Non-invasive prenatal testing for aneuploidy: current status and future prospects.

Non-invasive prenatal testing (NIPT) for aneuploidy using cell-free DNA in maternal plasma is revolutionizing prenatal screening and diagnosis. We review NIPT in the context of established screening and invasive technologies, the range of cytogenetic abnormalities detectable, cost, counseling and ethical issues. Current NIPT approaches involve whole-genome sequencing, targeted sequencing and assessment of single nucleotide polymorphism (SNP) differences between mother and fetus. Clinical trials have demonstrated the efficacy of NIPT for Down and Edwards syndromes, and possibly Patau syndrome, in high-risk women. Universal NIPT is not cost-effective, but using NIPT contingently in women found at moderate or high risk by conventional screening is cost-effective. Positive NIPT results must be confirmed using invasive techniques. Established screening, fetal ultrasound and invasive procedures with microarray testing allow the detection of a broad range of additional abnormalities not yet detectable by NIPT. NIPT approaches that take advantage of SNP information potentially allow the identification of parent of origin for imbalances, triploidy, uniparental disomy and consanguinity, and separate evaluation of dizygotic twins. Fetal fraction enrichment, improved sequencing and selected analysis of the most informative sequences should result in tests for additional chromosomal abnormalities. Providing adequate prenatal counseling poses a substantial challenge given the broad range of prenatal testing options now available.

Discordance among blastomeres renders preimplantation genetic diagnosis for aneuploidy ineffective.

PURPOSE: To investigate the contribution of discordance among blastomeres from the same embryo in the interpretation of blastomeres biopsied from day 3 embryos. METHODS: 228 IVF embryos had two blastomeres removed and fluorescent in situ hybridization (FISH) was used to detect aneuploidy of chromosomes 13, 15, 16, 18, 21, 22, X and Y. Of the 228 embryos, 102 had complete FISH results for both blastomeres. RESULTS: When the 2 blastomeres of 102 embryos with successful FISH results were compared, 26 (25.5%) were concordant for all 8 chromosomes and 76 (74.5%) were discordant for one or more chromosomes. Among the 102 embryos, 12 (12%) were disomy in both blastomeres and 37 (36%) were disomic in all 8 chromosomes in one of the two blastomeres. CONCLUSION: Discordance among blastomeres from the same embryo appears to present a significant problem in interpreting results of embryos biopsied on day 3 and analyzed by FISH especially when most PGD's are done on single blastomeres.

Late first-trimester invasive prenatal diagnosis: results of an international randomized trial.

OBJECTIVE: To assess, in a randomized trial, the safety and accuracy of amniocentesis and transabdominal chorionic villus sampling (CVS) performed at 11-14 weeks of gestation, given that this time frame is increasingly relevant to early trisomy screening. METHODS: We compared amniocentesis with CVS from 77 to 104 days of gestation in a randomized trial in a predominantly advanced maternal age population. Before randomization, the feasibility of both procedures was confirmed by ultrasonography, and experienced operators performed sampling under ultrasound guidance; conventional cytogenetic analysis was employed. The primary outcome measure was a composite of fetal loss plus preterm delivery before 28 weeks of gestation in cytogenetically normal pregnancies. RESULTS: We randomized 3,775 women into 2 groups (1,914 to CVS; 1,861 to amniocentesis), which were comparable at baseline. More than 99.6% had the assigned procedure, and 99.9% were followed through delivery. In contrast to previous thinking, in the cytogenetically normal cohort (n = 3,698), no difference in primary study outcome was observed: 2.1% (95% confidence interval 1.5, 2.8) for CVS and 2.3% (95% confidence interval, 1.7, 3.1) for amniocentesis. However, spontaneous losses before 20 weeks and procedure-related, indicated terminations combined were increased in the amniocentesis group (P =.07, relative risk 1.74). We found a 4-fold increase in the rate of talipes equinovarus after amniocentesis (P =.02) overall and in week 13 (P =.03, relative risk = 4.65), but data were insufficient to determine this risk in week 14. CONCLUSION: Amniocentesis at 13 weeks carries a significantly increased risk of talipes equinovarus compared with CVS and also suggests an increase in early, unintended pregnancy loss. LEVEL OF EVIDENCE: I

Preference assessment of prenatal diagnosis for Down syndrome: is 35 years a rational cutoff?

