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Taha MS, Ahmadian MR. Fragile X Messenger Ribonucleoprotein Protein and Its Multifunctionality: From Cytosol to Nucleolus and Back. Biomolecules 2024; 14:399. [PMID: 38672417 PMCID: PMC11047961 DOI: 10.3390/biom14040399] [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: 02/22/2024] [Revised: 03/17/2024] [Accepted: 03/19/2024] [Indexed: 04/28/2024] Open
Abstract
Silencing of the fragile X messenger ribonucleoprotein 1 (FMR1) gene and a consequent lack of FMR protein (FMRP) synthesis are associated with fragile X syndrome, one of the most common inherited intellectual disabilities. FMRP is a multifunctional protein that is involved in many cellular functions in almost all subcellular compartments under both normal and cellular stress conditions in neuronal and non-neuronal cell types. This is achieved through its trafficking signals, nuclear localization signal (NLS), nuclear export signal (NES), and nucleolar localization signal (NoLS), as well as its RNA and protein binding domains, and it is modulated by various post-translational modifications such as phosphorylation, ubiquitination, sumoylation, and methylation. This review summarizes the recent advances in understanding the interaction networks of FMRP with a special focus on FMRP stress-related functions, including stress granule formation, mitochondrion and endoplasmic reticulum plasticity, ribosome biogenesis, cell cycle control, and DNA damage response.
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Affiliation(s)
- Mohamed S. Taha
- Institute of Biochemistry and Molecular Biology II, Medical Faculty, Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany;
- Research on Children with Special Needs Department, Institute of Medical Research and Clinical Studies, National Research Centre, Cairo 12622, Egypt
| | - Mohammad Reza Ahmadian
- Institute of Biochemistry and Molecular Biology II, Medical Faculty, Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany;
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Taha MS, Haghighi F, Stefanski A, Nakhaei-Rad S, Kazemein Jasemi NS, Al Kabbani MA, Görg B, Fujii M, Lang PA, Häussinger D, Piekorz RP, Stühler K, Ahmadian MR. Novel FMRP interaction networks linked to cellular stress. FEBS J 2020; 288:837-860. [PMID: 32525608 DOI: 10.1111/febs.15443] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 04/09/2020] [Accepted: 06/03/2020] [Indexed: 12/12/2022]
Abstract
Silencing of the fragile X mental retardation 1 (FMR1) gene and consequently lack of synthesis of FMR protein (FMRP) are associated with fragile X syndrome, which is one of the most prevalent inherited intellectual disabilities, with additional roles in increased viral infection, liver disease, and reduced cancer risk. FMRP plays critical roles in chromatin dynamics, RNA binding, mRNA transport, and mRNA translation. However, the underlying molecular mechanisms, including the (sub)cellular FMRP protein networks, remain elusive. Here, we employed affinity pull-down and quantitative LC-MS/MS analyses with FMRP. We identified known and novel candidate FMRP-binding proteins as well as protein complexes. FMRP interacted with 180 proteins, 28 of which interacted with its N terminus. Interaction with the C terminus of FMRP was observed for 102 proteins, and 48 proteins interacted with both termini. This FMRP interactome comprises known FMRP-binding proteins, including the ribosomal proteins FXR1P, NUFIP2, Caprin-1, and numerous novel FMRP candidate interacting proteins that localize to different subcellular compartments, including CARF, LARP1, LEO1, NOG2, G3BP1, NONO, NPM1, SKIP, SND1, SQSTM1, and TRIM28. Our data considerably expand the protein and RNA interaction networks of FMRP, which thereby suggest that, in addition to its known functions, FMRP participates in transcription, RNA metabolism, ribonucleoprotein stress granule formation, translation, DNA damage response, chromatin dynamics, cell cycle regulation, ribosome biogenesis, miRNA biogenesis, and mitochondrial organization. Thus, FMRP seems associated with multiple cellular processes both under normal and cell stress conditions in neuronal as well as non-neuronal cell types, as exemplified by its role in the formation of stress granules.
