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Prognostic role of preimplantation genetic testing for aneuploidy in medically indicated fertility preservation
ORIGINAL ARTICLE: FERTILITY PRESERVATION
Prognostic role of preimplantation genetic testing for aneuploidy in medically indicated fertility preservation Jennifer K. Blakemore, M.D.,a Emma C. Trawick, M.D.,a,b James A. Grifo, M.D., Ph.D.,a and Kara N. Goldman, MDa,b a New York University Langone Fertility Center, New York, New York; and b Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
Objective: To investigate the use of preimplantation genetic testing for aneuploidy (PGT-A) among patients pursuing embryo banking (EB) for medically indicated fertility preservation (FP). Design: Retrospective cohort. Setting: University-affiliated fertility center. Patients: All patients who underwent in vitro fertilization with or without PGT-A for medically indicated FP between January 2014 and April 2018. Interventions: None Main Outcome Measures: EB cycle characteristics, subsequent cycle pursuit/outcomes, and frozen embryo transfer (FET) outcomes. Results: A total of 58 medical EB cycles were compared; 34 cycles used PGT-A. Of the EB patients with breast cancer, 67% used PGT-A; other indications were evenly divided between PGT-A (FP/PGT-A) and no PGT-A (FP). PGT-A use increased over the study period. Groups were similar in age, days of stimulation, and days from initial FP consultation to treatment initiation. Number of oocytes (14.5 [263] FP vs. 17.5 [164] FP/PGT-A), 2PN zygotes (7 [138] FP vs. 9 [036] FP/PGT-A), and blastocysts (5.5 [022] FP vs. 5 [018] FP/PGT-A) cryopreserved were similar between groups. Equal numbers cryopreserved both oocytes and embryos (5 vs. 3). Five FP/PGT-A patients underwent a second EB cycle. Among FP/PGT-A patients, an average of 6.7 5 blastocysts underwent PGT-A, with 3.5 3 (48.2%) euploid embryos cryopreserved for future FET compared to an average of 7.2 7 untested embryos in the FP group. Conclusion: PGT-A in medical EB cycles increased over time and did not limit the use of other FP methods such as oocyte cryopreservation. In some cases, poor PGT-A results informed patients to pursue a second EB cycle. When counseling patients, the prognostic benefits of PGT-A must be weighed against the financial costs and potential for ‘‘terminal’’ fertility diagnosis. (Fertil SterilÒ 2019;-: -–-. Ó2019 by American Society for Reproductive Medicine.) Key Words: Fertility preservation, preimplantation genetic testing for aneuploidy (PGT-A), embryo banking Discuss: You can discuss this article with its authors and other readers at https://www.fertstertdialog.com/users/16110-fertilityand-sterility/posts/53999-28792
M
ore than 91,000 women less than 45 years of age are diagnosed with cancer annually, but advances in treatment have led to increased rates of survival and improved quality of life (1). Many of
these life-saving treatments compromise fertility, however, and impair a patient’s ability to achieve familybuilding goals (2). According to the American Society of Clinical Oncology (ASCO) and the American Society for
Reproductive Medicine (ASRM), the standard of care in fertility preservation (FP) for those undergoing gonadotoxic treatment is oocyte and embryo cryopreservation (3–5). By freezing oocytes or embryos, cancer patients
Received August 13, 2019; revised September 25, 2019; accepted September 26, 2019. J.K.B. has nothing to disclose. E.C.T. has nothing to disclose. J.G. has nothing to disclose; K.N.G. has nothing to disclose. Research was performed at New York University and manuscript completed while at Northwestern University (E.C.T. and K.N.G.). Correspondence: Jennifer Blakemore, M.D., NYU Langone Fertility Center, 660 First Avenue, Fifth Floor, New York, NY 100 16-3295 (E-mail: Jennifer. [email protected]). Fertility and Sterility® Vol. -, No. -, - 2019 0015-0282/$36.00 Copyright ©2019 American Society for Reproductive Medicine, Published by Elsevier Inc. https://doi.org/10.1016/j.fertnstert.2019.09.040 VOL. - NO. - / - 2019
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ORIGINAL ARTICLE: FERTILITY PRESERVATION may pursue autologous reproduction following definitive cancer treatment. Unfortunately, the success of fertility preservation may be overestimated by cancer patients. Nearly half of FP patients believe that they have a >60% chance of pregnancy with each embryo transfer (6), a belief at odds with the <50% likelihood of pregnancy per embryo transfer, which declines as patients age beyond 35 years (7). Multiple studies have suggested that even those seeking infertility treatment overestimate the likelihood of success of assisted reproductive technology (ART) (6, 8–10). This optimism can have particularly devastating consequences for those undergoing FP prior to cancer treatment with a limited window in which to pursue FP. As cancer incidence rises with advancing age (11), many cancer patients are already subject to impaired fertility prior to treatment because of age-related aneuploidy (12). In the limited time that patients have to undergo FP while awaiting treatment, older patients will also have fewer oocytes retrieved (13). Compounding these problems, standard morphologic grading is a poor predictor of embryo competence, as up to 50% of high-quality blastocysts are aneuploid (14). With fewer embryos of unknown ploidy, cancer patients may face failed in vitro fertilization (IVF) cycles, miscarriages, and unintended childlessness when finally ready to build their family. Better assessing embryo quality and future reproductive capability is thus critical in providing patients maximal information for decision making. Preimplantation genetic testing for aneuploidy (PGT-A) may provide a more accurate picture of future reproductive capability, and its utility in fertility preservation for cancer patients has been suggested by ASRM (15). PGT-A has already played an increasing role in embryo selection in IVF, and its utility is particularly compelling among women more than 38 years of age (16). PGT-A helps to prioritize embryos for transfer and optimize chances of pregnancy after a single embryo transfer (17–19), which may be particularly important for cancer patients with limited time to complete fertility preservation and therefore finite numbers of available embryos. Although many studies have examined the use of preimplantation genetic testing for monogenic diseases and the use of PGT-A among infertile patients, to our knowledge, no study exists on the use of PGT-A in cancer patients undergoing FP. The use of PGT-A in FP for cancer patients may allow patients to better understand the reproductive potential of their banked embryos and aid in more directive counseling by providers. We thus investigated the use of PGT-A among patients undergoing embryo banking (EB) for FP.
MATERIALS AND METHODS Inclusion and Exclusion Criteria With Institutional Review Board approval #S13-00389, we performed a retrospective cohort study of all IVF cycles performed for EB at the NYU Langone Fertility Center from January 1, 2014, through April 30, 2018. Patients with cancer or other fertility-threatening diagnoses who presented for 2
fertility preservation were identified. All patients undergoing planned EB were excluded. Patients undergoing exclusive oocyte cryopreservation cycles for fertility preservation were also excluded. In addition, patients meeting inclusion criteria but whose cycles were canceled prior to oocyte retrieval for poor response were also excluded. In total, 58 cycles in 51 patients were identified and included. Included patients underwent standard PGT-A counseling at our center, including descriptions of clinic-specific outcomes by age and cost of testing.
