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Clinical experience of PB biopsy Clinical experience of PB biopsy and CGH micro-array and CGH micro-array

in poor prognosis IVF patientsin poor prognosis IVF patients

Stuart LaveryStuart LaveryConsultant Gynaecologist Consultant Gynaecologist

Director IVF HammersmithDirector IVF HammersmithHammersmith and Queen CharlotteHammersmith and Queen Charlotte’’s Hospitalss Hospitals

Imperial CollegeImperial CollegeLondonLondon

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Clinical experience of PB biopsy Clinical experience of PB biopsy and CGH micro-array and CGH micro-array

in poor prognosis IVF patientsin poor prognosis IVF patients

Stuart LaveryStuart LaveryConsultant Gynaecologist Consultant Gynaecologist

Director IVF HammersmithDirector IVF HammersmithHammersmith and Queen CharlotteHammersmith and Queen Charlotte’’s Hospitalss Hospitals

Imperial CollegeImperial CollegeLondonLondon

A new chapter in PGSA new chapter in PGS??

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BackgroundWhat is the evidence?

Clinical experienceEthical challenges

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Preimplantation genetic diagnosis (PGD) is a form of very Preimplantation genetic diagnosis (PGD) is a form of very early prenatal diagnosis. The technique combines assisted early prenatal diagnosis. The technique combines assisted

reproductive technology with molecular and cyto-genetics to reproductive technology with molecular and cyto-genetics to allow the identification of abnormalities in embryos prior to allow the identification of abnormalities in embryos prior to implantation. Couples at risk of having children with serious implantation. Couples at risk of having children with serious genetic diseases can have unaffected embryos transferred to genetic diseases can have unaffected embryos transferred to the uterus, eliminating the need for prenatal diagnosis and the uterus, eliminating the need for prenatal diagnosis and

termination of pregnancy.termination of pregnancy.

Screening of preimplantation embryos for aneuploidy (PGS) Screening of preimplantation embryos for aneuploidy (PGS) may ameliorate the effect of female age on reproduction: may ameliorate the effect of female age on reproduction: improving pregnancy rates and decreasing the chance of improving pregnancy rates and decreasing the chance of

multiple birth and miscarriage.multiple birth and miscarriage.

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BackgroundBackground• 20% of all UK births are to women >3520% of all UK births are to women >35• 2009: 706 248 live births in England and Wales, 114 288 women 2009: 706 248 live births in England and Wales, 114 288 women

aged 35-39, and 26 976 births to women over 40, 71 over 50aged 35-39, and 26 976 births to women over 40, 71 over 50• Background of media sensationalism Background of media sensationalism • Under-explored in serious discussionUnder-explored in serious discussion

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BackgroundBackground• Pregnancy and live birth rates Pregnancy and live birth rates

decline rapidly with advancing decline rapidly with advancing ageage

• Main factor is oocyte quality:Main factor is oocyte quality:– Age <35: 32% embryos abnormalAge <35: 32% embryos abnormal– Age 35-37: 42%, >37:53%Age 35-37: 42%, >37:53%– IVF failure x3: 54% embryos IVF failure x3: 54% embryos

abnormalabnormal– IVF failure x5: 63%IVF failure x5: 63%

Age 40-42 43-44 >44

Livebirth/cycle started 10.6%(262/2466)

4.9%(25/513)

0.8%(1/129)

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HypothesisHypothesis: screening oocytes and preimplantation : screening oocytes and preimplantation embryos should increase pregnancy rates, decrease embryos should increase pregnancy rates, decrease miscarriage and multiple pregnancy rates and help miscarriage and multiple pregnancy rates and help

prevent the birth of affected childrenprevent the birth of affected children

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HypothesisHypothesis: screening oocytes and preimplantation : screening oocytes and preimplantation embryos should increase pregnancy rates, decrease embryos should increase pregnancy rates, decrease miscarriage and multiple pregnancy rates and help miscarriage and multiple pregnancy rates and help

prevent the birth of affected childrenprevent the birth of affected childrenLavery S

, El-Shawarby SA, Moissidou M, Taylor D, Turner C, Lavender B, Trew G, Margara R, Winston R. Live birth following preimplantation genetic screening for trisomy 21. Should aneuploidy screening

be offered to all older patients undergoing IVF? Hum Fertil

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What is the evidence?What is the evidence?• Sound, self-evident, easily understood hypothesisSound, self-evident, easily understood hypothesis• Which patients: advanced maternal age, recurrent Which patients: advanced maternal age, recurrent

implantation failure, recurrent miscarriage, implantation failure, recurrent miscarriage, previous aneuploidy, MESA/TESE ?previous aneuploidy, MESA/TESE ?

• Different biopsy technique:1 or 2 cells?Different biopsy technique:1 or 2 cells?• Which chromosomes and how many?Which chromosomes and how many?• Multiple case series, retrospective case controlled, Multiple case series, retrospective case controlled,

prospective randomised controlled trials, meta-prospective randomised controlled trials, meta-analysisanalysis

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What is the evidence?What is the evidence?

