Time associations between U.S. birth rates and add-Ons to IVF practice between 2005-2016

Until 2010, the National Assisted Reproductive Technology Surveillance System (NASS) report, published annually by the Center for Disease Control and Prevention (CDC), demonstrated almost constantly improving live birth rates following fresh non-donor (fnd) in vitro fertilization (IVF) cycles. Almost unnoticed by profession and public, by 2016 they, however, reached lows not seen since 1996-1997. We here attempted to understand underlying causes for this decline. This study used publicly available IVF outcome data, reported by the CDC annually under Congressional mandate, involving over 90% of U.S. IVF centers and over 95% of U.S. IVF cycles. Years 2005, 2010, 2015 and 2016 served as index years, representing respectively, 27,047, 30,425, 21,771 and 19,137 live births in fnd IVF cycles. Concomitantly, the study associated timelines for introduction of new add-ons to IVF practice with changes in outcomes of fnd IVF cycles. Median female age remained at 36.0 years during the study period and center participation was surprisingly stable, thereby confirming reasonable phenotype stability. Main outcome measures were associations of specific IVF practice changes with declines in live IVF birth rates. Time associations were observed with increased utilization of "all-freeze" cycles (embryo banking), mild ovarian stimulation protocols, preimplantation genetic testing for aneuploidy (PGT-A) and increasing utilization of elective single embryo transfer (eSET). Among all add-ons, PGT-A, likely, affected fndIVF most profoundly. Though associations cannot denote causation, they can be hypothesis-generating. Here presented time-associations are compelling, though some of observed pregnancy and live birth loss may have been compensated by increases in frozen-thawed cycles and consequential pregnancies and live births not shown here. Pregnancies in frozen-thawed cycles, however, represent additional treatment cycles, time delays and additional costs. IVF live birth rates not seen since 1996-1997, and a likely continuous downward trend in U.S. IVF outcomes, therefore, mandate a reversal of current outcome trends, whatever ultimately the causes.

Utilization of preimplantation genetic testing for monogenic disorders

OBJECTIVE

To determine the rate of utilization, factors influencing the decision-making process, and patient satisfaction with preimplantation genetic diagnosis for monogenic disorders (PGT-M).

DESIGN

Survey study.

SETTING

Academic center.

PATIENT(S)

Genetically at-risk patients seen for PGT-M consultation between January 2010 and 2018.

INTERVENTION(S)

Electronic survey including demographics, genetic history, consultation experience, decision-making process, and satisfaction with PGT-M process.

MAIN OUTCOME MEASURE(S)

Rate of utilization of PGT-M, importance of decision-making factors, and satisfaction with PGT-M process.

RESULT(S)

Among survey respondents (n = 49), the rate of utilization of PGT-M after consultation was 89.8%. Ninety-three percent of participants decided whether to pursue PGT-M within 3 months of consultation. Factors that were considered most important to this decision-making process included information provided at consultation, accuracy of test results after PGT-M, avoidance of suffering of an affected child, and ability to avoid termination of an affected pregnancy. Key barriers to utilization included financial burden and overall complexity of the in vitro fertilization (IVF)/PGT-M process. Of those utilizing PGT-M (n = 44), 72.1% had at least one live birth or were pregnant during the study period. Satisfaction with PGT-M was high, and most couples would use IVF/PGT-M for a future pregnancy (84.1%). Participants with a live birth were more satisfied with the PGT-M process than those who had no live birth.

CONCLUSION(S)

Most patients seeking consultation for PGT-M were likely to pursue this technology despite financial burden and complexity of the process. Exploring factors that influence patient decision-making regarding PGT-M is important for tailoring the consultation and optimizing the overall experience.

Diminished ovarian reserve is associated with reduced euploid rates via preimplantation genetic testing for aneuploidy independently from age: evidence for concomitant reduction in oocyte quality with quantity

OBJECTIVE(S)

To determine whether women with diminished ovarian reserve (DOR) (quantitatively) had lower rates of euploid blastocysts, as a proxy for oocyte quality.

DESIGN

Retrospective cohort study.

SETTING

University reproductive health clinic.

PATIENT(S)

A total of 1,152 women aged 19-42 years underwent 1,675 IVF cycles yielding 8,073 blastocysts for biopsy from 2010 to 2019.

INTERVENTIONS(S)

Preimplantation genetic testing for aneuploidy.

MAIN OUTCOME MEASURE(S)

Euploid rates, defined as the number of euploid blastocysts divided by the number of biopsied blastocysts per cycle.