OBJECTIVE: To compare the perceptions of miscarriage and birth of a child with Down syndrome among pregnant women and to evaluate the implications of these preferences for the traditional 35-year old maternal age risk boundary. METHODS: An interviewer-administered survey was given to 186 pregnant women receiving antepartum care at a university hospital. Preferences, as reflected by utilities, for birth of a child with Down syndrome and pregnancy miscarriage, stratified by patient characteristics, were assessed. RESULTS: The utility for the birth of a child with Down syndrome decreased (p < 0.001) as clinical severity increased from mild (0.78) to severe (0.65). Miscarriage of a pregnancy had a mean utility of 0.76 +/- 0.31. Women who desired prenatal diagnosis had a utility value for miscarriage (0.79 +/- 0.28) that was significantly higher than for the birth of a child with Down syndrome of unknown severity (0.73 +/- 0.27). In multivariable logistic regression, desire for prenatal diagnosis was the only factor associated with a preference of miscarriage over birth of an affected child (odds ratio 2.26, 95% confidence interval 1.03, 4.96). CONCLUSION: Women who desire prenatal diagnosis do not perceive the birth of a child with Down syndrome and a pregnancy miscarriage to be equivalent health states. This finding calls into question the rationale of the 35-year-old maternal age criterion and suggests that actual patient preferences should be better incorporated into the decision to offer definitive prenatal diagnosis.

Assessment of fetal status in multiple gestation pregnancies using interphase FISH.

The use of fluorescence in situ hybridization (FISH) for women with multiple gestation pregnancies has been evaluated. Women were referred for chromosome analysis because of advanced maternal age, abnormal ultrasound findings or a positive family history and/or prior to fetal reduction. FISH was successfully applied to all specimens obtained by amniocentesis or chorionic villus sampling (CVS). Based on FISH results, fetal-fetal contamination of specimens following CVS was 11.5% in twin pregnancies and 16% in triplet or higher multiples. FISH detected trisomy 21 in three cases with no false negatives or positives. Whereas FISH may provide rapid and useful assessment of fetal status in decision-making regarding fetal reduction, the present study also highlighted the obstetrical difficulty of ensuring a sample representative of each fetus following CVS in addition to the possibility of not identifying clinically significant chromosome aberrations using currently available FISH probes.

New molecular techniques for chromosome analysis.

The advent of molecular genetic technology has significantly advanced knowledge about the structure of chromosomes and their behaviour during meiosis and mitosis, as well as delineating cytogenetic aberrations that cannot be identified by conventional chromosome analysis. Molecular cytogenetics, the visualization of genetic loci using the dynamic recombinant technology of fluorescence in situ hybridization (FISH), now provides the obstetrician and gynaecologist with increasingly important diagnostic and prognostic information heretofore unavailable. The technical principles underlying FISH are briefly discussed. Emphasis is placed on the clinical applications of FISH and technologies derived from FISH, in particular comparative genome hybridization, microdissection FISH and multiplex FISH. These technologies play increasingly significant roles in preimplantation and prenatal genetic diagnosis, in the identification of microdeletion syndromes, cryptic translocations and marker chromosomes, and in defining chromosome mosaicism. FISH and related technologies also constitute essential diagnostic modalities in follow-up of organ transplantation, in a variety of haematological disorders and in determining the amplification of oncogenes associated with specific forms of cancer and neoplasia.

Recurrent triploidy of maternal origin.

We report the occurrence of triploid preimplantation embryos following in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) in a woman with two previously-identified triploid conceptuses which spontaneously underwent fetal demise at 10 and 23 weeks' gestation. An error in maternal meiosis II is proposed as the most likely cause.

