Results of preimplantation genetic diagnosis in patients with Klinefelter's syndrome

The Effect of Teratozoospermia on Sex Chromosomes in Human Embryos

Purpose

The aim of this study is to evaluate the effect of abnormal semen morphology on the frequency of sex chromosomal abnormalities in embryos obtained by ICSI, which represents the first to be studied in Egyptian population.

Methods

Forty-two couples suffering from male infertility due to teratozoospermia were divided into two groups: patients with severe and moderate teratozoospermia (group A and B, respectively). All involved couples were subjected to careful history taking and had a normal clinical examination and karyotype. Females were subjected to hormonal assays, pelvic ultrasound, hysterosalpingography and yielded normal results, while male partners were subjected to computerized semen analysis. Preimplantation genetic diagnosis was performed for all suitably developed embryos including embryo biopsy, fixation of biopsied cells and fluorescent in situ hybridization (FISH) analysis.

Results

Couples included in the two groups were found to be homogenous in terms of age of both partners and duration of infertility. Interpretation of FISH results was performed by evaluation of embryos’ chromosomal constitution as regards abnormalities in chromosomes X, Y and 18. Twenty-seven embryos (48.2%) were found chromosomally abnormal in group A, while only 14 embryos (25.0%) were found chromosomally abnormal in group B. Aneuploidies involved only sex chromosomes were tripled in group A embryos when compared to their frequency in group B embryos (26.8% and 8.3%, respectively) with statistically significant difference between the two groups (p=0.002). Monosomies were the most common type of aneuploidy and were significantly higher in group A (14.3%) when compared to group B (3.6%) (p=0.047). Embryos with mosaic abnormalities were more common in group A (12.5%) when compared to group B (3.6%), however not statistically significantly different (p= 0.162). A significant difference between the two studied groups as regards the total number of potentially viable chromosomal abnormalities detected and the potentially viable sex chromosomal aneuploidies detected (p<0.001 and p=0.002), respectively.

Conclusion

The cases with severe teratozoospermia undergoing ICSI treatment can display a higher rate of sex chromosome aneuploidies in their embryos (threefold) than cases with moderate teratozoospermia.

Management of non-obstructive azoospermia

Non-obstructive azoospermia (NOA) is defined as no sperm in the ejaculate due to failure of spermatogenesis and is the most severe form of male infertility. The etiology of NOA is either intrinsic testicular impairment or inadequate gonadotropin production. Chromosomal or genetic abnormalities should be evaluated because there is a relatively high incidence compared with the normal population. Although rare, NOA due to inadequate gonadotropin production is a condition in which fertility can be improved by medical treatment. In contrast, there is no treatment that can restore spermatogenesis in the majority of NOA patients. Consequently, testicular extraction of sperm under an operating microscope (micro-TESE) has been the first-line treatment for these patients. Other treatment options include varicocelectomy for NOA patients with a palpable varicocele and orchidopexy if undescended testes are diagnosed after adulthood, although management of these patients remains controversial. Advances in retrieving spermatozoa more efficiently by micro-TESE have been made during the past decade. In addition, recent advances in biotechnology have raised the possibility of using germ cells produced from stem cells in the future. This review presents current knowledge about the etiology, diagnosis, and treatment of NOA.

Early Morphokinetic Monitoring of Embryos after Intracytoplasmic Sperm Injection with Fresh Ejaculate Sperm in Nonmosaic Klinefelter Syndrome: A Different Presentation

The patient was diagnosed with nonmosaic 47, XXY Klinefelter Syndrome with the AZF deletion absent and SRY+. The nonmosaic 47, XXY karyotype was confirmed on a skin biopsy chromosomal analysis. Using only ejaculate motile sperms, 11 oocytes underwent ICSI and were placed rapidly in a time lapse (Embryoscope ©) with a specific culture dish. Biopsies were performed on six embryos on the 3rd day, and numerical chromosomal abnormalities were observed using the FISH test before transfer. PGS results were normal in only two embryos with normal morphokinetics in the Embryoscope. For clinical confirmation of pregnancy, ultrasonographic examination was performed during the 7th week of pregnancy, and two gestational sacs and fetal heart beat were observed.