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Affiliation(s)
- Mohamed S Taha
- Institute of Biochemistry and Molecular Biology II, Medical Faculty of the Heinrich Heine University, Düsseldorf, Germany.,Research on Children with Special Needs Department, Medical Research Branch, National Research Centre, Cairo, Egypt
| | - Fereshteh Haghighi
- Institute of Biochemistry and Molecular Biology II, Medical Faculty of the Heinrich Heine University, Düsseldorf, Germany
| | - Anja Stefanski
- Molecular Proteomics Laboratory, Heinrich Heine-University, Düsseldorf, Germany
| | - Saeideh Nakhaei-Rad
- Institute of Biochemistry and Molecular Biology II, Medical Faculty of the Heinrich Heine University, Düsseldorf, Germany
| | - Neda S Kazemein Jasemi
- Institute of Biochemistry and Molecular Biology II, Medical Faculty of the Heinrich Heine University, Düsseldorf, Germany
| | - Mohamed Aghyad Al Kabbani
- Institute of Biochemistry and Molecular Biology II, Medical Faculty of the Heinrich Heine University, Düsseldorf, Germany
| | - Boris Görg
- Clinic of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty of the Heinrich Heine-University, Düsseldorf, Germany
| | - Masahiro Fujii
- Division of Virology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Phillip A Lang
- Department of Molecular Medicine II, Medical Faculty, Heinrich Heine-University, Düsseldorf, Germany
| | - Dieter Häussinger
- Clinic of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty of the Heinrich Heine-University, Düsseldorf, Germany
| | - Roland P Piekorz
- Institute of Biochemistry and Molecular Biology II, Medical Faculty of the Heinrich Heine University, Düsseldorf, Germany
| | - Kai Stühler
- Molecular Proteomics Laboratory, Heinrich Heine-University, Düsseldorf, Germany
| | - Mohammad R Ahmadian
- Institute of Biochemistry and Molecular Biology II, Medical Faculty of the Heinrich Heine University, Düsseldorf, Germany
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3
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Friedman-Gohas M, Elizur SE, Dratviman-Storobinsky O, Aizer A, Haas J, Raanani H, Orvieto R, Cohen Y. FMRpolyG accumulates in FMR1 premutation granulosa cells. J Ovarian Res 2020; 13:22. [PMID: 32101156 PMCID: PMC7045455 DOI: 10.1186/s13048-020-00623-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 02/10/2020] [Indexed: 12/18/2022] Open
Abstract
Background Fragile X premutation (Amplification of CGG number 55–200) is associated with increased risk for fragile X-Associated Premature Ovarian Insufficiency (FXPOI) in females and fragile X-associated tremor/ataxia syndrome (FXTAS) predominantly in males. Recently, it has been shown that CGG repeats trigger repeat associated non-AUG initiated translation (RAN) of a cryptic polyglycine-containing protein, FMRpolyG. This protein accumulates in ubiquitin-positive inclusions in neuronal brain cells of FXTAS patients and may lead to protein-mediated neurodegeneration. FMRpolyG inclusions were also found in ovary stromal cells of a FXPOI patient. The role of FMRpolyG expression has not been thoroughly examined in folliculogenesis related cells. The main goal of this study is to evaluate whether FMRpolyG accumulates in mural granulosa cells of FMR1 premutation carriers. Following FMRpolyG detection, we aim to examine premutation transfected COV434 as a suitable model used to identify RAN translation functions in FXPOI pathogenesis. Results FMRpolyG and ubiquitin immunostained mural granulosa cells from six FMR1 premutation carriers demonstrated FMRpolyG aggregates. However, co-localization of FMRpolyG and ubiquitin appeared to vary within the FMR1 premutation carriers’ group as three exhibited partial ubiquitin and FMRpolyG double staining and three premutation carriers demonstrated FMRpolyG single staining. None of the granulosa cells from the five control women expressed FMRpolyG. Additionally, human ovarian granulosa tumor, COV434, were transfected with two plasmids; both expressing 99CGG repeats but only one enables FMRpolyG expression. Like in granulosa cells from FMR1 premutation carriers, FMRpolyG aggregates were found only in COV434 transfected with expended CGG repeats and the ability to express FMRpolyG. Conclusions Corresponding with previous studies in FXTAS, we demonstrated accumulation of FMRpolyG in mural granulosa cells of FMR1 premutation carriers. We also suggest that following further investigation, the premutation transfected COV434 might be an appropriate model for RAN translation studies. Detecting FMRpolyG accumulation in folliculogenesis related cells supports previous observations and imply a possible common protein-mediated toxic mechanism for both FXPOI and FXTAS.
