Birth of healthy children after intracytoplasmic sperm injection in two couples with male Kartagener's syndrome

Diagnostics and Management of Male Infertility in Primary Ciliary Dyskinesia

Primary ciliary dyskinesia (PCD), a disease caused by the malfunction of motile cilia, manifests mainly with chronic recurrent respiratory infections. In men, PCD is also often associated with infertility due to immotile sperm. Since causative mutations for PCD were identified in over 50 genes, the role of these genes in sperm development should be investigated in order to understand the effect of PCD mutations on male fertility. Previous studies showed that different dynein arm heavy chains are present in respiratory cilia and sperm flagellum, which may partially explain the variable effects of mutations on airways and fertility. Furthermore, recent studies showed that male reproductive tract motile cilia may play an important part in sperm maturation and transport. In some PCD patients, extremely low sperm counts were reported, which may be due to motile cilia dysfunction in the reproductive tract rather than problems with sperm development. However, the exact roles of PCD genes in male fertility require additional studies, as do the treatment options. In this review, we discuss the diagnostic and treatment options for men with PCD based on the current knowledge.

Ultrastructural Sperm Flagellum Defects in a Patient With CCDC39 Compound Heterozygous Mutations and Primary Ciliary Dyskinesia/Situs Viscerum Inversus

Introduction: Primary ciliary dyskinesia (PCD) is a rare autosomal recessive disease characterized by structural or functional motile cilia abnormalities. Up to 40 different genes seem, at the moment, to be involved in the pathogenesis of PCD. A number of ultrastructural defects have also been reported in sperm flagella, but the sperm mitochondrial membrane potential (MMP) has never been described in these cases.

Aim: The aim of this study was to report the sperm MMP and ultrastructural abnormalities of the sperm flagella found in a patient with PCD and situs inversus (Kartagener syndrome) and its characterization from the genetic point of view.

Methods: Transmission electronic microscopy (TEM) analysis was used to evaluate flagella ultrastructure. The genetic testing was performed by next-generation sequencing. Sperm DNA fragmentation and MMP were also evaluated by flow cytometry.

Results: We report here the case of an 18-year-old male patient with PCD and situs inversus and severe oligo-astheno-teratozoospermia. TEM analysis of his spermatozoa showed an abnormal connecting piece. The mid piece appeared abnormally thickened, with cytoplasmic residue, dysplasia of fibrous sheath, loss of the outer dynein arms (ODAs), truncated inner dynein arms, and supernumerary outer fibers. The percentage of spermatozoa with fragmented DNA was normal, whereas a high percentage of spermatozoa had low MMP, suggesting an altered mitochondrial function. The genetic analysis showed the presence of c.610-2A > G, p.Arg811Cys compound heterozygous mutations in the CCDC39 gene.

Conclusion: The case herein reported suggests that the high percentage of sperm with low MMP may play a role in the pathogenesis of asthenozoospermia in patients with Kartagener syndrome. In addition, we report, for the first time, the missense variant p.Arg811Cys in the CCDC39 gene in a patient with Kartagener syndrome. Although in silico analysis predicts its damaging potential, its clinical meaning remains unclear.

Live birth after Laser Assisted Viability Assessment (LAVA) to detect pentoxifylline resistant ejaculated immotile spermatozoa during ICSI in a couple with male Kartagener's syndrome

Primary ciliary dyskinesia (PCD) is a rare, autosomal recessive disease with abnormalities in the structure of cilia, causing impairment of muco-ciliary clearance with respiratory tract infections, heterotaxia and abnormal sperm motility with male infertility. Here, with a comprehensive literature review, we report a couple with an infertility history of 9 years and three unsuccessful IVF treatments, where male partner has Kartagener's Syndrome, a subtype of PCD, displaying recurrent respiratory infections, dextrocardia and total asthenozoospermia. His diagnosis was verified with transmission electron microscopy and genetic mutation screening, revealing total absence of dynein arms in sperm tails and homozygous mutation in the ZMYND10, heterozygous mutations in the ARMC4 and DNAH5 genes. Laser assisted viability assay (LAVA) was performed by shooting the sperm tails during sperm retrieval for microinjection, following detection of pentoxifylline resistant immotile sperm. Live births of healthy triplets, one boy and two monozygotic girls, was achieved after double blastocyst transfer.