Birth of a healthy child after preimplantation genetic screening of embryos from sperm of a man with non-mosaic Down syndrome

PURPOSE

The purpose of this study is to present a case of healthy infant born after intracytoplasmic sperm injection-in vitro fertilization (ICSI-IVF) with preimplantation genetic screening (PGS) using sperm from a man with non-mosaic trisomy 21 and a literature review.

MATERIALS AND METHODS

A 26-year-old euploid female and 29-year-old male with non-mosaic trisomy 21 and male factor undergoing ICSI-IVF treatment for primary infertility with embryo biopsy for PGS with comprehensive chromosomal screening (CCS) presented to the Infertility Clinic at Highland Hospital, the Alameda County Medical Center, California, with 6-year history of primary infertility. The outcome measure is a live birth of a healthy child and ploidy status of biopsied blastocysts.

RESULTS

Egg retrieval yielded 33 oocytes, 29 of which underwent ICSI with ejaculated sperm. Twenty-eight 2PN zygotes were cultured, and 13 blastocysts underwent trophectoderm biopsy and vitrification 5 or 6 days after retrieval. CCS analysis revealed that 12 out of 13 (92 %) of blastocysts were euploid and one was a complex abnormal mosaic. Transfer of two grade I hatching blastocysts resulted in a singleton pregnancy with normal prenatal genetic screening and delivery of a healthy male infant at 41 weeks via primary cesarean section for non-reassuring fetal status.

CONCLUSION

This is the first report of a live birth of a healthy child after ICSI-IVF with PGS using ejaculated sperm from a man with non-mosaic trisomy 21 and male factor infertility.

Outcomes of Micro-Dissection TESE in Patients with Non-Mosaic Klinefelter's Syndrome without Hormonal Treatment

Background

Klinefelter syndrome (KS) is the most common sex chromosomal disorder in males and historically patients have been labeled as sterile. After the introduction of microdissection testicular sperm extraction (micro-TESE), successful sperm retrievals for intracytoplasmic sperm injection (ICSI) have been reported.

Materials and Methods

A retrospective study was undertaken on ten patients with non-mosaic KS undergoing micro-TESE for ICSI. The testicular volume and FSH and LH levels of each patient were measured. Karyotypes were confirmed by analyzing peripheral lymphocyte metaphases. Physical examination of the external genitalia was performed in all patients to rule out any co-existing anomaly. Micro-TESE was performed in order to investigate the presence of seminiferous tubules which may contain spermatozoa. When testicular spermatozoa were found in micro-TESE, ICSI was performed. Embryos were evaluated for further development. Fertilization was considered to have occurred after the visualization of the two pro-nuclei stage of the oocyte 24 hours after the intracytoplasmic injection of the motile spermatozoa. Pregnancy was confirmed by visualization of an intrauterine gestational sac under ultrasonographic examination.

Results

Testicular biopsy revealed motile spermatozoa in 6 of 9 patients (66.6 %). Fertilization rate per embryo-transfer was 40%. One patient was able to conceive and fathered a healthy boy weights 3410 g at the 39^th week of gestation.

Conclusion

Retrieval of testicular spermatozoa by micro-TESE is possible for azoospermic men with KS when assisted reproductive techniques are applied. For patients with KS who want to conceive, assisted reproductive techniques (ART) should be recommended.