Stimulation Protocols Controlled ovarian hyperstimulation (COH) using a GnRH antagonist protocol with administration of gonadotropins (recombinant follicle-stimulating hormone [FSH], human menopausal gonadotropins [HMG], or both) were prescribed for each patient based on that patient’s antral follicle count, age, FSH level, and anti-M€ ullerian hormone level (AMH) (if available) as determined by their physician. Hormone levels (estradiol [E2], FSH, luteinizing hormone [LH], and P4) and transvaginal ultrasound at time of initial consultation were used to determine cycle status for each patient to determine optimal cycle start. Patients used one of four possible cycle starts: 1) cycle day 2 after last menstrual period, 2) luteal phase start prior to menses, 3) scheduled start after use of oral contraceptive pill suppression, or 4) random start. Protocols using low-dose or micro-dose downregulation with leuprolide acetate are used at our center but were not employed for patients included in this study. A subset of patients, mostly with breast cancer, were also administered oral letrozole during follicular stimulation. Follicular growth and maturation were monitored by transvaginal ultrasound and serum E2 level. The GnRH antagonist (Cetrotide or Ganirelix) was added when a lead follicle was identified as 13 mm or greater or the E2 was greater than 1000 pg/mL. Either human chorionic gonadotropin (hCG) alone or hCG with leuprolide acetate was used for trigger of final follicular maturation, with planned oocyte aspiration scheduled for 35 hours after administration. Oocyte retrieval was performed via ultrasound-guided transvaginal aspiration. Both insemination and intracytoplasmic sperm injection (ICSI) were used for fertilization of oocytes; ICSI was used if indicated by semen parameters or if patients anticipated needing future preimplantation genetic testing for monogenic disorders (PGT-M), but in our center PGT-A alone is not an indication for the use of ICSI. Standard laboratory techniques were used to follow each patient’s individualized plan as follows: 1) to culture all zygotes to the day 5/6 blastocyst stage, 2) to cryopreserve zygotes at the 2PN stage, or 3) to cryopreserve a fraction of oocytes retrieved and to fertilize the remaining oocytes and culture to the day 5/6 blastocyst stage. If PGT-A was desired, trophectoderm biopsy was performed on day 5 or 6 at the blastocyst stage prior to embryo cryopreservation via vitrification. Biopsy analysis was performed by array comparative genomic hybridization (array CGH) or next-generation sequencing (NGS). VOL. - NO. - / - 2019
Fertility and Sterility®
FIGURE 1
Embryo Cryopreserva on without PGT-A (n=22)
Other: Nasopharyngeal Cancer Sarcoma Melanoma Scheduled BSO
Embryo Cryopreserva on with PGT-A (n=29)
Other: Male Prostate Sarcoma Acous c Neuroma Thyroid Cancer
Breast cancer
Lymphoma
Endometrial Cancer
Ovarian Cancer
Cervical Cancer
Other
Indication for embryo banking. Blakemore. Role of PGT-A in fertility preservation. Fertil Steril 2019.
Outcomes and Statistical Analysis Included patients who used PGT-A were compared to those who did not. We report included patient demographic and clinical characteristics including diagnosis. Outcomes measured include EB cycle characteristics including time to treatment, time to consult, oocytes retrieved, and the number of oocytes, 2PN zygotes, and embryos cryopreserved; pursuit VOL. - NO. - / - 2019
and outcomes of a subsequent cycles; and embryo transfer and live birth outcomes. Continuous variables were first assessed for normality using the AndersonDarling test. All parametric continuous variables were analyzed using Student’s t-test, and all nonparametric variables were compared using the MannWhitney U test. Categorical variables were analyzed 3
ORIGINAL ARTICLE: FERTILITY PRESERVATION
TABLE 1 Characteristics of cycle timing for medical embryo banking for FP. Characteristic Days of stimulation Time from initial consult to cycle start (d) Starting stimulation on initial consult day, n (%) Time from consult to start of treatment/ iatrogenic injury (d) Menstrual cycle phase at time of cycle start, n (%) Random start (follicular phase) Day 2 follicular start Luteal phase cycle start Oral contraceptive control for cycle start
FP (n [ 24 cycles) 11.1 2 6.5 (077) 7 (29.2) 24 (13102) 7 (29.2) 12 (50) 3 (12.5) 2 (8.3)
FP/PGT-A (n [ 34 cycles)
P value
11.8 2 5 (0119) 10 (29.4) 26 (10120)
.1 .5 .7 .9
7 (20.6) 20 (58.8) 5 (14.7) 2 (5.9)
.7 .5 1.0 1.0
Note: Data presented as mean standard deviation or median (range) unless specified otherwise. FP ¼ fertility preservation; PGT-A ¼ preimplantation genetic testing for aneuploidy; SD ¼ standard deviation Blakemore. Role of PGT-A in fertility preservation. Fertil Steril 2019.
using the Fisher’s exact or c2 test where appropriate. A P value of < .05 was considered statistically significant. Results are reported as mean standard deviation, median (range), or percentage where appropriate.
RESULTS A total of 58 medical EB cycles from 51 patients were identified and analyzed. In all, 34 cycles (59%) from 24 patients used PGT-A (FP/PGT-A) and were compared to 24 cycles (41%) from 20 patients who did not employ PGT-A (FP). One patient in the FP/PGT-A group intended PGT-A in her second cycle but ultimately had no embryos for biopsy. The use of FP/PGT-A increased over the study period, with three cycles of FP/PGT-A in 2014, six cycles in 2015, nine cycles in 2016, 11 cycles in 2017, and six cycles between January and April of 2018. There were a variety of diagnoses that were evenly divided between groups, including lymphoma, melanoma, endometrial cancer, ovarian cancer, cervical cancer, thyroid cancer, and male prostate cancer (Fig. 1). The majority of patients had a diagnosis of breast cancer (50.0% in the FP group vs. 62.1% in the FP/PGT-A group). None of the patients included in this study used donor sperm. Both groups were similar in mean age (years) at time of first cycle start (35.5 6 FP vs. 34.2 4 FP/PGT-A, P¼ .4) and in the timing of first cycle start prior to treatment, as shown in Table 1. In addition, the time (days) from fertility preservation consult to first cycle start (6.5 [077] FP vs. 5 [0119] FP/ PGT-A, P¼ .5) and number of days of stimulation (11.1 2 FP vs. 11.8 2 FP/PGT-A, P¼ .1) were not different between groups (Table 1). Patients in both the FP and FP/PGT-A groups had similar cycle characteristics (Table 2), including similar age at cycle start (as described above) and similar number of oocytes retrieved (14.5 [263] FP vs. 17.5 [164] FP/PGT-A, P¼ .5). Similar numbers of patients in each group cryopreserved both embryos and oocytes (n ¼ 3 FP vs. n ¼ 5 FP/PGT-A, P ¼ 1.0), with a similar number of oocytes cryopreserved in each group. Groups were also similar in the number of 2PN zygotes created (7 [138] FP vs. 9 [036] FP/PGT-A, P¼ .8) and the number of blastocysts vitrified (5.5 [022] FP vs. 5 [018] FP/PGT-A, P¼ .7). The mean number of blastocysts 4
vitrified excludes six patients in the FP group who cryopreserved at the 2PN stage, three of whom where carriers of the hereditary breast cancer susceptibility syndrome, BRCA1/2, and intended future genetic analysis with PGT-M. This comparison also excludes four patients in the FP/PGTA group who froze an average of 10.8 additional nonbiopsied blastocysts. Five patients in the FP/PGT-A group underwent a second medical EB cycle: two for poor response (one patient with all cleavage-stage embryos on day 6 and one patient with only 2 of 12 embryos meeting criteria for biopsy), two for low euploidy (1 euploid embryo after 1 cycle), and one patient with no euploid embryos. In comparison to two patients among the FP group; one patient with only two morulae on day 6 and one patient with only two blastocysts vitrified. All five patients in the FP/PGT-A group who completed a second cycle had breast cancer, and four of these five patients had a traditional cycle day 2 start for their second cycle. The average time between initial consult to initiation of treatment in the FP/PGT-A group who completed two cycles was 82 45 days. This includes one start in a patient during the luteal phase of the first stimulation, two true day 2 starts in patients who delayed tamoxifen after consultation with their oncologist, and two true day 2 starts in patients who returned after mastectomy prior to chemotherapy. In the FP group, one patient with nasopharyngeal cancer initiated her second cycle during the luteal phase following her first cycle, and one patient with an osteosarcoma started her second cycle on day 2 after her first stimulation. The average time from initial consult to treatment in the FP group who pursued a second cycle was 44.5 13 days. Despite use of a second cycle, however, the average time (days) from consult to start of treatment did not differ between groups overall (24 [1312] FP vs. 26 [10120] FP/PGT-A, P¼ .9) (Table 1). The FP/PGT-A patients had an average of 3.5 3 euploid embryos cryopreserved (48.2% of embryos biopsied) for future embryo transfer vs. 7.2 7 (median 5.5, range 022) untested embryos cryopreserved in the FP group. At the time of publication, two breast cancer survivors in the FP/PGT-A group have since undergone frozen embryo transfer, with two live births (both from a second euploid transfer) with one euploid embryo remaining between these two patients. Two others in VOL. - NO. - / - 2019
