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Chen X, Zhang X, Jiang T, Xu W. Klinefelter syndrome: etiology and clinical considerations in male infertility†. Biol Reprod 2024; 111:516-528. [PMID: 38785325 DOI: 10.1093/biolre/ioae076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 05/08/2024] [Indexed: 05/25/2024] Open
Abstract
Klinefelter syndrome (KS) is the most prevalent chromosomal disorder occurring in males. It is defined by an additional X chromosome, 47,XXY, resulting from errors in chromosomal segregation during parental gametogenesis. A major phenotype is impaired reproductive function, in the form of low testosterone and infertility. This review comprehensively examines the genetic and physiological factors contributing to infertility in KS, in addition to emergent assisted reproductive technologies, and the unique ethical challenges KS patients face when seeking infertility treatment. The pathology underlying KS is increased susceptibility for meiotic errors during spermatogenesis, resulting in aneuploid or even polyploid gametes. Specific genetic elements potentiating this susceptibility include polymorphisms in checkpoint genes regulating chromosomal synapsis and segregation. Physiologically, the additional sex chromosome also alters testicular endocrinology and metabolism by dysregulating interstitial and Sertoli cell function, collectively impairing normal sperm development. Additionally, epigenetic modifications like aberrant DNA methylation are being increasingly implicated in these disruptions. We also discuss assisted reproductive approaches leveraged in infertility management for KS patients. Application of assisted reproductive approaches, along with deep comprehension of the meiotic and endocrine disturbances precipitated by supernumerary X chromosomes, shows promise in enabling biological parenthood for KS individuals. This will require continued multidisciplinary collaboration between experts with background of genetics, physiology, ethics, and clinical reproductive medicine.
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Affiliation(s)
- Xinyue Chen
- Reproductive Endocrinology and Regulation Laboratory, Department of Obstetric and Gynecologic, West China Second University Hospital, Sichuan University, Chengdu 610041, China
| | - Xueguang Zhang
- Reproductive Endocrinology and Regulation Laboratory, Department of Obstetric and Gynecologic, West China Second University Hospital, Sichuan University, Chengdu 610041, China
| | - Ting Jiang
- Reproductive Endocrinology and Regulation Laboratory, Department of Obstetric and Gynecologic, West China Second University Hospital, Sichuan University, Chengdu 610041, China
| | - Wenming Xu
- Reproductive Endocrinology and Regulation Laboratory, Department of Obstetric and Gynecologic, West China Second University Hospital, Sichuan University, Chengdu 610041, China
- Key Laboratory of Obstetric, Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, West China Second University Hospital, Sichuan University-The Chinese University of Hong Kong (SCU-CUHK) Joint Laboratory for Reproductive Medicine, Chengdu 610041, China
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Xue Y, Shang L. Are we ready for the revision of the 14-day rule? Implications from Chinese legislations guiding human embryo and embryoid research. Front Cell Dev Biol 2022; 10:1016988. [PMID: 36353513 PMCID: PMC9637635 DOI: 10.3389/fcell.2022.1016988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 10/07/2022] [Indexed: 01/06/2024] Open
Abstract
The ISSCR recently released new guidelines that relaxed the 14-day rule taking away the tough barrier, and this has rekindled relevant ethical controversies and posed a fresh set of challenges to each nation's legislations and policies directly or indirectly. To understand its broad implications and the variation and impact of China's relevant national policies, we reviewed and evaluated Chinese laws, administrative regulations, departmental rules, and normative documents on fundamental and preclinical research involving human embryos from 1985 to 2022 in this paper. We have historically examined whether these regulations, including a 14-day rule, had restrictions on human embryo research, and whether and how these policies affected human embryo and embryoid research in China. We also discussed and assessed the backdrop in which China has endeavored to handle such as the need for expanding debates among justice practice, academia, and the public, and the shifting external environment influenced by fast-developing science and technology and people's culture and religions. In general, Chinese society commonly opposes giving embryos or fetuses the legal status of humans, presumably due to the Chinese public not seeming to have any strong religious beliefs regarding the embryo. On this basis, they do not strongly oppose the potential expansion of the 14-day rule. After the guidelines to strengthen governance over ethics in science, and technology were released by the Chinese government in 2022, Chinese policymakers have incorporated bioethics into the national strategic goals using a "People-Centered" approach to develop and promote an ecological civilization. Specifically, China follows the "precautionary principle" based on ethical priority as it believes that if scientific research carries any potential technological and moral risks on which no social ethical consensus has been attained, there would be a need to impose oversight for prevention and precaution. At the same time, China has adopted a hybrid legislative model of legislation and ethical regulations with criminal, civil and administrative sanctions and a 14-day limit specified within its national hESCs guidelines. This would certainly be a useful example for other countries to use when considering the possibility of developing a comprehensive, credible and sustainable regulatory framework.