Managing infertility in patients with Klinefelter syndrome

Klinefelter syndrome (KS) is the most frequent chromosomal abnormality with a prevalence of 150 per 100,000 males. It is now well known that the phenotype of Klinefelter adults varies from individual to individual and one registry study indicates that approximately 75% of KS subjects are not diagnosed probably because of very mild phenotypes. Due to seminiferous tubule fibrosis KS patients have small testes and are infertile because of azoospermia (>90%) or severe oligozoospermia (<10%). Adoption or heterologous insemination has been used in the past to achieve paternity. Currently it is well known that with TESE/micro-TESE (TESE = TEsticular Sperm Extraction) spermatozoa can be found in the testes of 28-67% of KS patients. Predictive factors of sperm retrieval success/failure, such as reproductive hormone plasma levels, testis volume and age, have been evaluated without any positive results. By combining TESE/micro-TESE with intracytoplasmic sperm injection an average of 50% of these patients have the possibility of fathering children and the birth of more than 150 children with normal karyotype has been reported in the last 20 years. However couples with a Klinefelter partner must be informed of the increased risk of autosomal/sex chromosomes aberrations in the sperm and embryos and of the possibility of preimplantation genetic diagnosis which is currently suggested by a minority of authors.

Outcome of microdissection testicular sperm extraction in azoospermic patients with Klinefelter syndrome and other sex-chromosomal anomalies

It has been indicated that approximately 20% of azoospermic patients have chromosomal anomalies, 90% of which are sex-chromosome abnormalities. Even azoospermic patients with sex-chromosomal anomalies might be able to father children using an advanced assisted reproductive technique such as microdissection testicular sperm extraction (micro-TESE) with intracytoplasmic sperm injection (ICSI). To evaluate the effect of micro-TESE in azoospermic patients with various sex-chromosomal anomalies, we reviewed their clinical results. A chromosomal survey using the G-banding technique was performed on males whose semen analysis demonstrated azoospermia at the Division of Male Infertilities at our institution between January 2004 and December 2009. Forty-two of these subjects demonstrated sex-chromosomal anomalies. The mean patient age was 34.4 ± 4.3 years. We classified them into two groups: Klinefelter syndrome (47,XXY) and other sex-chromosome abnormalities. Thirty-five patients showed Klinefelter syndrome and seven patients showed other sex-chromosome abnormalities. Serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), and testosterone (T) levels were 36.3 ± 14.0 IU/L, 15.8 ± 6.7 IU/L, and 3.2 ± 2.0 ng/ml in Klinefelter syndrome, and 20.8 ± 10.4 IU/L, 8.2 ± 5.2 IU/L and 4.1 ± 1.5 ng/ml in other sex-chromosome abnormalities, respectively. The mean testicular volume was 4.0 ± 2.1 ml in Klinefelter syndrome and 9.9 ± 4.6 ml in other sex-chromosome abnormalities. Serum FSH and LH in Klinefelter syndrome were significantly higher than those in other sex-chromosome abnormalities, and the mean testicular volume in Klinefelter syndrome was significantly smaller than that in other sex-chromosome abnormalities. The sperm retrieval rate (SRR) for micro-TESE showed no significant difference between the two groups (42.4% vs. 42.9%). In this study, the outcome of micro-TESE appeared not to differ between Klinefelter syndrome and other sex-chromosome abnormalities.

Spermatogenesis in Klinefelter syndrome

BACKGROUND

Klinefelter syndrome (KS) (47,XXY) is the most common sex chromosomal disorder, and it is a frequent form of male hypogonadism and infertility. Although the majority of these patients are azoospermic, they might have severe oligozoospermia or residual single-residual foci with spermatogenesis in the testis.

AIM

We report our experience on sperm retrieval in the ejaculate and testis, and evaluate the frequency of chromosome abnormalities in sperm of KS.

SUBJECTS AND METHODS

Eighty-four 47,XXY KS were evaluated with seminal analysis, body hair distribution, reproductive hormones, ultrasonographic scanning of the testis and prostate, bilateral testicular sperm extraction (TESE), sperm or testicular cells sex chromosomes aneuploidies.

