As described above, the calculation of risks is relatively straightforward when the consultands are known carriers of diseases due to single genes of major effect that show regular Mendelian inheritance. For a variety of reasons, however, the parental genotypes frequently are not clear and must be approximated from the available family data. Bayes’s theorem, a statistical method first devised by the English clergyman-scientist Thomas Bayes in 1763, can be used to assess the relative probability of two or more alternative possibilities (e.g., whether a consultand is or is not a carrier). The likelihood derived from the appropriate Mendelian law (prior probability) is combined with any additional information that has been obtained from the consultand’s family history or from any tests performed (conditional probability). A joint probability is then determined for each alternative outcome by multiplying the prior probability by all conditional probabilities. By dividing the joint probability of each alternative by the sum of all joint probabilities, the posterior probability is arrived at. Posterior probability is the likelihood that the individual, whose genotype is uncertain, either carries the mutant gene or does not. One example application of this method, applied to the sex-linked recessive disease Duchenne muscular dystrophy (DMD), is given below.

In this example, the consultand wishes to know her risk of having a child with DMD. The family’s pedigree is illustrated in the figure. It is known that the consultand’s grandmother (I-2) is a carrier, since she had two affected sons (spontaneous mutations occurring in both brothers would be extremely unlikely). What is uncertain is whether the consultand’s mother (II-4) is also a carrier. The Bayesian method for calculating the consultand’s risk is as follows:

If II-4 is a carrier (risk = 1/5), then there is a 1/2 chance that the consultand is also a carrier, so her total empirical risk is 1/5 × 1/2 = 1/10. If she becomes pregnant, there is a 1/2 chance that her child will be male and a 1/2 chance that the child, regardless of sex, will inherit the familial mutation. Hence, the total empirical risk for the consultand (III-2) to have an affected child is 1/10 1/2 1/2 = 1/40. Of course, if the familial mutation is known, presumably from molecular testing of an affected family member, the carrier status of III-2 could be determined directly by molecular analysis, rather than estimated by Bayesian calculation. If the family is cooperative and an affected member is available for study, this is clearly the most informative route to follow, because the risk for the consultand to carry the familial mutation would be either 1 or 0, and not 1/10. If her risk is 1, then each of her sons will have a 1/2 chance of being affected. If her risk is 0, none of her children will be affected (unless a new mutation occurs, which is very rare).

After determining the nature of the heredity, the counselor discusses with the consultand the likely risks and the available options to minimize impact of those risks on the individual and the family. In the case of a couple in which one member has a family history of a genetic disorder—for example, cystic fibrosis—typical options might include any of the following choices: (1) Accept the risks and take a chance that any future children may be affected. (2) Seek molecular testing for known mutations of cystic fibrosis in relevant family members to determine with greater accuracy whether either or both prospective parents are carriers for this recessive disorder. (3) If both members of the couple are determined to be carriers, utilize donor sperm for artificial insemination. This option is a good genetic solution only if the husband carries a dominant mutation, or if both parents are carriers of a recessive mutation. If the recessive trait is reasonably common, as are mutations for cystic fibrosis, however, it would be reasonable to ask that the sperm donor be checked for carrier status before pursuing this option. (4) Proceed with natural reproduction, but pursue prenatal diagnosis with the possibility of selective termination of an affected pregnancy, if desired by the parents. (5) Pursue in vitro fertilization with donor eggs, if the woman is the at-risk partner, or use both eggs and sperm from the couple but employ preimplantation diagnostics to select only unaffected embryos for implantation (see below). (6) Decide against biological reproduction because the risks and available options are unacceptable; possibly pursue adoption.