In this webinar, Dr Halyna Strelko, the Co-founder & Leading Reproduction Specialist at IVMED Fertility Center, Kyiv, Ukraine, talked about PGT-A, Non-invasive preimplantation genetic testing (niPGT), its benefits and outcomes. Dr Strelko provided a case of her past patient who had 3 previous failed attempts, and after changing the protocol and performing genetic testing, got finally pregnant.
Dr Strelko started her presentation by stating that around 10 years, it was thought that genetic testing on embryos will resolve all problems with repeated implantation failures, spontaneous abortions or unsuccessful IVF treatments, but this is not the case. In her presentation, Dr Strelko stated that sometimes standard genetic approaches may not be helpful and explained how they should be changed and modified and possibly that will become the gold standard in the next 5-10 years.
The patient presented by Dr Strelko was already in reproductive advanced age, the woman was 42 years old, and she was trying to conceive for 11 years, she had 1 spontaneous pregnancy 12 years before, and delivered a healthy baby, however, after that was unable to become pregnant.
She had a quite high ovarian reserve, her AMH was 6.4 ng/ml, and she was diagnosed with PCOS with a normal BMI. Her husband had a normal sperm count, and they had gone through 1 IVF attempt in another clinic, they received a lot of eggs, 28 eggs and produced 8 blastocysts, but after PGT-A testing, only 1 blastocyst was euploid. After the transfer, the patient got pregnant, but it ended in a biochemical pregnancy. After that, she decided to change the clinic, and they came to IVMED.
After discussing and taking PCOS into account, we decided to do a standard antagonist GnRH protocol with a-GNRH triggering, which prevents ovarian hyperstimulation syndrome. On the other hand, we knew it was necessary to receive as many as 20-30 eggs because of the low blastocyst formation rate and low euploidy of blastocysts. The standard protocol was done with 225 FSH per day, and we received quite a big number of eggs, it was 50 eggs, no hyperstimulation syndrome, the fertilization was done with ICSI, we received 11 blastocysts out of these eggs, and after genetic testing, we got 4 euploid embryos.
The first protocol was a standard replacement hormonal therapy (HRT), we gave her 6 mg of oestrogens and micronized progesterone 600 mg vaginally, unfortunately, the result was negative.
In the second cycle, a natural protocol was suggested with hCG triggering because sometimes a natural cycle can give a more natural level of hormones, better progesterone level, and better functioning of the corpus luteum. Therefore, we modified the protocol, did the hCG triggering, and from the day of ovulation, we started the support of the luteal phase with 400 milligrams of progesterone, the test, however, was also negative.
The third cycle was also a natural cycle done without hCG, the same amount of progesterone 400 milligrams, and again the result was negative.
As there were no more good quality blastocysts, we decided to do a second stimulation. At this point, we decided to start a new protocol with follitropin delta because, with this medication, we could calculate the dosage individually and according to AMH level and BMI. In some cases, it gives a better result, a bit fewer eggs, but there was no risk of hyperstimulation syndrome, and we get better quality oocytes with a better blastulation rate. We decided to change the medication, hoping that it will give a better embryological outcome. We retrieved 34 oocytes that were fertilized with ICSI, and we received 5 blastocysts, 3 of them of type CC, which we normally don’t freeze because they never give pregnancy. Type CC means a low number of cells. We only had 2 more blastocysts of not so good quality. The NGS testing revealed that no blastocyst was euploid.
After that, we evaluated and discussed it again. We knew that the patient had a good ovarian reserve, so we could expect quite a good number of eggs, but she had a high level of aneuploidy, therefore, it was probably necessary to modify the embryological approach, and it was possible that biopsying the trophectoderm could be decreasing implantation potential of the embryo. Some scientific publications showed biopsy at the trophectoderm stage may be sometimes harmful. We concluded that it was better to transfer the embryos in a natural cycle, as we saw better endometrium receptivity and a wider implantation window.
In the 3rd protocol, the same dosage was used because, in the first one, a good number of eggs were retrieved. The trigger was with agonists, we received 49 oocytes and we decided to do Piezzoactivation after ICSI, which can improve the cleavage and blastulation rate because this increases the concentration of calcium inside of oocyte, and we know that calcium may improve cleavage and increase the chance of good fertilization. We received 9 blastocysts and decided to do Non-Invasive PGT-A (niPGT-A) to avoid the influence of trophectoderm biopsy. We received only 1 euploid blastocyst, we prepared the patient for transfer in a natural cycle, and finally, after all these attempts, we got a positive test result and a pregnancy, currently at 6 weeks.
