BACKGROUND:Current professional society guidelines recommend genetic carrier screening be offered on the basis of ethnicity, or when using expanded carrier screening panels, they recommend to compute residual risk based on ethnicity. We investigated the reliability of self-reported ethnicity in 9138 subjects referred to carrier screening. Self-reported ethnicity gathered from test requisition forms and during post-test genetic counseling, and genetic ancestry predicted by a statistical model, were compared for concordance.RESULTS:We identified several discrepancies between the two sources of self-reported ethnicity and genetic ancestry. Only 30.3% of individuals who indicated Mediterranean ancestry during consultation self-reported this on requisition forms. Additionally, the proportion of individuals who reported Southeast Asian but were estimated to have a different genetic ancestry was found to depend on the source of self-report. Finally, individuals who reported Latin American demonstrated a high degree of ancestral admixture. As a result, carrier rates and residual risks provided for patient decision-making are impacted if using self-reported ethnicity.CONCLUSION:Our analysis highlights the unreliability of ethnicity classification based on patient self-reports. We recommend the routine use of pan-ethnic carrier screening panels in reproductive medicine. Furthermore, the use of an ancestry model would allow better estimation of carrier rates and residual risks.

Our aim was to assess the utility of social media as a platform for increasing access to fertility information and care. The ultimate goal of increased engagement and education through social media is greater exposure to, understanding of, and access to available fertility services. Retrospective. Retrospective analysis of uptake and engagement with social media outreach was performed for an academically-associated fertility practice with 7 clinical centers within the tri-state area. A variety of social media sites, including Facebook and Twitter, were utilized as platforms for sharing educational content. The target population included individuals of both genders, with varying ages and sexual orientations who are seeking information regarding fertility, infertility diagnoses and treatment, and/or fertility preservation. Analyzed measures included: page "like" and follower data; post reach, likes, shares, and comments; patient reviews; volume and source of website traffic; and time spent on website. The clinic studied had 8,929 Facebook page likes and 1,432 Twitter followers. A sample Facebook post by the clinic which linked to an article about Polycystic Ovarian Syndrome (PCOS) was seen by 7,294 people, was liked 94 times, was shared to users' personal pages 30 times, and was commented on four times by individuals sharing their experience or story. Of visitors to the clinic's website who came to the site from a social media platform, 81% were new viewers who had not previously visited the site. Overall, site visitors arriving via social media spent twice as much time on the clinic website as compared with any other source. All analyzed measures demonstrated high engagement and response to clinic outreach via social media. Social media may help to erase the stigma of infertility or assisted reproductive technologies by providing an open-forum and sense of community for individuals to find information and be heard. For individuals who otherwise might struggle to obtain information or care, such as the LGBT community, the use of social media could lower barriers. Furthermore, when patients comment and share their experience, the clinic has the opportunity to respond and offer support and resources. With minimal effort, direct and personalized engagement between clinic and audience may lead to increased awareness and education, as well as better communication with patients. Both of these factors ultimately contribute to bettering patient care. The examples shown here demonstrate the utility of social media as a platform for education and patient engagement, and thus increased access to care.

There has been a steady rise in the use of donor gametes in assisted reproductive technology (ART); however, recommendations regarding genetic screening of donors are still limited and based on the donors’ reported ethnicities. In contrast, pan-ethnic carrier screening is routinely offered to fertility patients across the US under the guidance of medical society recommendations. This discrepancy in screening practices may result in patients receiving donor gametes which confer a high reproductive risk. Screening donors and patients for the same genetic conditions will allow patients planning to use donor gametes to make the most informed decisions throughout the IVF process. We sought to examine if there are remarkable differences in the carrier frequencies of genetic diseases between general fertility patients and gamete donors. Retrospective. We calculated and compared the observed carrier frequencies of various genetic diseases in our general fertility population and our gamete donor population in order to identify any similarities or differences. Data was included from research-consenting patients tested for 200+ autosomal recessive and X-linked conditions over the last 3 years. To account for ethnicity, only individuals who self-reported being of European descent were included. The study population thus included 643 gamete donors and 6,248 general fertility patients (non-donors). We calculated and compared the observed carrier frequencies of select high-impact conditions in our donor and non-donor patient populations. No significant differences in carrier rates between the two populations were observed. For example, donors and non-donors were carriers of Smith-Lemli-Opitz Syndrome at a frequency of 1/58 and 1/53, respectively. For Glycogen Storage Disease (Type II), respective carrier frequencies for donors and non-donors were 1/80 and 1/86. A similarity in frequency was also seen in Nonsyndromic Hearing Loss & Deafness (GJB2 related), with rates of 1/21 (donors) and 1/18 (non-donors). These results show that, as predicted, gamete donors are equally as likely to be carriers as general fertility patients. Knowing this, the greatest reduction in risk for those receiving donated gametes will come from ensuring both donor and patient undergo similar levels of carrier screening. It will be important to ensure that the manner in which screening is conducted does not unnecessarily eliminate healthy carriers from the donation process.