A case of primary ciliary dyskinesia treated with ICSI using testicular spermatozoa: case report and a review of the literature

Purpose

To investigate whether or not intracytoplasmic sperm injection (ICSI) using spermatozoa extracted from testis (TESE-ICSI) is a more effective treatment than ICSI with ejaculated spermatozoa (EJ-ICSI) for primary ciliary dyskinesia (PCD).

Methods

We reported a case of PCD in which we performed TESE-ICSI after repeated failure of EJ-ICSI. Together with data from previous case reports, we compared the fertilization rate and pregnancy outcome of TESE-ICSI and EJ-ICSI.

Results

In our case, TESE-ICSI improved the morphology of spermatozoa and fertilization rate. However, the outcome was only a biochemical pregnancy. According to the analysis combined with previous reports, there was no difference in the fertilization rate and pregnancy outcome parameters between TESE-ICSI and EJ-ICSI.

Conclusions

TESE-ICSI for PCD may improve the fertilization rate compared to EJ-ICSI. However, it does not necessarily improve the pregnancy outcome for a patient with primary ciliary dyskinesia.

Healthy twin live-birth after ionophore treatment in a case of theophylline-resistant Kartagener syndrome

PURPOSE

To evaluate whether it is a feasible option to target the oocyte (with Ca(2+)-ionophore) in case that sperm motility cannot be restored in Kartagener syndrome.

METHODS

A case of a male Kartagener syndrome with exclusively immotile spermatozoa that did not react to the dimethylxanthine theophylline. Thus, half of the associated oocytes were treated for 15 min with the ready-to-use- ionophore CultActive immediately after ICSI whereas the other 50 % were injected with routine ICSI without artificial oocyte activation. Rates of fertilization, blastulation, pregnancy and live birth were evaluated.

RESULTS

Fertilization check revealed that none of the conventionally injected but 4/6 (66.7 %) of the artificially activated oocytes showed two pronuclei. Three embryos were of good and one of fair quality. Corresponding blastocyst formation rate was 3 out of 4 (75 %). A double embryo transfer led to a healthy twin birth in the 34th week of gestation (two boys with a birth weight of 1724 g and 2199 g).

CONCLUSIONS

This case indicates that Ca(2+)-ionophore treatment in cycles from theophylline-resistant Kartagener syndrome patients is a feasible option. The future will show if routine application of A23187 in Kartagener or primary cilia dyskinesis patients will be of benefit.

Normal live birth after vitrified/warmed oocytes intracytoplasmic sperm injection with immotile spermatozoa in a patient with Kartagener's syndrome

The present article is a report on two cases of male Kartagener's syndrome enrolled in intraconjugal IVF programme due to akinetospermia. Viable spermatozoa were selected using a hypo-osmotic swelling test (HOST) and pentoxifylline activation and subsequently microinjected into vitrified/warmed oocytes. The treatment enabled one of these two couples to achieve a pregnancy and to give birth to a healthy baby girl.

Management of primary ciliary dyskinesia/Kartagener's syndrome in infertile male patients and current progress in defining the underlying genetic mechanism

Kartagener's syndrome (KS) is an autosomal recessive genetic disease accounting for approximately 50% of the cases of primary ciliary dyskinesia (PCD). As it is accompanied by many complications, PCD/KS severely affects the patient's quality of life. Therapeutic approaches for PCD/KS aim to enhance prevention, facilitate rapid definitive diagnosis, avoid misdiagnosis, maintain active treatment, control infection and postpone the development of lesions. In male patients, sperm flagella may show impairment in or complete absence of the ability to swing, which ultimately results in male infertility. Assisted reproductive technology will certainly benefit such patients. For PCD/KS patients with completely immotile sperm, intracytoplasmic sperm injection may be very important and even indispensable. Considering the number of PCD/KS susceptibility genes and mutations that are being identified, more extensive genetic screening is indispensable in patients with these diseases. Moreover, further studies into the potential molecular mechanisms of these diseases are required. In this review, we summarize the available information on various aspects of this disease in order to delineate the therapeutic objectives more clearly, and clarify the efficacy of assisted reproductive technology as a means of treatment for patients with PCD/KS-associated infertility.