Fertility and Sterility®
TABLE 2 Characteristics and outcomes of women undergoing medical embryo banking for FP Characteristic
FP (n [ 22 patients)
Age at cycle start (y), mean SD Total cycles reviewed, n Patients with 1 cycle, n (%) Patients with 2 cycles, n (%) Oocytes retrieved, n Patients with both oocytes and embryos cryopreserved in same cycle, n (mean oocytes vitrified) 2PN created, n Blastocysts vitrified (excludes 2PN vitrified), n Patients with no embryos for vitrification or biopsy, n (%) Euploid embryos vitrified, n (% of embryos biopsied) Aneuploid embryos vitrified, n (% of embryos biopsied) Mosaic embryos vitrified, n (% of embryos biopsied),
FP/PGT-A (n [ 29 patients)
P value
35.5 6 24 20 (90.9) 2 (9.1) 14.5 (263) 3 (10.3)
34.2 4 34 24 (82.8) 5 (17.2) 17.5 (164) 5 (15.0)
.4 — .8 .7 .5 1.0
7 (138) 5.5 (022) 4 (18) — — —
9 (036) 5 (018) 1 (3.4) 3.5 3.4 (48.2) 2.9 1.8 (45.5) 1.4 1.6 (18.0)
.8 .7 .2 — — —
Note: Data presented as mean standard deviation or median (range) unless specified otherwise. FP ¼ fertility preservation; PGT-A ¼ preimplantation genetic testing for aneuploidy; SD ¼ standard deviation. Blakemore. Role of PGT-A in fertility preservation. Fertil Steril 2019.
the FP/PGT-A group have re-presented for consultation with intent for upcoming embryo transfer.
DISCUSSION Although PGT-A has been well described among infertility populations (15), to our knowledge this study is the first to examine the use of PGT-A in medically indicated fertility preservation. We saw use of PGT-A increase among FP patients over time without limiting use of other FP methods. PGT-A provides valuable prognostic information about the reproductive potential of an embryo, which may be particularly useful to cancer patients presenting for fertility preservation. In our center, over half of EB cycles for fertility preservation during the study period used PGT-A. Use of PGT-A increased over time; however, further analysis is required to confirm this trend, given a modest sample size. Reasons for increasing use are many. Fertility clinics nationwide are increasingly using PGT-A in IVF (20). The ASRM recently published a guideline outlining the evidence base for its use among infertility populations (15), highlighting multiple randomized controlled trials suggesting that PGT-A aids in increased use of single embryo transfer (SET) with improved sustained implantation and delivery rates (21–23). The use of PGT-A in the fertility preservation population has not previously been described in the literature but has a particularly strong rationale. Patients with cancer may overestimate success rates following fertility preservation, making PGT-A particularly useful to understand an embryo’s reproductive potential. In our population, the average age was similar across study groups, and PGT-A results were consistent with expectations of age-related aneuploidy. Although patients less than 35 years of age have a less than 35% aneuploidy rate and a less than 10% risk of having an all-aneuploid cycle cohort, the risk of aneuploidy increases sharply after age 37 years, and could lead to limited viable embryos in cancer patients unable to complete multiple cycles (13). Without PGT-A, emVOL. - NO. - / - 2019
bryos banked by advanced maternal age patients have an increased likelihood of being aneuploid, with each untested embryo less likely to result in a live birth and more likely to result in miscarriage (16). Euploid embryos demonstrate consistent implantation rates regardless of age (24); thus a cryopreserved PGT-Aselected euploid embryo offers patients a clear understanding of their embryo’s future reproductive potential. The use of FP/PGT-A was not uniform across our study population. As predicted based on cancer prevalence among reproductive-aged women, breast cancer patients comprised more than half of the study group, and they were notably overrepresented in the population using PGT-A. Because breast cancer patients in the FP/PGT-A group were older at diagnosis than those in the FP group, they may have been more likely to consider PGT-A, given the higher rates of aneuploidy in advanced age groups. Patients with estrogen-receptorpositive breast cancers require 510 years of ovarian suppression following definitive treatment with chemotherapy; thus, embryos cryopreserved by young breast cancer patients may represent their only chance at autologous reproduction. Moreover, patients with estrogen-receptorpositive tumors may be particularly motivated to avoid coming off of ovarian suppression, starting estrogen supplementation as endometrial preparation for embryo transfer only to have an unsuccessful or aneuploid gestation. These patients may value a better understanding of their likelihood of success at the time of FP. Patients in both the FP/PGT-A and FP groups chose to cryopreserve oocytes in addition to embryos (2PN zygotes and blastocysts), and use of PGT-A in our study group did not limit these complementary approaches to fertility preservation. Cryopreservation of mature oocytes, now a standard of care in fertility preservation, allows patients control over both gamete disposition and their own reproductive autonomy (4). Both options are particularly important for cancer patients, given increased rates of divorce among cancer survivors (25). Our group has demonstrated comparable pregnancy outcomes between PGT-Aselected embryos from 5
ORIGINAL ARTICLE: FERTILITY PRESERVATION fresh and previously cryopreserved oocytes (26), as well as high live birth rates in cancer patients who cryopreserved oocytes prior to definitive treatment (27). Consequently, a similar number of patients in the FP/PGT-A (five) and the FP (three) group elected to cryopreserve oocytes. Similarly, cryopreservation of both 2PN zygotes and blastocysts was not affected by the choice to pursue PGT-A. Although these embryos were by definition untested (28), and this approach limits a patient’s knowledge of her embryo’s reproductive potential, cryopreserving embryos at an earlier developmental stage may expand future reproductive options (including future day-3 transfer, day-5 transfer, or PGT-A/ PGT-M). Although selecting euploid embryos prioritizes those embryos most likely to lead to a pregnancy in the future, PGT-A also shrinks the cohort of embryos available for future transfer. As expected, patients in the FP/PGT-A group initiated cancer therapy with fewer cryopreserved embryos than those in the FP group, although the former cryopreserved only euploid embryos and the latter cryopreserved untested embryos. The rate of aneuploidy climbs as patients age beyond 35 years, and PGT-A results may prompt more patients to choose to pursue additional FP cycles prior to definitive cancer treatment, as we saw in the FP/PGT-A patients. For those without any euploid embryos at the end of the FP process, however, use of PGT-A in medical EB cycles could lead to a ‘‘terminal’’ fertility diagnosis. This can lead to compounded grief in the context of multiple other stressors, including malignancy diagnosis and impending chemotherapy. As FP patients experience high levels of anxiety and depression upon enrollment for treatment (6), the potential psychological effect of PGT-A, and a potential ‘‘terminal’’ fertility diagnosis that may come from testing, must be carefully considered when counseling patients. Knowledge of embryo ploidy likely informed decision making: PGT-A results of low or no euploidy prompted three patients to pursue another EB cycle. All three patients gained at least one euploid embryo from the second cycle. The choice to pursue a second cycle was not without cost, however; among the seven patients who elected to pursue a second EB cycle, regardless of reason, the average time from consult to cancer treatment was extended by more than 1 month. The choice of PGT-A itself did not extend treatment time, however, with time from consult to initiation of cancer treatment comparable between groups and similar to that reported previously (29, 30). As female cancer patients often cite reluctance to delay treatment when declining fertility preservation, time from consult treatment is critical to informing their decisions (30, 31). Although patients in both groups were faced with the decision of whether or not to pursue another cycle, patients in the PGT-A group possessed more accurate knowledge of their embryo’s future reproductive potential and thus a stronger foundation on which to base their decision. Although our period of study was only 4 years, four of 24 patients (16.67%) in the PGT-A group have already returned for consultation, and two have now undergone transfer and successful live birth. Given the short time interval, this is a consistent or higher return rate than previously published 6