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Affiliation(s)
- M Friedman-Gohas
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - S E Elizur
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel.,IVF Unit, Chaim Sheba Medical Centre, Tel-Hashomer, 52621, Ramat-Gan, Israel
| | - O Dratviman-Storobinsky
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel.,IVF Unit, Chaim Sheba Medical Centre, Tel-Hashomer, 52621, Ramat-Gan, Israel
| | - A Aizer
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel.,IVF Unit, Chaim Sheba Medical Centre, Tel-Hashomer, 52621, Ramat-Gan, Israel
| | - J Haas
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel.,IVF Unit, Chaim Sheba Medical Centre, Tel-Hashomer, 52621, Ramat-Gan, Israel
| | - H Raanani
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel.,IVF Unit, Chaim Sheba Medical Centre, Tel-Hashomer, 52621, Ramat-Gan, Israel
| | - R Orvieto
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel.,IVF Unit, Chaim Sheba Medical Centre, Tel-Hashomer, 52621, Ramat-Gan, Israel
| | - Y Cohen
- Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel. .,IVF Unit, Chaim Sheba Medical Centre, Tel-Hashomer, 52621, Ramat-Gan, Israel.
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Akemann C, Meyer DN, Gurdziel K, Baker TR. Developmental Dioxin Exposure Alters the Methylome of Adult Male Zebrafish Gonads. Front Genet 2019; 9:719. [PMID: 30687390 PMCID: PMC6336703 DOI: 10.3389/fgene.2018.00719] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 12/21/2018] [Indexed: 01/20/2023] Open
Abstract
2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD) is a persistent environmental toxicant and endocrine disrupting compound with reproductive and developmental effects in humans and model organisms, including zebrafish. Our previous microarray and histological studies found defects in spermatogenesis and fertility of zebrafish in response to acute developmental TCDD exposure. These effects are apparent following exposure during reproductive development, modeling fetal basis of adult-onset disease. Some outcomes of these previous studies (reduced fertility, changes in sex ratio, transcriptomic alterations) are also transgenerational – persisting to unexposed generations – through the male germline. We hypothesized that DNA methylation could be a possible mechanism for these reproductive effects and performed whole genome bisulfite sequencing (WGBS), which identifies whole genome DNA methylation status at the base pair level, on testes of adult zebrafish exposed to TCDD (two separate hour-long exposures to 50 pg/mL TCDD at 3 and 7 weeks post fertilization). In response to TCDD exposure, multiple genes were differentially methylated; many of which are involved in reproductive processes or epigenetic modifications, suggesting a role of DNA methylation in later-life health outcomes. Additionally, several differentially methylated genes corresponded with gene expression changes identified in TCDD-exposed zebrafish testes, indicating a potential link between DNA methylation and gene expression. Ingenuity pathway analysis of WGBS and microarray data revealed genes involved in reproductive processes and development, RNA regulation, the cell cycle, and cellular morphology and development. We conclude that site-specific changes in DNA methylation of adult zebrafish testes occur in response to acute developmental TCDD exposure.
