新加坡 PGS PGT-A 胚胎植入前遗传学筛查

Angelica Cheng

Active Member

中国不孕不育患者应对海外的体外受精胚胎中的基因检测和性别选择提高警惕 (PGS/PGT-A)


最近,许多中国不孕不育患者出国寻求国内禁止的辅助生殖服务。这通过基因测试对体外受精胚胎进行性别选择,即被称为胚胎植入前遗传学筛查(PGS/PGT-A)的技术是在伦理上最具争议的辅助生殖技术之一。这项技术涉及对非遗传性疾病携带者的体外受精胚胎进行筛查,这与密切相关联的专门测试未来父母携带的已知遗传缺陷的胚胎植入前基因诊断 (PGD) 技术不同。

目前,中国不孕不育患者可在在大多数外国生育诊所获取PGS(PGT-A)的服务。事实上,许多出国接受生育治疗的中国患者,往往都会选择对体外受精胚胎进行基因检测,这不仅是为了性别选择,也是为了减少年龄较大妇女的后代患唐氏综合症的风险,并提高最后的成功率。这种现象的产生主要是因为国外的生育诊所积极推广这项技术,这使生育治疗成本大幅提高了30% 到50%。因此,强调这项昂贵技术的被越来越多的科学证据所证实的医疗风险非常重要,中国患者在出国接受辅助生殖治疗之前应该意识到这一点。

目前,有充分证据表明,PGS(PGT-A)技术大量存在因辅助生殖技术中经常出现的"镶嵌型胚胎”而出现的假阳性误诊。这些胚胎是具有基因异常和正常的细胞的混合物。最近的研究表明,这种镶嵌型胚胎通常能产生健康和正常的婴儿。

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要理解为什么会这样,想象人类胚胎包含多层细胞,内层产生胎儿本身,而外层产生胎盘和脐带。事实上,许多对正常分娩的研究经常发现胎盘和脐带的遗传异常。

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这是因为在正常胚胎发育过程中,大自然拥有一个神奇的方法来纠正遗传缺陷,即通过逐步推动和分离基因异常细胞到产生胎盘和脐带的外层,同时保持最终将形成胎儿本身的内层遗传完整性。

PGS(PGT-A)技术的问题在于,它只从第五天胚胎 (囊胚, Blastocyst) 外层(形成胎盘的滋养层细胞 , Trophectoderm)中提取细胞进行基因测试,因为从胚胎内层取样细胞(形成婴儿的内细胞团 , Inner Cell Mass)会提高破坏胚胎的风险。因此,与PGS(PGT-A)相关的假阳性误诊发生率很高,这往往导致镶嵌型胚胎的丢弃,这其中许多胚胎实际上可能可以变成正常健康的胎儿。

因此,一些研究报告说,PGS(PGT-A)实际上减少了而不是提高了试管婴儿成功的累计成功率。由于在每一个辅助生殖治疗周期中,大龄妇女和卵巢功能储备低的妇女通常产生较少的胚胎,因此丢弃镶嵌型胚胎实际上可能对他们成功的机有着更负面的影响。

对于胚胎很少的患者来说,每一个胚胎(包括部分异常的镶嵌型胚胎)都更"珍贵",并且会对他们生殖成功的机会意味着更多。最近在澳大利亚,患者因PGS(PGT-A)技术误诊导致其本可以产生正常胎儿的有活力的胚胎被丢弃,而对一个辅助生殖诊所(Monash IVF)提起集体诉讼。此外,2019年结束的一项利用最新的基因组测序技术的,涉及美国、加拿大、澳大利亚和英国661名患者和34家辅助生殖诊所的大型临床试验,报告了PGS(PGT-A)在提高怀孕成功率方面没无益处。

虽然PGS(PGT-A)技术经常被吹捧为有助于避免大龄妇女胎儿的出生缺陷,如唐氏综合症,但患者必须意识到,尽管成本高昂,但它不是一种万无一失的基因缺陷筛查手段。

通常,PGS (PGT-A) 仅针对一组常见的遗传缺陷进行筛查,该这些不包括一些更加罕见的疾病。它也无用于检测涉及多个基因与出生环境中多个因素相互作用的更复杂的遗传条件,例如自闭症。

