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I Jornada Actualización en Genética Reproductiva y Fertilidad

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RGH ILLUMINA: Preimplantation Genetic Screening: Scientific Evidence, Alan Thornhill

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I Jornada Actualización en Genética Reproductiva y Fertilidad

  1. 1. 1 © 2015 Illumina, Inc. All rights reserved. Illumina, 24sure, BaseSpace, BeadArray, BlueFish, BlueFuse, BlueGnome, cBot, CSPro, CytoChip, DesignStudio, Epicentre, ForenSeq, Genetic Energy, GenomeStudio, GoldenGate, HiScan, HiSeq, HiSeq X, Infinium, iScan, iSelect, MiSeq, MiSeqDx, MiSeq FGx, NeoPrep, NextBio, Nextera, NextSeq, Powered by Illumina, SureMDA, TruGenome, TruSeq, TruSight, Understand Your Genome, UYG, VeraCode, verifi, VeriSeq, the pumpkin orange color, and the streaming bases design are trademarks of Illumina, Inc. and/or its affiliate(s) in the US and/or other countries. All other names, logos, and other trademarks are the property of their respective owners. New Concepts in Preimplantation Genetic Screening Professor Alan Thornhill Market Development Illumina Inc. 15th December 2016
  2. 2. 2 IVF outcomes: Overall Poor with Huge Variation 378k 192k 28k 180k 60k 250k 80k 104k 57k 20k 20k 1.5 million IVF cycles globally per year Only about 1 in 3 take home baby rate 2010-2014 (1% increase in LB YOY) 21% versus 67% - CP/cycle started
  3. 3. 3 Maternal Age, Aneuploidy, and Fertility 1. CDC, 2013 ART National Summary Presentation, http://www.cdc.gov/art/reports/2013/national-summary.html; Figures 14-16 2. Franasiak JM, Forman EJ, Hong KH, et al. The nature of aneuploidy with increasing age of the female partner: a review of 15,169 consecutive trophectoderm biopsies evaluated with comprehensive chromosomal screening. Fertil Steril. 2014;101(3):656-663.e1. Aneuploidy is a major cause of the age-related decline in fertility1,2 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 24 25 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 % Live Birth, Miscarriage, Aneuploidy vs. Age Live Birth % (CDC) Miscarriage % (CDC) D5 Aneuploidy %(Franasiak) Age (years)
  4. 4. 4 The Embryologist’s Dilemma.... Pick me ... No … pick me, don’t worry about a couple of fragments No … I’m the one … I’ve got nice nuclei Pick me ... Courtesy of Dr S.Troup/Prof C Kingsland. Hewitt Fertility Centre, Liverpool Women’s Hospital Worldwide this process occurs ~ 50,000 times daily .….
  5. 5. 5 Aneuploidy in Embryos – The Facts Aneuploidy = incorrect # of chromosomes (eg Trisomy 21/Down’s syndrome) Main reason for failed implantation and failed development to term Present in women of all ages (~50%) Increases with maternal age All chromosomes represented at day 5* Development to blastocyst stage does not eliminate specific aneuploidies Similar incidence between natural and stimulated cycles** (STREAM study?) Ref: S Munne. Preimplantation Genetic Diagnosis for Aneuploidy and Translocations Using Array Comparative Genomic Hybridization. Curr Genomics. 2012 Sep; 13(6): 463–470. *Franasiak et al. The nature of aneuploidy with increasing age of the female partner: a review of 15,169 consecutive trophectoderm biopsies evaluated with comprehensive chromosomal screening. Fertil Steril 2014 101:656-63 **Ata B, Kaplan B, Danzer H, et al. Array CGH analysis shows that aneuploidy is not related to the number of embryos generated. Reprod Biomed Online. 2012;24(6):614-620.
