Open Journal of Obstetrics and Gynecology, 2012, 2, 291-297 OJOG
http://dx.doi.org/10.4236/ojog.2012.23062 Published Online September 2012 (http://www.SciRP.org/journal/ojog/)
Preimplantation genetic diagnosis for gender selection:
You don’t always g et wh at y o u wa nt
Tanmoy Mukherjee1,2*, Eric Flisser1, Alan B. Copperman1,2, Lawrence Grunfeld1,2,
Benjamin Sandler1,2, Jason Barritt1,2
1Reproductive Medi c i ne Associates of New York, New York, USA
2Reproductive End o crinology, Mount Sinai School of Medicine, New York, USA
Received 16 May 2012; revised 20 June 2012; accepted 2 July 2012
ABSTRACT
Parenting children of opposite genders is a powerful
motive for parents to seek “sex-selection” services.
Medical beneficence and patient autonomy support
making these services available. Our goals in this
study included data to permit proper patient educa-
tion, assess outcome, and evaluation of potential bi-
ases in this technology. IVF/PGD cases from August
2004 to December 2009 were studied (n = 122). FISH
was used to analyze nuclear DNA of biopsied em-
bryos. The variables analyzed were patient age, Day 3
Fluorescent In Situ Hybridization (FISH), the num-
ber of fertilized embryos, the number of embryos bi-
opsied, Preimplantation Genetic Diagnosis (PGD) re-
sults, the number of embryos transferred, and the
fate of remaining embryos. Female embryos were
sought in 84 cycles, and male embryos desired in 38
cycles. Couples seeking female offspring had a re-
duced likelihood of a female-only transfer vs. those
seeking males (p < 0.001). No transfer was performed
in 32 cases for lack of normal embryos of desired
gender. Clinical pregnancy rate per embryo transfer
was 30.4%. PGD success rates for gender variety
were lower than expected comparative to traditional
IVF. In this report we present our clinical experience
with IVF/PGD for gender selection. We attempt to
analyze which patients seek this specialized treatment
and to provide direct clinical and laboratory outcome
data from our completed cycles.
Keywords: IVF; PGD; Gender Preference; Sex
Selection; Family Balancing
1. INTRODUCTION
Application of preimplantation genetic diagnosis (PGD)
during embryonic development to identify the presence
of lethal genetic diseases in cycles of assisted reproduc-
tion (ART) produced the first human live births in 1990
[1]. PGD testing has since been utilized to identify a
range of diseases (e.g. cystic fibrosis, sickle cell disease,
hemophilia A and B, Lesch-Nyhan syndrome, Duche-
nne’s Muscular Dystrophy), and the detection of addi-
tional genetic disorders is increasingly possible as the
genetic loci of diseases are identified [2-6]. In addition to
detection of single gene defects, technical advances in
single-cell genetic analysis, including single nucleotide
polymorphism (SNP) array, comparative genomic hybri-
dization (CGH), and whole genome amplification (WGA),
may improve diagnostic precision and permit useful
preimplantation genetic screening (PGS) in patients with
recurrent pregnancy loss and unexplained in vitro ferti-
lization (IVF) treatment failure, where chromosomal
errors are the result of potentially de novo mutations or
meiotic and mitotic aberrations [2 ,7-11].
Elective sex “selection” is a controversial variant of
PGD, enabling patients to identify the genetic gender of
embryos prior to transfer to the uterus, thus allowing
preferential selection in the absence of medical necessity.
The incidence of patient interest in non-medical elective
sex selection in the United States is difficult to estimate
because the Society for Assisted Reproductive Techno-
logy (SART), the agency tasked with tracking the use
and outcomes of in vitro fertilization (IVF) treatment in
the US, does not specifically denote PGD cycles under-
taken for the purposes of gender selection [8-11]. How-
ever, there is significant interest in this non-medical ap-
plication. Dahl found that 8% of respondents would use
preconception sex selection services [12] and Jain et al.
found that 40.8% of women undergoing IVF would se-
lect the gender of their child if they could easily do so
[13]. In contrast to preconception techniques for gender
selection, such as sperm-sorting protocols, the issue of
gender selection during cycles of assisted reproduction,
and especially so in the absence of infertility or genetic
disease, is additionally co mplicated by cost scale, alloca-
*Corresponding a uthor.

T. Mukherjee et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 291-297 292
tion of limited resources, and ethical considerations re-
garding the fate of supernumerary embryos, both of the
preferred gender and otherwise. Alternative options, such
as preconception techniques to influence embryo gender
using sperm sorting protocols including gradients or cen-
trifugation, however, lack the specificity and superior
outcom es of IVF-PGD [14].