There are a lot of little questions, so I will try to answer them one by one. When it comes to pregnancy chances, the first problem is that with day-3 embryos, we don’t know if they can reach the blastocyst stage. One egg and one embryo give a 46% chance to have a live birth. This is probably the same chance with one embryo. Of course, it is better to do the prognosis with blastocyst stage embryos. We transfer embryos at day-3 or blastocyst stage, the probability of pregnancy is the same. The difference is that with blastocysts, we are more certain that the embryos are viable and have a good chance to implant. At 40 years old, the average percentage of genetically abnormal embryos are 70-80%.
In your case, nobody knows without a diagnosis. At a young age, the morphology is better correlated with the genetics of the embryo and with advanced reproductive age, this correlation is less pronounced. We cannot say only based on the morphological description of the embryo that it has a chance or not. We can do genetic tests of this embryo, cultivate it until the blastocyst stage, do a biopsy and then freeze it. Is it necessary to do this? It’s a big question because, as we have seen, there are some false positive and false negative results with PGT-A. For me, it is better to transfer and not to do these tests with the embryo.
Concerning the prolonged use of DHEA and CoQ10, there is no problem. You can take it even for 2 years. There is no publication saying that it may be an issue. It may be helpful, you can continue taking it.
I’m not sure that I know exactly what they contain. I will see because, in each country, the commercial name may be different, and probably it is. It will be very helpful if you write the chemical name of this drug. Concerning Duphastone, I haven’t seen a lot of articles saying that it may provoke breast cancer. On the other hand, if we don’t take progesterone, taking replacement hormonal therapy and only oestrogens without progesterone in the second phase, it may increase the risk of endometrial cancer. So as for me, if you can change oral progesterone and oral oestrogens, if you’re taking for replacement hormonal therapy to transdermal form, it would be better. As the oral form may cause the cholesterol increase and it is better to take it in transdermal or transvaginal form. Probably Lutigest is something like Duphastone, and we can use it in a transvaginal way, but there is another commercial name in Ukraine.
It is a big question if it is necessary to thaw embryos, take a biopsy and then freeze them. Each extra manipulation with an embryo may cause some damage, and it depends on the quality of the embryos before freezing. If we have trophectoderm with not a lot of cells, whose quality is not very high, the more manipulation we do, the less viable the embryo will be after that. On the other hand, we have a couple of publications saying that we can freeze the embryos and all will be okay, but on another, we have publications saying that several cycles of freezing and thawing can decrease the viability of embryos.
With frozen embryos, we cannot do non-invasive PGT, so for this purpose, we should have new embryos. And the new stimulation also may be helpful because at 41 years old, we will have on average 80% of embryos with genetic abnormalities. So if we have more embryos, we will have a higher probability that we will have one or two with normal genetic makeup. As you have seen from 50 eggs at 43 years old, unfortunately, we may have one, two, or three euploid embryos, and for this purpose, it is better to do the next stimulation and test the embryos. When it comes to the method of possible, non-invasive PGT-A is best.
It is difficult to do the prognosis. With balanced translocation, normally we should have more or less 20-25% of balanced embryos. On the other hand, we have some percentage of aneuploid without translocation, and also it is very individual. Recently I had a case of a woman who has balanced translocation. She has given birth to two normal, healthy children without IVF treatment. She is 39 years old, and she came to a clinic with her sister, who is 40 or 45 years old, and she was an egg donor for her sister. We don’t expect to have even one normal embryo, she has not had a very high ovarian reserve and received two balanced embryos with normal genetics. So it is really by luck, by chance. The embryological method of working with your eggs and embryos may influence the presence of genetic abnormalities.
There was a very interesting publication about egg donation cycles showing that in some clinics, even after a donation, the percentage of genetically abnormal embryos reached 60-80%, and in other clinics, it was 30 per cent. Considering that egg donors are normally young women without any genetic problem, and it may be, so different shows how much depends on the methods of work, purity of air, media, which were used, etc. So some practical, technical things in the embryological laboratory are very important. In my opinion, you should probably try in another clinic, and you should discuss which method of work they are using and try to see what will happen with your embryos and what will be the percentage of normal and abnormal embryos.