RESULTS

Out of 84 patients, 7 (7/84; 8.3%) had sperm in the ejaculate. Out of the 77 azoospermic patients, 24 underwent TESE and 9 (9/24; 37.5%) had successful sperm recovery. The comparison of reproductive hormones, age and testicular volume did not show significant differences between patients with and without successful sperm recovery in semen or TESE . Patients without successful sperm recovery in semen analysis or TESE had signs of hypoandrogenism more evident than patients with successful sperm recovery. Patients with KS produced a higher number of sperm aneuploidy with respect to normozoospermic fertile controls and non-genetic severely oligozoospermic men.

CONCLUSIONS

Men with KS are not always sterile. In some of these patients sperm can be found in semen or in the testis, but the proportion of sperm aneuploidy is high. Signs of hypoandrogenism seem to be associated with low sperm recovery rate.

The genetic basis of male reproductive failure

Evolving therapies have allowed the use of sperm from men with spermatogenic compromise, obstructive azoospermia, and sperm functional deficiency, enabling these men to procreate when unable to do so naturally. The genetic basis of only a portion of these conditions is known and research must be pursued into the genetic underpinnings of those that have not yet been delineated. Education and provision of information to patients is the responsibility of all involved in the care of men with reproductive failure. The author concentrates on some of the known causes of nonobstructive azoospermia and obstructive azoospermia with a well-established genetic cause such as congenital bilateral absence of the vas deferens.

Intracytoplasmic sperm injection (ICSI) in 2006: Evidence and Evolution

The introduction of intracytoplasmic sperm injection (ICSI) in 1992 has dramatically changed the management of severe male infertility. In severe male infertility, live birth rates with ICSI are superior to those with other non-donor treatments. In non-male infertility, however, pregnancy rates are not better with ICSI than with in vitro fertilization (IVF). With obstructive or non-obstructive azoospermia, reasonable pregnancy rates are now possible with ICSI after recovery of sperm from the testes followed by ICSI. Genetic counselling is indicated for severe male infertility, whether or not ICSI is considered. ICSI is indicated in preimplantation genetic diagnosis (PGD) to avoid contamination by extraneous DNA in the case of PCR-based testing and to increase the number of embryos available for testing. In turn, PGD may be indicated in pregnancies that are at high risk of aneuploidy because of genetic factors associated with azoospermia. As with IVF, not all couples succeed, but 2% of couples with failed ICSI cycles will conceive without treatment. ICSI outcome studies indicate that there is a significant increase in prematurity, low birthweight, and perinatal mortality associated with single and multiple births, similar to the outcomes of conventional IVF. However, as evidenced in long-term follow-up studies, the higher rates of urogenital abnormalities and increased use of healthcare may be associated with paternal characteristics.

Preliminary FISH studies on spermatozoa and embryos in patients with variable degrees of teratozoospermia and a history of poor prognosis

The aim of this study was to analyse to what extent sperm aneuploidy is associated with sperm morphology and subsequently with embryo aneuploidy. Fifty-nine men with variable degrees of teratozoospermia and previously poor assisted reproduction prognosis were included in the study. Samples from 10 normozoospermic men with proven fertility were used as controls. Individual spermatozoa were scored for chromosomes 13, 21 and for 18, X, Y separately. Compared with controls, 23 out of 59 cases (39.0%) were found to have increased sperm aneuploidy for at least one of the chromosomes analysed in a treatment cycle. Fifty-two patients underwent a treatment cycle and were documented according to the pregnancy and spermatozoa fluorescence in-situ hybridization results. A total of 121 previous unsuccessful assisted reproduction cycles of the cases were then retrospectively reviewed. In 23 of the latest cycles, preimplantation genetic diagnosis was applied to 106 cleavage stage embryos and 47 of 94 embryos analysed (50.0%) were found to be chromosomally abnormal. Furthermore, 16 of 47 (34.0%) embryos with chromosomal abnormality were carrying complex chromosomal defects. The results imply that increased aneuploidy is present in both spermatozoa and embryos in couples with severe male infertility with a history of repeated unsuccessful attempts. Therefore, proper genetic counselling should be considered in these cases.