患者还应注意,在辅助生殖治疗期间,绝大多数基因异常的胚胎往往在移植到子宫时无法植入:甚至那些已经植入的基因异常的胚胎会在很早的阶段就自发流产,如生化怀孕。

因此,患者应考虑更经济的出生缺陷筛查方法,如新一代无创胎儿检测(NIPT),该检测可以筛查从孕妇血液样本中提取的胎儿DNA中的遗传缺陷。

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此外,患者还必须警惕在国外辅助生殖机构经常用来哄骗患者进行PGS (PGT-A)的激进销售策略和营销花招。

一个例子是相对风险的概念是如何为了引起患者对先天缺陷的恐惧而被错误呈现给他们的。例如,如果胎儿罹患唐氏综合症的风险在20岁产妇中为0.1%,在40岁产妇时增加到1%,在45岁时增加到4%:那么另一种呈现数据的方法是,胎儿罹患唐氏综合症的风险从产妇年龄20岁到40岁增加了10倍,从产妇年龄20岁到45岁增加了40倍。

因此,通过咬文嚼字,对不熟悉医学统计的患者,基因缺陷的风险被"夸大"了。

另一个不可靠的和道德上值得怀疑的营销策略是利用患者对男孩或女孩的偏爱,这可能得益于PGS(PGT-A)是目前最准确和最可靠的胚胎性别选择技术。

最后但并非最不重要的一点是,患者还应意识到"高度精尖"的PGS(PGT-A)技术损害胚胎的风险,其中涉及在胚胎外被(透明带, Zona pellucida)钻孔后从胚胎中提取细胞。

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这种技术的顺利进行能往往高度依赖于实验室工作人员(胚胎学家)的技能和培训。即使有高水平的培训和认证,仍然存在有人为错误的可能性,尤其是在一个非常繁忙的每天处理几起此类案件的实验室。

总之,越来越多的科学证据使人们对PGS(PGT-A)的医疗益处产生怀疑。中国卫生部目前对PGS(PGT-A)技术进行如此严格的监管,不遗余力地保护患者的福祉,这当然有充分的理由。

前往国外接受辅助生殖治疗的中国患者应当小心,不要被"强迫"进行不必要的PGS。他们应当扪心自问,为什么即使这种技术在国外以利润为目标的私人生育诊所被认为如此有益,但它在国内却受到如此严格的限制。
 

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Genetic testing of IVF embryos (PGS / PGT-A) – what Singaporean patients should know

Recently, Ms Rahayu Mahzam, Parliamentary Secretary of Ministry for Health — reported that the pilot trial of genetic testing of IVF (In Vitro Fertilization) embryos in Singapore suffers from a high attrition rate of 72% (2nd March 2021). She stressed the need to proceed carefully as there is some risk to the embryo during testing.

This procedure, also known as Preimplantation Genetic Screening (PGS) or Preimplantation Genetic Testing – Aneuploidy (PGT-A), involves screening the embryos of IVF patients whom are not known to be carriers of genetic diseases, unlike the closely-related Preimplantation Genetic Diagnosis (PGD) technique, which specifically tests for known genetic defects carried by prospective parents. Hence, the pertinent question that arises is why is there such a high attrition rate?

Yet at an earlier parliamentary session on 25th February 2021, MP Cheng Li Hui, called for less restrictions to make PGS (PGT-A) more widely available to IVF patients, on the basis that this procedure screens for the correct number of chromosomes to improve the chances of conception.

Hence, Singaporean IVF patients should be made aware of the widespread controversy and accumulating scientific evidence against the medical effectiveness of PGS (PGT-A) in improving the outcome of fertility treatment in patients, whom are non-carriers of genetic diseases.

Currently, PGS (PGT-A) is readily available to Singaporean patients at most foreign fertility clinics, particularly those from neighbouring countries. Indeed, many Singaporean patients who travel abroad for fertility treatment, often end up choosing to do genetic testing of their IVF embryos, not only for sex-selection, but also to eliminate the risks of Down Syndrome in older women and improve success rates.

This is due in large part to aggressive marketing of this technique by foreign fertility clinics, which substantially increases the costs of fertility treatment from 30% to 50%. Hence, it is imperative to highlight the controversial issues surrounding this expensive technique, which Singaporean patients and healthcare policymakers should be aware of.

Currently, there is good evidence that the PGS technique is fraught with false positive misdiagnoses due to the frequent occurrence of ‘mosaic’ embryos in IVF treatment. These are embryos that have a mixture of genetically abnormal and normal cells. Recent studies have shown that such ‘mosaic embryos’ can often give rise to healthy normal babies.