RESULT(S)

A total of 225 women (20%) had DOR as infertility diagnosis per the Bologna criteria. Age was higher among the women with DOR (39.5 y vs. 37.0 y). Euploid rates were lower among women with vs. without DOR (29.0% vs. 44.9%). In generalized linear models controlling for age, women with DOR had 24% reduced odds of a biopsied blastocyst being euploid versus women without DOR. In a secondary analysis assigning DOR status to women producing the lowest quartile of age-adjusted mature oocyte yield, this relationship remained. No differences were identified in live birth rates between women with and without DOR after euploid single-embryo transfer independently from age (n = 944 transfers; 56.8% vs. 54.8%, respectively).

CONCLUSION(S)

Blastocysts from women with DOR are less likely to be euploid than those from women without DOR after adjustment for age. Given the concomitant reduction in euploid rates with quantity of oocytes observed in this study, quantitative ovarian reserve assessments (i.e., follicular machinery) may yield insight into relative ovarian aging.

Regulating reproductive genetic services: dealing with spiral-shaped processes and techno-scientific imaginaries

PURPOSE

We have been inquiring into the diffusion process of reproductive genetic services (RGS) and the viability of geneticization in human reproduction.

METHOD

A 2-round modified-Delphi survey was applied amongst Israeli and Spanish experts to analyze regulatory attitudes and expectations about the future applications of RGS. We argue that an explanation of RGS diffusion based on a 'technology-push' impulse should be complemented by a 'demandpull' approach, which underscores the importance of regulatory frameworks and demand-inducing policies. The diffusion of RGS is advancing in a 'spiralshaped' process where technology acts as a cause and effect simultaneously, modulating social acceptance and redefining the notions of health and responsibility along the way.

RESULTS

We suggest that there is a 'grey-zone' of RGS regulations regarding four procedures: the use of germline genome modification (GGM) for severe monogenic disorders, preimplantation genetic testing (PGT) for detection of chromosomal abnormalities, PGT for multifactorial diseases, and PGT with whole-exome screening.

CONCLUSIONS

Although far from the geneticization of human reproduction, our findings suggest that, since techno-scientific imaginaries tend to shape regulations and thus favor the diffusion of RGS, policymakers should pay attention to those procedures by focusing on good practices and equity while providing sound information on potential risks and expected success rates. A broad and inclusive societal debate is critical for overcoming the difficulty of drawing a clear line between medical and non-medical uses of genetic selection and engineering while searching for the right balance between allowing reproductive autonomy and protecting the public interest.

Noninvasive preimplantation genetic testing in assisted reproductive technology: current state and future perspectives

Invasive genetic screening of pre-implantation embryos via biopsied trophectoderm (TE) cells has been in use for more than 20 years, while its benefits in selecting euploid embryos remain controversial. Recent advances in the ability to process embryonic cell-free DNA (cfDNA) from blastocoel fluid (BF) and spent culture media (SCM) of blastocysts in a manner similar to that of a biopsied TE sample provide a potential alternative holding great promise for obtaining cytogenetic information of the embryos without intrusive biopsy of traditional biopsy-based pre-implantation genetic testing (PGT). Several studies have reported even higher diagnostic accuracy in non-invasive PGT (ni-PGT) than conventional PGT. However, there are still several technical challenges to be overcome before ni-PGT can be accepted as a reliable genomic information source of embryo. In this review, we have summarized the emergence and current state of ni-PGT, and discussed our own perspectives on their limitations and future prospect. There is still a long way to go before truly wide clinical application of ni-PGT.

The Reproductive Journey in the Genomic Era: From Preconception to Childhood

It is estimated that around 10–15% of the population have problems achieving a pregnancy. Assisted reproduction techniques implemented and enforced by personalized genomic medicine have paved the way for millions of infertile patients to become parents. Nevertheless, having a baby is just the first challenge to overcome in the reproductive journey, the most important is to obtain a healthy baby free of any genetic condition that can be prevented. Prevention of congenital anomalies throughout the lifespan of the patient must be a global health priority. Congenital disorders can be defined as structural or functional anomalies that occur during intrauterine life and can be identified prenatally, at birth, or sometimes may only be detected later during childhood. It is considered a frequent group of disorders, affecting 3–6% of the population, and one of the leading causes of morbidity and mortality. Congenital anomalies can represent up to 30–50% of infant mortality in developed countries. Genetics plays a substantial role in the pathogenesis of congenital anomalies. This becomes especially important in some ethnic communities or populations where the incidence and levels of consanguinity are higher. The impact of genetic disorders during childhood is high, representing 20–30% of all infant deaths and 11.1% of pediatric hospital admissions. With these data, obtaining a precise genetic diagnosis is one of the main aspects of a preventive medicine approach in developed countries. The field of reproductive health has changed dramatically from traditional non-molecular visual microscope-based techniques (i.e., fluorescence in situ hybridization (FISH) or G-banding karyotype), to the latest molecular high-throughput techniques such as next-generation sequencing (NGS). Genome-wide technologies are applied along the different stages of the reproductive health lifecycle from preconception carrier screening and pre-implantation genetic testing, to prenatal and postnatal testing. The aim of this paper is to assess the new horizon opened by technologies such as next-generation sequencing (NGS), in new strategies, as a genomic precision diagnostic tool to understand the mechanisms underlying genetic conditions during the “reproductive journey”.

