Faculty Bibliography

BACKGROUND: Transgender individuals, individuals whose gender identity does not align with their sex assigned at birth, undergoing gender-affirming hormonal or surgical therapies may experience loss of fertility. Assisted reproductive technologies have expanded family-building options for transgender men who were assigned female at birth. CASES: Three transgender men underwent oocyte cryopreservation before gender-affirming hormonal therapy. One patient underwent fertility preservation as an adolescent. Two adult patients had children using their cryopreserved oocytes, with the pregnancies carried by their sexually intimate partners. CONCLUSION: Transgender men with cryopreserved gametes can build families in a way that affirms their gender identity. Obstetrician-gynecologists should be familiar with the fertility needs of transgender patients so appropriate discussions and referrals can be made.

Pre-implantation genetic diagnosis (PGD) has changed the landscape of clinical genetics by helping families reduce the transmission of monogenic disorders. However, given the high prevalence of embryonic aneuploidy, particularly in patients of advanced reproductive age, unaffected embryos remain at high risk of implantation failure or pregnancy loss due to aneuploidy. 24-chromosome aneuploidy screening has become widely utilized in routine in vitro fertilization (IVF) to pre-select embryos with greater pregnancy potential, but concurrent 24-chromosome aneuploidy screening has not become standard practice in embryos biopsied for PGD. We performed a retrospective cohort study of patients who underwent PGD with or without 24-chromosome aneuploidy screening to explore the value of concurrent screening. Among the PGD + aneuploidy-screened group (n = 355 blastocysts), only 25.6 % of embryos were both Single Gene Disorder (SGD)-negative (or carriers) and euploid; thus the majority of embryos were ineligible for transfer due to the high prevalence of aneuploidy. Despite a young mean age (32.4 +/- 5.9y), 49.9 % of Blastocysts were aneuploid. The majority of patients (53.2 %) had >/=1 blastocyst that was Single Gene Disorder (SGD)-unaffected but aneuploid; without screening, these unaffected but aneuploid embryos would likely have been transferred resulting in implantation failure, pregnancy loss, or a pregnancy affected by chromosomal aneuploidy. Despite the transfer of nearly half the number of embryos in the aneuploidy-screened group (1.1 +/- 0.3 vs. 1.9 +/- 0.6, p < 0.0001), the implantation rate was higher (75 % vs. 53.3 %) and miscarriage rate lower (20 % vs. 40 %) (although not statistically significant). 24-chromosome aneuploidy screening when performed concurrently with PGD provides valuable information for embryo selection, and notably improves single embryo transfer rates.

OBJECTIVE: Determine if the gender of the translocation carrier and the size of chromosome fragments involved in a translocation impact the segregation pattern during meiosis. DESIGN: Retrospective analysis of PGS results for embryos analyzed for reciprocal translocations (RT). MATERIALS AND METHODS: Results obtained from PGD lab internal data. Fragment sizes (FS) calculated using the UCSC Genome Browser and calculating the distance from the breakpoint of the translocation to the telomere and centromere. FS over 6 megabases (Mb) in size were considered "large"; those under 6Mb were considered "small." Segregation patterns were classified as: alternate, adjacent I, adjacent II, 3:1, 4:0 and atypical configurations (AC). An AC is characterized as one that cannot be explained by the standard segregation patterns and involves the breakage of the chromosomes involved in the RT. RESULTS: We review segregation patterns for 1,159 embryos (640 from female carriers, 519 from male carriers) for RT via array comparative genome hybridization (a CGH). Of the embryos, 58.2% involved RT where all FS were classified as large and 41.8% involved RT where one or more FS were classified as small. Embryos with one or more small FS were significantly more likely (p<0.001) to segregate in ACs than those with all large FS. When sorted by the gender of the parent with the RT, a significant increase in occurrence of 3:1 segregation was seen in female carriers (p<0.001); when divided by FS, female carriers of translocations with at least one small FS were more likely to have 3:1 configurations (p<0.001) (table 1). CONCLUSIONS: Patients with RT presenting for PGD testing are anxious to know the likelihood of identifying an embryo suitable for transfer and often inquire about numbers specific to their RT. As the almost endless permutations of RT make such numbers difficult to generate, this data suggests trends that may provided additional information for these patients. Those with small FS are more likely to produce embryos with ACs. Further, female carriers of RT, particularly those with small FS, are more likely to produce embryos with 3:1 segregations, and thus, may be more likely to produce unbalanced embryos than male carriers. This data will help manage expectations of RT patients presenting for PGD. (Table Presented)

