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PreimplantationGenetic Diagnosis: An Overview
Dr. Laila Bastaki, MDConsultant of Medical GeneticsDirector of KMGC
The development of PGD is one of the most exciting and important
milestones in the history of Assisted Reproductive Technology
Preimplantation Genetic Diagnosis(PGD)
PGD is a state-of-the-art procedure used in conjunction with In Vitro Fertilization (IVF)in which the embryo is tested for certain conditions prior to being placed in the womb of the woman.
PGD was first reported in 1990.
PGD combines the recent advances in molecular genetics and in assisted reproductive technology
Indications for PGD1. Chromosomal Disorders
NumericalChromosomal aneuploidy
StructuralInversionsTranslocationsDeletions and duplications
2. Gender determination for severe X-linked diseases with unknown gene
3. Severe monogenic diseases (cystic fibrosis, ß thalassaemia, sickle cell anemia, fragile X syndrome, myopathies)
4. PGD for HLA-typing (to allow selection of embryos that are histocompatiblewith live siblings)
HOW IS PREIMPLANTATION GENETIC DIAGNOSIS
PERFORMED?
Technically demanding
Very Complex
Requires special skills
How is PGD performed?Ovarian Stimulation
IVF
Blastomere Biopsy on Day 3
Genetic Analysis (FISH or
Molecular)
Transfer of
Unaffected Embryo
Outcome
Clinically Normal Baby
The Methods of Preimplantation Genetic
Diagnosis
1. Remove a single cell from the 6-8-cell embryo
using a fine glass needle to puncture the
zona pellucida and aspirate the cell
- In skilled hands, this generally does not harm
the developing embryo.
- Each cell is called a blastomere.
Blastomere Biopsy Video
The PGD process provides two categories of analysis
Fluorescence In Situ Hybridization (FISH).
Gene Chip array
Polymerase Chain Reaction (PCR)
Fluorescence In Situ Hybridization (FISH)
• Using fluorescent probes specific for each
chromosome.
• useful for identifying aneuploidies (incorrect
chromosome numbers) and translocations
• procedure destroys the tested cell
• limited number of chromosomes can be checked
simultaneously
• some abnormalities undetectable
Screening aneuploids with multiple probes
Aneuploidy is the most frequent cause of
spontaneous abortions
Gene chip array
(Array CGH Analysis)
What is array-CGH analysis?
Array-CGH allows the laboratory to determine if the correct number of each chromosome is present in the egg or embryo
This technology simultaneously tests for all 24 chromosomes (1-22, X and Y)
What is array-CGH analysis?
With array-CGH, the amount of DNA present for each chromosome is compared to that of a normal standard, enabling us to detect monosomies (missing chromosomes), trisomies (extra chromosomes), and other abnormalities
What is array-CGH analysis?
Genetic testing for specific disease loci (PCR)
Polymerase chain reaction (PCR)
-The gene causing the disorder should be confirmed and tested in the couple -Amplification of DNA specific to a gene of interest (family history guides choice of genes)-Second round PCR used for specific exonic sequencing and/or linkage analysis (Fragment analysis)
Fragment analysis for HLA matching
Sequence analysis
for a specific familial mutation
Examples of genetic disorders detectable via PCR-based tests:
- Tay Sachs (autosomal recessive)
- Cystic fibrosis (autosomal recessive)
- Huntington’s disease (autosomal dominant)
- Thalassemias (autosomal recessive blood disorder)
- Duchenne muscular dystrophy (X-linked recessive)
- Spinal muscular atrophy (X-linked recessive)
As more genetic tests are developed as diagnostic tools, more will be used for predictive purposes in PDG.
Limitations of PCR-based tests:
• Both alleles may not amplify equally (allele dropout),
leading to misdiagnosis or inconclusive results
• PCR-based tests only detect disorders at target loci; other
mutations may exist elsewhere
• To accommodate these limitations, prenatal
amniocentesis or chorionic villus sampling is usually
recommended as a supplement to PGD.
Benefits of PGDReduction in the
Chance of Having a Child with Aneuploidy
Reduces the possibility of pregnancy termination following a prenatal diagnosis of a genetic disorder.
Risks Embryo damageOocyte and Embryo Biopsy are invasive procedures
Misdiagnosis The accuracy of the PGD for translocation is 90%.
False negative resultFalse positive resultThe chance for NO result The chance for mosaicism
IVF Risks
Not Achieving PregnancyThere may not be any normal embryos
available for transfer.The embryos may not implant and develop
even if they do not have the defect.
The workup for PGD is expensive and labor intensive
PGD can only detect a specific genetic disease in an embryo. It cannot detect many genetic disorders at a time and cannot guarantee that the fetus will not have an unrelated birth defect.
Causes of Misdiagnosis
Human Error
Mislabeling, misidentification, misinterpretation
Wrong embryo transfer
Incorrect probes or primers
Technical
Probe or primer failure
Contamination (maternal, paternal, operator, carry-over)
Intrinsic (embryo)
Mosaicism
Allele drop out
Uniparental Disomy
PGD & Malformations
European Society of Human Reproduction and Embryology (ESHRE) PGD Consortium, 2003
Major malformations: 2.6%Phocomelia and pulmonary deficiency, chylothorax, congenital hip dislocation, abdominal cystic mass, pesequinivarus, exencephaly
Minor malformations: 1.4% syndactyly, hydrocele testis, ASD, mongolian spot, sacral dimple
Liebaers et al, Belgium 2010Major malformations: 2.1% vs ICSI: 3.4%
chylothorax, VSD, oeasophageal atresia, cataract, umbilical hernia, ichthyosis, cardiopathy
Alternatives to PGD
Conceive naturally and have prenatal diagnosis during pregnancy
Future of PGDEfforts continue to be focused on improving methods to obtain an accurate diagnosis.
PGD holds great promise for the future as techniques and genetic tests are perfected.
PGD may become routine in the next few years.
Conclusions
For couples at risk for producing offspring with either debilitating monogenic disorders or chromosomal abnormalities IVF/PGD represents a major scientific advance
Conclusions
Complications, both before and after birth, are no different in type or number from those found in a comparable ICSI population
Other parameters such as birth weight and length, are also similar to an ICSI population
PGD appears to be a safe method to avoid the birth of children with genetic defects
Conclusions
• Before PGD is performed, genetic counseling must be provided to ensure that patients fully understand the
risk for having an affected child
the impact of the disease
the available options
the multiple technical limitations including the possibility of an erroneous result
• Prenatal diagnostic testing is strongly encouraged to confirm the results of PGD
Thank You