First pregnancy after oocyte cryopreservation was reported by Chen in 1986

Less than 200 pregnancies have been Less than 200 pregnancies have been achieved worldwideachieved worldwide

Survival rate of 80% and fertilization rates of 83%, however low pregnancy rates

Although pregnancy rates might be Although pregnancy rates might be improving, rates appear to be improving, rates appear to be significantly less than those seen with significantly less than those seen with standard IVFstandard IVF

Fertility Preservation Fertility Preservation OptionsOptions

  AgeAge AverageAverage

CostCostTimeTime

RequiremRequirementent

Success RateSuccess Rate

Embryo Embryo FreezingFreezing

After Puberty After Puberty  $7,800; $7,800; $350/year $350/year storage fees storage fees 

2-4 weeks 2-4 weeks  ~40% per 3 embryos ~40% per 3 embryos transferred under 35; transferred under 35; lower in older women lower in older women 

Egg Egg (Oocyte) (Oocyte) FreezingFreezing

After Puberty After Puberty  $8,000; $8,000; $350/year $350/year storage fees storage fees 

2-4 weeks 2-4 weeks  Experimental; Experimental; ~3% per egg frozen ~3% per egg frozen 

Ovarian Ovarian Tissue Tissue FreezingFreezing

Before and After Before and After Puberty Puberty 

$12,000; $12,000; $350/year $350/year storage fees storage fees 

Outpatient Outpatient Surgical Surgical Procedure Procedure 

Experimental; Experimental; no live births to date no live births to date 

Ovarian Ovarian TranspositioTranspositionn

Before or After Before or After Puberty Puberty 

Unknown Unknown  Outpatient Outpatient Surgical Surgical Procedure Procedure 

~50% for ovarian ~50% for ovarian function, pregnancy function, pregnancy rates unknown rates unknown 

GnRH GnRH Analog Analog TreatmentTreatment

After Puberty After Puberty  $500 per $500 per dose dose 

1 dose per 1 dose per month in month in conjunction conjunction with with chemotherapy chemotherapy 

Experimental; study Experimental; study results vary: some results vary: some show no benefit, show no benefit, others show success others show success 

Donor EggsDonor Eggs Varies, usually Varies, usually 18-25+ 18-25+ 

$14,000-$14,000-$20,000 $20,000 

2-4 weeks per 2-4 weeks per cycle cycle 

ART with Egg ART with Egg Donation, Donation, 40-50% 40-50% 

SurrogacySurrogacy Varies, usually Varies, usually 18-25+ 18-25+ 

$10,000 - $10,000 - $100,000 $100,000 

Varies Varies  Similar to IVF, Similar to IVF, 20-30% 20-30% 

AdoptionAdoption Varies, usually Varies, usually 18-25+ 18-25+ 

$2,500 - $2,500 - $35,000 $35,000 

Varies Greatly Varies Greatly  Not Applicable Not Applicable 

Thank Thank youyou