Screening Embryos for Disease

Preimplantation genetic diagnosis (PGD) is a test that screens for genetic flaws among embryos used in in vitro fertilization. With PGD, DNA samples from embryos created in-vitro by the combination of a mother's egg and a father's sperm are analyzed for gene abnormalities that can cause disorders. Fertility specialists can use the results of this analysis to select only mutation-free embryos for implantation into the mother's uterus. Before PGD, couples at higher risks for conceiving a child with a particular disorder would have to initiate the pregnancy and then undergo chorionic villus sampling in the first trimester or amniocentesis in the second trimester to test the fetus for the presence of disease. If the fetus tested positive for the disorder, the couple would be faced with the dilemma of whether or not to terminate the pregnancy. With PGD, couples are much more likely to have healthy babies. Although PGD has been practiced for years, only a few specialized centers worldwide offer this procedure.

What Are Some of the Pros and Cons of Gene Testing?

Gene testing already has dramatically improved lives. Some tests are used to clarify a diagnosis and direct a physician toward appropriate treatments, while others allow families to avoid having children with devastating diseases or identify people at high risk for conditions that may be preventable. Aggressive monitoring for and removal of colon growths in those inheriting a gene for familial adenomatous polyposis, for example, has saved many lives. On the horizon is a gene test that will provide doctors with a simple diagnostic test for a common iron-storage disease, transforming it from a usually fatal condition to a treatable one.

Commercialized gene tests for adult-onset disorders such as Alzheimer's disease and some cancers are the subject of most of the debate over gene testing. These tests are targeted to healthy (presymptomatic) people who are identified as being at high risk because of a strong family medical history for the disorder. The tests give only a probability for developing the disorder. One of the most serious limitations of these susceptibility tests is the difficulty in interpreting a positive result because some people who carry a disease-associated mutation never develop the disease. Scientists believe that these mutations may work together with other, unknown mutations or with environmental factors to cause disease.

A limitation of all medical testing is the possibility for laboratory errors. These might be due to sample misidentification, contamination of the chemicals used for testing, or other factors.

Many in the medical establishment feel that uncertainties surrounding test interpretation, the current lack of available medical options for these diseases, the tests' potential for provoking anxiety, and risks for discrimination and social stigmatization could outweigh the benefits of testing.

For What Diseases Are Gene Tests Available?

Currently, more than 900 genetic tests are available from testing laboratories. Some gene tests available in the past few years from clinical genetics laboratories appear below. Test names and a description of the diseases or symptoms are in parentheses. Susceptibility tests, noted by an asterisk, provide only an estimated risk for developing the disorder. Contact GeneTests at www.genetests.com for comprehensive information on test availability and genetic testing facilities.

Some Currently Available DNA-Based Gene Tests

• Alpha-1-antitrypsin deficiency (AAT; emphysema and liver disease)

• Amyotrophic lateral sclerosis (ALS; Lou Gehrig's Disease; progressive motor function loss leading to paralysis and death)

• Alzheimer's disease* (APOE; late-onset variety of senile dementia)

• Ataxia telangiectasia (AT; progressive brain disorder resulting in loss of muscle control and cancers)

• Gaucher disease (GD; enlarged liver and spleen, bone degeneration)

• Inherited breast and ovarian cancer* (BRCA 1 and 2; early-onset tumors of breasts and ovaries)

• Hereditary nonpolyposis colon cancer* (CA; early-onset tumors of colon and sometimes other organs)

• Charcot-Marie-Tooth (CMT; loss of feeling in ends of limbs)

• Congenital adrenal hyperplasia (CAH; hormone deficiency; ambiguous genitalia and male pseudohermaphroditism)

• Cystic fibrosis (CF; disease of lung and pancreas resulting in thick mucous accumulations and chronic infections)

• Duchenne muscular dystrophy/Becker muscular dystrophy (DMD; severe to mild muscle wasting, deterioration, weakness)

• Dystonia (DYT; muscle rigidity, repetitive twisting movements)

• Fanconi anemia, group C (FA; anemia, leukemia, skeletal deformities)

• Factor V-Leiden (FVL; blood-clotting disorder)

• Fragile X syndrome (FRAX; leading cause of inherited mental retardation)

• Hemophilia A and B (HEMA and HEMB; bleeding disorders)

• Hereditary Hemochromatosis (HFE; excess iron storage disorder)

• Huntington's disease (HD; usually midlife onset; progressive, lethal, degenerative neurological disease)

• Myotonic dystrophy (MD; progressive muscle weakness; most common form of adult muscular dystrophy)

• Neurofibromatosis type 1 (NF1; multiple benign nervous system tumors that can be disfiguring; cancers)

• Phenylketonuria (PKU; progressive mental retardation due to missing enzyme; correctable by diet)

• Adult Polycystic Kidney Disease (APKD; kidney failure and liver disease)

• Prader Willi/Angelman syndromes (PW/A; decreased motor skills, cognitive impairment, early death)

• Sickle cell disease (SS; blood cell disorder; chronic pain and infections)

• Spinocerebellar ataxia, type 1 (SCA1; involuntary muscle movements, reflex disorders, explosive speech)

• Spinal muscular atrophy (SMA; severe, usually lethal progressive muscle-wasting disorder in children)

• Thalassemias (THAL; anemias - reduced red blood cell levels)

• Tay-Sachs Disease (TS; fatal neurological disease of early childhood; seizures, paralysis)

Currently in the United States, no regulations are in place for evaluating the accuracy and reliability of genetic testing. Most genetic tests developed by laboratories are categorized as services, which the Food and Drug Administration (FDA) does not regulate. Only a few states have established some regulatory guidelines. This lack of government oversight is particularly troublesome in light of the fact that a handful of companies have started marketing test kits directly to the public. Some of these companies make dubious claims about how the kits not only test for disease but also serve as tools for customizing medicine, vitamins and foods to each individual's genetic makeup. Another fear is that individuals who purchase such kits will not seek out genetic counseling to help them interpret results and make the best possible decisions regarding their personal welfare. More information on these questionable test kits is available from Dubious Genetic Testing, an online report provided by Quackwatch at www.quackwatch.com. For a brief overview of the current regulatory environment for genetic testing, see the Oversight of Genetic Testing, a Genetics Brief from the National Conference of State Legislatures.

Does Insurance Cover Genetic Testing?

In most cases, an individual will have to contact his or her insurance provider to see if genetic tests, which cost between $200 and $3000, are covered. Usually insurance companies do not cover genetic tests, those that do will have access to the results. Insured persons would need to decide whether they would want the insurance company to have this information. States have a patchwork of genetic-information nondiscrimination laws, none of them comprehensive. Existing state laws differ in coverage, protections afforded, and enforcement schemes. The National Conference of State Legislatures provides a listing of current legislation regarding genetic information and health insurance. The recent marketing of genetic test kits directly to consumers, may lead to an increase in demand for insurance coverage. See the Genetics and Health Insurance (PDF) policy brief from the National Conference of State Legislatures for more information.

Revision Date: July 9, 2004

Sources: Department Of Energy, Office of Biological and Environmental Research, Human Genome Program