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Affiliation(s)
- Yang Xue
- Law School, Tianjin University, Tianjin, China
- Center for Biosafety Research and Strategy, Tianjin University, Tianjin, China
| | - Lijun Shang
- School of Human Sciences, London Metropolitan University, London, United Kingdom
- Biological Security Center, London Metropolitan University, London, United Kingdom
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Savulescu J, Labude M, Barcellona C, Huang Z, Leverentz MK, Xafis V, Lysaght T. Two kinds of embryo research: four case examples. JOURNAL OF MEDICAL ETHICS 2022; 48:590-596. [PMID: 35534151 PMCID: PMC9411897 DOI: 10.1136/medethics-2021-108038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 04/19/2022] [Indexed: 06/14/2023]
Abstract
There are ethical obligations to conduct research that contributes to generalisable knowledge and improves reproductive health, and this should include embryo research in jurisdictions where it is permitted. Often, the controversial nature of embryo research can alarm ethics committee members, which can unnecessarily delay important research that can potentially improve fertility for patients and society. Such delay is ethically unjustified. Moreover, countries such as the UK, Australia and Singapore have legislation which unnecessarily captures low-risk research, such as observational research, in an often cumbersome and protracted review process. Such countries should revise such legislation to better facilitate low-risk embryo research.We introduce a philosophical distinction to help decision-makers more efficiently identify higher risk embryo research from that which presents no more risks to persons than other types of tissue research. That distinction is between future person embryo research and non-future person embryo research. We apply this distinction to four examples of embryo research that might be presented to ethics committees.Embryo research is most controversial and deserving of detailed scrutiny when it potentially affects a future person. Where it does not, it should generally require less ethical scrutiny. We explore a variety of ways in which research can affect a future person, including by deriving information about that person, and manipulating eggs or sperm before an embryo is created.
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Affiliation(s)
- Julian Savulescu
- Faculty of Philosophy, University of Oxford, Oxford, UK
- Biomedical Research Group, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
- Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Markus Labude
- Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Capucine Barcellona
- Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Zhongwei Huang
- NUS Bia-Echo Asia Centre for Reproductive Longevity and Equality, Singapore
- Institute of Molecular and Cell Biology, Agency of Science, Technology and Research, Singapore
- Obstetrics and Gynaecology, National University of Singapore, Singapore
| | | | - Vicki Xafis
- Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Tamra Lysaght
- Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Anifandis G, Sutovsky P, Turek PJ, Chavez SL, Kunej T, Messini CI, Schon SB, Mavroforou A, Adashi EY, Krawetz SA. Bioethics in human embryology: the double-edged sword of embryo research. Syst Biol Reprod Med 2022; 68:169-179. [PMID: 35380489 DOI: 10.1080/19396368.2022.2052771] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
There has been a significant increase in the use of assisted reproductive therapies (ARTs) over the past several decades, allowing many couples with infertility to conceive. Despite the achievements in this field, a mounting body of evidence concerning the epigenetic risks associated with ART interventions such as ovarian hormonal stimulation, intracytoplasmic sperm injection (ICSI), and in vitro culture (IVC) of oocytes and embryos has also emerged. Induced development of multiple follicles, the IVC media itself, and extended culture may alter the epigenome of both gametes and embryos, resulting in yet to be fully understood developmental, postnatal, and adult life health consequences. Investigators have attempted to decipher the molecular mechanisms mediating ART-induced epigenetic changes using either human samples or animal models with some success. As research in this field continues to expand, the ethical responsibilities of embryologists and researchers have become critically important. Here, we briefly discuss the ethical aspects of ART research, concentrating on the constraints arising from the perceived 'unnaturalness' of many of these procedures. Secondly, we focus on the bioethics and morality of human embryo research in general and how ethically acceptable model systems may be used to mimic early human embryogenesis. Lastly, we review the 14-day culture limit of human embryos and the notion that this rule could be considered of taken into account using new technologies and cues from animal models. The 'black box' of early post-implantation embryogenesis might be revealed using embryo models. As long as this distinct moral line has been drawn and closely followed, we should not fear scientific growth in embryo research. Although in vitro fertilization (IVF) is ethically acceptable, research with human embryos to improve its success raises serious ethical concerns that are in need of constant revisiting.Glossary index: Moral status: the ascription of obligations and rights to embryos on the basis of sentience; Sentience: the capacity of the developing embryo to experience feelings and sensations, such as the awareness of pain; Ectogenesis: the growth of the embryo in an artificial environment outside the mother's body.