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To understand why this is so, imagine the human embryo as containing multiple layers of cells, with the inner layers giving rise to the baby itself, while the outer layers give rise to the placenta and umbilical cord. Indeed, many studies of normal births often detect genetic abnormalities in the placenta and umbilical cord.

This is because nature has an amazing way of correcting genetic defects during the course of normal embryo development, by gradually pushing and segregating genetically abnormal cells to the outer layers that give rise to the placenta and umbilical cord, whilst preserving the genetic integrity of the inner layers that will eventually form the baby itself.

The problem with the PGS technique is that it only extract cells from the outer layers (Trophectoderm) for genetic testing, because sampling cells from the inner layers (Inner Cell Mass that forms the baby)
incurs too much risk of damaging the embryo. Hence the high incidence of false positive misdiagnoses associated with PGS, which often lead to discarding of ‘mosaic’ embryos, many of which can in fact give rise to a normal healthy baby.

Consequently, some studies have reported that PGS in fact reduces rather than improve the cumulative chances of IVF success. Because older women and women with low ovarian reserves usually produce less embryos during each IVF treatment cycle, the discarding of ‘mosaic’ embryos could in fact have a more devastating impact on their chances of success.

For such patients with very few available embryos, every single embryo (including mosaic ones) is more ‘valuable’, and would count more to their chances of reproductive success. Just recently in Australia, a class action lawsuit was launched by patients against Monash IVF for misdiagnosis by the PGS (PGT-A) technique, which led to discarding of their viable embryos that could have otherwise led to healthy births.

Although the PGS technique is often touted to be useful for avoiding birth defects such as Down syndrome in older women, patients must be aware that it is not a foolproof means of screening for genetic defects despite its high cost.

Usually, PGS screens only for a panel of common genetic defects, which excludes many rarer genetic diseases. It is also useless for detecting more complex genetic conditions that involve interaction of multiple genes with various factors within the birth environment, such as Autism Spectrum Disorders (ASD).

Patients should also be aware that the vast majority of genetically-abnormal embryos often fail to implant upon transfer to the womb during the IVF procedure; and even those genetically abnormal embryos that do implant often spontaneously abort at very early stages e.g. biochemical pregnancy.

Hence, patients should consider more economical means of screening for birth defects, such as the new generation of Non-Invasive Prenatal Testing (NIPT), that can screen for genetic defects in fetal DNA extracted from the pregnant mother’s blood sample.

Additionally, patients must also be wary of the aggressive sales pitch and marketing gimmicks routinely used to coax patients to undertake PGS during IVF treatment abroad.

One example is how the concept of relative risks is being misrepresented to patients, to play on their fears of birth defects. For example if the risk of Down syndrome is 0.1 % at age 20, and increases to 1% at age 40 and subsequently to 4% at age 45; then another way of presenting the data would be to say that the risk of Down syndrome increases 10-folds from age 20 to 40, and 40-folds from age 20 to 45.

Hence, through a sly manipulation of words and figures, the risks of genetic defects can be ‘exaggerated’ to patients who are unfamiliar with medical statistics.

Another dubious and ethically-questionable marketing tactic is to manipulate and play on the patient’s biased preference for either a boy or girl child, which may be helped by the fact that PGS is currently the most accurate and reliable embryo sex selection technique that is available in the market.

Last but not least, patients should also be aware of the risks of damaging the embryo during the ‘highly-delicate’ PGS procedure, which involves extracting cells from the embryo after drilling a hole through the embryo shell (Zona pellucida).

The smooth performance of this technique is often highly dependent on the skill and training of the laboratory staff (Embryologist). Even with high levels of training and accreditation, there is still a possibility of human error, particularly in a very busy laboratory that handles several such cases a day.

In conclusion, there is increasing scientific evidence that cast doubts on the medical benefits of PGS (PGT-A). There are certainly good reasons why the PGS technique is so stringently regulated by the MOH here in Singapore at the present moment, which is exercising due diligence to protect the welfare of patients.

Singaporean patients traveling abroad for IVF treatment should be cautious not to be ‘pushed’ into undertaking PGS unnecessarily, by asking themselves why this technique is so severely restricted in their own country, even if it is deemed to be so beneficial by profit-driven private fertility clinics abroad.
 