Chromosome abnormalities and their relationship to morphology and development of human embryos

This review covers the relationship between chromosome abnormalities, morphological abnormalities and embryonic development. The baseline of chromosome abnormalities in human embryos produced by assisted reproduction is higher than 50%, regardless of maternal age. While aneuploidy increases with maternal age, abnormalities arising post-meiotically, such as mosaicism, chaoticism, polyploidy and haploidy, have similar incidence in all age groups (about 33%). Post-meiotic abnormalities do increase with dysmorphism. The most common dysmorphisms found in cleavage-stage embryos are multinucleation, fragmentation and uneven cells, among others. All dysmorphisms are associated with an increase in post-meiotic chromosome abnormalities and a decreased implantation potential. Similarly, embryos developing slowly or with arrested development have higher incidence of post-meiotic abnormalities than normally developing ones. Chromosome studies in blastocysts indicate that mosaicism is the most common abnormality but that the load of abnormal cells decreases with increasing blastocyst quality. Regardless of blastocyst quality, more than 40% of mosaics are still chromosomally abnormal and will not implant or will spontaneously abort. Because aneuploidy is not related to cleavage stage dysmorphism and trisomies can reach blastocyst stage and beyond, morphological analysis is not enough to select against chromosome abnormalities, and thus preimplantation genetic diagnosis should be recommended in patients 35 and older.

Evaluation and management of genital anomalies in two patients with Klinefelter syndrome and review of literature

OBJECTIVES

To present the evaluation and management of cryptorchidism and varicocele in patients with Klinefelter syndrome and review the literature. Recent advances in reproductive medicine have resulted in fertility in patients with Klinefelter syndrome. However, cryptorchidism and varicocele can affect the fertility potential on their own.

METHODS

We present 2 cases and review the literature with an emphasis on the fertility potential.

RESULTS

Germ cells were present in the testicular biopsy of an infant with cryptorchidism but not in the adolescent with a varicocele. The latter biopsy showed tubular sclerosis.

CONCLUSIONS

The fertility potential of patients with Klinefelter syndrome and cryptorchidism may be preserved or enhanced by an early orchiopexy. However, the potential benefit of ligation of internal spermatic veins in patients with Klinefelter syndrome and a varicocele warrants further study. Cryopreservation should be considered early in adolescence or adulthood as germ cells become depleted at an accelerated rate after puberty.

Chromosome abnormalities in sperm of individuals with constitutional sex chromosomal abnormalities

The most common type of karyotype abnormality detected in infertile subjects is represented by Klinefelter's syndrome, and the most frequent non-chromosomal alteration is represented by Y chromosome long arm microdeletions. Here we report our experience and a review of the literature on sperm sex chromosome aneuploidies in these two conditions. Non mosaic 47,XXY Klinefelter patients (12 subjects) show a significantly lower percentage of normal Y-bearing sperm and slightly higher percentage of normal X-bearing sperm. Consistent with the hypothesis that 47,XXY germ cells may undergo and complete meiosis, aneuploidy rate for XX- and XY-disomies is also increased with respect to controls, whereas the percentage of YY-disomies is normal. Aneuploidy rates in men with mosaic 47,XXY/46,XY (11 subjects) are lower than those observed in men with non-mosaic Klinefelter's syndrome, and only the frequency of XY-disomic sperm is significantly higher with respect to controls. Although the great majority of children born by intracytoplasmic sperm injection from Klinefelter subjects are chromosomally normal, the risk of producing offspring with chromosome aneuploidies is significant. Men with Y chromosome microdeletions (14 subjects) showed a reduction of normal Y-bearing sperm, and an increase in nullisomic and XY-disomic sperm, suggesting an instability of the deleted Y chromosome causing its loss in germ cells, and meiotic alterations leading to XY non-disjunction. Intracytoplasmic injection of sperm from Y-deleted men will therefore transmit the deletion to male children, and therefore the spermatogenic impairment, but raises also concerns of generating 45,X and 47,XXY embryos.