The PGS/PGT-A controversy in IVF addressed as a formal conflict resolution analysis

PURPOSE

To use conflict resolution analysis on the conflict between proponents and opponents of preimplantation genetic testing for aneuploidy (PGT-A), previously called preimplantation genetic screening (PGS).

METHODS

Considered in conflict analysis a case study, we reviewed the English literature based on key-word searches at www.pubmed.com and www.google.com, and interviewed professional opinion leaders and other actor-representatives. This analysis was the product of a mandated externship by L.M. at the Foundation for Reproductive Medicine (FRM), as part of the Master of Science Program in Negotiations and Conflict Resolution at Columbia University, New York, NY.

RESULTS

Initially a typical difference of opinion, conflict evolved after proponents rejected studies that failed to confirm expected benefits, and authors felt demeaned by their criticism. Becoming "destructive," the conflict evolved according to Glasl's escalation model stages. Proponents became continuous attractors. Unable to produce validations for PGT-A, proponents moved goal posts through 3 stages (PGS 1.0-PGS 3.0). Ultimately concurring that pregnancy and live birth rates are unaffected, they started claiming new benefits.

CONCLUSIONS

The FRM underwrote this study as a starting tool for a conflict resolution process. A consensus building conference of stakeholders appears as of this point to represent the most promising potential intervention. The goal of such a conference should be sustainable consensus about clinical utilization of PGS/PGT-A in IVF, based on transparent and validated criteria. A potential date for such a conference is set for 2020.

Germline genome editing versus preimplantation genetic diagnosis: Is there a case in favour of germline interventions?

CRISPR is widely considered to be a disruptive technology. However, when it comes to the most controversial topic, germline genome editing (GGE), there is no consensus on whether this technology has any substantial advantages over existing procedures such as embryo selection after in vitro fertilization (IVF) and preimplantation genetic diagnosis (PGD). Answering this question, however, is crucial for evaluating whether the pursuit of further research and development on GGE is justified. This paper explores the question from both a clinical and a moral viewpoint, namely whether GGE has any advantages over existing technologies of selective reproduction and whether GGE could complement or even replace them. In a first step, I review an argument of extended applicability. The paper confirms that there are some scenarios in which only germline intervention allows couples to have (biologically related) healthy offspring, because selection will not avoid disease. In a second step, I examine possible moral arguments in favour of genetic modification, namely that GGE could save some embryos and that GGE would provide certain benefits for a future person that PGD does not. Both arguments for GGE have limitations. With regard to the extended applicability of GGE, however, a weak case in favour of GGE should still be made.

[Preimplantation genetic diagnosis]

In Denmark, preimplantation genetic diagnosis (PGD) is offered within the public healthcare to families with a known risk of an inherited disease in a child - as an alternative to prenatal diagnosis. It is a well-established technique with rather well-described perinatal- and neonatal outcomes, being comparable to what is seen following in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI). The most common strategy is now to perform trophectoderm biopsy and then vitrify, while the diagnostic test is performed. Until 2013, 134 children have been born following PGD. Today, the clinical pregnancy rates are comparable to those following IVF/ICSI.

Why Is Studying the Genetics of Intelligence So Controversial?

From the very beginning, studies of the nature and nurture of intelligence have been closely associated with an interest in intervening, and those interventions have been surrounded by controversy. The nature of those controversies has not always been the same, however. Since the mid-nineteenth century, when Francis Galton imagined a science that would assess the extent to which a trait like "genius" was due to nature or due to nurture, science and technology have changed dramatically, and so have the interventions that have been envisioned in light of those developments. A scientist today can search for particular stretches of DNA and assess whether differences in those stretches are associated with differences in a human trait of interest; a genetic counselor today can genetically test an individual (be it an embryo, fetus, newborn, child, or adult) and provide information about what that genetic result means, allowing for interventions that can range from terminating a pregnancy to prescribing chemotherapy. So when one asks a question like, "Why is studying the genetics of intelligence controversial?," it is important to realize up front that the answer will be, "It can be controversial for a variety of different reasons, and those reasons have evolved over time." The purpose of this essay is to provide a survey of the controversies that surround genetic studies of intelligence. With the survey in place, I will then draw out several lessons both for scientists who study the genetics of intelligence as well as for science studies scholars (bioethicists, philosophers, historians, sociologists) who reflect and comment on the controversies surrounding that research.