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Affiliation(s)
- George Anifandis
- Department of Obstetrics and Gynecology, ART Unit, School of Health Sciences, Faculty of Medicine, University of Thessaly, Larisa, Greece
| | - Peter Sutovsky
- Division of Animal Sciences and the Department of Obstetrics, Gynecology and Women's Health, University of Missouri, Columbia, MO, USA
| | | | - Shawn L Chavez
- Division of Reproductive & Developmental Sciences, Oregon National Primate Research Center, Departments of Obstetrics & Gynecology, Molecular & Medical Genetics, and Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
| | - Tanja Kunej
- Biotechnical Faculty, Department of Animal Science, University of Ljubljana, Domzale, Slovenia
| | - Christina I Messini
- Department of Obstetrics and Gynecology, ART Unit, School of Health Sciences, Faculty of Medicine, University of Thessaly, Larisa, Greece
| | - Samantha B Schon
- Division of Reproductive Endocrinology & Infertility, Department of Obstetrics & Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Anna Mavroforou
- School of Health Sciences, Faculty of Nursing, University of Thessaly, Larisa, Greece
| | - Eli Y Adashi
- Center for Prisoner Health and Human Rights, The Warren Alpert Medical School, Division of Biology and Medicine, Brown University, Providence, RI, USA
| | - Stephen A Krawetz
- Department of Obstetrics and Gynecology, Molecular Medicine & Genetics, C.S. Mott Center for Human Growth and Development, Wayne State University School of Medicine, Detroit, MI, USA
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Revisiting selected ethical aspects of current clinical in vitro fertilization (IVF) practice. J Assist Reprod Genet 2022; 39:591-604. [PMID: 35190959 PMCID: PMC8995227 DOI: 10.1007/s10815-022-02439-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 02/16/2022] [Indexed: 12/19/2022] Open
Abstract
Ethical considerations are central to all medicine though, likely, nowhere more essential than in the practice of reproductive endocrinology and infertility. Through in vitro fertilization (IVF), this is the only field in medicine involved in creating human life. IVF has, indeed, so far led to close to 10 million births worldwide. Yet, relating to substantial changes in clinical practice of IVF, the medical literature has remained surprisingly quiet over the last two decades. Major changes especially since 2010, however, call for an updated commentary. Three key changes deserve special notice: Starting out as a strictly medical service, IVF in recent years, in efforts to expand female reproductive lifespans in a process given the term “planned” oocyte cryopreservation, increasingly became more socially motivated. The IVF field also increasingly underwent industrialization and commoditization by outside financial interests. Finally, at least partially driven by industrialization and commoditization, so-called add-ons, the term describing mostly unvalidated tests and procedures added to IVF since 2010, have been held responsible for worldwide declines in fresh, non-donor live birthrates after IVF, to levels not seen since the mid-1990s. We here, therefore, do not offer a review of bioethical considerations regarding IVF as a fertility treatment, but attempt to point out ethical issues that arose because of major recent changes in clinical IVF practice.