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Affiliation(s)
- Camille Akemann
- Department of Pharmacology, Wayne State University, Detroit, MI, United States
| | - Danielle N Meyer
- Department of Pharmacology, Wayne State University, Detroit, MI, United States.,Institute of Environmental Health Sciences, Wayne State University, Detroit, MI, United States
| | - Katherine Gurdziel
- Applied Genome Technology Center, School of Medicine, Wayne State University, Detroit, MI, United States
| | - Tracie R Baker
- Department of Pharmacology, Wayne State University, Detroit, MI, United States.,Institute of Environmental Health Sciences, Wayne State University, Detroit, MI, United States
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Wang Q, Barad DH, Darmon SK, Kushnir VA, Wu YG, Lazzaroni-Tealdi E, Zhang L, Albertini DF, Gleicher N. Reduced RNA expression of the FMR1 gene in women with low (CGGn<26) repeats. PLoS One 2018; 13:e0209309. [PMID: 30576349 PMCID: PMC6303073 DOI: 10.1371/journal.pone.0209309] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 12/04/2018] [Indexed: 11/18/2022] Open
Abstract
Low FMR1 variants (CGGn<26) have been associated with premature ovarian aging, female infertility and poor IVF treatment success. Until now, there is little published information concerning possible molecular mechanisms for this effect. We wished to examine whether relative expression of RNA and the FMR1 gene’s fragile X mental retardation protein (FMRP) RNA isoforms differ in women with various FMR1 sub-genotypes (normal, low CGGn<26 and/or high CGGn≥34). This prospective cohort study was conducted between 2014 and 2017 in a clinical research unit of the Center for Human Reproduction in New York City. The study involved a total of 98 study subjects, including 18 young oocyte donors and 80 older infertility patients undergoing routine in vitro fertilization (IVF) cycles. The main outcome measure was RNA expression in human luteinized granulosa cells of 5 groups of FMRP isoforms. The relative expression of FMR1 RNA in human luteinized granulosa cells was measured by real-time PCR and a possible association with CGGn was explored. All 5 groups of FMRP RNA isoforms examined were found to be differentially expressed in human luteinized granulosa cells. The relative expression of four FMR1 RNA isoforms showed significant differences among 6 FMR1 sub-genotypes. Women with at least one low allele expressed significantly lower levels of all 5 sets of FRMP isoforms in comparison to the non-low group. While it would be of interest to see whether FMRP is also decreased in the low-group we recognize that in recent years it has been increasingly documented that information flow of genetics may be regulated by non-coding RNA, that is, without translation to a protein product. We, thus, conclude that various CGG expansions of FMR1 allele may lead to changes of RNA levels and ratios of distinct FMRP RNA isoforms, which could regulate the translation and/or cellular localization of FMRP, affect the expression of steroidogenic enzymes and hormonal receptors, or act in some other epigenetic process and therefore result in the ovarian dysfunction in infertility.
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Affiliation(s)
- Qi Wang
- The Center for Human Reproduction, New York, NY, United States of America
| | - David H. Barad
- The Center for Human Reproduction, New York, NY, United States of America
- The Foundation for Reproductive Medicine, New York, NY, United States of America
- * E-mail:
| | - Sarah K. Darmon
- The Center for Human Reproduction, New York, NY, United States of America
| | - Vitaly A. Kushnir
- The Center for Human Reproduction, New York, NY, United States of America
- Department of Obstetrics and Gynecology, Wake Forest University, Winston Salem, NC, United States of America
| | - Yan-Guang Wu
- The Center for Human Reproduction, New York, NY, United States of America
| | | | - Lin Zhang
- The Center for Human Reproduction, New York, NY, United States of America
| | - David F. Albertini
- The Center for Human Reproduction, New York, NY, United States of America
- Department of Molecular and Integrative Physiology, University of Kansas Hospital, Kansas City, KS, United States of America
| | - Norbert Gleicher
- The Center for Human Reproduction, New York, NY, United States of America
- The Foundation for Reproductive Medicine, New York, NY, United States of America
- Stem Cell and Molecular Embryology Laboratory, the Rockefeller University, New York, NY, United States of America
- Department of Obstetrics and Gynecology, Vienna University School of Medicine, Vienna, Austria
