The frequency of X-linked disorders in preimplantation genetic diagnosis (PGD): a call for wider screening

BACKGROUND: Until the first birth from uterine transplantation in 2015, uterine factor infertility (UFI) was considered an incurable problem. MayerRokitansky-Kuster-Hauser (MRKH) syndrome is the predominant congenital cause of UFI, with a prevalence of 1:4000 women (1). Some acquired cases of UFI are the results of surgery or uterine damage. Gestational surrogacy and adoption have historically been the only reproductive options for women with UFI. However, these choices may be limited by religious, ethical, legal, or cultural factors. OBJECTIVE: The objective of this study is to describe characteristics of women with UFI seeking information on uterine transplantation at our institution. MATERIALS AND METHODS: 34 reproductive aged women contacted our institution regarding uterine transplantation and were screened from 4/ 24/2015 to present. Descriptive characteristics are reported below. RESULTS: 34 women with UFI were screened for our transplantation protocol. The mean age was 31 years (range: 20-47 years). 26% (n¼9) of patients had UFI secondary to MRKH versus 70% (n¼24) with prior hysterectomy. One patient had an intersex diagnosis. The mean age in the MRKH group was 25 versus 32 in the acquired UFI group. The most common cause for seeking uterine transplantation was hysterectomy, with indications for surgery including endometriosis, fibroids, post-partum hemorrhage, and gynecological malignancies. Of these hysterectomies, only 20% (n¼5) were due to a gynecologic malignancy. 29% (n¼7) were secondary to obstetric complications. The remainder were performed for benign reasons (Chart 1). Patients were largely Caucasian (62%, n¼21) or African American (20%, n¼7) (Chart 2). 91% of patients (n¼31) were American and 3 were international. 15 out of 34 women were legally married (44%) and 2 (6%) were without a partner. Six women (17%) had at least one biological child. CONCLUSIONS: Following recent reported live births after uterine transplantation, patients are now actively seeking uterine transplantation protocols in the United States. These women have wide-ranging ages, social situations, and medical histories. The greater number of patients with acquired UFI compared to MRKH syndrome in the first 34 screened patients was unexpected. Careful consideration and screening of candidates including

medical, surgical, social and cultural histories is a prerequisite to a successful transplant protocol. FINANCIAL SUPPORT: None. Reference 1. Oppelt P, Renner SP, Kellermann A, Brucker S, Hauser GA, Ludwig KS, Strissel PL, Strick R, Wallwiener D, Beckmann MW. Clinical aspects of Mayer-Rokitansky-Kuester-Hauser syndrome: recommendations for clinical diagnosis and staging. P-7 THE FREQUENCY OF X-LINKED DISORDERS IN PREIMPLANTATION GENETIC DIAGNOSIS (PGD): A CALL FOR WIDER SCREENING. E. Armenti,a S. Munne,a C. Mullen,b T. Singer,b A. Jordan,a A. Hershlag.b aReprogenetics, Livingston, NJ, USA; bNorthwell Health, Manhasset, NY, USA. BACKGROUND: With the advent of pan-ethnic carrier screening, testing IVF patients for a broad spectrum of genetic disorders is becoming increasingly common. However, X-linked disorders are often excluded from these panels, though identification of carrier females would allow for such patients to undergo preimplantation genetic diagnosis (PGD) to avoid the birth of an affected child. OBJECTIVE: Assess the benefit of including X-linked disorders on carrier screening panels by characterizing the population of patients pursuing IVF and PGD for X-linked disorders relative to the disorders included on standard pan-ethnic carrier screening panels. MATERIALS AND METHODS: Information regarding X-linked cases obtained from Reprogenetics’ internal data (2004-present) and chart review. List of disease screened by pan-ethnic companies obtained from public websites. RESULTS: Of the 1,910 single gene disorder PGD cases assessed, 326 (17.1%) were for X-linked disorders. Commonly tested disorders included fragile X syndrome, hemophilia A and B, Duchenne muscular dystrophy and Alport syndrome (chart 1). Upon review of the test lists for six pan-ethnic carrier screen companies, one of the six screens for over four X-linked disease; two screen for only fragile X syndrome and one does not screen for X-linked disorders. Of the X-linked cases presenting for PGD, 24% (79) would have been missed by all carrier screens surveyed and 46.6% (152) by 5 /6 of screens. CONCLUSIONS: While X-linked disorders represent a large percentage of PGD cases, they comprise a much smaller proportion of diseases included in standard carrier screening. An X-linked disease poses a 50% risk to the male offspring, equivalent to dominant autosomal mutation. The elimination of male offspring by ‘‘sexing the embryo’’ is ethically challenged and should be replaced by PGD identifying healthy male and female embryos. Diagnosis of X-linked mutations is especially critical in egg donors, where family history may be intentionally or unintentionally omitted. The non-inclusion of these diseases from such panels results in decreased identification of IVF patients who need PGD. The significance of finding these mutations far outweighs the difficulty in the molecular technique required in some cases