studies (27, 30), although our sample size is small and limited to only those patients who cryopreserved embryos. Because the majority of patients banking embryos over oocytes have a partner with whom they are creating embryos, they may be more likely to return to attempt pregnancy (30). The high rate of return and live birth in our PGT-A population may suggest increased confidence in fertility preservation using PGT-Aselected embryos. To our knowledge, our study represents the first published report of PGT-A in patients undergoing fertility preservation ahead of gonadotoxic therapies. We provide insight into the applications of PGT-A in medical EB, including suggestions as to how it might inform decision making in an oncofertility population. Our study is limited by a retrospective study design with inherent biases and relatively small sample size, although our center serves a relatively large number of FP patients. The content of our counseling may have shaped patient choice to use PGT-A. Our center routinely counsels medical EB patients on the benefits and drawbacks of PGT-A. Counseling surrounding the benefits of PGT-A includes the potential for gained knowledge of future reproductive potential and possible stratification for embryo selection in future embryo transfer. Counseling on the limitations of PGT-A includes the financial cost, risk of having no euploid embryos available, and the associated stress or anxiety this ‘‘terminal’’ fertility outcome, as well as technical limitations of the technology, which may include the low, but not zero, rates of error and ‘‘no-diagnosis’’ embryos. Counseling practices and availability of PGT-A services for FP patients may differ from center to center and therefore limit the generalizability of our results. This study was not designed to examine the decision to pursue or to decline PGT-A. However, three patients with breast cancer chose to cryopreserve at the 2pn zygote stage for possible future single-gene analysis (PGT-M), and one patient specifically quoted cost as her reason not to pursue PGTA. Future prospective studies are needed to better clarify the role of PGT-A in fertility preservation and to identify any potential for harm. Our study did not examine patient expense, although financial cost is a critical determinant in patients who decline PGT-A in IVF (32). Because cycle costs and insurance can vary, patients may be variably burdened financially by medical EB with PGT-A (15). PGT-A is becoming more widely understood as cost-effective in IVF, however (33). A recent decision analytic model suggested that for patients with more than one and fewer than 12 embryos, PGT-A can be cost saving and reduce time in treatment (34). The wide adoption of Next Generation Sequencing over array comparative genomic hybridization as the preferred platform for aneuploidy screening may also decrease cost (35) and improve outcomes, as our center saw during the study period (24). Patients banking embryos will also benefit from PGT-A by avoiding storage fees for potentially aneuploid embryos. As PGT-A in medical EB becomes more common, cost-effectiveness will be a needed future area of study. The long-term implications and costs of unidentified aneuploidy in FP patients— including future miscarriage, failed IVF cycles, and potentially delayed diagnosis of infertility—require further examination. VOL. - NO. - / - 2019
Fertility and Sterility® Use of PGT-A in medical EB can mitigate future psychological stress by optimizing future reproductive potential of frozen embryos, minimizing unnecessary storage fees of untested potentially aneuploid embryos, and providing critical information for patients faced with high levels of uncertainty. Although patients who elect to use PGT-A risk ending an EB cycle without usable embryos, many patients have already faced the prospect of loss of fertility when they were first counseled by their oncologist or FP provider (36, 37). Given the multiple stressors burdening the oncofertility population, robust psychosocial support is critical for patients undergoing fertility counseling (37). This is particularly critical for patients counseled on the use of PGT-A, given the implications of PGT-A results on future reproductive potential and the increased decision regret and anxiety among patients with negative outcomes following PGT-A (38). Our study demonstrated increasing use of PGT-A by patients cryopreserving embryos for fertility preservation at our center. With clear and appropriate counseling, PGT-A may provide patients facing fertility-threatening diagnoses a clearer understanding of their future reproductive potential and help guide decision making in these uniquely vulnerable patients. Acknowledgments: The authors gratefully acknowledge the patients who participated in this study, and thank the physician, nursing, laboratory, and ancillary staff at the New York University Langone Fertility Center.
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by site, incidence, survival and mortality. Bethesda, MD: National Cancer Institute; 2015. Hassold T, Hunt P. To err (meiotically) is human: the genesis of human aneuploidy. Nat Rev Genet 2001;2:280–91. Franasiak JM, Forman EJ, Hong KH, Werner MD, Upham KM, Treff NR, 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. Alfarawati S, Fragouli E, Colls P, Stevens J, Gutierrez-Mateo C, Schoolcraft WB, et al. The relationship between blastocyst morphology, chromosomal abnormality, and embryo gender. Fertil Steril 2011;95: 520–4. Penzias A, Bendikson K, Butts S, Coutifaris C, Falcone T, Fossum G, et al. The use of preimplantation genetic testing for aneuploidy (PGT-A): a committee opinion. Fertil Steril 2018;109:429–36. Rubio C, Bellver J, Rodrigo L, Castillon G, Guillen A, Vidal C, et al. In vitro fertilization with preimplantation genetic diagnosis for aneuploidies in advanced maternal age: a randomized, controlled study. Fertil Steril 2017; 107:1122–9. Forman EJ, Hong KH, Franasiak JM, Scott RT Jr. Obstetrical and neonatal outcomes from the BEST Trial: single embryo transfer with aneuploidy screening improves outcomes after in vitro fertilization without compromising delivery rates. Am J Obstet Gynecol 2014;210:157. Simon AL, Kiehl M, Fischer E, Proctor JG, Bush MR, Givens C, et al. Pregnancy outcomes from more than 1,800 in vitro fertilization cycles with the use of 24-chromosome single-nucleotide polymorphism–based preimplantation genetic testing for aneuploidy. Fertil Steril 2018;110:113–21. Ubaldi FM, Capalbo A, Colamaria S, Ferrero S, Maggiulli R, Vajta G, et al. Reduction of multiple pregnancies in the advanced maternal age population after implementation of an elective single embryo transfer policy coupled with enhanced embryo selection: pre- and post-intervention study. Hum Reprod 2015;30:2097–106. Kuliev A, Rechitsky S. Preimplantation genetic testing: current challenges and future prospects. Expert Rev Mol Diagn 2017;17:1071–88. Yang Z, Liu J, Collins GS, Salem SA, Liu X, Lyle SS, 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;5:24. Forman EJ, Hong KH, Ferry KM, Tao X, Taylor D, Levy B, et al. In vitro fertilization with single euploid blastocyst transfer: a randomized controlled trial. Fertil Steril 2013;100:100–7. Scott RTJ, Upham KM, Forman EJ, Hong KH, Scott KL, Taylor D, et al. Blastocyst biopsy with comprehensive chromosome screening and fresh embryo transfer significantly increases in vitro fertilization implantation and delivery rates: a randomized controlled trial. Fertil Steril 2013;100:697–703. Harton GL, Munne S, Surrey M, Grifo J, Kaplan B, McCulloh DH, et al. Diminished effect of maternal age on implantation after preimplantation genetic diagnosis with array comparative genomic hybridization. Fertil Steril 2013; 100:1695–703. Kirchhoff AC, Yi J, Wright J, Warner EL, Smith KR. Marriage and divorce among young adult cancer survivors. J Cancer Surviv 2012;6:441–50. Goldman KN, Kramer Y, Hodes-Wertz B, Noyes N, McCaffrey C, Grifo JA. Long-term cryopreservation of human oocytes does not increase embryonic aneuploidy. Fertil Steril 2015;103:662–8. Druckenmiller S, Goldman KN, Labella PA, Fino ME, Bazzocchi A, Noyes N. Successful oocyte cryopreservation in reproductive-aged cancer survivors. Obstet Gynecol 2016;127:474–80. Sabatini M, Wolkovich A, Macklin EA, L Wright D, Souter I, Toth T. Pronuclear embryo cryopreservation experience: outcomes for reducing the risk of ovarian hyperstimulation syndrome and for fertility preservation in cancer patients. J Assist Reprod Genet 2010;28:279–84. Baynosa J, Westphal LM, Madrigrano A, Wapnir I. Timing of breast cancer treatments with oocyte retrieval and embryo cryopreservation. J Am Coll Surg 2009;209:603–7. Moravek MB, Confino R, Smith KN, Kazer RR, Klock SC, Lawson AK, et al. Long-term outcomes in cancer patients who did or did not pursue fertility preservation. Fertil Steril 2018;109:349–55.