The application of fluorescence in-situ hybridization to prenatal diagnosis.

Fluorescence in-situ hybridization has become essential in prenatal diagnosis for identifying chromosome aberrations as well as in preimplantation genetic diagnosis and the analysis of fetal cells in maternal blood. Comparative genome hybridization, multicolor fluorescence in-situ hybridization and telomere probes provide technical approaches for the characterization of fetal chromosome anomalies not possible by conventional karyotyping.

The clinical application of interphase FISH in prenatal diagnosis.

Fluorescence in situ hybridization (FISH) for five chromosomes (13, 18, 21, X and Y) detected 87 of 107 (81%) of the chromosome aberrations identified by conventional chromosome analysis applied to fetal interphase cells obtained by chorionic villus sampling or amniocentesis. The choice of FISH was solely determined by prospective parents after formal genetic counselling concerning the advantages and disadvantages of FISH analysis. Excluding known familial chromosome aberrations, if FISH analysis revealed normal signals, there was an overall residual risk of 1 in 149 for an undetectable chromosome aberration. This risk varied according to the indication for prenatal diagnosis: 1 in 177 for women of advanced maternal age; 1 in 60 for women at increased risk for Down syndrome based on maternal serum screening; and, 1 in 43 for women whose ultrasound examination revealed fetal anomalies. There were 20 cases of discordance between the FISH results and standard karyotype analysis: four were the outcome of a failure to apply the appropriate FISH probe; 16 were not detectable by the available FISH probes. Of these 16, nine were chromosome abnormalities with clinical significance and seven were familial. If FISH is to become a standard part of prenatal genetic diagnosis, genetic counselling that is sensitive to patient health needs must be based on accurate information about the biological and obstetrical implications of the results of FISH analysis.

At the crossroads: the intersection of the Internet and clinical oncology.

The Internet is rapidly becoming a third party in the doctor-patient relationship. The World Wide Web, electronic mail (e-mail), and discussion groups have dramatically increased the quantity of medical and health information available to patients, who, in turn, vary greatly in their understanding of that newly discovered information. This article reviews the advantages and disadvantages of the Internet for both oncology patients and physicians. This forms the background for a discussion of three steps that clinical oncologists and other health care professionals can take to direct and control the potential of the Internet so as to optimize patient care. These steps include: (1) finding out what type of cancer information is being disseminated on the Web; (2) using Internet-derived material that patients bring to the clinic as a stepping-stone for patient education; and (3) becoming an active participant on the Web. Each of these strategies requires health professionals to be proactive. The appropriate and effective use of the Internet, as well as its boundaries, are rapidly expanding in medicine and are likely to co-evolve with changes in patient-health care provider relationships.

The role of the preimplantation geneticist in human cloning.

If human cloning is to become a reality, the preimplantation geneticist must be responsible for determining the indications for undertaking cloning and for establishing the risks and benefits of human cloning. The unresolved issue is whether a compelling argument can be made for cloning a human for therapeutic reasons while outweighing legal, moral and ethical objections. At present, 'whole person' cloning does not seem justified under any circumstance, whereas cloning for the replacement of diseased cells, tissues or organ systems, i.e. 'spare parts', seems to be a likely, acceptable application of cloning strategies for humans.

Hybridization of chromosome 18 alpha-satellite DNA probe to chromosome 22.

Fluorescence in situ hybridization (FISH) of uncultured chorionic villus diploid cells with a chromosome 18 alpha-satellite DNA probe (D18Z1) revealed a third small signal in addition to two large signals. FISH analysis of diploid metaphase cells from cultured chorionic villus cells and from maternal lymphocytes revealed that the third signal resulted from hybridization to the centromere of chromosome 22. This is the first report of a variant involving D18Z1 detected by FISH and of hybridization of alpha-satellite from a sub-metacentric chromosome to the centromere of an acrocentric chromosome. We propose that this inherited variant resulted from insertion of chromosome 18 specific alpha-satellite DNA sequences into the centromeric region of chromosome 22.