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Gustin SLF, Wang G, Baker VM, Latham G, Sebastiano V. Use of human-derived stem cells to create a novel, in vitro model designed to explore FMR1 CGG repeat instability amongst female premutation carriers. J Assist Reprod Genet 2018; 35:1443-1455. [PMID: 29926373 DOI: 10.1007/s10815-018-1237-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 06/08/2018] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Create a model, using reprogrammed cells, to provide a platform to identify the mechanisms of CGG repeat instability amongst female fragile X mental retardation 1 gene (FMR1) premutation (PM) carriers. METHODS Female PM carriers (with and without POI) and healthy controls were enrolled from June 2013 to April 2014. Patient-derived fibroblasts (FB) were reprogrammed to induced pluripotent stem cells (iPSC) using viral vectors, encoding KLF4, OCT4, SOX2, and MYC. FMR1 CGG repeat-primed PCR was used to assess the triplet repeat structure of the FMR1 gene. FMR1 promoter methylation (%) was determined using FMR1 methylation PCR (mPCR). Quantification of FMR1 transcripts by RT-qPCR was used to evaluate the effect of reprogramming on gene transcription, as well as to correlate patient phenotype with FMR1 expression. Production of FMR1 protein (FMRP) was determined using a liquid bead array-based immunoassay. RESULTS Upon induction to pluripotency, all control clones exhibited maintenance of progenitor cell CGG repeat number, whereas 10 of 12 clones derived from PM carriers maintained their input CGG repeat number, one of which expanded and one contracted. As compared to parent FB, iPSC clones exhibited a skewed methylation pattern; however, downstream transcription and translation appeared unaffected. Further, the PM carriers, regardless of phenotype, exhibited similar FMR1 transcription and translation to the controls. CONCLUSIONS This is the first study to establish a stem cell model aimed to understand FMR1 CGG repeat instability amongst female PM carriers. Our preliminary data indicate that CGG repeat number, transcription, and translation are conserved upon induction to pluripotency.
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Affiliation(s)
- Stephanie L F Gustin
- Department Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Stanford University School of Medicine, Stanford, CA, 94305, USA.
| | - Guangwen Wang
- Department of Genetics, Stanford University, Stanford, CA, 94305, USA
| | - Valerie M Baker
- Department Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Gary Latham
- Research and Technology Development, Asuragen, Inc., Austin, TX, 78744, USA
| | - Vittorio Sebastiano
- Institute for Stem Cell Biology &Regenerative Medicine, Stanford University School of Medicine, Stanford University, Stanford, CA, 94305, USA
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Richards JS, Ren YA, Candelaria N, Adams JE, Rajkovic A. Ovarian Follicular Theca Cell Recruitment, Differentiation, and Impact on Fertility: 2017 Update. Endocr Rev 2018; 39:1-20. [PMID: 29028960 PMCID: PMC5807095 DOI: 10.1210/er.2017-00164] [Citation(s) in RCA: 114] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 09/12/2017] [Indexed: 12/24/2022]
Abstract
The major goal of this review is to summarize recent exciting findings that have been published within the past 10 years that, to our knowledge, have not been presented in detail in previous reviews and that may impact altered follicular development in polycystic ovarian syndrome (PCOS) and premature ovarian failure in women. Specifically, we will cover the following: (1) mouse models that have led to discovery of the derivation of two precursor populations of theca cells in the embryonic gonad; (2) the key roles of the oocyte-derived factor growth differentiation factor 9 on the hedgehog (HH) signaling pathway and theca cell functions; and (3) the impact of the HH pathway on both the specification of theca endocrine cells and theca fibroblast and smooth muscle cells in developing follicles. We will also discuss the following: (1) other signaling pathways that impact the differentiation of theca cells, not only luteinizing hormone but also insulinlike 3, bone morphogenic proteins, the circadian clock genes, androgens, and estrogens; and (2) theca-associated vascular, immune, and fibroblast cells, as well as the cytokines and matrix factors that play key roles in follicle growth. Lastly, we will integrate what is known about theca cells from mouse models, human-derived theca cell lines from patients who have PCOS and patients who do not have PCOS, and microarray analyses of human and bovine theca to understand what pathways and factors contribute to follicle growth as well as to the abnormal function of theca.