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Shnorhavorian M, Harlan LC, Smith AW, Keegan THM, Lynch CF, Prasad PK, et al. Fertility preservation knowledge, counseling, and actions among adolescent and young adult patients with cancer: a population-based study. Cancer 2015;121:3499–506. Gebhart MB, Hines RS, Penman A, Holland AC. How do patient perceived determinants influence the decision-making process to accept or decline preimplantation genetic screening? Fertil Steril 2016;105:188–93. Neal S, Morin SJ, Franasiak JM, Juneau CR, Zhan Y, Scott RT. Single embryo transfer (SET) following comphrehensive chromosome screening (CCS) is more cost effective than unscreened sequential SET. Fertil Steril 2016;106: e19. Neal SA, Morin SJ, Franasiak JM, Goodman LR, Juneau CR, Forman EJ, et al. Preimplantation genetic testing for aneuploidy is cost-effective, shortens
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treatment time, and reduces the risk of failed embryo transfer and clinical miscarriage. Fertil Steril 2018;110:896–904. Fragouli E. Next generation sequencing for preimplantation genetic testing for aneuploidy: friend or foe? Fertil Steril 2018;109:606–7. Hershberger PE, Finnegan L, Pierce PF, Scoccia B. The decision-making process of young adult women with cancer who considered fertility cryopreservation. J Obstet Gynecol Neonatal Nurs 2013;42:59–69. Deshpande NA, Braun IM, Meyer FL. Impact of fertility preservation counseling and treatment on psychological outcomes among women with cancer: a systematic review. Cancer 2015;121:3938–47. Goldman KN, Blakemore J, Kramer Y, McCulloh DH, Lawson A, Grifo JA. Beyond the biopsy: predictors of decision regret and anxiety following preimplantation genetic testing for aneuploidy. Hum Reprod 2019;34:1260–9.
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Prognostic role of preimplantation genetic testing for aneuploidy in medically indicated fertility preservation Jennifer K. Blakemore, M.D.,a Emma C. Trawick, M.D.,a,b James A. Grifo, M.D., Ph.D.,a and Kara N. Goldman, MDa,b a New York University Langone Fertility Center, New York, New York; and b Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
Objective: To investigate the use of preimplantation genetic testing for aneuploidy (PGT-A) among patients pursuing embryo banking (EB) for medically indicated fertility preservation (FP). Design: Retrospective cohort. Setting: University-affiliated fertility center. Patients: All patients who underwent in vitro fertilization with or without PGT-A for medically indicated FP between January 2014 and April 2018. Interventions: None Main Outcome Measures: EB cycle characteristics, subsequent cycle pursuit/outcomes, and frozen embryo transfer (FET) outcomes. Results: A total of 58 medical EB cycles were compared; 34 cycles used PGT-A. Of the EB patients with breast cancer, 67% used PGT-A; other indications were evenly divided between PGT-A (FP/PGT-A) and no PGT-A (FP). PGT-A use increased over the study period. Groups were similar in age, days of stimulation, and days from initial FP consultation to treatment initiation. Number of oocytes (14.5 [263] FP vs. 17.5 [164] FP/PGT-A), 2PN zygotes (7 [138] FP vs. 9 [036] FP/PGT-A), and blastocysts (5.5 [022] FP vs. 5 [018] FP/PGT-A) cryopreserved were similar between groups. Equal numbers cryopreserved both oocytes and embryos (5 vs. 3). Five FP/PGT-A patients underwent a second EB cycle. Among FP/PGT-A patients, an average of 6.7 5 blastocysts underwent PGT-A, with 3.5 3 (48.2%) euploid embryos cryopreserved for future FET compared to an average of 7.2 7 untested embryos in the FP group. Conclusion: PGT-A in medical EB cycles increased over time and did not limit the use of other FP methods such as oocyte cryopreservation. In some cases, poor PGT-A results informed patients to pursue a second EB cycle. When counseling patients, the prognostic benefits of PGT-A must be weighed against the financial costs and potential for ‘‘terminal’’ fertility diagnosis. (Fertil SterilÒ 2019;-: -–-. Ó2019 by American Society for Reproductive Medicine.) Key Words: Fertility preservation, preimplantation genetic testing for aneuploidy (PGT-A), embryo banking Discuss: You can discuss this article with its authors and other readers at https://www.fertstertdialog.com/users/16110-fertilityand-sterility/posts/53999-28792
M
ore than 91,000 women less than 45 years of age are diagnosed with cancer annually, but advances in treatment have led to increased rates of survival and improved quality of life (1). Many of
these life-saving treatments compromise fertility, however, and impair a patient’s ability to achieve familybuilding goals (2). According to the American Society of Clinical Oncology (ASCO) and the American Society for
Reproductive Medicine (ASRM), the standard of care in fertility preservation (FP) for those undergoing gonadotoxic treatment is oocyte and embryo cryopreservation (3–5). By freezing oocytes or embryos, cancer patients
Received August 13, 2019; revised September 25, 2019; accepted September 26, 2019. J.K.B. has nothing to disclose. E.C.T. has nothing to disclose. J.G. has nothing to disclose; K.N.G. has nothing to disclose. Research was performed at New York University and manuscript completed while at Northwestern University (E.C.T. and K.N.G.). Correspondence: Jennifer Blakemore, M.D., NYU Langone Fertility Center, 660 First Avenue, Fifth Floor, New York, NY 100 16-3295 (E-mail: Jennifer. [email protected]). Fertility and Sterility® Vol. -, No. -, - 2019 0015-0282/$36.00 Copyright ©2019 American Society for Reproductive Medicine, Published by Elsevier Inc. https://doi.org/10.1016/j.fertnstert.2019.09.040 VOL. - NO. - / - 2019
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ORIGINAL ARTICLE: FERTILITY PRESERVATION may pursue autologous reproduction following definitive cancer treatment. Unfortunately, the success of fertility preservation may be overestimated by cancer patients. Nearly half of FP patients believe that they have a >60% chance of pregnancy with each embryo transfer (6), a belief at odds with the <50% likelihood of pregnancy per embryo transfer, which declines as patients age beyond 35 years (7). Multiple studies have suggested that even those seeking infertility treatment overestimate the likelihood of success of assisted reproductive technology (ART) (6, 8–10). This optimism can have particularly devastating consequences for those undergoing FP prior to cancer treatment with a limited window in which to pursue FP. As cancer incidence rises with advancing age (11), many cancer patients are already subject to impaired fertility prior to treatment because of age-related aneuploidy (12). In the limited time that patients have to undergo FP while awaiting treatment, older patients will also have fewer oocytes retrieved (13). Compounding these problems, standard morphologic grading is a poor predictor of embryo competence, as up to 50% of high-quality blastocysts are aneuploid (14). With fewer embryos of unknown ploidy, cancer patients may face failed in vitro fertilization (IVF) cycles, miscarriages, and unintended childlessness when finally ready to build their family. Better assessing embryo quality and future reproductive capability is thus critical in providing patients maximal information for decision making. Preimplantation genetic testing for aneuploidy (PGT-A) may provide a more accurate picture of future reproductive capability, and its utility in fertility preservation for cancer patients has been suggested by ASRM (15). PGT-A has already played an increasing role in embryo selection in IVF, and its utility is particularly compelling among women more than 38 years of age (16). PGT-A helps to prioritize embryos for transfer and optimize chances of pregnancy after a single embryo transfer (17–19), which may be particularly important for cancer patients with limited time to complete fertility preservation and therefore finite numbers of available embryos. Although many studies have examined the use of preimplantation genetic testing for monogenic diseases and the use of PGT-A among infertile patients, to our knowledge, no study exists on the use of PGT-A in cancer patients undergoing FP. The use of PGT-A in FP for cancer patients may allow patients to better understand the reproductive potential of their banked embryos and aid in more directive counseling by providers. We thus investigated the use of PGT-A among patients undergoing embryo banking (EB) for FP.