[Genetic aspects of fertility disorders]

Genetic disorders of fertility can occur at the level of gonadal differentiation or function, germ cell production or function, and the genital ducts. In gonadal dysgenesis, the differentiation of testes or ovaries is impaired. Gonadal dysgenesis can be caused by chromosome aberrations or monogenetic defects in XY or XX gonadal dysgenesis. For the biosynthesis of sexual hormones, a normal development of the gonads and an intact hypothalamic-pituitary-gonadal axis is necessary. Disorders of steroid hormone synthesis are associated with an increased or diminished production of sexual hormones. Clinical and genetic aspects of adrenogenital syndrome are discussed here. Mutations of the androgen receptor cause a spectrum of androgen insensitivity ranging from women with female external genitalia through patients with genital ambiguity to men with infertility. Disturbed spermatogenesis is heterogeneous and can be the result of chromosome aberrations such as Klinefelter syndrome or structural aberrations as translocations and microdeletions of the Y chromosome. Premature ovarian failure is characterized by amenorrhea and hypergonadotropic hypogonadism before 40 years of age. Beside nongenetic factors, premature ovarian failure can be caused by chromosome aberrations or monogenetic defects. Disorders of the genital ducts such as anomalies of the müllerian ducts in females and of the wolffian ducts in males can be associated with sterility or infertility.

Tales of the tail and sperm head aches: changing concepts on the prognostic significance of sperm pathologies affecting the head, neck and tail

This article presents an update on the variable prognostic significance of different sperm pathologies in patients with severe male factor infertility due to morphology and motility disorders. Severe asthenozoospermia is one of the leading causes of male infertility as spermatozoa cannot reach the oocyte and/or penetrate normally. Identifying structural causes of sperm immotility was of great concern before the advent of intracytoplasmic sperm injection (ICSI), because immotility was the limiting factor in the treatment of these patients. In these cases, in vitro methods are used to identify live spermatozoa or stimulate sperm motility to avoid selection of non-viable cells. With these advances, fertilization and pregnancy results have improved dramatically. The identification of genetic phenotypes in asthenozoospermia is important to adequately inform patients of treatment outcomes and risks. The one sperm characteristic that seriously affects fertility prognosis is teratozoospermia, primarily sperm head and neck anomalies. Defects of chromatin condensation and acrosomal hypoplasia are the two most common abnormalities in severe teratozoospermia. The introduction of microscopic methods to select spermatozoa and the development of new ones to evaluate sperm quality before ICSI will assure that ultrastructural identification of sperm pathologies will not only be of academic interest, but will also be an essential tool to inform treatment choice. Herein, we review the differential roles played by sperm components in normal fertilization and early embryo development and explore how assisted reproductive technologies have modified our concepts on the prognostic significance of sperm pathologies affecting the head, neck, mid-piece and tail.

Normal live birth after testicular sperm extraction and intracytoplasmic sperm injection in variant primary ciliary dyskinesia with completely immotile sperm and structurally abnormal sperm tails

OBJECTIVE

To report on the investigation and fertility management of variant primary ciliary dyskinesia (PCD).

DESIGN

Case report.

SETTING

University-affiliated assisted reproductive technologies practice.

PATIENT(S)

A 40 year-old man presenting with 12 months' primary infertility, complete sperm immotility, severe morphologic defects, and moderate sinopulmonary disease.

INTERVENTION(S)

Electron microscopy (EM) of sperm, nasal cilial function studies, open testis biopsy, and sperm extraction for intracytoplasmic sperm injection (ICSI).

MAIN OUTCOME MEASURE(S)

Outcome of ICSI treatment using immotile testicular sperm.