To date there is insufficient data to determine whether PGS To date there is insufficient data to determine whether PGS is an effective intervention in IVF/ICSI for improving live is an effective intervention in IVF/ICSI for improving live birth rates. Available data on PGS for advanced maternal birth rates. Available data on PGS for advanced maternal age showed no difference in live birth rate and ongoing age showed no difference in live birth rate and ongoing

pregnancy rate. However, only two randomised trials were pregnancy rate. However, only two randomised trials were found, of which one included only 39 patients. For both found, of which one included only 39 patients. For both

studies comments on their methodological quality can be studies comments on their methodological quality can be made. Therefore more properly conducted randomised made. Therefore more properly conducted randomised controlled trials are needed. Until such trials have been controlled trials are needed. Until such trials have been

performed PGS should not be used in routine patient care.performed PGS should not be used in routine patient care.

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Is PGS dead?Is PGS dead?Yes, for FISH on cleavage stage embryosYes, for FISH on cleavage stage embryos

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Is PGS dead?Is PGS dead?Yes, for FISH on cleavage stage embryosYes, for FISH on cleavage stage embryos

What about for alternative genetic techniques What about for alternative genetic techniques looking at different stages of biopsy?looking at different stages of biopsy?

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Is PGS dead?Is PGS dead?Yes, for FISH on cleavage stage embryosYes, for FISH on cleavage stage embryos

What about for alternative genetic techniques looking What about for alternative genetic techniques looking at different stages of biopsy?at different stages of biopsy?

We just don’t know… We just don’t know…

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New Scientific DevelopmentsNew Scientific Developments

• Whole Genome Whole Genome Amplification (WGA)Amplification (WGA)

• Comparative Genomic Comparative Genomic Hybridisation (CGH)Hybridisation (CGH)– Metaphase spreadMetaphase spread– Micro-arrayMicro-array

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EuploidEuploid

-4, +5, +7, -9, +17, -22, +X-4, +5, +7, -9, +17, -22, +X

-8p, -15-8p, -15

+3, +15+3, +15

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CGH Aneuploidy ScreeningCGH Aneuploidy ScreeningPreliminary EvidencePreliminary Evidence

• Blastomere biopsy, CGH metaphase and cryopreservation Blastomere biopsy, CGH metaphase and cryopreservation Wilton 2003Wilton 2003• PB biopsy CGH microarray PB biopsy CGH microarray Obradors 2008Obradors 2008

• 45 couples, mean age 38, 2.4 previous failed cycles45 couples, mean age 38, 2.4 previous failed cycles– Blastocyst biopsy: CGH 24 chromosomesBlastocyst biopsy: CGH 24 chromosomes– 94% embryos diagnosed94% embryos diagnosed– 51% aneuploid51% aneuploid– Implantation rateImplantation rate 69%69%– Pregnancy rate 82%Pregnancy rate 82%

Schoolcraft Nov Schoolcraft Nov 20092009

• ESHRE call for proof of concept trial of PB biopsy and CGH ESHRE call for proof of concept trial of PB biopsy and CGH microarray microarray Geraedts Dec 2009Geraedts Dec 2009

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ESHRE trial of PB biopsy and ESHRE trial of PB biopsy and CGH microarray CGH microarray

‘Proof of principle’ ‘Proof of principle’• 2 centres: 226 eggs, 41 couples in 42 cycles, average 2 centres: 226 eggs, 41 couples in 42 cycles, average

maternal age 40maternal age 40• 177 eggs analysed: 34 euploid, 122 aneuploid (69%)177 eggs analysed: 34 euploid, 122 aneuploid (69%)• 19 cycles, all eggs aneuploid (45%)19 cycles, all eggs aneuploid (45%)• 37 embryos transferred in 23 cycles, 8 clinical 37 embryos transferred in 23 cycles, 8 clinical

pregnancies, 27% implantation rate/ETpregnancies, 27% implantation rate/ET• PB1 72% aneuploidy in eggsPB1 72% aneuploidy in eggs• PB1+2 89 % aneuploidy in eggsPB1+2 89 % aneuploidy in eggs• Reliable and accurate Reliable and accurate Geraraedts 2010Geraraedts 2010

Recent Work: Recent Work: why not just culture to blastocyst?why not just culture to blastocyst?• Aneuploid embryos cannot be distinguished Aneuploid embryos cannot be distinguished

from euploid embryos by culturing to from euploid embryos by culturing to blastocyst blastocyst Cater 2011Cater 2011

• 554 blastocysts: 57% were aneuploid, 41% 554 blastocysts: 57% were aneuploid, 41% were mosaic, 72% of most advanced were were mosaic, 72% of most advanced were male male Alfarawati 2011Alfarawati 2011