  6. 6. 6 Benefits of PGS
  7. 7. 7 Next Generation IVF Improving Clinical Outcomes by PGS Avoid transfer + storage of aneuploid embryos Mitigates the effect of maternal age1 Increase Implantation Rates 2,3 Increase pregnancy & live birth rates/embryo transfer 3,4 Reduce miscarriage rate 2,4,5 Select euploid blastocysts to support single-embryo transfer (reduce multiple pregnancy and birth, especially twins) 2,3,4,5 Reduce time to live birth? Costs? 1. Harton G, Munné S, Surrey M, et al. Diminished effect of maternal age on implantation after Preimplantation Genetic Diagnosis with array comparative genomic hybridization. Fertil Steril. 2013; 100(6):1695-703. 2. Grifo JA, Hodes-Wertz B, Lee HL, Amperloquio E, Clarke-Williams M, Adler A. Single thawed euploid embryo transfer improves IVF pregnancy, miscarriage, and multiple gestation outcomes and has similar implantation rates as egg donation. J. Assist. Reprod. Genet. 2013; 30, 259–64. 3. Scott RT, Upham KM, Forman EF, et al. Blastocyst biopsy with comprehensive chromosome screening and fresh embryo transfer significantly increases IVF IRs and delivery rates: a randomized controlled trial. Fertil. Steril. 2013; 100(3):697-703 4. Yang Z, Liu J, Collins GC, et al. Selection of single blastocysts for fresh transfer via standard morphology assessment alone and with array CGH for good prognosis IVF patients: results from a randomized pilot study. Mol. Cytogenet. 2012; 5(1):24 5. Forman EJ, Hong KH, Ferry KM, et al. In vitro fertilization with single euploid blastocyst transfer: a randomized controlled trial. Fertil Steril. 2013; 100(1):100-7.
  8. 8. 8 Clinical Evidence Supporting PGS
  9. 9. 9 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% 30-34 35-37 38-40 41-42 Implantation Aneuploidy Miscarriage Harton GL, Munne S, Surrey M, et al. Diminished effect of maternal age on implantation after preimplantation genetic diagnosis with array comparative genomic hybridization. Fertil Steril. 2013;100(6):1695-1703. PGS Helps Mitigate Maternal Age Effect 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% 30-34 35-37 38-40 41-42 Implantation Aneuploidy Miscarriage Selective transfer of euploid embryos diminishes the adverse effect of maternal age (up to 42 years) on implantation1
  10. 10. 10 Improved IVF outcomes with 24sure® PGS – good prognosis patients Ongoing pregnancy (> 20 weeks) 41.7% Morphology Alone 69.1% aCGH PGS + Morphology For Research Use Only. Not for use in diagnostic procedures. Ref: Selection of single blastocysts for fresh transfer via standard morphology assessment alone and with array CGH for good prognosis IVF patients: results from a randomized pilot study. Yang Z, Liu J, Collins GS, Salem SA, Liu X, Lyle SS, Peck AC, Sills ES, Salem RD. Mol Cytogenet. 2012 May 2;5(1):24. doi: 10.1186/1755-8166-5-24 *Young, good prognosis patients; n=103, age<35, first-time IVF, no history of miscarriage
  11. 11. 11 1. Forman EJ, Hong KH, Ferry KM, et al. In vitro fertilization with single euploid blastocyst transfer: a randomized controlled trial. Fertil Steril. 2013;100(1):100- 107.e101.
  12. 12. 12 PGS Enables More Efficient Elective Single Embryo Transfer (eSET) 1. Forman EJ, Hong KH, Ferry KM, et al. In vitro fertilization with single euploid blastocyst transfer: a randomized controlled trial. Fertil Steril. 2013;100(1):100-107.e101. 61% 65% SINGLE EUPLOID BLASTOCYST TRANSFER (N=89) UNTESTED 2- BLASTOCYST TRANSFER (N=86) 100% 52% 0% 48% SINGLE EUPLOID BLASTOCYST TRANSFER (N=54) UNTESTED 2-BLASTOCYST TRANSFER (N=56) Singletons Multiples Similar ongoing pregnancy rates. Single euploid transfer dramatically reduced the risk of a multiple gestation.1 Patients less than 43 years of age Fetal Number in Ongoing PregnanciesOngoing Pregnancy
  13. 13. 13 Whitney et al (2016) JARG Advance online • An observational, retrospective cohort study of first transfer outcomes was performed in two groups: Group 1 (PGS) all blastocysts were biopsied on days 5/6, vitrified and array CGH (24Sure™) performed Group 2 (no PGS) included the first transfer on day 3 or day 5 from non-PGS fresh cycles or cycles in which all blastocysts had been vitrified • Clinical pregnancies and implantation were confirmed by ultrasound and live birth information obtained
  14. 14. 14
  15. 15. 15 Whitney et al (2016) JARG Advance online
  16. 16. 16 43 41 37 12 64 32 35 15 PGS n = No PGS n = Whitney et al (2016) JARG Advance online
  17. 17. 17 Meta-analyses and Real world Data
  18. 18. 18 Lee E, Illingworth P, Wilton L, Chambers GM. The clinical effectiveness of preimplantation genetic diagnosis for aneuploidy in all 24 chromosomes (PGD-A): systematic review. Hum Reprod. 2015;30(2):473-483.