RESULT(S)

EM revealed abnormal connecting pieces, shortened midpieces with attenuated mitochondrial sheaths, poorly developed annulus, abnormal outer dense fibers, and axonemes missing the two central mircotubules. Nasal ciliary beat frequency was subnormal and dyssynchronous. Immotile testicular sperm were selected for ICSI based on physical characteristics and fertilized 12 of 18 eggs. A single day-5 blastocyst achieved a normal pregnancy and delivery of a healthy 3,840-g girl at 38 weeks' gestation.

CONCLUSION(S)

Nonclassic PCD may present with structurally abnormal completely immotile sperm, with seemingly little prospect of fertility, and moderate respiratory dysfunction supporting the presence of an underlying ciliopathy. Despite testicular sperm also being immotile and showing profound structural defects that would seem to preclude fertilization, more morphologically normal sperm are capable of establishing a normal pregnancy.

A sperm viability test using SYBR-14/propidium iodide flow cytometry as a tool for rapid screening of primary ciliary dyskinesia patients and for choosing sperm sources for intracytoplasmic sperm injection

Spermatozoa viability tests based on dual-color flow cytometry after staining with Sybr-14/propidium iodide were performed on 44 men with complete asthenospermia for primary ciliary dyskinesia (PCD) screening, and seven were identified with PCD by electron microscopy of ultrastructural ciliary defects. Six PCD patients underwent eight intracytoplasmic sperm injection therapy cycles using ejaculated sperm or testicular sperm, obtaining a mean fertilization rate of 46.6%, with three healthy babies born and one in utero at the time of writing.

The biology of infertility: research advances and clinical challenges

Reproduction is required for the survival of all mammalian species, and thousands of essential 'sex' genes are conserved through evolution. Basic research helps to define these genes and the mechanisms responsible for the development, function and regulation of the male and female reproductive systems. However, many infertile couples continue to be labeled with the diagnosis of idiopathic infertility or given descriptive diagnoses that do not provide a cause for their defect. For other individuals with a known etiology, effective cures are lacking, although their infertility is often bypassed with assisted reproductive technologies (ART), some accompanied by safety or ethical concerns. Certainly, progress in the field of reproduction has been realized in the twenty-first century with advances in the understanding of the regulation of fertility, with the production of over 400 mutant mouse models with a reproductive phenotype and with the promise of regenerative gonadal stem cells. Indeed, the past six years have witnessed a virtual explosion in the identification of gene mutations or polymorphisms that cause or are linked to human infertility. Translation of these findings to the clinic remains slow, however, as do new methods to diagnose and treat infertile couples. Additionally, new approaches to contraception remain elusive. Nevertheless, the basic and clinical advances in the understanding of the molecular controls of reproduction are impressive and will ultimately improve patient care.

Successful twin birth following blastocyst culture of embryos derived from the immotile ejaculated spermatozoa from a patient with primary ciliary dyskinesia: a case report

PURPOSE

To describe the ultrastructure of spermatozoa from a patient with complete asthenozoospermia that resulted in live births following blastocyst culture.

MATERIALS AND METHODS

Analyses of spermatozoa from a 36 year old patient were performed using light and electron microscopy. The hypo-osmotic swelling test was used to select spermatozoa for intracytoplasmic sperm injection. Embryos were cultured to the blastocyst stage.

RESULTS

100% of the spermatozoa had dynein arm deficiency with secondary defects varying from 3-17%. Six oocytes were injected; five fertilized normally and one was digynic. All five zygotes formed good quality blastocysts. Three blastocysts were cryopreserved and two blastocysts were transferred. Twin females were born at 37 weeks.

CONCLUSIONS

The hypo-osmotic swelling test can be used to select viable immotile ejaculated spermatozoa from a patient with dynein arm deficiency and can produce excellent fertilization rates and blastocyst development resulting in live births.

Pregnancy after laser-assisted selection of viable spermatozoa before intracytoplasmatic sperm injection in a couple with male primary cilia dyskinesia

OBJECTIVE

To report an intracytoplasmatic sperm injection (ICSI) pregnancy achieved in a couple with male primary cilia dyskinesia (PCD) with viable sperm that were detected using a 1.48 microm wavelength diode laser.

