Fragile X testing in obstetrics and gynaecology in Canada

To provide Canadian family physicians, genetic counsellors, medical geneticists, midwives, and obstetrician-gynaecologists with recommendations regarding screening for fragile X in the obstetrical and gynaecological population.

Medline, the Cochrane Library, journals, and textbooks were searched for English-language articles, published between 1966 and March 2008, relating to fragile X testing outcomes. Search terms included fragile X, screening, prenatal testing, pregnancy outcome, premutation, trinucleotide repeats, and ovarian failure. All study types were reviewed. Randomized controlled trial results were considered evidence of the highest quality, followed by results of cohort studies. Key individual studies on which the recommendations are based are referenced. Supporting data for each recommendation are summarized with evaluative comments and references. This document represents an abstraction of the information.

The quality of evidence reported in this document has been described using the criteria outlined in the report of the Canadian Task Force on Preventive Health Care.

1. Any testing for fragile X syndrome must occur only following thorough counselling and with the informed consent of the woman to be tested. (III-A) 2. Fragile X testing is indicated for a woman with a family history of fragile X syndrome, fragile X tremor/ataxia syndrome, or premature ovarian failure (in more than one family member) if the pedigree structure indicates that she is at risk of inheriting the mutated gene. Referral to a medical geneticist for counselling and assessment should be considered in these cases. (II-2A) 3. Fragile X testing is indicated for women who have a personal history of autism or mental retardation/developmental delay of an unknown etiology or who have at least one male relative with these conditions within a three-generation pedigree. (II-2A) 4. Fragile X testing is indicated for women who have reproductive or fertility problems associated with an elevated level of follicle stimulating hormone before the age of 40. (III-A) 5. Prenatal fetal testing via chorionic villus sampling or amniocentesis should be offered to women who are confirmed to be carriers of a premutation or full mutation of the fragile X gene (FMR-1). (II-2A) Pre-implantation genetic diagnosis is available as another reproductive option. (III-A) 6. Population screening for fragile X syndrome for all women in the reproductive age-range is feasible. However, it should be considered only when there is a provincial/regional program that can test and adequately counsel the targeted population about the meaning and implications of the results. (II-2B).