Gender variety or “family balancing” as it is some-
times known, is a particular form of PGD that is under-
taken in families in which all offspring are of the same
gender. Patients pursuing this option are interested in the
unique experience of raising a child of the unrepresented
gender [15,16]. The motivation of couples seeking this
application of PGD in this setting may be different from
that of other patients seeking gender selection, suggest-
ing that gender variety and sex selection may be consi-
dered distinct applications of PGD/ART [15,17]. Increas-
ing utilization of gender variety has prompted various
ART regulatory organizations to formulate criteria for
permitting application of PGD in this scenario. In 2002,
the Human Fertilization and Embryology Authority (HFEA)
of the United Kingdom attempted to codify the practice
by limiting its application to families in which no chil-
dren of a given gender existed, but conceded that a gen-
der imbalance of more than two when both genders were
represented in an existing family would also fulfill the
prerequisite [18].
The ethics committees of both the American Congress
of Obstetricians and Gynecologists (ACOG) and the
American Society for Reproductive Medicine (ASRM)
have established acceptable medical justifications for sex
selection. However, the committees differ on the ethics
of gender selection for non-medical indications [19]. The
ACOG Ethics Committee opposes sex selection for per-
sonal and family reasons, including family balancing,
because of the concern that such requests may ultimately
support sexist practices. The ASRM committee recog-
nizes the serious ethical concerns that the application of
these techniques raise and counsels against their wide-
spread use while additionally emphasizing that practitio-
ners offering assisted reproductive services are not under
legal or ethical obligation to provide non-medically in-
dicated methods of gender selection. The committee,
however, concludes that, “Until a more clearly persua-
sive ethical argument emerges, or there is stronger em-
pirical evidence that most choices to select the gender of
offspring would be harmful, policies to prohibit or con-
demn as unethical all uses of non-medically indicated
preconception gender selection are not justified [20,21].”
A primary concern is that when widely applied, services
for gender selection can distort the natural sex ratio and
lead to gross societal gender imbalance, as has occurred
in China and India through the use of abortion [22-24].
In the United States, for a gross gender imbalance to oc-
cur, a number of prerequisites are necessary. First, a
strong preference for one gender over another must exist.
And, second, child bearing must preclude conceiving a
child of the opposit e gender.
Couples seeking gender variety may constitute a spe-
cial case of elective gender selection. The experience of
parenting a child of the opposite gender is unique and
may present a powerful motivator for parents whose off-
spring are comprised of a single gender [25-30]. As dis-
cussion of PGD utilization for gender variety evolves,
not only is it essential to discus s ethical arguments in the
abstract, it is also necessary to analyze empiric practice
data in order to reconcile practical and theoretical aspects
of this controversial therapeutic intervention. In this re-
port we present our clinical experience with IVF/PGD
for gender selection. We attempt to analyze which pa-
tients seek this specialized treatment and to provide di-
rect clinical and laboratory outcome data from our com-
pleted cycles.
2. MATERIALS AND METHODS
All IVF/PGD cases for gender selection performed in ou r
clinic from August 2004 to December 2009 were in-
cluded in this study (n = 122). All patients were coun-
seled by their medical providers and then provided in-
formed consent to participate in IVF/PGD. Patients un-
derwent ovarian stimulation with gonadotropins using
GnRH-antagonist or GnRH-agonist luteal-phase down
regulation with or without birth control pill overlap to
prevent premature luteinization of follicles. Serial moni-
toring by a physician was performed for controlled ova-
rian stimulation by hormone and ultrasound analysis.
When at least two follicles measured 18 mm in diameter,
Human Chorionic Gonadotropin (HCG) (5000 - 10,000
IU intramuscularly) or ovidrel (250 mcg su bcutaneously)
was administered by injection and transvaginal ultra-
sound-guided oocyte retrieval was performed 36 hours
later. In all cases, intracytoplasmic sperm injection (ICSI)
was performed. All patients had embryo biopsy per-
formed on Day 3 after oocyte retrieval, by direct aspira-
tion of a single blastomere through an opening created by
acidified Tyrodes degradation of the zona pellucida. The
biopsied blastomere was fixed to a glass microscope
slide and the cytoplasm was removed before PGD analy-
sis.