DESIGN

Case report.

SETTING

University hospital.

PATIENT(S)

A 37-year-old man with infertility due to primary cilia dyskinesia; semen analysis revealed a severe oligoasthenoteratozoospermia with absence of motile spermatozoa. A 34-year-old healthy woman with a 10-year history of primary infertility.

INTERVENTION(S)

Selection of viable spermatozoa using the hypo-osmotic swelling (HOS) test or a 1.48 microm wavelength diode laser and subsequent ICSI.

MAIN OUTCOME MEASURE(S)

Sperm analysis. Fertilization and cleavage rates and pregnancy.

RESULT(S)

Semen samples showed no motile spermatozoa and high percentages of spermatozoa with curled flagella resembling HOS-reactive spermatozoa. To identify viable spermatozoa we used the HOS test or a 1.48 microm diode laser. The ICSI using HOS-selected spermatozoa resulted in two fertilized out of four oocytes (50%), and injection of laser-selected spermatozoa resulted in four fertilized out of seven oocytes (57%). The transfer of two frozen/thawed oocytes of the laser group led to a singleton pregnancy.

CONCLUSION(S)

Use of a noncontact diode laser for sperm viability assessment may be a useful alternative, especially in cases where the HOS test is not informative.

Sperm morphology and aneuploidies: defects of supposed genetic origin

As individuals with genetic sperm defects are intracytoplasmic sperm injection candidates, the study of the chromosomal constitution of their spermatozoa is of great interest. This study is a review of the current literature concerning fluorescence in situ hybridisation studies in spermatozoa with genetic sperm defect as 'round head', 'dysplasia of fibrous sheath' (DFS), 'primary ciliary dyskinesia' (PCD), the 'detached tail' and the 'absence of fibrous sheath'. Regarding sperm head defects, elevated XY disomy and diplodies were detected. Genetic defects affecting the sperm tail seemed to have a different correlation with chromosome meiotic segregation. Only chromosome 18, among the autosomes, was studied and the percentage of frequency of disomy was generally within the normal range. In the more frequently studied defect, DFS, the alterations in gonosome disomy and diploidy were recorded by different groups. Regarding PCD defects, elevated frequencies of disomy of sex chromosomes and diploidy were observed, whereas the absence of the fibrous sheath and the detached tail did not show any meiotic disturbance. The problem of genetic sperm defects should be seriously considered when these sperm are used for assisted reproduction, owing to the high risk of transmission of chromosomal imbalance and of mutations that could cause genetic sperm defects in offspring.

Outcome of ICSI with ejaculated spermatozoa in a series of men with distinct ultrastructural flagellar abnormalities

BACKGROUND

Severe sperm motility impairment results in human infertility, which can be overcome by ICSI. Whether some particular, possibly genetic, flagellar abnormalities can influence embryonic development is a matter of debate.

METHODS

Analysis of ultrastructural flagellar abnormalities and ICSI outcomes with ejaculated spermatozoa in a series of 21 infertile patients with asthenozoospermic or dyskinetic spermatozoa due to a primary and specific flagellar abnormality was carried out.

RESULTS

Patients were sorted into six categories according to flagellar ultrastructural defects. Oocyte fertilization occurred in the 21 couples with a mean 2PN fertilization rate reaching 61.85%. No difference was observed in the kinetics of in vitro development or in the morphological quality of the embryos between the different types of flagellar abnormalities. Pregnancy occurred in 12 couples (57.1%) and delivery in nine couples (42.86%). Both the implantation rate and the clinical pregnancy rate per cycle were lower in type III abnormalities and in patients with an initial sperm motility less than 5%.

CONCLUSIONS

The rate of ICSI success may be influenced by the type of flagellar abnormality. ICSI provides a suitable solution for patients with sperm flagellar defects but raises the question of the consequences of a specific (and primary flagellar) abnormality on oocyte fertilization, on embryo and fetal development as well as on live birth.

