Preimplantation genetic screening is an excellent tool but not perfect A guide to counseling patients considering PGS

Authors:
Paul R. Brezina, M.D., M.B.A., William H. Kutteh, M.D., Ph.D., Amelia P. Bailey, M.D., Raymond W. Ke, M.D.

Volume 105, Issue 1, Pages 49-50

Abstract:

Reflections on “How do patient perceived determinants influence the decision making process to accept or decline preimplantation genetic screening?” by Gebhart et al.

  • Marty Gebhart

    The authors would like to thank Brezina, et al. for contributing to the discussion of the article titled “How do patient perceived determinants influence the decision making process to accept or decline preimplantation genetic screening?” The concise and applicable counseling guide – “PGS is an excellent tool, but not perfect: A guide to counseling patients considering PGS”, is beneficial for providers and clinicians to utilize during counseling.

    As clinicians, it is our duty and responsibility to inform patients of their reproductive options. Techniques which may identify embryos with the capacity to result in a healthy newborn, make the IVF process more efficient, and keep failed cycles to a minimum would be desired [1]; however, the challenge for clinicians remains how to use this knowledge to improve clinical practice [2]. From the infancy of embryo screening, many techniques have been utilized and improved upon, and progress has continued to determine which patient is best suited to achieve benefits from PGS. Array comparative genomic hybridization (a-CGH) is the first technology to become widely available for reliability, accuracy, and relatively prompt analysis despite the relatively high cost of screening [2]. Although limited, RCTs suggest a benefit of PGS, versus morphology alone, for patients with AMA, RPL, and even good prognosis patients electing single embryo transfers to avoid the risk of multiple gestations [3]. As identified in the BEST Trial, infertile patients may express a desire for twins, yet most would prefer an eSET if the chance of delivery was not compromised by utilization of PGS [4].

    Given the lack of unified support for embryo screening and the varied opinions of clinicians for this increasingly popular, yet invasive and costly method of embryo selection, we believed it important to identify the determinants affecting the patient decision to accept or decline PGS. The increasing awareness of the patient’s desire to be an active participant in decisions regarding treatment options should not be overlooked. With the value placed on reproductive liberty, it is evident that particular vulnerabilities often accompany patients when considering procedures which may impact the outcome of IVF and the decision-making process can be challenging[5].

    The basis of our study considered four categories and how these impacted the decision making process for the patient: (1) The patient’s knowledge regarding risks, alternatives, and benefits of PGS, (2) The source of PGS knowledge or information (3) The attitudes and motivations including costs, social, religious, ethical beliefs, values, and considerations on the decision and (4) The patients prior reproductive history and experience. Several determinants were identified and considered as influencing the patient decision; however, social support from family/friends, the additional cost associated with PGS and the influence of the clinician were identified as statistically significant when electing to accept or decline PGS. With this understanding, the provider/clinician has been identified as a determinant in the decision making process; therefore, stressing the importance of adequate education and counseling for any patient considering PGS.

    As identified in our study, 68% of our patient population had no knowledge of PGS prior to IVF; however, after counseling 93% reported sufficient knowledge to make an informed decision to accept or decline PGS. This certainly stresses the importance of the provider as an educator and the authors of this article would like to see 100% of patients reporting sufficient knowledge to make an informed decision.

    The additional cost associated with PGS was statistically significant as well and this should be another source of concern and opportunity for change for the stakeholders associated with providing PGS analysis. Within our study population, of those accepting PGS, cost was not a significant factor, but of those who declined PGS, the additional cost was identified as a determinant to decline PGS. If patients with AMA, RPL, or even those desiring an eSET, are unable to afford technological advances which may be beneficial to their success, then it is critical for stakeholders to provide these options at reduced costs. The authors are aware of advancing technologies in the screening process which are promising to lower the costs of PGS in the future and we are optimistic for patients who would have accepted PGS, but did not secondary to the associated financial burden.

    In conclusion, it is the opinion of this author that each IVF program, in conjunction with the patient, will decide on the utilization of PGS as an elective option to possibly expedite the success within a given IVF cycle [1]. Evidence-based literature is lagging when examining how the patient becomes aware of and decides to accept or decline genomic biotechnology leaving both clinician and patient with little decision-making support [6] and it is our desire that this study increase awareness of the topic and become the beginning for additional research.

    Again, much appreciation is given to Brezina et al. for supporting the clinician with guidelines for counseling patients as we navigate technological advances in reproductive therapy.

    Author:

    Marty B. Gebhart, DNP, NP-BC, RNFA

    Mississippi Reproductive Medicine, PLLC

    1040 River Oaks Drive, Suite 202

    Flowood, MS 39232

    601-936-3650

    mgebhart@reproductivemedms.com

    1.Meldrum, D. Preimplantation genetic screening is alive and very well. Fertil Steril, 2013. 100 (3): p593-594.

    2.Handyside, A. 24-chromosome copy number analysis: a comparison of available technologies. Fertil Steril, 2013. 100(3) p595-602.

    3.Yang, Z., Liu, J., Collins, G, Salem, S, Liu X, Lyle S, et al. Selection of single blastocysts for fresh transfer via standard morphology assessment alone and with array CGH for good prognosis IVF patients: resuls from a randomized pilot study. Mol Cytogenet 2012, 5:24

    4.Forman, E., Hong, K., Franasiak, J., Scott, R. Obstetrical and neonatal outcomes from the BEST Trial: single embryo transfer with aneuploidy screening improves outcomes after in vitro fertilization without compromising delivery rates. Am J Obstet Gynecol 2014; 210:157.e1-6

    5.Ethics Committee of the American Society of Reproductive Medicine. Moving innovation to practice: A committee opinion. Fertil Steril, 2015. 104(1) p39-42.

    6.Hershberger, P, Gallo,A, Kavanaugh, K, Olshankshy, E, Schwartz, A., Tur-Kaspa. The decision-making process of genetically at-risk couples considering preimplantation genetic diagnosis: Initial findings from a grounded theory study. Soc Sci Med, 2015, 74(10): p1536-43

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