Nuclear DNA was analyzed by Fluorescent In Situ
Hybridization (FISH). 2-chromosome (X, Y), 3-chro-
moso me ( 21, X, Y), 5 -chro moso me (1 3, 18 , 21, X , Y) o r
10-chromosome (9, 13, 14, 15, 16, 18, 21, 22, X, Y)
probes were used for FISH. PGD results were evaluated
by geneticists, embryologists and th e physician respon se-
ble for embryo transfer on Day 5 of embryo development.
Patients were counseled about the FISH results prior to

T. Mukherjee et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 291-297 293
embryo transfer to determine the gender and number of
embryos to transfer.
Variables analyzed included female patient age, day 3
FSH, basal antral follicle count (BAFC), number of re-
trieved oocytes, number of oocytes injected by Intracy-
toplasmic Sperm Injection (ICSI), number of fertilized
embryos, number of embryos biopsied, PGD results,
number of embryos transferred, and the fate of the re-
maining embryos. Patients were categorized by preferred
embryo gender (female or male) and by country of resi-
dence (US or foreign). Statistical analysis was per-
formed using Chi square test and Mann-Whitney U test
for non-parametric data. A p value < 0.05 was considered
statistically significant.
3. RESULTS
Ninety-three patients underwent 122 IVF/PGD cycles:
69 patients attempted 1 cycle, 20 patients underwent 2
cycles, 3 patients underwent 3 cycles and 1 patient un-
derwent 4 cycles. Female embryos were sought in 84
cycles (68.9%) initiated, and male embryos were desired
in 38 cycles (31.1%). The distribution of FISH panels
ordered were as follows: 14 (11.5%) cases 2-probe, 16
(13.1%) cases 3-probe, 78 (63.9%) 5-probe and 13
(10.7%) 10-probe. According to patient records, in 106
cycles (86.9%), patients had at least one child prior to the
IVF/PGD cycle; in 5 cases (4.1%) no birth history was
available.
Table 1 summarizes the IVF/PGD patient population
by gender of interest. There were no statistical differ-
ences between the two groups in the following categories:
number of days of gonadotropin administration, Day 3
Follicle Stimulating Hormone (FSH IU/l) levels, peak
estradiol (E2 pg/ml), number of oocytes retrieved, and
number of normally fertilized (2PN) embryos. A signifi-
cant difference was noted in maternal age between those
desiring females (37.2 ± 4.1) and those desiring males
(34.7 ± 4. 5, p = 0. 003).
Figure 1 represents the embryo genotype according to
FISH results.
A total of 919 embryos were biopsied. The average
number of embryos biopsied per patient was 7.5 ± 5.1. A
normal genotype was defined as XX or XY and the
balanced presence of any autosomes analyzed. In cases
where female embryos were preferred, 600 embryos
underwent biopsy. The biopsy results included 249 XX
embryos (41.5%), 270 XY embryos (45.0%), and 81
(13.5%) embryos with inconclusive or no result for
genetic gender. For patients desiring male embryos, 319
embryos were biopsied. The biopsy results included 138
XY embryos (43.2%), 150 XX embryos (47.0%), and 31
(9.7%) embryos with inconclusive or no result. There
were more male embryos in the cycles with a preference
for female embryos, and more female embryos in the
cycles with a preference for male embryos, althoug h, the
difference in embryo numbers did not reach statistical
significance (p = 0.29). All embryo transfers occurred at
the blastocyst stage of development on Day 5 after
oocyte retrieval. The embryo transfer results fro m all 122
cases are shown in Figure 2.
In the 84 cases where female embryos were preferred,
58 embryo transfers were performed. Of these transfers,
51 consisted of only XX embryos, and 7 embryo trans-
fers contained either male only or included embryos of
Table 1. IVF/PGD patient population by gender of interest.
Desiring female embryos (n = 84)Desiring male embryos (n = 38)Overall (n = 122) p value
Age 37.2 ± 4.1* 34.7 ± 4.5* 36.4 ± 4.4 0.003*
Day 3 FSH 7.9 ± 2.6 8.0 ± 2.4 7.9 ± 2.5 0.86
Peak E2 2232 .5 ± 1186.3 2275.3 ± 1162.6 2245.3 ± 943.9 0.94
BAFC 8.8 ± 5.6 9.3 ± 6.7 8.9 ± 8.6 0.71
Gonadotropin stimulation 12.4 ± 2.8 12.5 ± 3.9 12.5 ± 5.0 0.98
Oocytes retrieved 17.0 ± 11.2 16.8 ± 9.1 16.9 ± 10.5 0.93
Oocytes ICSI’d 12.4 ± 7.9 13.7 ± 7.8 12.8 ± 7.9 0.42
Count of 2PN 9.8 ± 6.7 10.8 ± 6.5 10.1 ± 6.6 0.44
Fertilization rate 80.7% 79.0% 80.1% 0.82
Biochemical pregnancy rate 45.2% 47.4% 45.9% 0.89
Clinical pregnancy rate 32.1% 26.3% 30.4% 0.63
*p < 0.05 for a significant difference between those age groups desiring a male or female offspring; FSH = Follicle Stimulating Hormone (IU/l); E2 = Estradiol
pg/ml); B AFC = Basal Antral Follicle Coun t; ICSI = Intracytoplasmic Sperm Injection ; 2PN = 2 Pro nu clear Embryo. (

T. Mukherjee et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 291-297 294
Figure 1. Embryo genotype according to FISH results. n =
number of embryos biopsied.