Pre-implantation genetic diagnosis and screening: now and the future

Since 1989, the year of the first pre-implantation genetic diagnosis (PGD), many developments occurred both in assisted reproduction techniques and in molecular tools. While PGD is a well-established and documented application, pre-implantation genetic screening (PGS) for the detection of aneuploid embryos is still debated due to the presence of mosaicism in the embryo, but especially to the knowledge of the limits that label an embryo as healthy or as appropriate to the life. The aim of this review is to present the state-of-the-art in the field of PGD and PGS, illustrating its benefits and limitations, along with biopsy techniques and the use of new high-throughput technologies.

New advances of preimplantation and prenatal genetic screening and noninvasive testing as a potential predictor of health status of babies

The current morphologically based selection of human embryos for transfer cannot detect chromosome aneuploidies. So far, only biopsy techniques have been able to screen for chromosomal aneuploidies in the in vitro fertilization (IVF) embryos. Preimplantation genetic diagnosis (PGD) or screening (PGS) involves the biopsy of oocyte polar bodies or embryonic cells and has become a routine clinical procedure in many IVF clinics worldwide, including recent development of comprehensive chromosome screening of all 23 pairs of chromosomes by microarrays for aneuploidy screening. The routine preimplantation and prenatal genetic diagnosis (PND) require testing in an aggressive manner. These procedures may be invasive to the growing embryo and fetus and potentially could compromise the clinical outcome. Therefore the aim of this review is to summarize not only the new knowledge on preimplantation and prenatal genetic diagnosis in humans, but also on the development of potential noninvasive embryo and fetal testing that might play an important role in the future.

Incorporating information regarding preimplantation genetic diagnosis into discussions concerning testing and risk management for BRCA1/2 mutations: a qualitative study of patient preferences

BACKGROUND

Studies have shown that BRCA1/2 mutation carriers are interested in learning about reproductive options such as preimplantation genetic diagnosis (PGD) to prevent passing their risk onto their children. However, attitudes vary widely, and the procedure raises complex ethical and psychosocial issues. This complexity, plus the highly technical nature of PGD, makes it difficult to integrate PGD information into genetic counseling sessions that already cover probabilistic, emotionally charged risk information.

METHODS

A total of 33 carriers of the BRCA1/2 mutation who were of reproductive age and had previously undergone genetic counseling viewed a tutorial regarding PGD and were interviewed concerning their attitudes toward PGD and preferences about how to include PGD information in genetic counseling.

RESULTS

The majority of participants preferred to be briefly informed of the availability of PGD information, and to receive written materials regarding PGD, but with the option of deferring detailed discussion if they already believed themselves to be overloaded or perceived that PGD was not immediately relevant to their risk management and/or childbearing plans. For some individuals, the stress of testing temporarily interfered with information processing, producing states of cognitive avoidance ("in a fog," or "tuning out"). Some preferred to discuss PGD with a physician with whom they had an ongoing relationship (eg, obstetrician/gynecologist, primary care provider, or oncologist).

CONCLUSIONS

Providers offering cancer genetic testing may consider indicating the availability of PGD information to their patients, while attending to the patients' level of interest and ability to absorb information. Research is needed to link patient responses to information overload with psychosocial outcomes (eg, distress, and quality of decision-making). Continuing medical education is needed to support providers in facilitating informed decisions regarding PGD.

The decision-making process of genetically at-risk couples considering preimplantation genetic diagnosis: initial findings from a grounded theory study