Expanded carrier screening (ECS) is routinely offered to patients seeking fertility treatment. ECS provides an abundance of information for patients, which may inform reproductive decisions. However this volume of information may be perceived as causing anxiety, particularly for individuals identified as carriers. Our aim was to assess the effect of ECS results on patients identified as carriers compared to non-carriers. Patients who underwent ECS were sent a survey 3 weeks after results were reported. Post-test genetic counseling (GC) was offered to all patients. Consenting participants were asked to report 1) with whom they discussed their results and 2) how often they felt a number of emotions post-test. Responses were compared between carriers and non-carriers. 420 patients completed the survey and were eligible for analysis. 178 were identified as carriers (42%). Post-test GC was received by 158 (89%) of carriers. When asked to report with whom they discussed results, carriers were significantly more likely to have discussed results with family members (p = 0.0003). Among both carriers and non-carriers, most participants reported not discussing their results with a primary care provider/other medical professional. When reporting on emotions felt post-test, carriers felt anxious, nervous, and a loss of control significantly more often than non-carriers (p=5.689e-05; Fisher p= 0.0005). While the difference here was significant, the overall frequency of feeling said emotions was low; the large majority of both carriers and non-carriers felt this way rarely/never. It is expected that carriers may feel anxiety regarding their results. However, even among carriers, the majority reported feeling these emotions rarely/never. This may be due to post-test GC. The benefit of ECS paired with GC extended to participants' families, as carriers reported discussing results with their family members. Participants reported not discussing their results with other medical professionals. The clinical impact of this is important; despite discussing their results with a genetics professional, carriers may feel anxiety regarding how their carrier status affects other areas of their health. These emotions could be mitigated by the sharing of results with other healthcare providers. Future studies around facilitation of such discussions and the impact of post-test genetic counseling will be important, as will implementation of pre-test counseling for patients undergoing screening.

OBJECTIVES: To evaluate the diagnostic performance of the BACs-on-beads assay for prenatal detection of aneuploidy and microdeletion/microduplication. METHODS: A total of 927 amniocytes samples referred for advanced maternal age, abnormal maternal serum screen, or isolated ultrasound markers were collected; a simultaneous analysis was performed both with the use of BACs-on-beads method and classical karyotyping. BACs-on-beads probes were designed for sex chromosomes, common autosomal aneuploidies, and 9 microdeletion/microduplication syndromes. RESULTS: Interpretable results were obtained in all but one case, with 98% receiving results in 48 hours. Aneuploidies were detected in 17 (1.83%) cases, which showed full accordance with classical results. Partial chromosome abnormalities (0.54%) were detected in 5 cases, including three 22q11.2 microduplication, one 10p14 microdeletion, and one Yp11.2 microdeletion. Neither false negatives nor false positives were found; only one karyotype finding was not identified due to the known limitations of the technique. CONCLUSIONS: The great advantage of BACs-on-BEADS assay is the possibility of obtaining quick diagnosis within 48 hours with much wider spectrum of detected anomalies using small amounts of fetal DNA. It is an accurate, robust, and efficient method for the rapid diagnosis of common aneuploidies and microdeletion syndromes in prenatal samples.