  19. 19. 19 PGS RCTs in Young Women with Good Prognosis Ongoing Pregnancy 0 0.5 1 1.5 2 2.5 Yang, 2012 Forman, 2013 Scott, 2013 Combined RCT RiskRatio Randomized Controlled Trials PGS vs. Routine Care Ongoing Pregnancy >20 Weeks FavorsPGS FavorsControl Ongoing pregnancy 1.39x more likely with PGS in RCTs Lee E, Illingworth P, Wilton L, Chambers GM. The clinical effectiveness of preimplantation genetic diagnosis for aneuploidy in all 24 chromosomes (PGD-A): systematic review. Hum Reprod. 2015;30(2):473-483.
  20. 20. 20 Meta-analysis of published studies on PGS using comprehensive chromosome screening (CCS) versus routine care in embryo selection Determine clinical and sustained implantation rates In-depth evaluation of the available evidence for this new form of PGS Dahdouh EM, Balayla J, García-Velasco JA. Comprehensive chromosome screening improves embryo selection: a meta- analysis. 2015; 104(6):1503-12.
  21. 21. 21 Matched Cohort Studies of PGS in AMA Women Clinical Implantation Rate (IR) 0 1 2 3 4 5 6 7 Sher, 2009 Schoolcraft, 2010 Fishel, 2011 Forman, 2012 Keltz, 2013 Greco, 2014 Combined OS RiskRatio Observational Studies PGS vs. Routine Care Clinical IR (Gestational Sacs/#ET) Dahdouh EM, Balayla J, García-Velasco JA. Comprehensive chromosome screening improves embryo selection: a meta-analysis. Fertil Steril. 2015;104(6):1503-1512. FavorsPGS FavorsControl Clinical IR 1.78x more likely with PGS in observational studies
  22. 22. 22 Matched Cohort Studies of PGS in AMA Women Ongoing Pregnancy Dahdouh EM, Balayla J, García-Velasco JA. Comprehensive chromosome screening improves embryo selection: a meta-analysis. Fertil Steril. 2015;104(6):1503-1512. 0 1 2 3 4 5 Sher, 2009 Forman, 2012 Lee, 2015 Feichtinger, 2015 Combined OS RiskRatio PGS vs. Routine Care Ongoing Pregnancy >20 weeks FavorsPGS FavorsControl Ongoing pregnancy 1.75x more likely with PGS in observational studies Observational Studies
  23. 23. 23 Chang J, Boulet SL, Jeng G, Flowers L, Kissin DM. Outcomes of in vitro fertilization with preimplantation genetic diagnosis: an analysis of the Unites States Assisted Reproductive Technology Surveillance Data, 2011-2012. Fertil Steril. 2016;105(2):394-400. ~107,000 fresh, non-donor cycles with blastocyst transfer from clinics with ≥1 PGD cycle – 5,471 cycles w/ PGD Aneuploidy (same as PGS) vs. 97,069 non-PGD cycles – 2,859 PGD Other & 1,503 PGD Genetics cycles For women who underwent IVF with PGD Aneuploidy (PGS): Decreased risk of miscarriage in women ≥35 years of age Increased chance of live birth in women >37 years of age
  24. 24. 24 PGS – Does choice of technology matter?