Exponential growth in genomics has led to public and private initiatives worldwide that have dramatically increased the number of procreative couples who are aware of their ability to transmit genetic disorders to their future children. Understanding how couples process the meaning of being genetically at-risk for their procreative life lags far behind the advances in genomic and reproductive sciences. Moreover, society, policy makers, and clinicians are not aware of the experiences and nuances involved when modern couples are faced with using Preimplantation Genetic Diagnosis (PGD). The purpose of this study was to discover the decision-making process of genetically at-risk couples as they decide whether to use PGD to prevent the transmission of known single-gene or sex-linked genetic disorders to their children. A qualitative, grounded theory design guided the study in which 22 couples (44 individual partners) from the USA, who were actively considering PGD, participated. Couples were recruited from June 2009 to May 2010 from the Internet and from a large PGD center and a patient newsletter. In-depth semi-structured interviews were completed with each individual partner within the couple dyad, separate from their respective partner. We discovered that couples move through four phases (Identify, Contemplate, Resolve, Engage) of a complex, dynamic, and iterative decision-making process where multiple, sequential decisions are made. In the Identify phase, couples acknowledge the meaning of their at-risk status. Parenthood and reproductive options are explored in the Contemplate phase, where 41% of couples remained for up to 36 months before moving into the Resolve phase. In Resolve, one of three decisions about PGD use is reached, including: Accepting, Declining, or Oscillating. Actualizing decisions occur in the Engage phase. Awareness of the decision-making process among genetically at-risk couples provides foundational work for understanding critical processes and aids in identifying important gaps for intervention and future research.

Assisted reproductive technology in Europe, 2007: results generated from European registers by ESHRE

BACKGROUND

This 11th European IVF-monitoring report presents the results of assisted reproductive technology (ART) treatments initiated in Europe during 2007.

METHODS

From 33 countries, 1029 clinics reported 493 184 treatment cycles: IVF (120 761), ICSI (256 642), frozen embryo replacement (91 145), egg donation (15 731), preimplantation genetic diagnosis/preimplantation genetic screening (4638), in vitro maturation (660) and frozen oocytes replacements (3607). Overall, this represents a 7.6% increase since 2006, mostly related to an increase in all registers. IUI using husband/partner's (IUI-H) and donor (IUI-D) semen was reported from 23 countries: 142 609 IUI-H (+6.2%) and 26 088 IUI-D (+7.2%).

RESULTS

In 18 countries where all clinics reported, 376 971 ART cycles were performed in a population of 425.6 million (886 cycles per million). The clinical pregnancy rates per aspiration and per transfer were 29.1 and 32.8% for IVF, and 28.6 and 33.0% for ICSI. Delivery rate after IUI-H was 10.2% in women aged < 40 years. In IVF/ICSI cycles, 1, 2, 3 and ≥4 embryos were transferred in 21.4, 53.4, 22.7 and 2.5% of cycles, with no decline in the number of embryos per transfer since 2006. The proportion of multiple deliveries (22.3: 21.3% twin and 1.0% triplet), did not decrease compared with 2006 (20.8%) and 2005 (21.8%). In women < 40 years undergoing IUI-H, twin deliveries occurred in 11.7% and triplets in 0.5%.

CONCLUSIONS

In comparison with previous years, the reported number of ART cycles in Europe increased in 2007; pregnancy rates increased marginally, but the earlier decline in the number of embryos transferred and multiple births did not continue.

[Ten years' experience of preimplantation genetic diagnosis in Paris: remaining obstacles and potential solutions]

Preimplantation genetic diagnosis (PGD) has been authorized in France since 1999. Encouraging results have been obtained during the past 10 years in our Paris center, where 832 patients have undergone 1056 IVF-PGD procedures. With the advent of new techniques for the identification of genetic disease markers, our center can now offer PGD procedures for aneuploidy and 75 single-gene diseases. New indications for PGD have also been developed, such as mitochondrial DNA diseases, amyloid neuropathy, pulmonary arterial hypertension, and HLA typing The implantation rate is currently 29,6% and, by 31 December 2009, 151 healthy babies had been born. Unfortunately, demand for PGD procedures far outstrips available technical capacity, and the waiting period is longer than 18 months. Increased funding is urgently needed

The use of arrays in preimplantation genetic diagnosis and screening

BACKGROUND

In preimplantation genetic diagnosis (PGD), polymerase chain reaction has been used to detect monogenic disorders, and in PGD/preimplantation genetic screening (PGS), fluorescence in situ hybridization (FISH) has been used to analyze chromosomes. Ten randomized controlled trials (RCTs) using FISH-based PGS on cleavage-stage embryos and one on blastocyst-stage embryos have shown that PGS does not increase delivery rates. Is the failure of PGS due to a fundamental flaw in the idea, or are the techniques that are being used unable to overcome their own, inherent flaws? Array-based technology allows for analysis of all of the chromosomes. Two types of arrays are being developed for use in PGD; array comparative genomic hybridization (aCGH) and single nucleotide polymorphism-based (SNP) arrays. Each array can determine the number of chromosomes, however, SNP-based arrays can also be used to haplotype the sample.

OBJECTIVE(S)

To describe aCGH and SNP array technology and make suggestions for the future use of arrays in PGD and PGS.