MATERIALS AND METHODS Inclusion and Exclusion Criteria With Institutional Review Board approval #S13-00389, we performed a retrospective cohort study of all IVF cycles performed for EB at the NYU Langone Fertility Center from January 1, 2014, through April 30, 2018. Patients with cancer or other fertility-threatening diagnoses who presented for 2
fertility preservation were identified. All patients undergoing planned EB were excluded. Patients undergoing exclusive oocyte cryopreservation cycles for fertility preservation were also excluded. In addition, patients meeting inclusion criteria but whose cycles were canceled prior to oocyte retrieval for poor response were also excluded. In total, 58 cycles in 51 patients were identified and included. Included patients underwent standard PGT-A counseling at our center, including descriptions of clinic-specific outcomes by age and cost of testing.
Stimulation Protocols Controlled ovarian hyperstimulation (COH) using a GnRH antagonist protocol with administration of gonadotropins (recombinant follicle-stimulating hormone [FSH], human menopausal gonadotropins [HMG], or both) were prescribed for each patient based on that patient’s antral follicle count, age, FSH level, and anti-M€ ullerian hormone level (AMH) (if available) as determined by their physician. Hormone levels (estradiol [E2], FSH, luteinizing hormone [LH], and P4) and transvaginal ultrasound at time of initial consultation were used to determine cycle status for each patient to determine optimal cycle start. Patients used one of four possible cycle starts: 1) cycle day 2 after last menstrual period, 2) luteal phase start prior to menses, 3) scheduled start after use of oral contraceptive pill suppression, or 4) random start. Protocols using low-dose or micro-dose downregulation with leuprolide acetate are used at our center but were not employed for patients included in this study. A subset of patients, mostly with breast cancer, were also administered oral letrozole during follicular stimulation. Follicular growth and maturation were monitored by transvaginal ultrasound and serum E2 level. The GnRH antagonist (Cetrotide or Ganirelix) was added when a lead follicle was identified as 13 mm or greater or the E2 was greater than 1000 pg/mL. Either human chorionic gonadotropin (hCG) alone or hCG with leuprolide acetate was used for trigger of final follicular maturation, with planned oocyte aspiration scheduled for 35 hours after administration. Oocyte retrieval was performed via ultrasound-guided transvaginal aspiration. Both insemination and intracytoplasmic sperm injection (ICSI) were used for fertilization of oocytes; ICSI was used if indicated by semen parameters or if patients anticipated needing future preimplantation genetic testing for monogenic disorders (PGT-M), but in our center PGT-A alone is not an indication for the use of ICSI. Standard laboratory techniques were used to follow each patient’s individualized plan as follows: 1) to culture all zygotes to the day 5/6 blastocyst stage, 2) to cryopreserve zygotes at the 2PN stage, or 3) to cryopreserve a fraction of oocytes retrieved and to fertilize the remaining oocytes and culture to the day 5/6 blastocyst stage. If PGT-A was desired, trophectoderm biopsy was performed on day 5 or 6 at the blastocyst stage prior to embryo cryopreservation via vitrification. Biopsy analysis was performed by array comparative genomic hybridization (array CGH) or next-generation sequencing (NGS). VOL. - NO. - / - 2019
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FIGURE 1
Embryo Cryopreserva on without PGT-A (n=22)
Other: Nasopharyngeal Cancer Sarcoma Melanoma Scheduled BSO
Embryo Cryopreserva on with PGT-A (n=29)
Other: Male Prostate Sarcoma Acous c Neuroma Thyroid Cancer
Breast cancer
Lymphoma
Endometrial Cancer
Ovarian Cancer
Cervical Cancer
Other
Indication for embryo banking. Blakemore. Role of PGT-A in fertility preservation. Fertil Steril 2019.
Outcomes and Statistical Analysis Included patients who used PGT-A were compared to those who did not. We report included patient demographic and clinical characteristics including diagnosis. Outcomes measured include EB cycle characteristics including time to treatment, time to consult, oocytes retrieved, and the number of oocytes, 2PN zygotes, and embryos cryopreserved; pursuit VOL. - NO. - / - 2019
and outcomes of a subsequent cycles; and embryo transfer and live birth outcomes. Continuous variables were first assessed for normality using the AndersonDarling test. All parametric continuous variables were analyzed using Student’s t-test, and all nonparametric variables were compared using the MannWhitney U test. Categorical variables were analyzed 3
ORIGINAL ARTICLE: FERTILITY PRESERVATION
TABLE 1 Characteristics of cycle timing for medical embryo banking for FP. Characteristic Days of stimulation Time from initial consult to cycle start (d) Starting stimulation on initial consult day, n (%) Time from consult to start of treatment/ iatrogenic injury (d) Menstrual cycle phase at time of cycle start, n (%) Random start (follicular phase) Day 2 follicular start Luteal phase cycle start Oral contraceptive control for cycle start
FP (n [ 24 cycles) 11.1 2 6.5 (077) 7 (29.2) 24 (13102) 7 (29.2) 12 (50) 3 (12.5) 2 (8.3)
FP/PGT-A (n [ 34 cycles)
P value
11.8 2 5 (0119) 10 (29.4) 26 (10120)
.1 .5 .7 .9
7 (20.6) 20 (58.8) 5 (14.7) 2 (5.9)
.7 .5 1.0 1.0
Note: Data presented as mean standard deviation or median (range) unless specified otherwise. FP ¼ fertility preservation; PGT-A ¼ preimplantation genetic testing for aneuploidy; SD ¼ standard deviation Blakemore. Role of PGT-A in fertility preservation. Fertil Steril 2019.
using the Fisher’s exact or c2 test where appropriate. A P value of < .05 was considered statistically significant. Results are reported as mean standard deviation, median (range), or percentage where appropriate.