Utrastructural analysis of asthenozoospermic ejaculates in the era of assisted procreation

OBJECTIVE

To define by transmission electron microscopy (TEM) analysis, the prevalence of sperm tail defects of genetic origin among men suffering for a reduced or absent sperm motility.

DESIGN

A retrospective study.

SETTING

Andrology Clinic, University of L'Aquila, Italy.

PATIENT(S)

The 120 ejaculates of infertile men with a forward motility (FM) < or =20% were compared to 200 ejaculates with a FM >20%. All ejaculates had a sperm vitality >50%.

INTERVENTION(S)

Some 25-50 tails were analyzed by TEM in each ejaculate.

MAIN OUTCOME MEASURE(S)

Receiver operating characteristics (ROC) analysis was applied by plotting the FM of cases with or without genetic tail defects detected by TEM.

RESULT(S)

The area under the ROC curve was 0.96 (95% confidence interval 0.92-0.98). The positive predictive accuracy for genetic tail defects in ejaculates with 0% FM was 46%. Three of 17 cases with genetic tail defects were classified as false negative when TEM analysis was restricted to ejaculates with 0% FM. A FM < or =7%, allowed the identification of all cases with genetic tail defects.

CONCLUSION(S)

The TEM analysis identifies sperm tail defects of genetic origin and should be restricted to ejaculates with severe asthenozoospermia (< or =7% motile sperm) and sperm vitality >50%.

Intracytoplasmic injection of spermatozoa and spermatogenic cells: its biology and applications in humans and animals

Intracytoplasmic sperm injection (ICSI) has become the method of choice to overcome male infertility when all other forms of assisted fertilization have failed. Animals in which ICSI has produced normal offspring include many species. Success rate with normal spermatozoa is well above 50% in the mouse but ICSI success rates in other animals have been low, ranging from 0.3 to 16.5%. Mouse ICSI revealed that spermatozoa that cannot participate in normal fertilization can produce normal offspring by ICSI, provided their nuclei are genomically intact. Human ICSI using infertile spermatozoa has been highly successful perhaps because of the intrinsic instability of human sperm plasma membrane. The health of children born after ICSI and other assisted fertilization techniques is of major concern. Careful analyses suggest that higher incidences of congenital malformations and/or low birth weights after assisted fertilization are largely attributable to parental genetic background and increased incidence of multiple births, rather than to the techniques of assisted fertilization. Since the physiological and nutritional environments of developing embryos may cause persisting alteration in DNA methylation, extreme caution must be exercised in handling gametes and embryos in vitro. In the mouse, round spermatid injection (ROSI) has been routinely successful but its use in humans is controversial. Whether human ROSI and assisted fertilization involving younger spermatogenic cells are medically safe must be the subject of further investigations.

Primate models for assisted reproductive technologies

Although the deliberate creation of human embryos for scientific research is complicated by ethical and practical issues, a detailed understanding of the cellular and molecular events occurring during human fertilization is essential, particularly for understanding infertility. It is clear from cytoskeletal imaging studies of mouse fertilization that this information cannot be extrapolated to humans because of unique differences in centrosomal inheritance. However, the cytoskeletal rearrangements during non-human primate fertilization are very similar to humans, providing a compelling animal model in which to examine sperm–egg interactions. In order to address this key step in primate fertilization and to avoid the complexities in working with fertilized human zygotes, studies are now exploring the molecular foundations of various assisted fertilization techniques in a monkey model. While intracytoplasmic sperm injection with ejaculated or testicular sperm is quite successful in primate models, there are some specific differences when compared with standard IVF that warrant further investigation, particularly in regards to nuclear remodeling, genomic imprinting, Y-chromosome deletions and developmental outcomes. Similarly, primate models have been useful for examining spermatid function during fertilization but these have met with limited success. One area of primate reproductive research that has yet to be mastered is reproductive cloning. Genetically identical primates would provide the ultimate approach for accelerating stem cell-based therapies for a number of neurodegenerative diseases such as Alzheimer’s and Parkinson’s disease, as well as targeted gene therapies for various metabolic disorders.