CONCLUSION(S)

If array-based testing is going to prove useful, three steps need to be taken: [1] Validation of the array platform on appropriate cell and tissue samples to allow for reliable testing, even at the single-cell level; [2] deciding which embryo stage is the best for biopsy: polar body, cleavage, or blastocyst stage; [3] performing RCTs to show improvement in delivery rates. If RCTs are able to show that array-based testing at the optimal stage for embryo biopsy increases delivery rates, this will be a major step forward for assisted reproductive technology patients around the world.

Technology requirements for preimplantation genetic diagnosis to improve assisted reproduction outcomes

Preimplantation genetic diagnosis has been proposed as a method to improve assisted reproduction technology outcomes, but different techniques have produced conflicting results. The use of appropriate techniques may provide positive outcomes.

Genetic testing of embryos: practices and perspectives of US in vitro fertilization clinics

OBJECTIVE

To better understand the current practices of IVF clinics regarding preimplantation genetic diagnosis (PGD) and explore the attitudes and opinions of clinic directors toward PGD.

DESIGN

On-line Survey of 415 assisted reproductive technology (ART) clinics in the United States. The Survey had a valid response rate of 45% (186 clinics).

SETTING

Not applicable.

PATIENT(S)

Respondents were medical directors, laboratory directors, IVF directors, or directors' designees of ART clinics offering IVF.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Practices and beliefs of IVF clinic directors with respect to PGD.

RESULT(S)

Preimplantation genetic diagnosis is widely provided for a variety of indications, and clinic directors support professional guidelines to guide PGD in the future.

CONCLUSION(S)

Preimplantation genetic diagnosis is an established technology and medical procedure offered by a majority of US IVF clinics. Many clinics currently provide PGD for controversial indications such as sex selection. Although there is little support for government regulation of PGD, there is significant support among IVF clinics for strong professional guidelines for PGD practice. Ongoing collection of data on PGD practice and outcomes would help patients make informed decisions and aid professionals in developing appropriate guidelines and standards.

Attitudes of high-risk women toward preimplantation genetic diagnosis

OBJECTIVE

To explore the knowledge and attitudes toward preimplantation genetic diagnosis (PGD) of women who have been personally affected by hereditary breast and ovarian cancer.

DESIGN

A 33-item quantitative survey covering five domains, including demographics, knowledge and attitudes about PGD, usage of PGD, and informational needs.

SETTING

Attendees of a national conference for individuals and families affected by hereditary breast and ovarian cancer participated in the survey.

PATIENT(S)

Not applicable.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Frequencies and proportions were summarized for all variables, and Fisher's exact tests were conducted to test association between two discrete variables.

RESULT(S)

Of the women surveyed, only 32% had ever heard of PGD before taking the survey. None of the women surveyed had actually used PGD, and 44% believed they would not use it in the future. However, 57% of attendees believed that PGD was an acceptable option for high-risk individuals, and 74% believed that high-risk individuals should be given information about PGD.

CONCLUSION(S)

Health care professionals who serve cancer patients should consider incorporating information about PGD into patient education. Further research is needed to survey physicians and genetic counselors about their knowledge and opinions of PGD.

Preimplantation genetic diagnosis: present and future

PURPOSE

Preimplantation genetic diagnosis (PGD) was developed more than a decade ago and aims to identify embryos free of genetic disease attributed either to gene mutations or chromosome errors. The purpose of this article is to provide an update on the current status and future prospects of PGD.

METHODS

Review of studies employing different strategies for the detection of single gene defects, and chromosome abnormalities, both structural and numerical in the context of PGD.

RESULTS

Amplification of several DNA fragments is feasible via multiplex PCR for the PGD of single gene disorders, whilst current FISH protocols employ up to 10 probes to identify embryos with a normal chromosome complement. New methods are being developed which will enable the assessment of the entire chromosome complement of embryonic blastomeres.

CONCLUSIONS

PGD has come a long way since its first application, and has become very accurate and reliable. Technical advances in the field of preimplantation genetics mean that PGD holds great promise for the future.

Preimplantation genetic diagnosis: current and future perspectives

Over the last 30 years prenatal diagnosis has been available to couples at genetic risk to determine the genetic health of a naturally conceived pregnancy. Prenatal diagnosis involves fetal cell sampling either by chorionic villous sampling at 10-12 weeks or by amniocentesis at 12-15 weeks gestation and testing for genetic disease. If the fetus is affected, termination of pregnancy is a difficult and emotional issue for the couple. The advent of assisted reproductive technologies (ARTs) and more recently preimplantation genetic diagnosis (PGD) now provides an alternative reproductive option that allows couples to commence a pregnancy knowing that their baby will not be affected with the indicated genetic condition. This article explores the option of PGD, its clinical application now and into the future and the current status of regulation and legislation. With recent changes to national legislation, scientists now have the opportunity to access affected PGD embryos donated by patients to establish disease-specific stem cells that may be useful models of human disease and a means to develop more effective therapies for treatment.