RESULTS A total of 58 medical EB cycles from 51 patients were identified and analyzed. In all, 34 cycles (59%) from 24 patients used PGT-A (FP/PGT-A) and were compared to 24 cycles (41%) from 20 patients who did not employ PGT-A (FP). One patient in the FP/PGT-A group intended PGT-A in her second cycle but ultimately had no embryos for biopsy. The use of FP/PGT-A increased over the study period, with three cycles of FP/PGT-A in 2014, six cycles in 2015, nine cycles in 2016, 11 cycles in 2017, and six cycles between January and April of 2018. There were a variety of diagnoses that were evenly divided between groups, including lymphoma, melanoma, endometrial cancer, ovarian cancer, cervical cancer, thyroid cancer, and male prostate cancer (Fig. 1). The majority of patients had a diagnosis of breast cancer (50.0% in the FP group vs. 62.1% in the FP/PGT-A group). None of the patients included in this study used donor sperm. Both groups were similar in mean age (years) at time of first cycle start (35.5 6 FP vs. 34.2 4 FP/PGT-A, P¼ .4) and in the timing of first cycle start prior to treatment, as shown in Table 1. In addition, the time (days) from fertility preservation consult to first cycle start (6.5 [077] FP vs. 5 [0119] FP/ PGT-A, P¼ .5) and number of days of stimulation (11.1 2 FP vs. 11.8 2 FP/PGT-A, P¼ .1) were not different between groups (Table 1). Patients in both the FP and FP/PGT-A groups had similar cycle characteristics (Table 2), including similar age at cycle start (as described above) and similar number of oocytes retrieved (14.5 [263] FP vs. 17.5 [164] FP/PGT-A, P¼ .5). Similar numbers of patients in each group cryopreserved both embryos and oocytes (n ¼ 3 FP vs. n ¼ 5 FP/PGT-A, P ¼ 1.0), with a similar number of oocytes cryopreserved in each group. Groups were also similar in the number of 2PN zygotes created (7 [138] FP vs. 9 [036] FP/PGT-A, P¼ .8) and the number of blastocysts vitrified (5.5 [022] FP vs. 5 [018] FP/PGT-A, P¼ .7). The mean number of blastocysts 4
vitrified excludes six patients in the FP group who cryopreserved at the 2PN stage, three of whom where carriers of the hereditary breast cancer susceptibility syndrome, BRCA1/2, and intended future genetic analysis with PGT-M. This comparison also excludes four patients in the FP/PGTA group who froze an average of 10.8 additional nonbiopsied blastocysts. Five patients in the FP/PGT-A group underwent a second medical EB cycle: two for poor response (one patient with all cleavage-stage embryos on day 6 and one patient with only 2 of 12 embryos meeting criteria for biopsy), two for low euploidy (1 euploid embryo after 1 cycle), and one patient with no euploid embryos. In comparison to two patients among the FP group; one patient with only two morulae on day 6 and one patient with only two blastocysts vitrified. All five patients in the FP/PGT-A group who completed a second cycle had breast cancer, and four of these five patients had a traditional cycle day 2 start for their second cycle. The average time between initial consult to initiation of treatment in the FP/PGT-A group who completed two cycles was 82 45 days. This includes one start in a patient during the luteal phase of the first stimulation, two true day 2 starts in patients who delayed tamoxifen after consultation with their oncologist, and two true day 2 starts in patients who returned after mastectomy prior to chemotherapy. In the FP group, one patient with nasopharyngeal cancer initiated her second cycle during the luteal phase following her first cycle, and one patient with an osteosarcoma started her second cycle on day 2 after her first stimulation. The average time from initial consult to treatment in the FP group who pursued a second cycle was 44.5 13 days. Despite use of a second cycle, however, the average time (days) from consult to start of treatment did not differ between groups overall (24 [1312] FP vs. 26 [10120] FP/PGT-A, P¼ .9) (Table 1). The FP/PGT-A patients had an average of 3.5 3 euploid embryos cryopreserved (48.2% of embryos biopsied) for future embryo transfer vs. 7.2 7 (median 5.5, range 022) untested embryos cryopreserved in the FP group. At the time of publication, two breast cancer survivors in the FP/PGT-A group have since undergone frozen embryo transfer, with two live births (both from a second euploid transfer) with one euploid embryo remaining between these two patients. Two others in VOL. - NO. - / - 2019
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TABLE 2 Characteristics and outcomes of women undergoing medical embryo banking for FP Characteristic
FP (n [ 22 patients)
Age at cycle start (y), mean SD Total cycles reviewed, n Patients with 1 cycle, n (%) Patients with 2 cycles, n (%) Oocytes retrieved, n Patients with both oocytes and embryos cryopreserved in same cycle, n (mean oocytes vitrified) 2PN created, n Blastocysts vitrified (excludes 2PN vitrified), n Patients with no embryos for vitrification or biopsy, n (%) Euploid embryos vitrified, n (% of embryos biopsied) Aneuploid embryos vitrified, n (% of embryos biopsied) Mosaic embryos vitrified, n (% of embryos biopsied),
FP/PGT-A (n [ 29 patients)
P value
35.5 6 24 20 (90.9) 2 (9.1) 14.5 (263) 3 (10.3)
34.2 4 34 24 (82.8) 5 (17.2) 17.5 (164) 5 (15.0)
.4 — .8 .7 .5 1.0
7 (138) 5.5 (022) 4 (18) — — —
9 (036) 5 (018) 1 (3.4) 3.5 3.4 (48.2) 2.9 1.8 (45.5) 1.4 1.6 (18.0)
.8 .7 .2 — — —
Note: Data presented as mean standard deviation or median (range) unless specified otherwise. FP ¼ fertility preservation; PGT-A ¼ preimplantation genetic testing for aneuploidy; SD ¼ standard deviation. Blakemore. Role of PGT-A in fertility preservation. Fertil Steril 2019.
the FP/PGT-A group have re-presented for consultation with intent for upcoming embryo transfer.