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Blackshaw BP, Rodger D. Why we should not extend the 14-day rule. JOURNAL OF MEDICAL ETHICS 2021; 47:712-714. [PMID: 34112713 PMCID: PMC8479730 DOI: 10.1136/medethics-2021-107317] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/21/2021] [Accepted: 04/25/2021] [Indexed: 05/08/2023]
Abstract
The 14-day rule restricts the culturing of human embryos in vitro for the purposes of scientific research for no longer than 14 days. Since researchers recently developed the capability to exceed the 14-day limit, pressure to modify the rule has started to build. Sophia McCully argues that the limit should be extended to 28 days, listing numerous potential benefits of doing so. We contend that McCully has not engaged with the main reasons why the Warnock Committee set such a limit, and these still remain valid. As a result, her case for an extension of the 14-day rule is not persuasive.
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Affiliation(s)
| | - Daniel Rodger
- Allied Health Sciences, London South Bank University School of Health and Social Care, London, UK
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Piergentili R, Del Rio A, Signore F, Umani Ronchi F, Marinelli E, Zaami S. CRISPR-Cas and Its Wide-Ranging Applications: From Human Genome Editing to Environmental Implications, Technical Limitations, Hazards and Bioethical Issues. Cells 2021; 10:cells10050969. [PMID: 33919194 PMCID: PMC8143109 DOI: 10.3390/cells10050969] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 04/18/2021] [Accepted: 04/19/2021] [Indexed: 12/14/2022] Open
Abstract
The CRISPR-Cas system is a powerful tool for in vivo editing the genome of most organisms, including man. During the years this technique has been applied in several fields, such as agriculture for crop upgrade and breeding including the creation of allergy-free foods, for eradicating pests, for the improvement of animal breeds, in the industry of bio-fuels and it can even be used as a basis for a cell-based recording apparatus. Possible applications in human health include the making of new medicines through the creation of genetically modified organisms, the treatment of viral infections, the control of pathogens, applications in clinical diagnostics and the cure of human genetic diseases, either caused by somatic (e.g., cancer) or inherited (mendelian disorders) mutations. One of the most divisive, possible uses of this system is the modification of human embryos, for the purpose of preventing or curing a human being before birth. However, the technology in this field is evolving faster than regulations and several concerns are raised by its enormous yet controversial potential. In this scenario, appropriate laws need to be issued and ethical guidelines must be developed, in order to properly assess advantages as well as risks of this approach. In this review, we summarize the potential of these genome editing techniques and their applications in human embryo treatment. We will analyze CRISPR-Cas limitations and the possible genome damage caused in the treated embryo. Finally, we will discuss how all this impacts the law, ethics and common sense.
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Affiliation(s)
- Roberto Piergentili
- Institute of Molecular Biology and Pathology, Italian National Research Council (CNR-IBPM), 00185 Rome, Italy;
| | - Alessandro Del Rio
- Department of Anatomical, Histological, Forensic, and Orthopedic Sciences, Sapienza University of Rome, 00161 Rome, Italy; (F.U.R.); (E.M.); (S.Z.)
- Correspondence: or
| | - Fabrizio Signore
- Obstetrics and Gynecology Department, USL Roma2, Sant’Eugenio Hospital, 00144 Rome, Italy;
| | - Federica Umani Ronchi
- Department of Anatomical, Histological, Forensic, and Orthopedic Sciences, Sapienza University of Rome, 00161 Rome, Italy; (F.U.R.); (E.M.); (S.Z.)
| | - Enrico Marinelli
- Department of Anatomical, Histological, Forensic, and Orthopedic Sciences, Sapienza University of Rome, 00161 Rome, Italy; (F.U.R.); (E.M.); (S.Z.)
| | - Simona Zaami
- Department of Anatomical, Histological, Forensic, and Orthopedic Sciences, Sapienza University of Rome, 00161 Rome, Italy; (F.U.R.); (E.M.); (S.Z.)
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