Figure 2. Embryo transfer results by gender of interest. XX =
female, XY = male, ET = embryo transfer.
both genders. In 26 cases (31.0%) that patients expressed
a preference for female embryos but no normal XX em-
bryos were available for transfer, the cycle was cancelled
at the patient’s request. In 38 cases requesting male em-
bryos, 32 embryo transfers were performed. Of these
transfers, 27 consisted of only XY embryos, and 5 trans-
fers contained either female on ly or included embryos of
both genders. In 6 cases (15.8%) seeking male embryos
for transfer where no normal XY embryos were available
for transfer, the cycle was cancelled at the patient’s re-
quest. Couples seeking gender variety for female off-
spring had a significantly reduced likelihood of a female
embryo only transfer vs those seeking male offspring (p
< 0.001)
There were 32 IVF/PGD cases (26.2%) with cancelled
embryo transfers due to the lack of normal embryos of
the desired gender for transfer. In the 26 cancelled cases
preferring female embryos, 10 patients had no normal
embryos and 16 had viable embryos of the other gender.
Two patients chose to cryopreserve supernumerary XY
embryos, whereas 14 declined cryopreservation of pre-
sumed-euploid male embryos. In the 6 cancelled cases
seeking male embryos without embryos for transfer, two
had no normal embryos, and the remaining 4 patients
with presumably-euploid XX embryos declined cryopre-
servation of the supernumerary embryos.
Figure 3 provides a flow diagram for the embryo
transfer and cryopreservation decisions made in 122 cy-
cles.
The biochemical pregnancy rate per embryo transfer
was 45.9% (56/122). The clinical pregnancy rate (the
presence of at least one intrauterine gestational sac iden-
tified by ultrasonography) per embryo transfer was
30.4% (37/122) (Ta ble 1 ). For the 84 cycles with a fe-
male embryo preference, 38 had a biochemical preg-
nancy (45.2%) and 27 had a clinical pregnancy (32.1%).
For the 38 cases with a male embryo preference, 18 had
a biochemical pregnancy (47.4%) and 10 had a clinical
pregnancy (26 . 3%) .
In order to determine if a skewed preference for one
gender existed based on regional preferences, the 122
IVF/PGD cycles were sorted by US residents (domestic)
and non-US residents (foreign ). Of 88 domestic cases, 61
were for female embryos (69.3%) and 27 for male
embryos (30.7%). Of the 34 foreign cases, 23 were for
female embryos (67.6%) and 11 for male embryos
(32.3%). No significant difference between domestic and
foreign cases was detected in terms of gender preference
(p = 0.61).
4. DISCUSSION
The practice of PGD for gender variety is clinically dis-
tinct from traditional gender selection. In vitro fertiliza-
tion and preimplantation genetic diagnosis is more effi-
cacious than sperm centrifugation, medical therapy, tim-
ing of intercourse and other various interventions that

T. Mukherjee et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 291-297 295
Figure 3. Gender selection patient decision tree. XX = female; XY = ma le; Cryo = cryopreservation; PGD = pre-implantation genetic
diagnosis; n = number of patient cycles.
have been employed in efforts to alter gender proportions
[31-33]. Participation in elective gender selection is po-
tentially controversial, but its technology offers the abi-
lity to experience the un ique possibility of raisin g a child
of a specific gender. The principles of patient autonomy
and medical beneficence support making gender selec-
tion services available. Nonetheless, non-malfeasance
must be addressed, and proper patient counseling is
mandatory for ethical application of gender variety ser-
vices. In our case series, gender variety demonstrated a
unique profile of gender preference, success rates, and
cryopreservation utilization, which should be discussed
in detail before patients undertake treatment.