使用胚胎基因测试 (PGT-A / PGS) 预防唐氏综合症是否具有成本效益和价值吗?为什么不利用更便宜的无创产前检测 (NIPT) 呢? (360doc.com)

随着中国提出新的三胎政策,尝试怀孕的高龄女性人数预计将会增加。然而,随着母亲年龄的增长,怀上唐氏综合症患儿的风险增加。唐氏综合症是一种遗传性疾病,由21号染色体的额外复制引起,其特征是患儿精神和身体发育受损,以及有某些身体状况, 如先天性心脏缺陷、糖尿病和阿尔茨海默病(40岁以后)的倾向增加。虽然年长母亲和唐氏综合症之间是有确切联系的,但必须指出,因为年轻妇女的生育率要高得多,大多数患有唐氏综合症的婴儿都是由35岁以下的妇女所生。

目前在中国,超过95%的唐氏综合症胎儿在产前检测呈阳性后通常会被人工流产。中国卫生法规允许唐氏综合症胎儿在怀孕9个月前人工流产。对于患者来说,除了情感创伤之外,在人工流产唐氏综合症胎儿后,其精神、身体和生殖健康也面临风险。

对于接受辅助生殖治疗的高龄女性,有一种方法可以避免这种人工流产的困境,具体方法是在进入子宫之前对试管婴儿胚胎进行基因筛查,这个过程称为胚胎植入前染色体非整倍性检测 (PGT-A) 或胚胎植入前遗传学筛查 (PGS)。因此,对接受辅助生殖治疗的高龄女性来说出现的问题是,利用PGT-A (PGS)筛查和排除唐氏综合症胚胎是否值得,是否具有成本效益?患者必须仔细比较 PGT-A (PGS)以及常规产前筛查技术如无创产前检测 (NIPT) 的好处和风险。


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要做出明智的选择,患者应首先了解 PGT-A (PGS) 的各种缺点和风险。特别应建议他们仔细考虑这一昂贵方法的成本效益方面,该过程可能使试管婴儿治疗费用增加50%。相比之下,唐氏综合症和其他遗传缺陷的产前测试要便宜得多,尽管这还需要考虑人工流产基因异常胎儿的可能。鉴于试管婴儿治疗的结果不确定,成本高昂,一些资金有限的患者最好不做PGT-A (PGS) 从而降低成本,以便为今后试管婴儿治疗的尝试节省资金。毕竟要成功通常需要多次尝试,而为每个试管婴儿的治疗周期做 PGT-A (PGS) 在经济上会是较大的负担。

根据公布的医学统计数据,近40岁(约37至39岁)妇女的胎儿患唐氏综合症的风险大致在0.5%左右。在40岁时,胎儿唐氏综合症的风险上升到 1.0% 左右,45岁时则上升到3.5%左右。因此,在女性生育周期的几乎整个跨度中,唐氏综合症的风险实际上相对较低,不到4%。归根结底,需要由经济能力有限的患者来决定,为了进行更多的试管婴儿尝试,避免这种高费用操作的风险是否是值得的。


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因此,对于所有接受试管婴儿的高龄女性来说,使用PGT-A(PGS)的成本效益低,因为唐氏综合症的风险在整个女性生育周期(20至45岁)中发病率不足4%。特别是40岁以下的妇女产的胎儿唐氏综合症的发病率通常低于1%,因此利用PGT-A (PGS) 为唐氏综合症筛查是多余的。如果患者在 PGT-A (PGS) 上花费太多金钱, 导致没有更多的钱用于进一步的试管婴儿的尝试, 那将会是可悲的。

此外,患者还应小心 PGT-A (PGS) 容易出现误诊,导致患者丢弃一些能够导致健康分娩的有活力的胚胎。这是因为PGT-A(PGS) 的样本细胞只来自产生胎盘和脐带的外胚胎层(滋养层细胞),而这并不能代表产生婴儿本身的内胚胎层 (内细胞团)。含有遗传正常细胞和异常细胞混合物的”镶嵌型胚胎”已显示出自我纠正和产生健康分娩的能力。

最近,澳大利亚患者对PGT-A(PGS)的误诊提起了集体诉讼,误诊导致他们有活力的胚胎被丢弃,从而丧失为人父母的机会。另外值得注意的是,2019年,美国、加拿大、英国和澳大利亚的600多名患者参加了一项大型国际多中心临床试验,此项实验显示,尽管利用了最新的基因组测序技术,但PGT-A (PGS)组 的怀孕率并没有显著改善。