The recent recognition of increased genetic admixture and advances in technology advances have caused a shift to broader acceptance of pan-ethnic expanded carrier screening (ECS) panels. However, ECS has not been widely accepted across Europe. The resistance is partially due to a belief that the US is genetically diverse from years of admixture while the European population is genetically homogeneous, making pan-ethnic screening unnecessary. We sought to determine if this difference in admixture was present. Retrospective. Genomic data from an ECS panel was analyzed for 7544 participants, 6297 from US clinics and 1247 from European clinics. For all participants, genetic ancestral origin was predicted by a statistical model based on 672 SNPs validated using samples from the 1000 Genomes Project, and admixture proportions were calculated for 6 ancestral populations (European, Oceania Native, Native American, East Asian, Sub-Saharan African, and South Asian). A comparison of the resulting predicted admixture proportions was made between patients in Europe against patients in the US. Consent to use de-identified genomic data was obtained for all participants. For comparison, the European and American patients were further subdivided into four groups, based upon which ethnicity they self-reported on test requisition forms: European, Mediterranean, Latin American, or African. Across all four comparison groups, our results showed similar average admixture proportions. For example, European patients who self-identified as Mediterranean were genetically predicted to be an average of 86% European, and 5% Sub-Saharan African. American patients who self-identified as Mediterranean were genetically predicted to be an average of 81% European and also 5% Sub-Saharan African. European patients who self-identified as African were predicted to be an average of 78% African and 16% European, which was strikingly similar to the predictions for American patients who self-identified as African (78% African and 12% European). This similarity in admixture proportions was also seen between European and American patients who self-identified as European and Latin American. These results demonstrate that on a genetic level, both European and American patients demonstrate equal degrees of admixture. The European patient population may not be as genetically homogenous as previously believed. Pan-ethnic carrier screening panels could prove to be effective at identifying carriers in a European population, who would otherwise be missed.

Current guidelines published by professional societies recommend genetic carrier screening be offered on the basis of ethnicity. However, as the genetic pool homogenizes people are less aware of, or less likely to identify with, a specific ethnicity. Our goal was to investigate the accuracy of self-reported ethnicity as a basis for making clinical decisions. Retrospective. Self-reported ethnicity was evaluated in 1442 patients who received expanded carrier screening. Reports were gathered from patient requisition forms and during genetic counseling appointments. Comparisons were made to ancestral origin as predicted by a statistical model based on 672 SNPs validated using samples from the 1000 Genomes Project. Documented informed consent was obtained from all patients. We found several discrepancies when comparing self-reported ethnicities on requisition forms, self-reported ethnicity during genetic counseling consults, and genetic ancestry. For example, only 33.3% of individuals who would be considered to be of Mediterranean ancestry based on genetic counseling consults self-reported this background. Further, in 27.2% of cases, patients predicted to be of South Asian descent by the statistical model and confirmed during consults self-reported a different ancestry. Finally, individuals who reported Latin American ancestry demonstrated a high degree of genetic admixture; the 3 highest contributing ancestral origin groups were European (0.509±0.126), Native American (0.234±0.185), and African (0.101±0.183). Our comparison has demonstrated inconsistencies between self-reported ethnicities on requisition forms, self-reported ethnicity during genetic counseling consults, and genetic ancestry, highlighting the unreliability of patient self-reports. Basing carrier screening on patient-reported ethnicity may result in failure to screen for all appropriate genetic conditions and thus failure to identify individuals at high reproductive risk. This emphasizes the importance of offering pan-ethnic expanded carrier screening to all patients. Moreover, as identification of patient ethnicity is critical to the accurate calculation of residual reproductive risk, it may be worthwhile to factor both self-reported and genetic ancestry in these calculations. Finally, in the clinical setting, considerations should be made in how ethnic groups are defined for patient reporting purposes.