OBJECTIVE: To perform a thorough investigation using a combination of the most advanced technologies available in an effort to decipher the aneuploidy 'code' in the human preimplantation embryo. DESIGN: Quantitative assessment and genotyping were undertaken concurrently for human blastocysts using SNP arrays and NGS. MATERIALS AND METHODS: Single trophectoderm biopsies were obtained from blastocysts of couples undergoing in vitro fertilization (IVF) with preimplantation genetic diagnosis (PGD) for single gene disorders (SGD) and aneuploidy screening. Karyomapping SNP array (Illumina, USA) was used for PGD of SGD while, NGS via the VeriSeq PGS assay (Illumina) was utilized for comprehensive chromosome screening. Fisher's exact test (GraphPad Software, USA) was used for statistical analysis. RESULTS: In total, over 19,000 chromosomes were screened in 417 embryos from 75 couples [maternal age: 34.1+/-0.5 years (mean +/- SE)]. At least one chromosomal abnormality was detected in 49.2% (205/417) of the embryos assessed, with 48.3% of the embryos exhibiting only abnormalities of meiotic origin, 40% having only mitotic abnormalities and the remainder of the embryos presenting both types of abnormalities. Notably, maternal meiosis was associated with an equal number of events leading to gain vs. loss of chromosomal material (74 gains vs. 75 losses) and prevailed over paternal meiosis which consisted of events mainly involving loss of chromosomal material (27 losses vs. 1 gain) with almost half of the losses (40.7%) being partial. Of the overall number of aneuploidies detected, 15.7% were determined to be partial with the size of segments gained or lost ranging from 7.8 to 145.6 megabases. Incidences of maternally-derived meiotic errors and overall mitotic errors detected are presented in the table below in relation to maternal age: CONCLUSIONS: The incidence of maternal meiotic abnormalities was associated with increasing age, consistent with the higher rates of implantation failure and miscarriage experienced by older women. Mitotic errors, potentially producing mosaicism, were also common. Interestingly, aneuploidy of male meiotic origin was characterized by a predominance of monosomies compared with that of female origin, suggesting a sex-specific difference in the mechanism underlying segregation errors. (Table Presented)

This longitudinal study reports preliminary findings of six patients who underwent first polar body biopsy followed by oocyte vitrification. All oocytes were warmed, inseminated by intracytoplasmic sperm injection and cultured to blastocyst. All suitable blastocysts underwent trophectoderm biopsy for aneuploidy screening, and supernumerary blastocysts were vitrified. Euploid blastocysts were transferred either fresh or in a subsequent programmed cycle. Of the 91 metaphase II oocytes, 30 had euploid first polar bodies. Development to blastocyst was more likely in oocytes with a euploid first polar body (66.7% versus 24.6%; P < 0.001). Nineteen euploid blastocysts were produced: 10 from oocytes with a euploid first polar body and nine from oocytes with an aneuploid first polar body. Five out of six patients (83%) had a live birth or ongoing pregnancy at the time of analysis. Eleven euploid blastocysts have been transferred and seven implanted (64%). Although the chromosomal status of the first polar body was poorly predictive of embryonic ploidy, an association was found between chromosomal status of the first polar body and development to blastocyst. Further study is required to characterize these relationships, but proof of concept is provided that twice biopsied, twice cryopreserved oocytes and embryos can lead to viable pregnancies.

OBJECTIVE: To compare the euploidy outcome in patients that underwent 2 ovarian stimulation cycles with trophectoderm biopsy. DESIGN: Retrospective repeated-measures cohort study. SETTING: University-based fertility center. PATIENT(S): A total of 116 patients, from 2011 through 2013, that underwent 2 ovarian stimulation cycles followed by trophectoderm biopsy with array comparative genomic hybridization. INTERVENTION(S): Days of stimulation, average diameter of the 2 lead follicles on day of trigger, dose of gonadotropins, type of cycle (gonadotropin-releasing hormone [GnRH] antagonist, GnRH-antagonist plus clomiphene citrate [CC], microdose GnRH agonist). MAIN OUTCOME MEASURE(S): Number of euploid embryos. RESULT(S): Patients were analyzed based on whether they had >/=1 euploid embryos in their first cycle vs. none. There was no increase in the number of euploid embryos with more days of stimulation or increases in the dose of gonadotropins in either group. Significantly more euploid embryos were seen in patients who had no euploid embryo(s) in the first cycle (Group 0) that had CC added to a GnRH-antagonist cycle (1.11 more euploid embryos) or were triggered when follicle sizes were 2 mm larger (0.40 euploid embryos), but these increases were not significant compared with a control group. Patients with euploid embryo(s) in the first cycle (Group 1) had significantly more euploid embryos when daily dose was increased by 75-149 international units, but this relationship was not significant compared with a control group with no increase in daily dose. CONCLUSION(S): No specific intervention increased the number of euploid embryos within the same patient any more than simply repeating a similar stimulation cycle. An attempt was made to control for interpatient variability, but individual patients have considerable intercycle variability.

Our objective is to describe a successful live birth from oocyte vitrification followed by thaw, fertilization, blastocyst culture, trophectoderm biopsy, vitrification, and subsequent thaw. Fifteen mature oocytes were frozen from a patient with uterine factor infertility. Thirteen oocytes survived the thaw, and five underwent trophectoderm biopsy and were refrozen. Three euploid embryos were obtained. A single euploid embryo was transferred in the second thaw cycle to a known recipient leading to the delivery of a normal male infant. This case report is proof of the concept that preimplantation screening and diagnosis is an option for fertility preservation patients.