Couples seeking PGD for g ender variety have reduced
success rates when compared to traditional IVF, there
were 32 IVF/PGD cases (26.2%) with cancelled embryo
transfers due to the lack of embryos of the desired gender,
abnormal genotype and/or arrested embryonic develop-
ment. In total, 12 couples (9.8%) accepted mixed gender
transfers (Figure 2). While the majority of these patients
had no clearly identified fertility dysfunction, the low
success rate and high cancellation rate may be explained
by the exclusion of approximately 50% of candidate em-
bryos because of i nco n cl usive result s o r undesired gen der.
Our patients are counseled that only 64% of couples have
the desired embryos for transfer (Figure 2).
In our series, success rates varied with choice of gen-
der. Couples seeking gender variety for female offspring
had a reduced likelihood of having a successful transfer.
One possible explanation of this observation may be a
potential bias in embryo evaluation systems that appear
to effectively assign a higher grade to embryos that are
more likely to be genetically male [33]. This would also
account for the finding that couples seeking male off-
spring had a greater chance to have a single gender
transfer and overall a reduced cancellation rate. We also
considered the possibility that families in which one
gender was over represented were producing a higher
than expected rate of aneuploid embryos in the unrepre-
sented gender. Two families had extreme distributions of
XX and XY embryos: in one case a couple desiring a
male produced eighteen XX embryos and only two XY
embryos, and another couple seeking female embryos
produced 11 male embryos and a single female embryo.
Clearly these observations, while intriguing, are not suf-
ficient to suggest that gender imbalance is related to
non-random meiotic distribution in certain families,
however further data collection and analysis is certainly
warranted.
In our series, twice as many couples sought to transfer
female embryos than male embryos (Figure 3). Female
gender preference did not vary by patient origin, sug-
gesting that ethnographic preferences for male children
were not a motivating factor in our study. It is also im-
portant to note that our patients sought treatment that was
not covered by health insurance. Further assessment of

T. Mukherjee et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 291-297 296
couples seeking gender selection is necessary, but a pre-
liminary interpretation suggests that socioecono mic status ,
maternal interest, and declining fertility coupled with a
desire to minimize family size all play an important role
in motivating coup les seeking gender variety [29,30].
The practice of elective gender selection frequently
elicits emotional reactions concerning issues of morality
and autonomy, covering a wide spectrum of opinions that
include valuing all embryos as sacrosanct, libertarian
attitudes towards market forces, and concerns regarding
feminism and sexism. More empirical data needs to be
collected before gender bias in the cases of PGD for sex
selection can be definitively established. However, it
must also be recognized that economic factors, such as
the high cost of treatment and the requirement for so-
phisticated systems and technical expertise may be limi-
ting the observation of gender bias in IVF/PGD by re-
stricting its use from communities th at lack the resources
to have it performed, biasing data collection to commu-
nities where personal worth or societal status is not re-
lated to gender. In cultures where subsistence agriculture
or other manual labor is the norm, prejudice in favor of
male children capable of performing these tasks is a
strong factor in gender bias, as it is in cultures in which
male children are expected to provide continued familial
fealty and support to elderly parents when they become
incapable of providing for themselves. Female children
may also represent ad ditional h ardship in poor co mmuni-
ties that require a dowry for marriage. Artificial restric-
tions on family size, such as the “one child rule” in
China, further compound imbalances [34]. In these types
of communities, un iversal availability of PGD for gend er
selection would be expected to exacerbate gender im-
balance [35].
However, in developed communities where distinct
social gender roles have been significantly reduced, if
not entirely eliminated, the preference for a single gender
in offspring may not exist [36-38]. While the worldwide
elective gender selection experience, whether precon-
ceptual or antenatal, sugg ests a bias towards male gender,
our data suggests th at preference for male children is not
universal. In Western families, a preference towards a
balance in gender of offspring is preferred [39,40].
The application of non-medical gender selection will
continue to remain a controversial topic. In our limited
series, interest in elective gender selection services con-
tradicted anticipated norms, since female embryos were
more frequently sought than male embryos. The size of
our sample or the community from which it was drawn
may have significantly influenced our observation. In all
cases, patients must be carefully counseled prior to un-
dertaking this procedure since it is associated with a
higher than anticipated failure rate related to lack of
desired embryos for transfer.
5. ACKNOWLEDGEMENTS
Marlena Duke, MS, Lesley Chuang, MS, Casey A. McDonald, MS, En -
rique Cervantes, MD, Joseph A. Lee, BS.
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