Chart 1. Underlying Causes of Hysterectomy

Chart 2. Uterine Transplant Candidates’ Ethnicity

e12

PCRS Abstracts

Chart 1.

Vol. 105, No. 2, Supplement, February 2016

(e.g. deletions and inversions). De novo x-linked mutations present another challenge, and novel PGD techniques have been suggested (e.g. haplotyping). As many X-linked disorders have implications for the health of female carriers, these conditions do carry a heavier genetic counseling burden. However, with the proper genetic counseling, inclusion of X-linked disorders on broad-spectrum carrier screen panels should be strongly considered. P-8 RECIPIENTS OF OOCYTE DONATION HAVE HIGHER RATES OF GESTATIONAL HYPERTENSIVE DISEASE THAN THOSE CONCEIVED VIA AUTOLOGOUS IN VITRO FERTILIZATION (IVF). E. Barnard, K. Borowski, J. Jensen, L. Vaughan, K. Mara, E. Stewart, C. Coddington. Obstetrics and Gynecology, Mayo Clinic, 200 1st Street SW, Rochester, MN, USA. BACKGROUND: Hypertensive disease is a leading cause of maternal and neonatal morbidity and mortality, as well as a significant contributor to medically-indicated preterm delivery. OBJECTIVE: The purpose of this study was to examine the incidence of pre-eclampsia and other adverse perinatal outcomes in our population of donor oocyte recipients compared to age-matched women undergoing in vitro fertilization (IVF) using autologous oocytes. MATERIALS AND METHODS: Donor oocyte recipients (OD) who delivered at twenty weeks gestation or greater (n¼27 pregnancies in 21 women) were matched to women who underwent IVF with autologous oocytes (n¼27 pregnancies in 27 women) (AO) at Mayo Clinic in Rochester, Minnesota, from 2005 to 2014. Patients were matched on parity, plurality, and age (+/- 5 years). In order to account for correlation between multiple pregnancies in the same woman, generalized linear models were fit using generalized estimating equation (GEE) methodology to test for differences between the OD and AO groups after adjusting for residual differences in age. RESULTS: Gestational hypertension occurred more frequently in the OD group compared to the AO group (33% vs 7%, p¼0.02). Although differences in pre-eclampsia did not reach statistical significance (p¼0.12), preeclampsia with severe features occurred in 4 OD (15%) and no AO pregnancies while pre-eclampsia without severe features occurred in 1 pregnancy in each group. Gestational age at delivery (35.75.1 vs 38.32.5 weeks, p¼0.08) and birthweight (27401072 vs 3322504 grams, p¼0.06) tended to be lower in the OD group but also did not reach statistical significance. Mode of delivery was similar between groups (p¼0.22), with cesarean section occurring in 63% of OD and 48% of AO pregnancies. Mean (SD) maternal age at delivery for OD and AO pregnancies was 42.14.5 and 40.62.2, respectively (p¼0.28). CONCLUSIONS: Hypertensive disease in pregnancy is more likely to develop in OD patients compared to women with AO pregnancies. OD infants also tended to have lower birth weights and be born at earlier gestational ages; while this did not reach statistical significance, there is clinical significance in the results due to consequences of prematurity with the average OD delivery at 35 weeks. These findings are consistent with results seen in prior studies and should be used when counseling patients interested in oocyte donation. FINANCIAL SUPPORT: None.

