PGS: Enough outcome errors means caution: Hard-selling is taking advantage of patients No r bert G le icher, M D M e d i ca l D i r e c t o r a n d C h i ef S c i e nt i s t , C e nt e r Fo r H u m a n R e p r o d u c t i o n , N e w Yo r k , N Y Pr e s i d e n t , Fo u n d a t i o n Fo r R e p r o d u c t i v e M e d i c i n e , N e w Yo r k , N Y G u e st I nv e st i g a t o r, R o c kefe l l e r U n i v e r s i t y, N e w Yo r k , N Y Pr o fe s s o r ( A d j ) , D e p a r t m e n t O f O b st e t r i c s & G y n e c o l o g y, V i e n n a U n i v e r s i t y S c h o o l O f M e d i c i n e , V i e n n a , A u st r i a

Ovarian Club X and CoGEN in Asia | December 16-17, 2017 | Hong Kong

Conflict Statement Dr. Gleicher is listed as co-inventor on a number of pending patent applications claiming diagnostic and therapeutic benefits from determination of CGG repeat numbers and ovarian FMR1 genotypes and sub-genotypes.

Dr. Gleicher is co-inventor of awarded U.S. patents, claiming therapeutic benefits for supplementation of DHEA in women with diminished ovarian reserve, a topic discussed in this talk. Other patent applications in regards to DHEA and other fertility-related claims, with no relationship to this talk, are pending. Dr. Gleicher receives royalties from, and owns shares in Fertility Neutraceuticals, LLC, a distributor of a DHEA product.

Dr. Gleicher is co-inventor of three pending patent applications claiming potential therapeutic benefit for anti-Müllerian hormone (AMH) in infertile women. Dr. Gleicher owns shares in OvaNova Laboratories, LLC.

The PGS Hypothesis Aneuploidy is a major cause of IVF failure and

miscarriages after IVF

Elimination of aneuploid embryo before embryo transfer, therefore, will improve IVF outcomes and reduce miscarriages

History Polar body biopsy (Verlinsky et al 1990s)

PGS 1.0 (~2000-2008)

PGS 2.0 (2008-2017)

PGS 3.0/PGT-A (as of July 2017)

History cont. PBB, PGS 1.0 and PGS 2.0, all, reported results as

euploid/aneuploidy

Only PGS 3.0/PGT-A reports results as euploid/mosaic/aneuploid

“Implementation of the most recent PGS technologies has been shown to improve pregnancy rates per transfer in randomized controlled trials, meta-analysis and case-controlled prospective studies.”

Besser and Mounts 2017

The errors in IVF outcome assessments with reference embryo transfer

n=10

PGS

Blastocysts

Selection by OR

General population (n=100)

Assuming 8 live births, the live birth rate will be 80% with reference ET, but only 8% with reference cycle start (“intent to treat”)

Is there evidence that the PGS hypothesis does not work? 2 models Orvieto R, Reprod Biol Endocrinol 2016

Scriven PN, Reprod Biol Endocrinol 2017

Barad DH et al, Am J Obstet Gynecol 2017

The Value of PGS

Can a single TEB reliably reflect the whole TE?

P-values for observing no mosaicism, given different hypotheses r and a threshold of 0.05 (dotted line)

P-values for observed mosaicism, given different hypotheses r, and varying numbers of abnormal-aneuploidy cells in biopsy

Reprod Biol Endocrinol; In press

Effects of Pre-Implantation Chromosome Mosaicism on Embryo Development and Survival

Richard J. Paulson • Preimplantation genetic screening: What is the

clinical efficiency? • Fertil Steril 2017;108:228-230

• “We must be cognizant of the reality that this type of screening is inherently inefficient and that many normal embryos are discarded”

• “The proportion of normal embryos that are discarded...may be as high as 40%”

Greco and et al, N Engl J Med 2015;373:2089-90.