The future (r)evolution of preimplantation genetic diagnosis/human leukocyte antigen testing: ethical reflections

There has been increasing support for combining preimplantation genetic diagnosis (PGD) for specific diseases with a test for human leukocyte antigens (HLA) because the generation of HLA-matched umbilical cord blood cells may save the life of a diseased sibling. To date, this procedure has taken place in the context of conceiving another child--PGD/HLA testing type 1. However, it may well become possible to perform PGD/HLA testing outside this context, that is, to select matched embryos from which embryonic stem cells could be derived and used in cell therapy--PGD/HLA testing type 2. A proactive ethical analysis is needed and is presented in this article. Although PGD/HLA testing type 1 can be morally justified, the risks, pitfalls, and practical limitations of this procedure make it necessary to develop alternative strategies. PGD/HLA testing type 2 may provide an alternative strategy. From an ethical point of view, the controversial issue is that this procedure creates embryos purely for instrumental use. However, given the dominant view that the preimplantation embryo has only limited moral value, this alternative may be as morally justified as PGD/HLA testing type 1.

[New options in prenatal and preimplantation diagnosis of genetic disorders]

During recent years the progress with the most important practical impact in prenatal diagnosis has been the implementation of first trimester risk screening for common aneuploidies leading to a much improved identification of pregnancies at risk. Molecular methods for a rapid, cost-effective, but selective aneuploidy diagnosis such as interphase FISH or QF-PCR have been around for years, do have their specific indications, but will unlikely replace conventional cytogenetic tools in routine diagnosis. They apparently do also play a role as marketing instruments in the competition among cytogenetic laboratories. The most thrilling issue for all cytogeneticists in the years to come will be the introduction of array-based methods in the prenatal routine diagnosis of chromosomal abnormalities. Polar body diagnosis has been the only option available for preimplantation genetic diagnosis in german speaking countries. The overwhelming majority of all professionals involved and many families concerned share the hope that the legal situation will improve in these countries to allow the examination of early embryos in high risk situations.

New methods in genetic diagnosis including prenatal diagnosis

Recent advances in newborn screening and molecular genetics are transforming our understanding of the genetic basis of diseases that affect individuals of all ages. It is essential for clinicians to understand the methods and goals of newborn screening (NBS), the principles of genetics, and the methods of molecular analysis including Southern blots, PCR amplification, DNA sequence analysis, Reverse Transcriptase PCR, Multiplex Ligation- dependent Probe Amplification analysis, Fluorescence in Situ Hybridization, Comparative Genomic Hybridization, as well as Fetal Ultrasonography. This understanding and applications of these tools can lead to genetic diagnoses by identifying risks from newborn screening results or family histories, selecting appropriate tests and understanding the implications of test results to the patient and their families. To facilitate this understanding we will review newborn screening, basic genetics, inheritance and examples of established and new methods used in genetic testing. It is our hope that this material will facilitate clinician's abilities to consider and detect genetic disorders so that earlier interventions and optimal outcomes can occur.

Opinions about new reproductive genetic technologies: hopes and fears for our genetic future

OBJECTIVE

To identify underlying beliefs and values shaping Americans' opinions about the appropriate use of new reproductive genetic technologies (RGTs), including preimplantation genetic diagnosis, hypothetical genetic modification, and sperm sorting for sex selection.

DESIGN

Scenarios with ethical dilemmas presented to 21 focus groups organized by sex, race/ethnicity, religion, age, education, and parental status.

SETTING

A city in each state: California, Colorado, Massachusetts, Michigan, and Tennessee.

PARTICIPANT(S)

One hundred and eighty-one paid volunteers, ages 18 to 68.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Beliefs and values that shape participants' opinions about the appropriate use of new RGTs.

RESULT(S)

Regardless of demographic characteristics, focus group participants considered six key factors when determining the appropriateness of using RGTs: [1] whether embryos would be destroyed; [2] the nature of the disease or trait being avoided or sought; [3] technological control over "natural" reproduction; [4] the value of suffering, disability, and difference; [5] the importance of having genetically related children; and [6] the kind of future people desire or fear.