Carrier screening in gamete donors varies. Protocols are based on ASRM guidelines, positive screening rates, and recipient testing protocols. We assessed screening practices of varying scope and analyzed the number of donors identified as carriers. With this data, our goal is to propose a carrier screening protocol for gamete donors. Retrospective. Genotyping was performed for over 1500 mutations associated with over 200 autosomal recessive and X-linked genetic diseases. Custom testing panels were developed for referring institutions; this allows for results reporting of only those diseases within a specific panel. The analysis includes data obtained from 621 gamete donors referred by reproductive endocrinologists and donor banks/agencies. Documented informed consent was obtained. Frequently ordered testing panels were identified. Overall genotyping results were compared to reported results, as determined by inclusion in the ordered testing panel. Of 78 custom donor screening panels, 2 panels were used to screen ∼86% of donors. A limited panel of ∼10 diseases and <300 mutations was ordered for ∼36% (225/621) of gamete donors. An expanded panel was ordered for ∼49% (307/621) of gamete donors. Genotyping results for all donors were analyzed, and 38% (236/621) of donors were identified as carriers for at least one condition included in the expanded panel. However, as results are reported based only on ordered panel, only ∼21% (132/621) of donors were reported as carriers, leaving ∼17% (104/621) of donors with un-reported positive results. Our data demonstrate that ∼17% of carrier states within gamete donors, of which 77% were associated with a high impact disease, were not reported due to the use of limited panels. Missed carrier status may lead to high risk pairings of donors and recipients, resulting in unexpected serious genetic disorders in children. While professional organizations have published guidelines for expanded carrier screening in the general population (1), guidelines in gamete donors are much less comprehensive (2). However, donor programs may still prefer this approach because results are used as an exclusion criteria for donor selection. The disconnect between donor and patient screening practices in the IVF center can cause complications. Given this, it may be important to reassess and align carrier screening guidelines and protocols in the gamete donor population with practices performed in the general IVF population. We propose expanded screening be utilized for gamete donor testing and that matching between donors and recipients occur based on screening results with appropriate genetic counseling for both.

Recent statements by professional societies have provided guidance on appropriate approaches to expanded carrier screening.1 Our aim was to determine the effectiveness of expanded panels in a clinical setting by comparing the percentage of carriers identified on 3 carrier screening panels of increasing scope. Retrospective. Documented informed consent was obtained to use de-identified genetic data from expanded carrier screening tests for 8511 patients. Individuals were screened for up to 213 recessive genetic diseases using Illumina’s Infinium HD Genotyping Platform. Carrier counts were tallied for each disease screened, and overall number of carriers was analyzed for 3 disease panels of increasing scope: (1) diseases currently recommended for screening by professional society guidelines; (2) diseases considered to be high-impact for reproductive decision making; and (3) a broad panel of 213 diseases that range in severity. On the most limiting panel, which only screened for diseases currently included in professional society guidelines, 10.7% of patients were identified as carriers. When compared to a larger panel inclusive of 188 high impact diseases, our results indicated that limited screening failed to identify 26.5% of carriers in our patient population. An additional 5% of patients were identified as carriers when the panel was expanded further to include a total of 213 diseases of varying impact. New technologies have provided the ability to simultaneously screen for a multitude of mutations at a reduced cost. Concurrently, genetic diversity has increased due to the admixture of different ethnic groups. These cultural and technological changes have altered the clinical approach to genetic carrier screening, and expanded carrier panels with greater than 100 diseases are increasingly being offered to patients. Data from our ethnically diverse patient population demonstrate that screening for only traditionally recommended diseases failed to identify over a quarter of carriers. Such oversight might contribute to decreased detection of carrier couples, and thus the inability for patients to make fully informed reproductive decisions. Furthermore, an additional 5% of patients were identified as carriers when including moderate impact conditions, which may not affect reproductive decisions but may provide helpful information to couples about their future child’s health. Overall, our data support that expanded carrier panels are more effective at identifying patients at risk of having children with genetic conditions who thus may benefit from increased reproductive options. The continued support of genetic counselors will be critical to guiding all patients through the screening process, regardless of carrier status or disease severity.