Factors associated with maternal cell contamination in amniocentesis samples as evaluated by fluorescent in situ hybridization.

OBJECTIVE: To determine which patient- and procedure-related factors contribute to maternal cell contamination in uncultured amniocentesis fluid. METHODS: One hundred thirty amniotic fluid (AF) samples were obtained by three operator groups: maternal-fetal medicine faculty (n=50), general obstetrician gynecologists (n=50), and obstetrics and gynecology residents supervised by maternal-fetal medicine faculty (n=30). These groups were designated "most," "intermediate," and "least experience," respectively. Study variables were recorded at the time of the procedure. Amniotic fluid cells from male fetuses underwent fluorescent in situ hybridization. Maternal cell contamination was calculated by analyzing 100 cells and determining the number of XX and XY cells. A control system was created to validate the methods used for AF processing and cell counting. RESULTS: Median maternal cell contamination was 2.0%. Maternal cell contamination did not vary with body mass index (r=-.13, P=.14), gestational age (r=.08, P=.35), or placental location (P=.55). Maternal cell contamination was significantly elevated with placental penetration (6.0% compared with 1.0%, P < .001), two passes (27.5% compared with 2.0%, P=.002), blood-tinged fluid color (14.0% compared with 2.0%, P < .001), and operator inexperience ("intermediate experience" compared with "most experience," 4.5% compared with 1.0%, P=.026). Maternal cell contamination did not differ between the "most experience" and "least experience" groups (1.0% compared with 2.0%, not significant). Concordance between detected and actual maternal cell contamination in the control system was extremely high (concordance coefficient=0.98, P=.008), confirming the validity of the techniques used. CONCLUSION: Our techniques of cell counting and maternal cell contamination calculation are accurate. Maternal cell contamination is increased with placental penetration, two passes, and operator inexperience. However, with expert supervision, inexperienced physicians can perform amniocentesis without an increase in maternal cell contamination.

Insulin receptor substrate-1 is expressed at high levels in all cells of the peri-implantation mouse embryo.

Insulin and insulinlike growth factors are important for embryonic growth and metabolism. Intracellular transduction for these factors has not been studied in the preimplantation mouse embryo. Peri-implantation mouse embryos synthesize insulinlike growth factor (IGF)-II ligand, insulin receptor, IGF-I receptor, and IGF-II receptor and respond to IGF-II, IGF-I, and insulin metabolically and mitogenically. Maternal tissues in the oviduct and uterus are also sources of IGF-I and insulin. Signaling of IGFs occurs through insulin receptor substrate (IRS)-1 and IRS-2. This paper shows that IRS-1 mRNA and protein are highly expressed in preimplantation mouse embryos, in embryonic cell lines, and in cultured blastocyst outgrowths. IRS-1 mRNA and protein are detected in embryo-derived cell lines cultured to produce the three cell lineages (stem cells, endoderm, and trophoblast cells). IRS-1 mRNA is detected by reverse transcription-polymerase chain reaction (RT-PCR) in the E3.5 blastocyst before implantation and in F9 teratocarcinoma stem cells and parietal endoderm cells. IRS-1 mRNA is detected by Northern blot hybridization at high levels in stem cells and in differentiated progeny of F9 cells and C3H/NE trophectoderm cells. IRS-1 protein was detected in these cell lines and in an overexpressing CHO-IRS-1 fibroblast cell line by immunocytochemistry. Cultured blastocyst outgrowths are a model for implantation events of the trophoblast/placenta lineage and endoderm/yolk sac lineage. In the blastocyst outgrowth, IRS-1 protein is detected in inner cell mass cells (ICM cells), primitive endoderm, parietal endoderm, and trophectoderm cells. These data suggest that IRS-1 is expressed in all cell lineages of the peri-implantation mouse embryo and mediates some effects of insulin and IGFs at this stage.