Clinical aspects of preimplantation genetic diagnosis for single gene disorders combined with HLA typing

Preimplantation genetic diagnosis (PGD) for single gene disorders combined with human leukocyte antigen (HLA) matching has recently emerged as a therapeutic tool for stem cell transplantation in couples bearing an affected offspring. There may exist, however, several patient- or cycle-specific limitations for certain couples. This article documents data regarding experience of single gene disorders combined with HLA matching obtained at Istanbul Memorial Hospital, Turkey. The data were obtained from 20 couples undergoing 26 PGD-HLA cycles for thalassaemia (n = 23), Wiscott-Aldrich syndrome (n = 1) and acute lymphoblastic leukaemia (n = 2). A total of 206 embryos was biopsied on day 3 of embryo development and subsequently analysed. After the analysis, 26 (12.6%) of them were found to be both healthy and HLA compatible. In 16 embryo transfers performed, seven (43.7%) clinical pregnancies were obtained, one of which resulted in miscarriage. Ten of the 26 cycles started (38.4%) were cancelled due to a lack of suitable (mutation-free and/or HLA-compatible) embryos. The data suggest that application of PGD in combination with HLA typing is a promising therapeutic tool for an affected sibling.

Klinefelter's syndrome

Klinefelter's syndrome is the most common genetic cause of human male infertility, but many cases remain undiagnosed because of substantial variation in clinical presentation and insufficient professional awareness of the syndrome itself. Early recognition and hormonal treatment of the disorder can substantially improve quality of life and prevent serious consequences. Testosterone replacement corrects symptoms of androgen deficiency but has no positive effect on infertility. However, nowadays patients with Klinefelter's syndrome, including the non-mosaic type, need no longer be considered irrevocably infertile, because intracytoplasmic sperm injection offers an opportunity for procreation even when there are no spermatozoa in the ejaculate. In a substantial number of azoospermic patients, spermatozoa can be extracted from testicular biopsy samples, and pregnancies and livebirths have been achieved. The frequency of sex chromosomal hyperploidy and autosomal aneuploidies is higher in spermatozoa from patients with Klinefelter's syndrome than in those from normal men. Thus, chromosomal errors might in some cases be transmitted to the offspring of men with this syndrome. The genetic implications of the fertilisation procedures, including pretransfer or prenatal genetic assessment, must be explained to patients and their partners.

Effect of PGD on implantation and ongoing pregnancy rates in cases with predominantly macrocephalic spermatozoa

Although its occurrence is rare, the presence of large headed or macrocephalic spermatozoa and increased chromosomal abnormality has recently been reported by several groups. Moreover, when intracytoplasmic sperm injection (ICSI) was performed with samples containing macrocephalic spermatozoa, lower fertilization and implantation rates result in poor clinical outcome. In order to evaluate the impact of preimplantation genetic diagnosis (PGD) on implantation and ongoing pregnancy rates in these couples, the results of 23 PGD cycles were compared with non-PGD cycles (n = 60) as well as cycles with absolute teratozoospermia (having zero normal morphology) with (n = 14) or without PGD (n = 66). Out of 82 embryos biopsied in the macrocephalic sperm group, abnormalities were detected in 46.4% of the embryos analysed. Most of the abnormalities were trisomies (37.0%) and complex aneuploidies (51.9%). A 33.3% pregnancy rate was achieved by selectively transferring euploid embryos after PGD with the statistically higher implantation rate of 25.0% compared with non-PGD cycles (IR: 12.3%, P < 0.01). Moreover, only one missed abortion (14.3%) was observed in the PGD group, whereas seven of the 15 pregnancies resulted in abortion in the non-PGD group (46.7%). Preliminary results indicate that patients should be counselled for increased chromosomal abnormality and a possible beneficial effect of eliminating chromosomally abnormal embryos with PGD on a bortion rates.