CONCLUSION(S)

Public opinions about the appropriate use of RGTs are shaped by numerous complementary and conflicting values beyond classic abortion arguments. Clinicians and policy-makers have the opportunity to consider these opinions when creating messages and crafting policy.

Preimplantation genetic diagnosis: technological promise and ethical perils

OBJECTIVE

To describe the ethical issues inherent to the current and foreseeable uses of preimplantation genetic diagnosis (PGD).

DESIGN

Review of ethical principles and their application to PGD.

SETTING

Academic medical center.

PATIENT(S)

None.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

A discussion of the current ethical perils surrounding the use of PGD, and a prediction of future ethical quandaries that will arise from the use of this technology.

RESULT(S)

Although PGD may be used to predict and prevent disease, it may also be used to determine nondisease traits. The ever-expanding ability of genetics to determine qualities of the preimplantation embryo continues to open up new ethical questions relating to the use of PGD for preimplantation diagnosis.

CONCLUSION(S)

Preimplantation genetic diagnosis is a powerful technique with many positive applications. As with all such new technologies, care should be taken to ponder the ethical implications of its use before routinely accepting PGD as a tool in the reproductive armamentarium.

Questioning the assumptions in the debate on assisted reproduction: comment on the House of Commons report Human Reproductive Technologies and the Law

The House of Commons Science and Technology Committee has issued a series of non-dogmatic recommendations. Also regarding elective sex selection, it has adopted a controversial position. Sex selection should be allowed for family balancing. However, the acceptability of preimplantation genetic diagnosis as a method for selecting the embryos can be questioned on the basis of social harm. In countries with a shortage of medical personnel and a limited health care budget, elective procedures are a loss to society. This loss should be compensated by imposing a 'social compensation tax' for every application of elective sexing.

Designing babies: what the future holds

Advances in reproductive technology have opened new opportunities to avoid inherited diseases in offspring. The preimplantation genetic diagnosis (PGD) of human embryos permits those embryos carrying gene disorders or a non-diploid chromosome constitution to be identified. Numerous disease genes including those with a late onset have been identified and the conditions averted in children. Risks of abortion have been reduced, and the incidence of live births raised after PGD. It is also possible to select embryos with human leukocyte antigens (HLA) identical to those of a sick elder sibling, and then use stem cells from cord blood at birth to supply the necessary therapy. This form of treatment has alleviated the inherited disease in many recipients. The outlook and ethics of this approach to the alleviation of human disorders are discussed.

Germinal choice technology and the human future

This paper examines the likely impacts of emerging technologies that will give prospective parents the potential to directly influence the genetics of their offspring. My primary focus is on advanced prenatal genetic diagnosis (PGD) for both disease and non-disease traits, since this is likely to emerge before such possibilities as direct germline engineering. I place these technologies within the larger context of today's revolution in the life sciences and consider the progress likely to occur in this realm in the next few generations. I take a common sense look at the types of screening choices people are likely to make once these possibilities become possible, their broad consequences for human society, and the advantages and disadvantages of plausible regulatory paths in this realm. I also reflect upon today's debate about cloning and other such issues in the life sciences, looking at the driving forces behind these discussions and the tensions likely to develop in the next few decades.

[The latest development in preimplantation genetic diagnosis]

Preimplantation genetic diagnosis is the integration of both assisted reproductive technologies and molecular genetic technologies. Since the birth of the first healthy females after PGD in 1990, remarkable advances have been achieved in this field. Most research in PGD is focused on new methods to improve the sensitivity and accuracy of single cell analysis. The principal problems in single cell PCR include amplification failure, ADO and contamination. Fluorescent PCR with multiplex amplifications of highly polymorphic markers is a highly effective strategy to avoid contamination and detect ADO. The advantages and disadvantages of fluorescence in situ hybridization to detect age-related aneuploidy are still under debate. We summarize the most recent developments in this review, and also introduce our own experiences in PGD.

The status of preimplantation genetic diagnosis in Japan: a criticism

Advances in preimplantation genetic diagnosis (PGD) are occurring worldwide. New clinics specializing in this approach to the control of disease genes or imbalanced chromosome numbers in human preimplantation embryos continue to increase. One exception is Japan, where the Japanese Society of Obstetrics and Gynecology disapproves of this practice because it discriminates against people with genetic abnormalities. Yet, some doctors there wish to introduce this method to help their couples to improved forms of IVF. This paper stresses the rights of patients to have a healthy baby, if necessary by the use of PGD. It argues against prohibition, since it complements the current nature of prenatal diagnosis and avoids the need for abortions in case of afflicted embryos. Consideration is also given to other attempts at restriction that have failed.