[Kartagener's syndrome and infertility: observation, diagnosis and treatment]

Primary ciliary dyskinesia is a rare etiology of sterility in man (prevalence between 1/6000 and 1/40000). Kartagener's syndrome is an autosomal recessive disorder, characterized by total or partial dysfunction of the ciliary or flagellated cells. This syndrome associates situs inversus, sinusitis, bronchiectasis and occasionally sterility in males. We report a case of immotile cilia syndrome with male infertility and compare the data with four other couples reported in the literature (two couples in Germany, two in the United States). The difficulty is to select an alive sperm cell for ICSI.

[Primary ciliary dyskinesia]

In patients with chronic respiratory diseases that last since the early childhood, primary ciliary dyskinesia (PCD) needs to be considered. Four patients reviewed in this paper were with typical disease history and clinical picture, as well as clear ciliary axonema damage. Complete examination was performed in all the patients, including bronchoscopy with bronchography, and the examination of the biopsy samples of respiratory airways' mucous membrane, obtained by transmission electron microscope (TEM). In two of the patients spermatozoa were also examined by TEM. Large anatomic defects of airways were found in all the patients, but pulmonary function was normal (except in one case), representing one of PCD's significant characteristics. First two cases fulfilled the criteria for Kartagener's syndrome, which was initially sufficient for the diagnosis of PCD.

Pregnancy after ICSI with ejaculated immotile spermatozoa from a patient with immotile cilia syndrome: a case report and review of the literature

This study presents a case of intracytoplasmic sperm injection (ICSI) with ejaculated immotile spermatozoa from a patient with immotile cilia syndrome. Semen analysis of the patient suffering from immotile cilia syndrome revealed an extreme oligoasthenoteratozoospermia (OAT: count <1.4 x 10(6)/ml, 0% motility and 3% normal morphology). Electron microscopy of sperm flagella showed the absence of inner and outer dynein arms. During the ICSI cycle, the hypo-osmotic swelling test (HOS) was used for the identification of viable spermatozoa in the pool of immotile spermatozoa for ICSI. A normal fertilization rate was found in eight out of the 12 oocytes. A first fresh double embryo transfer resulted in a late miscarriage at 21 weeks. A second healthy singleton pregnancy occurred after transfer of two frozen-thawed embryos from the same ICSI procedure. Although only one successful ICSI case of the immotile cilia syndrome combined with HOS is described here, HOS might be a simple but valuable tool to obtain normal fertilization and pregnancy for patients suffering from immotile spermatozoa.

Current and future genetic screening for male infertility

Although much of male infertility is currently unexplained, it is likely that underlying defects in critical genes or entire gene pathways are responsible. Because powerful technologies exist to bypass severe male-factor infertility, improving the diagnosis of genetic infertility is important for the infertile couple, not only to explain the problem but also to inform them of conditions potentially transmissible to offspring.

Successful ICSI in a case of severe asthenozoospermia due to 93% non-specific axonemal alterations and 90% abnormal or absent mitochondrial sheaths

The use of IVF and intracytoplasmic sperm injection (ICSI) to treat male infertility due to severe asthenozoospermia in cases of electron microscopically confirmed axonemal abnormalities has been reported. However, even with these sophisticated technologies, very few pregnancies and births have been achieved with ejaculated spermatozoa in infertility due to this condition. The existence of sperm-derived defects preclude normal embryo development, and another reason for low success rates may be that the most commonly used method for selecting viable spermatozoa for ICSI is sperm motility, which is absent in affected men. Consequently, the likelihood of selecting non-viable spermatozoa for ICSI is higher in these cases. This report describes a case of a pregnancy achieved by ICSI with ejaculated spermatozoa containing 93% non-specific axonemal alterations and 90% abnormal or absent mitochondrial sheaths. A total of 14 oocytes was obtained from the 31-year-old patient in her first IVF treatment cycle. Three of the 13 matured (metaphase II) oocytes were inseminated conventionally, and the other 10 metaphase II oocytes were submitted to ICSI. None of the oocytes inseminated conventionally were fertilized. Of the 10 oocytes submitted to ICSI, four zygotes and cleavage embryos resulted. Three embryos were transferred on day 3, and a successful pregnancy was achieved. One gestational sac, together with regular heart activity, was recorded by ultrasonography at 8 weeks of gestation. A pregnancy is currently ongoing.

