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
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