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Basic genetics for ART practitioners
 

Basic genetics for ART practitioners

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  • Genetic condition may be proven or suspected Ideally: genetic counselling should be preconceptual, but many clients are already pregnant - sometimes limitations on what can be offered due to time constraints Importance of ethnicity in certain conditions

Basic genetics for ART practitioners Basic genetics for ART practitioners Presentation Transcript

  • Basic genetics for ART practitioners Genetic Counselling Alison Lashwood Centre for Genetics & PGD Guy’s Hospital, London. 23.3.07
  • Learning objectives
    • Understand what genetic counselling is.
    • Awareness of specific issues affecting families with genetic disorders
    • Review specific issues relating to PGD
  • What is “genetic counselling”?
    • “ A communication process which deals with the human problems associated with the occurrence, or risk of occurrence, of a genetic disorder in a family….”
    • (Ad Hoc Committee on Genetic Counselling,
    • American Society of Human Genetics, 1975)
  • It involves an attempt to help the individual or family……..
    • Comprehend the medical facts about a disorder
    • Appreciate the way in which heredity contributes to the disorder and to the risk of recurrence
    • Understand the options for dealing with the risk of recurrence
    • Choose the course of action which seems most appropriate to them
    • Make the best possible adjustment to the disorder in an affected family member
  • Who may need genetic counselling?
    • Those with a genetic condition
    • Those with a family history of a genetic condition
    • Parents with an affected child/pregnancy
    • Those who request a diagnostic opinion
    • Those in consanguineous partnerships
    • Couples with recurrent miscarriages
    • Ethnic background indicates an increased genetic risk
    • Pregnant couples/individuals who fall into any of the above categories.
  • Roles in Genetic Counselling
    • Genetic Counsellor
    • ‘ Non-directive’ 
    • Provides information
    • Offers genetic tests
    • Counsels
    • Supports
    • Offers follow-up
    •  
    • Patient
    • Makes the decisions
    • Lives with the consequences
  • The consultation
    • Case history
    • Ellie has cystic fibrosis- diagnosed after birth
    • Sue & John had no FH of CF
    • Couple want to have more children
    Affected with CF
    • Let the couple
    • Tell their story
    • Ask what questions they have
    • Acknowledge their feelings i.e. grief, anger etc.
    • Discuss
    • Recurrence risks
    • Future options
    • Other support?
    Affected with CF
  • Specific issues
    • Grief
    • Impact on family
    • Perception of risk
  • Grief
    • Loss of health of self
    • Loss of reproductive freedom
    • Loss of health of family
    • Guilt
    • Fear
  • Impact on family
    • Dee & Paul are 9/40 pregnant
    • Different agenda
    • - no/yes PND
    • Differing views
    • Impact of guilt- remember grandparents
    Affected with CF John Sue Paul Dee
  • Risk perception
    • Never attach your view of risk.
    • Family myths “it only happens to boys in our family”
    • Past experience
  • You will never convince this family……… 50% ???
    • Risk figures can be a difficult concept
    • Present risk figures in different ways
    • Present both positive and negative
  • What do risks mean? 20% 1% 4:1 2/3
  • High or low?
    • 1 in 200
    • 1 in 100
    • 1 in 10
  • 20% or 1 in 5
    • 
    • 
    • 
    • 
    • 
  • 1% or 1 in 100
    • 
    • 
    • 
    •   
    • 
    • 
    • 
  • Difficult issues in genetic counselling
    • Confidentiality
    • Late onset disorders
    • Testing in pregnancy
  • Confidentiality
    • Case history
    • Donald has Becker muscular dystrophy
    • XL inheritance
    • Daisy is an obligate carrier
    • Daisy is asking for PGD to avoid having an affected son
    X Y X X X X
    • Neurologist informs me of AID
    • Father does not want Daisy to know
    • On testing Daisy is not a carrier
    • Outcome………………???
  • Late-onset disorders and presymptomatic testing
  • Presymptomatic testing: Case history
    • Jo has Huntington Disease
    • Beth and Peter at 50% risk
    • Both want to be tested
    • Outcome……
    • Beth has –ve test result
    • Peter has +ve test result
    45 years 19 years 21 years Jo Peter Beth
  • Implications of presymptomatic testing
      • Impact of result when HD is an untreatable, incurable, late-onset genetic condition (e.g. HD)?
      • Social and psychological impact
      • Practical impact e.g., jobs, insurance
      • Survivor guilt
  • Genetic testing in pregnancy
  • Genetic testing in pregnancy
      • Impact of time frame for testing
      • Do couple understand implications of testing?
      • Is decision making compromised by emotion?
      • Potential for multiple bereavements
  • Case history
    • Homer and Marge-1 st cousin partnership
    • No family history of note
    • Cystic fibrosis carriers
    • PND- affected fetus
    • TOP
    CF carrier Marge CF carrier 18/40 Homer
  • Issues
    • Request for reassurance
    • No previous knowledge of CF
    • Late stage of pregnancy urgency of making a decision
    • Loss of a much wanted pregnancy.
    • “ Confirmation” of family fears
  • Genetic Counselling & PGD
    • PGD Genetic counselling offers a couple:
    • An opportunity to review the genetics of the disorder
    • Discuss reproductive options again.
    • Talk through their previous experience
    • PGD Genetic counselling offers a clinician:
    • A chance to clarify why the couple have requested PGD
    • Time for full discussion of the procedure involved.
  • Why couples request PGD?
    • Prenatal diagnosis and TOP not acceptable
    • Knowledge of having an unaffected child from conception
    • Avoidance of further miscarriage
    • Genetic disorder and fertility problems
  • Factors affecting request
    • Level of genetic risk
    • Previous experience
    • Expectation of success
    • Perception of fertility
  • Level of genetic risk
    • Paul affected with Duchenne muscular dystrophy
    • Sally may have a 50% risk or a lower 10% risk
    • Test looks for high and low risk X chromosome only
    • PGD may be more acceptable than PND
    Sally
  • Previous experience
    • PND and TOP experience
    • Health of affected child
    • Death of affected child-timing
    • Belief in genetic risk
  • Expectation of success
    • Do the couple understand the success rate of PGD
    • Do the couple understand the impact of a PGD cycle
    • Limitations of PGD
    • PGD reduces risk rather than eliminates it
  • Perception of fertility
    • Delayed spontaneous conception
    • Do the couple have concerns over their fertility?
    • Recurrent miscarriage, is this due to the chromosome abnormality?
  • Special issues
    • Affect of PGD treatment on previous children
    • Welfare of the child
  • Impact on affected children
    • Case history
    • Matt carries a balanced reciprocal translocation
    • Sophie has inherited an unbalanced version
    • Severe developmental delay and now on dialysis
    • Potential impact of OHSS and multiple pregnancy.
    18 months Matt
  • Welfare of the child
    • Case history
    • Alex +ve HD gene test
    • Early signs present
    • Onset of HD likely to affect child care abilities
    • Simon will be dual carer
    • Impact of this on the couple
    22 years Early signs of HD 42 yrs Alex Simon
  • Genetic counselling after PGD cycle
    • Support if treatment unsuccessful
    • Discussion around confirmatory prenatal testing.
    • Confirmatory testing at delivery- conveying results
    • Follow up of babies born
  • In summary
    • Genetic counselling is an important part of a clinical genetics service.
    • It often raises complex issues for both individuals and families.
    • Many of the basic skills it employs are transferable to other specialities.
    • PGD should include genetic counselling to meet the needs of a good quality treatment programme.