MATERIALS AND METHODS: All couples undergoing their first IVF cycle with surgically-extracted sperm and comprehensive chromosome screening (CCS) at a single infertility center between April 2009 and July 2015 were included. CCS was performed utilizing a validated screening platform after trophectoderm biopsy. The cohort was divided into obstructive and non-obstructive azoospermia, as well as stratified by oocyte age < 35 years and R 35 years. The aneuploidy rates were compared to a large referent infertility population. RESULTS: There were 51 patients and 256 embryos in the surgical sperm group compared to 2,701 patients and 15,169 embryos in the reference group. Aneuploidy rate for obstructive (34%) versus non-obstructive (25%) azoospermic patients were equivalent (p¼0.14) The rate of aneuploidy in embryos resulting from surgically extracted sperm (31%) was found to be lower than the general population for all age groups (41%), (p¼0.001). However, when aneuploidy rates in embryos from <35 year old oocytes were compared in the surgical and reference population, there was no longer a difference (p¼0.21). When looking at cases of oocyte age R35 years, the rate of aneuploidy was lower in the surgical sperm group compared with the reference population (p¼0.02) (Figure 1). CONCLUSION: This is the largest study to date utilizing CCS to determine aneuploidy rates in patients undergoing IVF with surgically-extracted sperm. The risk of aneuploidy in embryos does not seem to be increased when surgically-extracted sperm is used for ICSI; in fact, the risk was lower than the expected age related risk for those with a female partner R35 years old. These data further confirm that meiotic errors in the oocyte are the primary contributor to embryonic aneuploidy, even for couples with severe spermatogenic defects. Thus, in surgical sperm cases, routine counseling in terms of aneuploidy screening is sufficient. FINANCIAL SUPPORT: None. References: 1. ‘‘Chromosome abnormalities in embryos derived from microsurgical epididymal sperm aspiration and testicular sperm extraction’’. Weng, SF; Surrey, MW; Danzer, HC; et al. Taiwan J Obstet Gynecol. 2014 Jun; 53(2):202-5. 2. ‘‘The nature of aneuploidy with increasing age of the female partner: a review of 15,169 consecutive trophectoderm biopsies evaluated with comprehensive chromosomal screening’’. Franasiak, JM; Forman, EJ; Hong, KH; et al. Fertil Steril. 2014 Mar;101(3):656-63.

P-9 EMBRYOS DERIVED FROM SURGICALLY-EXTRACTED SPERM ARE NOT AT AN INCREASED RISK OF ANEUPLOIDY. R. L. Barnett,a J. M. Franasiak,a,b R. T. Scott,a,b E. J. Forman.a,b aDivision of Reproductive Endocrinology, Department of Obstetrics, Gynecology and Reproductive Science, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA; bReproductive Medicine Associates of New Jersey, Basking Ridge, New Jersey, USA. BACKGROUND: The introduction of ICSI has afforded males with severe oligospermia or azoospermia IVF success rates that are comparable to the general infertility population (1). For azoospermic males, surgical sperm extraction allows for ICSI where once donor sperm was the only option. Previous studies utilizing FISH suggested aneuploidy rates in embryos from couples requiring surgical sperm extraction are higher than the general infertility population. However, they are limited by sample size, the accuracy of FISH and a limited chromosomal analysis. OBJECTIVE: To evaluate the rate of aneuploidy via 24 chromosome screening in embryos derived from surgical sperm cases compared to the aneuploidy rate in a large reference infertility population (2).

FERTILITY & STERILITYÒ

Figure 1. Rate of Aneuploidy in Embryos Using Surgical Sperm vs. Reference Population

P-10 FACTORS ASSOCIATED WITH USE OF ELECTIVE SINGLE EMBRYO TRANSFER AND MULTIPLE PREGNANCY RISK AT FERTILITY CENTERS IN THE UNITED STATES. C. E. Bedient,a,b S. T. Daneshmand,a,b F. C. Garner,a,b M. Aguirre,a C. Hudson,a B. S. Shapiro.a,b aFertility Center of Las Vegas, Las Vegas, NV, USA; bUniversity of Nevada School of Medicine, Las Vegas, NV, USA. BACKGROUND: The transfer of multiple embryos in cycles of in vitro fertilization is associated with multiple pregnancy and numerous increased maternal and fetal risks. The primary means for controlling these risks is to transfer a single embryo. There has been gradually increasing use of elective single embryo transfer (eSET) among fertility centers in the United States. In 2013, the Centers for Disease Control and Prevention (CDC) reported that 21.4% of fresh embryo transfers in patients <35 years old

e13