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最后,虽然PGT-A (PGS) 可以规避接受试管婴儿治疗的高龄女性人工流产唐氏综合症胎儿后的情感创伤和健康风险,但鉴于手术费用高昂,而且存在各种风险和不利因素,她们需要仔细考虑成本效益。 大夫有责任让患者通过恰当且严格的咨询,做出明智的决定,使他们注意到使用PGT-A (PGS)来预防唐氏综合症的成本效益和风险。此外, 医疗卫生部门必须制定严格的保障措施, 防止生育诊所采取激进的营销策略,通过操纵患者对唐氏综合症的恐惧来夸大风险。


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Avoiding the moral dilemma and emotional trauma of Down syndrome abortions by mainstreaming IVF genetic testing (PGS/PGT-A) for older women

Down syndrome is a genetic condition caused by an extra copy of chromosome 21, which is characterized by impairment of mental and physical development, together with increased predisposition to certain medical conditions such as congenital heart defects, diabetes, and Alzheimer’s disease (after the age of 40).

It has a worldwide prevalence rate of approximately 1 to 800 live births, and occurs throughout all ethnicity and social classes. Although the link between older mothers and Down syndrome is well-established, it must be noted that most babies with Down syndrome are born to women below 35 years of age, due to the much higher fertility rates of younger women.

In recent years, there have been a number of local media reports of pregnant women deciding to keep their Down syndrome baby after prenatal testing. Undoubtedly, couples undergo much emotional trauma upon learning the results of prenatal testing, and face an agonizing dilemma of whether to proceed with abortion.

The conscientious objection of some women against abortion should be commended, given the many unique challenges and sacrifices that they face in raising a Down syndrome child.

Highly contentious issue overseas

Currently, this is a highly contentious issue overseas, as evidenced by some recent high-profile court cases.

In the United States, an appellate court ruling upheld Ohio state law prohibiting abortion of Down syndrome fetuses.

In Britain, a review of abortion law relating to Down syndrome is set to be heard at the High Court after vigorous campaigning by pro-life groups.

In India, a legal precedent was set in 2020 by a landmark supreme court ruling that permitted abortion of a 25 week-old fetus diagnosed with Down syndrome; whereas previously, abortion was permitted only for fetuses less than 20 weeks-old.

Difficult moral choices to expectant parents

Undoubtedly, continuous improvements in the accuracy of prenatal screening technology now present difficult moral choices to expectant parents faced with a positive diagnosis, who have to weigh the heavy financial, emotional and physical toll of raising a Down syndrome child, with their conscience, as well as personal and religious beliefs on abortion.

On one hand, there is right-to-life of the unborn child and respect for the dignity of disabled people. On the other hand, there are grave concerns on the happiness and quality-of-life for the child and themselves, together with the nagging fear that they would be unable to cope with the heavy burden of raising a special needs child.

Additionally, there are also risks to the mental, physical, and reproductive health of the patient to consider, when aborting a Down syndrome fetus.

The incidence of Down syndrome rises with increasing maternal age, which is particularly significant for Singapore, given the increasing trend of late marriages and parenthood.

For older women undergoing IVF (in vitro fertilization) treatment, there is a way of avoiding this abortion dilemma and emotional quagmire by genetic screening of IVF embryos prior to transfer into the womb, a procedure known as Preimplantation Genetic Testing – Aneuploidy (PGT-A) or Preimplantation Genetic Screening (PGS).

This is designed for IVF patients without any known heritable genetic disorders.

PGT-A (PGS) service in Singapore

To date, PGT-A (PGS) is still not approved as mainstream clinical service in Singapore, and is restricted to a pilot clinical trial at public IVF centers, in contrast to genetic testing of IVF embryos for patients with known genetic disorders, which was recently approved as mainstream clinical service.

The criteria for participation in this pilot PGT-A trial are that the female patient must be at least 35 years old, or have experienced at least two miscarriages or two failed IVF cycles.

A recent article in Channel NewsAsia (‘So near, yet so far: Aspiring parents and their embryos separated by the pandemic‘, 23 May) reported on local women traveling overseas to do IVF with PGT-A, because this procedure is much more readily available and less strictly regulated abroad, compared to Singapore.

