Great post. Thank you. Fertility doctor here and a supporter of ART (assisted reproductive technologies) in general. A few thoughts (although you touched on a few of these below, worth emphasizing in my opinion):
PGT-P has not been validated yet, which may take decades to do, if ever.
The science in terms of GWAS isn’t quite there yet IMHO—we don’t know all the genes that are important for most traits and we may be inadvertently selecting against some desirable traits, for example.
Comparing clinic success rates using CDC data is imperfect because of different patient characteristics, patient selection, and reporting bias.
IVF pregnancies carry a significantly higher complication rate (hypertensive disorders, preterm birth, placental abnormalities, etc.) compared to spontaneous pregnancies—unclear if this is due to IVF or underlying infertility diagnosis.
The risk-benefit calculus of PGT-P is going to be different for a couple who already needs to do IVF anyway to have a baby (low additional risk/cost) compared to a couple doing IVF just so that they can do PGT-P (higher additional risk/cost).
IVF is notoriously inefficient at present. Depending on female partner age, each cycle may yield only very few embryos making the benefit and utility of PGT-P limited. It may not be practical, safe, or financially feasible to do multiple cycles of IVF to increase the cohort of transferable embryos.
IVF is expensive and often not covered by insurance which creates access disparities. PGT-P would exacerbate these disparities in access. This is not unique to IVF I realize.
Slippery-slope eugenics and discrimination are real ethical concerns that would need to be mitigated.
In-vitro gametogenesis (IVG) would be a game-changer. The utility of PGT-P would be greatly enhanced if suddenly you had thousands of eggs and hundreds of embryos to select from.
Thanks for the response.
I thought the following article does a good job of outlining some of the limitations of PRS for embryo selection:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9527452/
Like any new (medical) technology, I think that it’s important to consider the ethical implications. This doesn’t mean that we shouldn’t do it or allow it, but just that we should be thoughtful about it.
As for clinic success rates, I didn’t mean to imply that “they don’t mean anything”. It’s just that prospective patients should be aware that they can’t always be taken at face value. Clinic populations may differ significantly and the data can be manipulated to some extent. The good news though is that as long as a clinic does a significant volume of IVF cycles per year and reports decent success rates, it’s probably fine.
I agree that increasing insurance coverage for infertility services would help improve access and reduce disparities.
RE IVG, I see your point. I guess germline/embryo gene-editing (if it were proven safe, efficient, and efficacious) would have greater utility than PGT-P (preimplantation genetic testing for polygenic risk).