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CGH Aneuploidy ScreeningCGH Aneuploidy ScreeningIVF Hammersmith experienceIVF Hammersmith experience

• 93 cycles started93 cycles started– 20 patients age 36 and under20 patients age 36 and under– 61 patients 37 and above61 patients 37 and above– 55 patients had >3 failed implantations55 patients had >3 failed implantations

• all 93 got to egg collectionall 93 got to egg collection• 89 had polar body 1 biopsied (96%)89 had polar body 1 biopsied (96%)• 12 patients had non-fertilisation (13%)12 patients had non-fertilisation (13%)

CGH Aneuploidy ScreeningCGH Aneuploidy ScreeningIVF Hammersmith experienceIVF Hammersmith experience

• 629 eggs injected629 eggs injected• 421 fertilised (67%)421 fertilised (67%)• 437 PB analysed437 PB analysed

– No resultNo result 56 (13%)56 (13%)– EuploidEuploid 84 (19%)84 (19%)– Aneuploid Aneuploid 297 (68%)297 (68%)

• All PB aneuploid in 14 cycles (15%) All PB aneuploid in 14 cycles (15%)

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CGH Aneuploidy ScreeningCGH Aneuploidy ScreeningIVF Hammersmith experienceIVF Hammersmith experience

• 85 embryos transferred in 53 cycles 85 embryos transferred in 53 cycles 57% 57%• Clinical pregnancy rate/cycle started 16/93 17%Clinical pregnancy rate/cycle started 16/93 17%• Clinical pregnancy rate/ETClinical pregnancy rate/ET 16/5316/53 30% 30%

<37 years CPR/ET <37 years CPR/ET 5/14 5/14 36% >37 36% >37 years CPR/ETyears CPR/ET 11/39 11/39 28% 28%

• 1 ectopic, 2 miscarriages, 5 livebirths, 8 ongoing 1 ectopic, 2 miscarriages, 5 livebirths, 8 ongoing pregnanciespregnancies

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Comparison with matched controlsComparison with matched controls

CGHCGH Controls Controls Age 40 40 40Age 40 40 40Previous cycles 2.8 - 2.5 Previous cycles 2.8 - 2.5 CPR/cycle started 17% 25% 16% CPR/cycle started 17% 25% 16% CPR/ETCPR/ET 30% 31% 20% 30% 31% 20%

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ImpressionsImpressions• High attrition rate, low success rateHigh attrition rate, low success rate• Strong patient demand despite high cost and Strong patient demand despite high cost and

unproven efficacyunproven efficacy• What to do when no diagnosis?What to do when no diagnosis?• What is significance of all eggs aneuploid?What is significance of all eggs aneuploid?

ImpressionsImpressions• Move towards PB1 and 2 Move towards PB1 and 2 Handyside 2011Handyside 2011

• Are there two groups of patients?Are there two groups of patients?– Older patients offer PB 1 and 2 biopsyOlder patients offer PB 1 and 2 biopsy– Young patients with recurrent implantation failure offer Young patients with recurrent implantation failure offer

blastocyst biopsy and CGHblastocyst biopsy and CGH• Blastocyst biopsy?Blastocyst biopsy?

– 2 cases of blastocyst biopsy, vitrification, thaw and 2 cases of blastocyst biopsy, vitrification, thaw and transfer in drug-assisted cycle, no pregnancytransfer in drug-assisted cycle, no pregnancy

– 2 cases analysis performed with ET on morning of day 2 cases analysis performed with ET on morning of day 6, 1 pregnancy6, 1 pregnancy

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Ethical challengesEthical challenges• Is it ethical to offer this treatment Is it ethical to offer this treatment

in absence of robust evidence from in absence of robust evidence from prospective RCT?prospective RCT?

• Is it ethical to deny this treatment Is it ethical to deny this treatment to a fully informed patient who has to a fully informed patient who has a poor prognosis?a poor prognosis?

• Could we do any harm?Could we do any harm?– High non fertilisation rateHigh non fertilisation rate– ? Discarding normal undiagnosed ? Discarding normal undiagnosed

eggseggs– Possibility of self-correctionPossibility of self-correction– CGH does not diagnose triploidyCGH does not diagnose triploidy– Comparisons against SNP arraysComparisons against SNP arrays

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In ConclusionIn Conclusion

• Efficacy of PGS remains hotly disputedEfficacy of PGS remains hotly disputed• PB biopsy and CGH micro-array can predict PB biopsy and CGH micro-array can predict

chromosomal abnormality in 89% of caseschromosomal abnormality in 89% of cases• Initial clinical data looks promising, adds to Initial clinical data looks promising, adds to

our understandingour understanding• Await ESHRE’s prospective multicentre Await ESHRE’s prospective multicentre

RCT for confirmationRCT for confirmation

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Thanks to Tony Gordon at Bluegnome and Dagan Wells, Elpeda Fragouli

at Reprogenetics

IVF Hammersmith Team

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