  25. 25. 25 Evolution of PGS Technology - Which is the best? FISH 24sure ® VeriSeqTM PGS Arrays SequencingTechnique Product Data points 5 3,000 1,000,000 Vysis Aneuvysion For Research Use Only. Not for use in diagnostic procedures
  26. 26. 26 Advantages of NGS vs aCGH for PGS (courtesy of Dr Tony Gordon, Genesis Genetics) Whole copy chromosome changes – no real advantage Sub chromosomal changes – smaller gains and losses – NGS more sensitive and specific Mosaic samples – 50% detection limit aCGH – 25% detection limit NGS* Noisy samples – NGS more able to determine signal vs noise Detect common 69XXY and 69XYY triploid – 70% all triploids Scalable and cost-effective for large sample volume * Mosaic embryos have reduced implantation potential but can produce normal live births
  27. 27. 27 1. Bolton H, Graham SJL, Van der Aa N, et al. Mouse model of chromosome mosaicism reveals lineage-specific depletion of aneuploid cells and normal developmental potential. Nat Commun. 2016;7:11165. 2. Taylor TH, Gitlin S a., Patrick JL, Crain JL, Wilson JM, Griffin DK. The origin, mechanisms, incidence and clinical consequences of chromosomal mosaicism in humans. Hum Reprod Update. 2014;20(4):571-581. Mosaicism in Embryos Mechanisms by which chromosomal mosaicism can arise in embryonic development include errors during:2 – Normal cell division (mitotic) in the first few cell divisions  Mitotic errors later in development can also lead to mosaicism  Can be confined to certain fetal/placental tissues or organism systems – Production of sperm or egg cells (meiotic error) and the error is corrected (rescued)
  28. 28. 28 Mosaicism in human embryos Is it real? Can all technology reliably detect and measure it? What is the incidence? What is the clinical impact? Are there any professional guidelines? PGDIS, COGEN (TBC)
  29. 29. 29 Best Practice Reporting Working Group PGDIS Bologna, Italy May 2016 Genoma, Rome, Italy Francesca Spinella, Francesco Fiorentino IVI, Valencia, Spain Carmen Rubio Repromeda, Brno, Czech Republic Jakub Horák, Kateřina Veselá Safe Fertility Clinic, Bangkok, Thailand Sunanta Nabu, Wiwat Quangkananurug Repromed, Dulwich, South Australia Deirdre Zander-Fox Genesis Genetics, London, UK Mike Large, Leoni Xanthopoulou, Tony Gordon Bridge Centre, London, UK Alan Handyside, Christian Ottolini, Michael Summers
  30. 30. 30 Euploid 45% Multiple aneuploidies ± other abns 14% Karyotype wide abns 1% Mosaic (11%) or segmental abns (7%) only 18% Single aneuploidy ± other abns 21% All data from labs D-G n=1952 Trophectoderm biopsy data from all labs reporting mosaic aneuploidy
  31. 31. 31 COGEN Data on Mosaicism Incidence? 15k sample study presented at COGEN showed 18% mosaicism Genesis, Repro also have large scale data sets Author to give talk at ILMN 31 Courtesy of Genesis Genetics, A Cooper Surgical company
  32. 32. 3232 Courtesy of Genesis Genetics, A Cooper Surgical company
  33. 33. 33 The Future
  34. 34. 34
  35. 35. 35 ClinicalTrials.gov NCT02268786 Study Details Locations Patient Details Protocol Multicenter International Blinded RCT 9 Laboratories 34 Clinical Sites Aus, Can, UK, USA Women aged 25–40 years Moderate prognosis ≥2 blastocysts at day 5/6 Randomization (day 5/6) Vitrification Single Embryo Transfer Intervention Arm Trophectoderm biopsy VeriSeq PGS system Comparator Arm Standard morphological assessment For Research Use Only. Not for use in diagnostic procedures.
  36. 36. 36 Other Clinical Trials Ongoing: IVI : Advanced maternal age – day 3 biopsy – 24Sure (submitted) IVI: Male Factor Infertility – day 3 – 24Sure (interim analysis) Richard Scott – NGS Richard Scott – Poor prognosis China – BEACON trial – NGS IVF Sweden – day 5 – 24Sure ESTEEM – polar body – 24Sure
  37. 37. 37 “ Whilst we recognize that as yet much of the published data do not meet the very highest level of medical analysis, there is now a significant, and increasing body of scientific literature supporting the recommendation of PGS to patients undergoing IVF, for the reasons stated above. Based on available data PGS should no longer be considered as an experimental procedure. We therefore believe that PGS should be part of the discussion with all patients considering/undergoing IVF treatment ” http://www.ivf-worldwide.com/cogen/general/cogen-statement.html COGEN PGS Statement (2015) http://www.ivf-worldwide.com/cogen/general/cogen-statement.html ASRM, CFAS, Czech Republic………..BFS/HFEA?
  38. 38. 38 Take Home Messages ….. Aneuploidy is a problem in all IVF patient populations aCGH/NGS screening of 24 chromosomes is highly accurate and reproducible (but clear advantages with NGS) All published RCTs to date using 24 chromosome screening are positive (with more studies ongoing) STAR study (and other) results will add to this body of data Need to further understand mosaicism Poor IVF is not rescued by PGS
  39. 39. 39 Thank You!

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