1. Anish A. Shah, MD, MHS, FACOG B OARD C ERTIFIED R EPRODUCTIVE E NDOCRINOLOGIST Preimplantation Genetic Testing Gateway to the Future of Fertility Dennis W. Matt, PhD, HCLD H IGH C OMPLEXITY C LINICAL L ABORATORY D IRECTOR

2. DisclosuresDisclosures Nothing to discloseNothing to disclose No conflicts of interestNo conflicts of interest

3. What can you genetically screen? Egg?  not reliable because sperm is not present.Egg?  not reliable because sperm is not present. Sperm  same problem as egg, need the DNA of mom and dad to combine to see if came together normallySperm  same problem as egg, need the DNA of mom and dad to combine to see if came together normally Embryo  Excellent target to screenEmbryo  Excellent target to screen

4. Basic Genetics Men  46 XYMen  46 XY Women  46 XXWomen  46 XX Objective:Objective: –Half DNA of Mom needs to be packaged into the Egg –Half DNA of Dad needs to be packaged into the Sperm

5. Normal Karyotype

6. The Dance

7. Normal Chromosomal Division Polar Body (Discarded) Haploid Oocyte Haploid Sperm Diploid Embryo

8. Aneuploidy: Meiotic Nondisjunction Monoploid Oocyte Diploid Oocyte Haploid Sperm Trisomic Embryo Haploid Sperm Monosomic Embryo

9. Aneuploidy: Down’s Syndrome

10. Risk for Down’s Syndrome increases with Maternal Age

11. Age Matters, Why? Aneuploidy

12. Eggs age, Aneuploidy increases

13. How do we get the Egg?

14. Give FSH and LH

15. How do we get the Egg? Give FSH and LH

16. How do we get the Egg? Give FSH and LH

17. PGD vs PGS Preimplantaton Genetic DiagnosisPreimplantaton Genetic Diagnosis –Specific genetic mutations documented in the parent(s) Cystic FibrosisCystic Fibrosis Breast Cancer gene (BRCA 1 and 2)Breast Cancer gene (BRCA 1 and 2) Etc….Etc…. Preimplantaton Genetic ScreeningPreimplantaton Genetic Screening –Screen embryos to see which one is genetically NORMAL, or rather which one will not be a miscarriage or unhealthy pregnancy

18. Stages of Embryo Development

19. BlastocystBlastocyst http://www.reproduction-online.org/content/139/1/35/F2.large.jpghttp://www.reproduction-online.org/content/139/1/35/F2.large.jpg http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/9980.jpghttp://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/9980.jpg

20. Blastocyst Stage Embryo Biopsy http://www.youtube.com/watch?v=53fzEMYdOUchttp://www.youtube.com/watch?v=53fzEMYdOUc

21. The Evolution Of Pre-implantation Embryo Genetic Evaluation Biopsy Technique Trophoblast from Day 5, 6, or 7 Embryo Single Blastomere from Day 3 Embryo Fluorescence in situ hybridization (FISH) Single Gene Disorder Comprehensive Genomic Hybridization (cGH)

22. Day 3 vs Blastocyst Biopsy Fertility and Sterility 2013 100, 624-630DOI: (10.1016/j.fertnstert.2013.04.039) Copyright © 2013 American Society for Reproductive Medicine Terms and Conditions Terms and Conditions

23. Results of PGS

24. 4,873 Embryos from 571 PGS Cycles Percentage of IVF Cycles Resulting in Live Birth Brezina PR, Tobler K, Benner AT, Du L, Boyd B, Kearns WG. Evaluation of 571 In Vitro Fertilization (IVF) Cycels and 4,873 Embryos Using 23-Chromosome Single Nucleotide Polymorphism (SNP) Microarray Preimplantation Genetic Screening (PGS). Pacific Coast Reproductive Society Annual Meeting, Rancho Mirage, CA, April 18-22 2012 [Accepted December 22, 2011] [Poster Presentation]

25. PGS Conclusions Appropriate patient populationAppropriate patient population –RPL –Balanced parental translocation Day 5 preferable to day 3Day 5 preferable to day 3 Must evaluate all 23 pairs of chromosomesMust evaluate all 23 pairs of chromosomes

27. Future Directions  NOW!!!!!! Next Generation (Gen) SequencingNext Generation (Gen) Sequencing –Fast –Cheaper –More Sensitive MAJORITY Frozen Embryo TransferMAJORITY Frozen Embryo Transfer –Higher live birth rate than fresh transfer (randomized control trials) –Healthier delivery outcomes of babies and mothers

28. Anish A. Shah, MD, MHS, FACOG B OARD C ERTIFIED R EPRODUCTIVE E NDOCRINOLOGIST Dennis W. Matt, PhD, HCLD H IGH C OMPLEXITY C LINICAL L ABORATORY D IRECTOR THANK YOU