DISCUSSION Although PGT-A has been well described among infertility populations (15), to our knowledge this study is the first to examine the use of PGT-A in medically indicated fertility preservation. We saw use of PGT-A increase among FP patients over time without limiting use of other FP methods. PGT-A provides valuable prognostic information about the reproductive potential of an embryo, which may be particularly useful to cancer patients presenting for fertility preservation. In our center, over half of EB cycles for fertility preservation during the study period used PGT-A. Use of PGT-A increased over time; however, further analysis is required to confirm this trend, given a modest sample size. Reasons for increasing use are many. Fertility clinics nationwide are increasingly using PGT-A in IVF (20). The ASRM recently published a guideline outlining the evidence base for its use among infertility populations (15), highlighting multiple randomized controlled trials suggesting that PGT-A aids in increased use of single embryo transfer (SET) with improved sustained implantation and delivery rates (21–23). The use of PGT-A in the fertility preservation population has not previously been described in the literature but has a particularly strong rationale. Patients with cancer may overestimate success rates following fertility preservation, making PGT-A particularly useful to understand an embryo’s reproductive potential. In our population, the average age was similar across study groups, and PGT-A results were consistent with expectations of age-related aneuploidy. Although patients less than 35 years of age have a less than 35% aneuploidy rate and a less than 10% risk of having an all-aneuploid cycle cohort, the risk of aneuploidy increases sharply after age 37 years, and could lead to limited viable embryos in cancer patients unable to complete multiple cycles (13). Without PGT-A, emVOL. - NO. - / - 2019
bryos banked by advanced maternal age patients have an increased likelihood of being aneuploid, with each untested embryo less likely to result in a live birth and more likely to result in miscarriage (16). Euploid embryos demonstrate consistent implantation rates regardless of age (24); thus a cryopreserved PGT-Aselected euploid embryo offers patients a clear understanding of their embryo’s future reproductive potential. The use of FP/PGT-A was not uniform across our study population. As predicted based on cancer prevalence among reproductive-aged women, breast cancer patients comprised more than half of the study group, and they were notably overrepresented in the population using PGT-A. Because breast cancer patients in the FP/PGT-A group were older at diagnosis than those in the FP group, they may have been more likely to consider PGT-A, given the higher rates of aneuploidy in advanced age groups. Patients with estrogen-receptorpositive breast cancers require 510 years of ovarian suppression following definitive treatment with chemotherapy; thus, embryos cryopreserved by young breast cancer patients may represent their only chance at autologous reproduction. Moreover, patients with estrogen-receptorpositive tumors may be particularly motivated to avoid coming off of ovarian suppression, starting estrogen supplementation as endometrial preparation for embryo transfer only to have an unsuccessful or aneuploid gestation. These patients may value a better understanding of their likelihood of success at the time of FP. Patients in both the FP/PGT-A and FP groups chose to cryopreserve oocytes in addition to embryos (2PN zygotes and blastocysts), and use of PGT-A in our study group did not limit these complementary approaches to fertility preservation. Cryopreservation of mature oocytes, now a standard of care in fertility preservation, allows patients control over both gamete disposition and their own reproductive autonomy (4). Both options are particularly important for cancer patients, given increased rates of divorce among cancer survivors (25). Our group has demonstrated comparable pregnancy outcomes between PGT-Aselected embryos from 5
ORIGINAL ARTICLE: FERTILITY PRESERVATION fresh and previously cryopreserved oocytes (26), as well as high live birth rates in cancer patients who cryopreserved oocytes prior to definitive treatment (27). Consequently, a similar number of patients in the FP/PGT-A (five) and the FP (three) group elected to cryopreserve oocytes. Similarly, cryopreservation of both 2PN zygotes and blastocysts was not affected by the choice to pursue PGT-A. Although these embryos were by definition untested (28), and this approach limits a patient’s knowledge of her embryo’s reproductive potential, cryopreserving embryos at an earlier developmental stage may expand future reproductive options (including future day-3 transfer, day-5 transfer, or PGT-A/ PGT-M). Although selecting euploid embryos prioritizes those embryos most likely to lead to a pregnancy in the future, PGT-A also shrinks the cohort of embryos available for future transfer. As expected, patients in the FP/PGT-A group initiated cancer therapy with fewer cryopreserved embryos than those in the FP group, although the former cryopreserved only euploid embryos and the latter cryopreserved untested embryos. The rate of aneuploidy climbs as patients age beyond 35 years, and PGT-A results may prompt more patients to choose to pursue additional FP cycles prior to definitive cancer treatment, as we saw in the FP/PGT-A patients. For those without any euploid embryos at the end of the FP process, however, use of PGT-A in medical EB cycles could lead to a ‘‘terminal’’ fertility diagnosis. This can lead to compounded grief in the context of multiple other stressors, including malignancy diagnosis and impending chemotherapy. As FP patients experience high levels of anxiety and depression upon enrollment for treatment (6), the potential psychological effect of PGT-A, and a potential ‘‘terminal’’ fertility diagnosis that may come from testing, must be carefully considered when counseling patients. Knowledge of embryo ploidy likely informed decision making: PGT-A results of low or no euploidy prompted three patients to pursue another EB cycle. All three patients gained at least one euploid embryo from the second cycle. The choice to pursue a second cycle was not without cost, however; among the seven patients who elected to pursue a second EB cycle, regardless of reason, the average time from consult to cancer treatment was extended by more than 1 month. The choice of PGT-A itself did not extend treatment time, however, with time from consult to initiation of cancer treatment comparable between groups and similar to that reported previously (29, 30). As female cancer patients often cite reluctance to delay treatment when declining fertility preservation, time from consult treatment is critical to informing their decisions (30, 31). Although patients in both groups were faced with the decision of whether or not to pursue another cycle, patients in the PGT-A group possessed more accurate knowledge of their embryo’s future reproductive potential and thus a stronger foundation on which to base their decision. Although our period of study was only 4 years, four of 24 patients (16.67%) in the PGT-A group have already returned for consultation, and two have now undergone transfer and successful live birth. Given the short time interval, this is a consistent or higher return rate than previously published 6
studies (27, 30), although our sample size is small and limited to only those patients who cryopreserved embryos. Because the majority of patients banking embryos over oocytes have a partner with whom they are creating embryos, they may be more likely to return to attempt pregnancy (30). The high rate of return and live birth in our PGT-A population may suggest increased confidence in fertility preservation using PGT-Aselected embryos. To our knowledge, our study represents the first published report of PGT-A in patients undergoing fertility preservation ahead of gonadotoxic therapies. We provide insight into the applications of PGT-A in medical EB, including suggestions as to how it might inform decision making in an oncofertility population. Our study is limited by a retrospective study design with inherent biases and relatively small sample size, although our center serves a relatively large number of FP patients. The content of our counseling may have shaped patient choice to use PGT-A. Our center routinely counsels medical EB patients on the benefits and drawbacks of PGT-A. Counseling surrounding the benefits of PGT-A includes the potential for gained knowledge of future reproductive potential and possible stratification for embryo selection in future embryo transfer. Counseling on the limitations of PGT-A includes the financial cost, risk of having no euploid embryos available, and the associated stress or anxiety this ‘‘terminal’’ fertility outcome, as well as technical limitations of the technology, which may include the low, but not zero, rates of error and ‘‘no-diagnosis’’ embryos. Counseling practices and availability of PGT-A services for FP patients may differ from center to center and therefore limit the generalizability of our results. This study was not designed to examine the decision to pursue or to decline PGT-A. However, three patients with breast cancer chose to cryopreserve at the 2pn zygote stage for possible future single-gene analysis (PGT-M), and one patient specifically quoted cost as her reason not to pursue PGTA. Future prospective studies are needed to better clarify the role of PGT-A in fertility preservation and to identify any potential for harm. Our study did not examine patient expense, although financial cost is a critical determinant in patients who decline PGT-A in IVF (32). Because cycle costs and insurance can vary, patients may be variably burdened financially by medical EB with PGT-A (15). PGT-A is becoming more widely understood as cost-effective in IVF, however (33). A recent decision analytic model suggested that for patients with more than one and fewer than 12 embryos, PGT-A can be cost saving and reduce time in treatment (34). The wide adoption of Next Generation Sequencing over array comparative genomic hybridization as the preferred platform for aneuploidy screening may also decrease cost (35) and improve outcomes, as our center saw during the study period (24). Patients banking embryos will also benefit from PGT-A by avoiding storage fees for potentially aneuploid embryos. As PGT-A in medical EB becomes more common, cost-effectiveness will be a needed future area of study. The long-term implications and costs of unidentified aneuploidy in FP patients— including future miscarriage, failed IVF cycles, and potentially delayed diagnosis of infertility—require further examination. VOL. - NO. - / - 2019
Fertility and Sterility® Use of PGT-A in medical EB can mitigate future psychological stress by optimizing future reproductive potential of frozen embryos, minimizing unnecessary storage fees of untested potentially aneuploid embryos, and providing critical information for patients faced with high levels of uncertainty. Although patients who elect to use PGT-A risk ending an EB cycle without usable embryos, many patients have already faced the prospect of loss of fertility when they were first counseled by their oncologist or FP provider (36, 37). Given the multiple stressors burdening the oncofertility population, robust psychosocial support is critical for patients undergoing fertility counseling (37). This is particularly critical for patients counseled on the use of PGT-A, given the implications of PGT-A results on future reproductive potential and the increased decision regret and anxiety among patients with negative outcomes following PGT-A (38). Our study demonstrated increasing use of PGT-A by patients cryopreserving embryos for fertility preservation at our center. With clear and appropriate counseling, PGT-A may provide patients facing fertility-threatening diagnoses a clearer understanding of their future reproductive potential and help guide decision making in these uniquely vulnerable patients. Acknowledgments: The authors gratefully acknowledge the patients who participated in this study, and thank the physician, nursing, laboratory, and ancillary staff at the New York University Langone Fertility Center.
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