The answer is a minimum of 60 days before you start your stimulation. You can take it for a long time, like 3-5 months, even more. The minimum is 2 months. There’s no harm, even if someone takes it for a few months. Some people take it for general health because it is an antioxidant and may increase your energy. You can take it, there is no harm in using it.
Progesterone is used for the luteal phase support. For example, in cryo protocol or a fresh cycle. Normally, we use micronized progesterone-like Utrogestan, or something like that, close to the natural hormone. Sometimes we can use progesterone in injections, but it is quite difficult for patients to take injections every day. If you are asking concerning the previous question, in this case probably it is better to use micronized progesterone, probably in a vaginal way. It is the least harmful. But it also depends on the purpose for which you are using the progesterone.
Also, if it is for the luteal phase support, it should be a bigger dosage. It is always better to measure your progesterone level in the blood because even with some dosage, the way of taking progesterone and somebody’s body mass index may result in absolutely different levels in your blood circulation. In literature, we have the term ‘progesterone resistance’ and we can see that around 20-30% of our patients with good dosage taken correctly have quite a low level of progesterone in blood. If it’s for endometrium problem prevention, we can use a much lower progesterone dosage, like 100-200 milligrams of micronized progesterone during 10 days of the second phase of the cycle.
We start to offer non-invasive embryo testing, and this morning, we talked with a laboratory that proposed doing this testing for us called Igenomix, and of course, there are a lot of clinics in Spain like IVI clinic and also other clinics that are working with this laboratory as outsource. I cannot name all these clinics, but our clinic is collaborating with our Igenomix laboratory, and we are offering these non-invasive tests to our patients.
Normally we do some advanced genetic testing for our patients, especially with low blastocyst formation rates, and we do oxidative stress, and also DNA fragmentation tests and sometimes FISH tests. We measure the percentage of aneuploid sperm cells in case we find that DNA fragmentation is very high, we can propose some specific methods of sperm preparation that help us to select the sperm cells with less DNA fragmentation. For example, we use what we call a sperm chip, a specific method of selection that decreases the percentage of DNA fragmentation around 30-40 times. We have a better blastocyst formation rate after that and less aneuploidy.
It is also a topic of wide discussion in literature, and a lot of controversial publications are available. High-risk mosaic means a mosaic rate of more than 50%. But as you have seen during the presentation, it may be caused sometimes by chance. Embryologists cannot see which part of the embryo was taken, and these abnormal cells may be like clusters, if we do the second biopsy, we can consider this embryo as low level of mosaicism, abnormal, or normal.
The correspondence of results if we do the second biopsy may be like 20 -30% less or more. We can transfer mosaic embryos. Some problems like Down syndrome or Trisomy of the 18 chromosomes may cause some health problems to children if this embryo implants. The recommendation is that some types of mosaicism should not be transferred, some of them are more or less safe to transfer. The main issue is that mosaicism may increase the spontaneous miscarriage rate, and if pregnancy occurs after the transfer, it is good to do some additional genetic tests for this pregnancy, the NIPT test or amniocentesis. It will give even more information with this technique.
I think you can transfer this embryo. It is not the 21st chromosome, not the 18th chromosome. But if pregnancy occurs and is viable, then after 16 weeks, you can discuss the procedure of amniocentesis with your doctor, and it is quite safe. You can receive the whole 24 chromosome information and see some additional tests, even some molecular, genetic tests or some mutations, so you can do all possible examinations with these genetic materials, and it is quite safe. I think you can transfer your embryo.
It is only possible in the blastocyst, and it is better to do it in a 6-day blastocyst, it is more exact with more advanced blastocyst. So not five-day but six-day blastocyst age, and it is impossible to do with frozen embryos. We cannot thaw in the blastocyst stage and give the result of this test necessary to cultivating the blastocyst, and all this liquid should be used for the test, not with previously frozen embryos without test.
It seems that non-invasive PGT-A may be helpful for some categories of patients. We will see that with more statistics, but it seems it is interesting. It’s quite promising, and it’s worth checking.
Yes, first, it is necessary to cultivate a blastocyst, take this liquid material for diagnostics and then freeze, not the opposite. First, it is necessary to take the liquid after cultivation because DNA passes from the embryo to this liquid, and there should be some exposition. It is necessary to have some concentration of DNA in it.