Egg donors with negative family history of X-linked disorders may still be carriers and thus put male offspring at risk. Carrier screening for such disorders, with the exception of Fragile X, is currently limited. We here present a case where an undiagnosed carrier state in the donor led to an affected male child, review the literature, and propose a novel approach to prevent transmission of X-linked disorders through egg donation. A case report and literature review Case: An egg donation from a patient’s sister led to the birth of a male child who experienced excessive bleeding at circumcision and was diagnosed with Hemophilia A. The donor had a de novo mutation. Second egg donor cycle using PGD for Hemophilia A was performed and resulted in a birth of healthy unaffected girl. Previously reported births of affected males have uncovered unsuspected mutations for X-linked diseases in egg donors (hemophilia; adrenal hypoplasia congenita; ocular albinism). While donors are screened for the most common autosomal recessive disorders such as CF, SMA (1:2500;1:6000 LB), they are not screened for the most common X-linkeddiseases, such as Hemophilia A, Duchenne Muscular Dystrophy (DMD)(1:5000;1:3300 male LB). Gender selection for females can reduce the risk of symptoms but has ethical issues. Other approaches include molecular testing (such as targeted mutation analysis or sequencing) in the donor to determine carrier status and/or in the embryo to determine disease status. In the case of Hemophilia A, with over 615 point mutations, 57 insertions, 270 deletions ranging from a single nucleotide to over 150 kb, and complex inversions, testing techniques are cumbersome, technically challenging and applicable only to a small number of families with a particular mutation. Similarly, in the case of other X-linked disorders such as DMD, screening is challenging due to deletions accounting for a significant proportion of disease, large numbers of “private” mutations, and high de novo mutation rates. Preimplantation genetic haplotyping (PGH), originally described in 2006, combines a haplotyping approach and whole genome amplification, and may be a robust, efficient and successful alternative method to detect X-linked disorders in embryos. It is incumbent upon us to do everything within the reach of reproductive genetics to prevent X-linked diseases in male offspring from egg donation, as well as from all ART in general. We need to incorporate screening for X-linked disorders as part of regular carrier screening practice, and overcome technical challenges to ensure we are effectively able to test for the wide heterogeneity of mutations that cause X-linked disorders. Preimplantation genetic haplotyping (PGH) may be a promising method for X-linked disease screening in embryos.

Purpose: Technological advances now allow for multiplex platforms to simultaneously test many genetic conditions. Typically, such platforms are validated by assaying samples with known genotypes and/or phenotypes and/or with synthetic plasmids; however, these methods have limitations and with the inclusion of rarer diseases and mutations, we can no longer rely solely on them. We used a novel genomic database to validate an expanded genetic carrier screening platform. Methods: Our expanded carrier screening assay uses the Illumina Infinium iSelect HD Custom genotyping platform to test for 213 genetic diseases by assaying 1,663 pathogenic mutations. We leveraged two Coriell Institute biorepositories for validation: the Subcollection of Heritable Diseases and the 1000 Genomes Project. Results: We measured 12,394 mutation observations in 206 samples, resulting in 246 true positives, 12,147 true negatives, 1 false positive, and no false negatives. Results demonstrated high sensitivity (99.99%) and specificity (99.99%). Conclusion: We successfully validated our platform with two biorepositories, demonstrating high sensitivity and specificity. The 1000 Genomes Project samples provided both positive and negative validation for mutations in genes not available through other biorepositories, expanding the depth of validated variants. We recommend including samples from the 1000 Genomes Project in the validation of future multiplex testing platforms. Genet Med advance online publication 30 July 2015

The hypothalamic-pituitary-ovarian (HPO) axis is a critical signaling pathway in female reproduction, including reproductive hormones such as gonadotropin releasing hormone (GnRH), follicle stimulating hormone (FSH), luteinizing hormone (LH), estradiol, and progesterone. Previous studies have shown that endocrine levels in women are affected by single nucleotide polymorphisms (SNPs). This study aimed to identify SNPs impacting the HPO by exploring links between SNPs and baseline serum hormone levels in women referred from fertility centers. Retrospective Clinical and genetic data was collected for 143 women less than 40 years of age. Day 2/3 serum FSH, LH, estradiol, and progesterone levels and AMH levels were collected by chart review. Genetic polymorphisms within FSH receptor (FSHR), FSH beta polypeptide (FSHB), anti-Mullerian hormone (AMH), and AMH receptor type II (AMHR2) were measured using Illumina's Infinium HD Genotyping assay. Welch's t-test was used to test 150 associations between hormone levels and SNPs. A p-value of p<0.05 was considered significant. Documented informed consent was obtained to utilize data in a de-identified manner. Several associations between endocrine levels and polymorphisms were observed. FSH levels were associated between two FSHR variants: p.S680N (rs6166; p=0.002) and p.A307T (rs6165; p=0.0065). Progesterone levels were associated with an FSHB variant: c.-280G>T (rs10835638; p=0.034). Finally, LH levels were associated with two AMH variants: c.-649C>T (rs4807216; p=0.019) and p.S49I (rs10407022; p=0.03). This study has demonstrated the impact of SNPs on the HPO signaling pathway, particularly FSHR, FSHB, and AMH. The link between FSH levels and FSHR SNPs and between progesterone levels and FSHB SNPs have been shown before, demonstrating our ability to validate previous findings. We also identified a novel interaction between LH levels and AMH SNPs, indicating a potential interaction between AMH and LH that has yet to be characterized. While individual interactions are significant, the combination of these and other SNPs have not been studied. This endocrine signaling pathway is highly interconnected. Thus, multiple SNPs inherited together may influence signaling efficiency in more complex ways than previously thought. Further and larger studies designed to investigate the possibility of multifactorial influences on endocrine signaling in female reproduction will lead to a deeper understanding of the clinical implications of hormone levels on fertility.