Hence, based on compassionate grounds, to avoid future abortion dilemmas and emotional trauma for older women undergoing IVF, whom are at increased risk of Down syndrome, the Ministry of Health (MOH) should approve PGT-A as mainstream clinical service specifically for such older patients.

Nevertheless in doing so, MOH should ensure rigorous counseling to inform patients of the various downsides and risks of PGT-A.

In particular, patients should be advised to think carefully on the cost-benefit aspect of this expensive procedure that may increase the cost of IVF treatment by up to 50 per cent.

By contrast, prenatal testing for Down syndrome and other genetic defects is much cheaper, albeit the risks of needing to consider aborting an abnormal fetus.

Given the uncertain outcome and high costs of IVF, it may be preferable for some patients with limited funds to cut costs by not doing PGT-A, so as to save money for future IVF attempts.

After all, more than one IVF attempt is usually needed to achieve reproductive success, and it would be financially exhausting to do PGT-A for each and every IVF treatment cycle.

Risk of Down syndrome for women

According to published medical statistics, the risk of Down syndrome for women in their late 30’s, around 37 to 39 years old, hovers around 0.5 per cent.

Even at age 40, the risk of Down syndrome increases to about 1 per cent, and then to around 3.5 per cent at age 45.

Hence, for almost the entire span of a woman’s reproductive life, the risks of Down syndrome are in fact relatively low, at less than 4 per cent.

Ultimately, it is up to patients with limited financial resources to decide whether it is worthwhile taking a calculated risk of avoiding this highly-expensive procedure, to get more shots at IVF.


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Utilization of public funding to detect and prevent Down syndrome in older female IVF patients

Unlike subsidizing the genetic testing of IVF patients with known heritable disorders, which is currently being considered by MOH, the utilization of public funding to detect and prevent Down syndrome in older female IVF patients by PGT-A is neither economical, cost-efficient nor politically-justifiable in the long term.

First, there is the issue of personal choice and responsibility for late motherhood, unlike the case of heritable genetic disorders, which is involuntary.

Second, heritable genetic disorders are relatively rare, and represent only a tiny fraction of IVF patients, as compared to the much larger numbers of older female IVF patients, which would mean that subsidies would cost much more.

Third, there is a much cheaper, yet accurate and reliable alternative to detect Down syndrome, in the form of Non-Invasive Prenatal Testing (NIPT), albeit the risks of abortion after positive diagnosis.

Lastly, it would be highly cost-inefficient to subsidize PGT-A for all older women undergoing IVF, given that the risks of Down syndrome do not exceed 4 per cent for almost the entire female reproductive lifespan (20 to 45 years old).

Additionally, patients should beware that PGT-A is prone to false-positive misdiagnosis, leading to discarding of some of their viable embryos that can otherwise give rise to healthy births.

This is because PGT-A sample cells only from the outer embryo layer (Trophectoderm) that generates the placenta and umbilical cord, which is not representative of the inner embryo layer (Inner Cell Mass) that gives rise to the baby itself.

Mosaic embryos containing a mixture of genetically normal and abnormal cells, have demonstrated ability to self-correct and give rise to healthy births. Recently, a class-action lawsuit was filed by Australian patients against misdiagnosis by PGT-A that led to discarding of their viable embryos and consequent loss of chance at parenthood.

Another note of caution is that at a recent parliamentary debate, MOH reported a relatively high attrition rate of 72 per cent for the pilot trial of PGT-A at public IVF centers in Singapore; and consequently voiced the need to proceed carefully, because there are some risks of damaging the embryo by this procedure.

Earlier in 2019, a large international multi-centre clinical trial involving more than 600 patients in the USA, Canada, UK and Australia, reported no significant improvements in pregnancy rates from PGT-A, despite utilizing the latest next-generation sequencing assay for aneuploidy testing.

More choices to circumvent the moral dilemma and emotional trauma of aborting a Down syndrome fetus

In conclusion, by mainstreaming PGT-A for older female IVF patients at higher risks of Down syndrome, this would confer them with more choices to circumvent the moral dilemma and emotional trauma of aborting a Down syndrome fetus.

The primary responsibility of MOH is to ensure that patients make an informed decision, via proper and thorough counseling on the cost-effectiveness and risks of utilizing PGT-A for this particular purpose.

It is also imperative that MOH enact stringent safeguards to prevent aggressive marketing tactics by private fertility clinics that exaggerate risks and exploit patients’ fear of Down syndrome.
 

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