Bernabeu et al ESHRE 2016

Mosaic Euploid

Age (years) 31.0 30.6

Embryos (n) 54 382

Clinical pregnancies (%) 26.9% 40.2%

Clinical miscarriages (%) 7.1% 18.1%

Ongoing pregnancies (%)* 25.0% 32.9%

* All births normal

OBJECTIVE: To determine the pregnancy outcome potential of mosaic embryos, detected by means of preimplantation genetic screening (PGS) with the use of next-generation sequencing (NGS). DESIGN: Retrospective study. SETTING: Genetics laboratories. PATIENT(S): PGS cycles during which either mosaic or euploid embryos were replaced. INTERVENTION(S): Blastocysts were biopsied and processed with the use of NGS, followed by frozen embryo transfer. Trophectoderm (TE) biopsies were classified as mosaic if they had 20%-80% abnormal cells. MAIN OUTCOME MEASURE(S): Implantation, miscarriage rates, and ongoing implantation rates (OIRs) were compared between euploid and types of mosaic blastocysts. RESULT(S): Complex mosaic embryos had a significantly lower OIR (10%) than aneuploidy mosaic (50%), double aneuploidy mosaic (45%), and segmental mosaic (41%). There was a tendency for mosaics with 40%-80% abnormal cells to have a lower OIR than those with <40% (22% vs. 56%). However, few embryos (n = 34) with a mosaic error in 40%-80% of the TE sample were replaced. There was no difference between monosomic and trisomic mosaics or between entire chromosome mosaicism or segmental mosaicism. Implantation rates were significantly higher (70% vs. 53%), miscarriage rates lower (10% vs. 25%), and OIRs higher (63% vs. 40%) after euploid embryo transfer than after mosaic embryo transfer. CONCLUSION(S): Forty-one percent of mosaic embryos produced an ongoing implantation. Complex mosaic blastocysts had a lower OIR than other mosaics. Mosaic monosomies performed as well as mosaic trisomies and mosaic segmental aneuploidies. The results suggest that embryos with >40% abnormal cells and those with multiple mosaic abnormalities (chaotic mosaics) are likely to have lower OIRs and should be given low transfer priority.

2016 PGDIS Guidelines

Hypothesis Like cancer cells, blastomeres of early stage embryos

show Increased expression of gene products favoring cell

progression While lacking cell cycle checkpoint genes

Such a constellation favors genetic instability and mitotic errors in cancer and embryos

Embryo aneuploidy was believed to be mostly meiotic; now known to be mostly mitotic

Kort et al, Hum Reprod 2016

Ghevaria et al, RBMOnline 2016

Hypothesis

Hypothesis cont. Counterintuitively to the PGS hypothesis,

aneuploidy in trophectoderm may play a role in invasiveness of the embryo during implantation

Supported by excellent live birth rates and low miscarriage rates

Supported by tolerance-inducing aneuploidy recently reported in cancer

Conclusions PGS biopsy results:

Are biologically nonsensical

Are technically unfeasible

Are unvalidated

Produce large numbers of false-positive diagnoses and, therefore, have resulted in disposal of large numbers of normal embryos

Fail to improve IVF outcomes

Negatively affect IVF outcomes in at least selected patient populations

CHR Staff (* Visiting Scientists) David F Albertini, PhD David H Barad, MS, MD Ali Brivanlou, PhD, MD* Sarah Darmon, PhD, MS Dieter Egli, PhD* Norbert Gleicher, MD Vitaly A Kushnir, MD Emanuela Lazzaroni-Tealdi, MS Kenneth Seier, MS* Aya Shohat-Tal, PhD* Andrea Vidali, MD* Andrea Weghofer, PhD, MS, MBA, MD* Ping Zhou, PhD Yan-Guang Wu, PhD* Yao Yu, PhD*

Affiliates Rockefeller University: Ali Brivanlou, PhD, MD Gist Croft, PhD Salk Institute for Biological Studies: Pradeep Reddy, PhD