Several genetic variants in the CYP21A2 gene eliminate or reduce P450c21 activity, which is involved in cortisol biosynthesis. These variants can cause 21-hydroxylase deficient classical or nonclassical CAH, which are associated with several clinical symptoms including decreased fertility in males and females. The purpose of this study was to measure the carrier rates of genetic variants in CYP21A2 in fertility patients to determine if testing for these variants should be considered in this population. Retrospective. The Illumina Infinium HD Custom Genotyping platform was used to test for variants in the CYP21A2 gene, including c.293-13C>G (rs6467) and p.G425S (rs72552758) associated with classical CAH and p.H63L (rs9378252) and p.P454S (rs6445) associated with nonclassical CAH. Genotype frequencies were calculated based on data obtained from 2,188 clinical referrals from fertility centers. Documented informed consent to utilize clinical data in a de-identified manner was obtained. We found that 1,908 individuals (87.2%) do not carry any of the tested CYP21A2 variants. A total of 237 (10.83%) and 22 (1.01%) of the tested individuals were carriers or homozygous for the p.H63L nonclassical variant, respectively. Only one individual (0.05%) was homozygous for the p.P454S nonclassical variant. We identified 18 individuals (0.82%) that carried both nonclassical CAH variants. Further, two individuals (0.09%) carried both the classical c.293-13C>G and nonclassical p.H63L variants. Compared to findings from other studies, the nonclassical p.H63L variant is much more common in our population of fertility patients than previously reported. As of 2013, only 31 cases of p.H63L had been identified in individuals presenting with CAH [1]. However, we found that 12.76% of our population carries at least one copy of this variant. The literature suggests that the p.H63L variant reduces P450c21 activity and is associated with mild clinical features. The relatively high frequency of this variant in our population of fertility patients suggests the need to investigate the association of this variant with infertility specifically. If an association exists, this could inform hormone-based fertility treatment decisions.

Expanded carrier screening is now routinely performed at fertility centers. While such panels focus on identifying genetic diseases with high impact on quality of life or life expectancy, some vary in severity. Further, different mutations in the same gene can lead to variable expression of disease. The goal of this study was to explore VSMs and assess their impact on our positive screen rate. Retrospective. The Illumina Infinium HD Custom Genotyping platform identified 1679 mutations associated with 213 recessive diseases. The analysis includes data from 3208 clinical referrals from reproductive endocrinologists, obstetricians, and genetic counselors. Documented informed consent to utilize data in a de-identified manner was obtained. VSMs were identified for several high impact recessive diseases and allele frequencies for each mutation were calculated. We measured the positive screen rate within our patient population for all mutations, high impact disease mutations and high impact disease mutations excluding the select VSMs. We identified common variable spectrum mutations for high impact diseases, including p.D1270N in Cystic Fibrosis, p.A28S in β Thalassemia, the 4.2kb deletion in α Thalassemia, p.V37I and p.M34T in GJB2-Related Nonsyndromic Hearing Loss & Deafness, and p.D444H in Biotinidase Deficiency. The positive screen rate for all panel mutations was 59.4%. When looking only at high impact disease mutations, the positive screen rate was 42%. After excluding VSMs our positive screen rate reduced to 29.5%. Our results indicate that VSMs within high impact diseases account for a significant portion of carriers on our panel (12.5%). We continue to report these mutations, as they can be clinically significant when in cis with other mutations or when in trans with a severe mutation. Therefore, genetic counseling for carrier screening results is critical. We could additionally consider removing VSMs, flagging these mutations on clinical reports or reporting these mutations only when a couple's reproductive risk is high. Advances in genomic technology will lead to continued identification of VSMs; therefore, a consensus should be reached on how to manage these mutations in a clinically responsible way.