Birth after intracytoplasmic sperm injection with use of testicular sperm from men with Kartagener/immotile cilia syndrome

OBJECTIVE

To describe two cases of in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) with testicular sperm in men with immotile cilia syndromes.

DESIGN

Case report.

SETTING

A university-based male infertility clinic and assisted reproduction unit.

PATIENT(S)

Two couples with male factor infertility due to Kartagener/immotile cilia syndrome.

INTERVENTION(S)

IVF/ICSI with testicular sperm.

MAIN OUTCOME MEASURE(S)

Semen characteristics, sperm viability, fertilization rate, and pregnancy.

RESULT(S)

With testicular sperm, the two pronuclear fertilization rates were 63% and 60% in two cases. One case resulted in the birth of normal healthy girl.

CONCLUSION(S)

With testicular sperm, successful oocyte fertilization after ICSI in couples with male Kartagener/immotile cilia syndrome is possible despite the lack of sperm motility.

Genetic causes of male infertility: current concepts

Infertile men with severe spermatogenic defects and low or no sperm counts have a significantly higher rate of genetic abnormalities than fertile men. The fact that intracytoplasmic sperm injection can potentially bypass natural selection barriers to genetic disease transmission has brought a sobering but important impetus to recent research in the area of genetic infertility. Recent studies have focused on examining the prevalence of certain genetic defects in infertile men, analyzing the molecular basis of infertility in genetic disorders, and detecting new causes of genetic infertility. Several novel research findings deserve mention for their potential impact on genetic infertility. It has been demonstrated that elongated and round spermatids can be successfully injected into human oocytes and viable births obtained. Likewise, significant advances have been made in the arena of interspecies germ cell transplantation. Of some concern is the finding of a relationship between faulty DNA repair and infertility in men with severe testis failure. This review summarizes the recent genetic advances in these areas of male genetic infertility.

Primary ciliary dyskinesia (the immotile cilia syndrome)

OBJECTIVE

The purpose of this review is to familiarize the reader with the genetic aspects, clinical manifestations, diagnostic techniques and management of the primary ciliary dyskinesia syndrome. Further, this article illustrates some unusual features of this syndrome and discusses some speculative hypotheses concerning its pathogenesis and clinical presentation.

DATA SOURCES

The bibliography includes references in English as well as some references of historical interest in German. Both human and veterinary literature are quoted. Sources included computerized bibliographic searches of recent literature and reviews of literature.

STUDY SELECTION

Selection of papers was made based on their historic importance in the definition and characterization of the disease, and on reviews of large bodies of novel or interesting information. Some review papers were not included to avoid repetition.

RESULTS

Although the incidence of primary ciliary dyskinesia is low, the inclusion of this condition in the differential diagnosis of chronic and recurrent sinobronchial disease in children and older individuals is very common. Primary ciliary dyskinesia should be suspected in individuals who present chronic respiratory symptoms already in the neonatal period, develop profuse, chronic mucopurulent rhinorrhea, and chronic otitis media and sinusitis. Chronic cough, obstructive lung disease, and bronchorrhea associated with the aforementioned manifestations should also make clinicians suspect this syndrome. Male sterility is almost universally present and situs inversus is present in 50% of affected persons. The diagnosis of primary ciliary dyskinesia is clinical and is confirmed by studies of ciliary motility and ultrastructure of the respiratory mucosa. Management is directed to microbial suppression by frequent antibiotic administration, and to clearing of retained secretions.

CONCLUSIONS

The diagnosis of primary ciliary dyskinesia requires familiarity with the clinical picture and the specific techniques of identification. Although the basic mechanism of disease is known, the molecular genetics of primary ciliary dyskinesia and the causes for the phenotypic variability remain to be explained. Future research should be directed to the identification of the gene(s) responsible for the manifestations of the disease and to effective methods of activation, in vivo, of dysfunctional cilia.