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Affiliation(s)
- JoAnne S. Richards
- Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, Texas 77030
| | - Yi A. Ren
- Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, Texas 77030
| | - Nicholes Candelaria
- Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, Texas 77030
| | - Jaye E. Adams
- Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, Texas 77030
| | - Aleksandar Rajkovic
- Department of Obstetrics, Gynecology and Reproductive Medicine, Magee-Women’s Research Institute, Pittsburgh, Pennsylvania 15213
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The importance of redundancy of functional ovarian reserve when investigating potential genetic effects on ovarian function. J Assist Reprod Genet 2016; 33:1157-60. [PMID: 27423666 DOI: 10.1007/s10815-016-0762-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 06/22/2016] [Indexed: 10/21/2022] Open
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Buijsen RAM, Visser JA, Kramer P, Severijnen EAWFM, Gearing M, Charlet-Berguerand N, Sherman SL, Berman RF, Willemsen R, Hukema RK. Presence of inclusions positive for polyglycine containing protein, FMRpolyG, indicates that repeat-associated non-AUG translation plays a role in fragile X-associated primary ovarian insufficiency. Hum Reprod 2015; 31:158-68. [PMID: 26537920 DOI: 10.1093/humrep/dev280] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 10/15/2015] [Indexed: 12/11/2022] Open
Abstract
STUDY QUESTION Does repeat-associated non-AUG (RAN) translation play a role in fragile X-associated primary ovarian insufficiency (FXPOI), leading to the presence of polyglycine containing protein (FMRpolyG)-positive inclusions in ovarian tissue? SUMMARY ANSWER Ovaries of a woman with FXPOI and of an Fmr1 premutation (PM) mouse model (exCGG-KI) contain intranuclear inclusions that stain positive for both FMRpolyG and ubiquitin. WHAT IS KNOWN ALREADY Women who carry the FMR1 PM are at 20-fold increased risk to develop primary ovarian insufficiency (FXPOI). A toxic RNA gain-of-function has been suggested as the underlying mechanism since the PM results in increased levels of mRNA containing an expanded repeat, but reduced protein levels of fragile X mental retardation protein (FMRP). Recently, RAN translation has been shown to occur from FMR1 mRNA that contains PM repeat expansions, leading to FMRpolyG inclusions in brain and non-CNS tissues of fragile X-associated tremor/ataxia syndrome (FXTAS) patients. STUDY DESIGN, SIZE, DURATION Ovaries of a woman with FXPOI and women without PM (controls), and ovaries from wild-type and exCGG-KI mice were analyzed by immunohistochemistry for the presence of inclusions that stained for ubiquitin and FMRpolyG . The ovaries from wild-type and exCGG-KI mice were further characterized for the number of follicles, Fmr1 mRNA levels and FMRP protein expression. The presence of inclusions was also analyzed in pituitaries of a man with FXTAS and the exCGG-KI mice. PARTICIPANTS/MATERIALS, SETTING, METHODS Human ovaries from a woman with FXPOI and two control subjects and pituitaries from a man with FXTAS and a control subjects were fixed in 4% formalin. Ovaries and pituitaries of wild-type and exCGG mice were fixed in Bouin's fluid or 4% paraformaldehyde. Immunohistochemistry was performed on the human and mouse samples using FMRpolyG, ubiquitin and Fmrp antibodies. Fmr1 mRNA and protein expression were determined in mouse ovaries by quantitative RT-PCR and Western blot analysis. Follicle numbers in mouse ovaries were determined in serial sections by microscopy. MAIN RESULTS AND THE ROLE OF CHANCE FMRpolyG-positive inclusions were present in ovarian stromal cells of a woman with FXPOI but not in the ovaries of control subjects. The FMRpolyG-positive inclusions colocalized with ubiquitin-positive inclusions. Similar inclusions were also observed in the pituitary of a man with FXTAS but not in control subjects. Similarly, ovaries of 40-week-old exCGG-KI mice, but not wild-type mice, contained numerous inclusions in the stromal cells that stained for both FMRpolyG- and ubiquitin, while the ovaries of 20-week-old exCGG-KI contained fewer inclusions. At 40 weeks ovarian Fmr1 mRNA expression was increased by 5-fold in exCGG-KI mice compared with wild-type mice, while Fmrp expression was reduced by 2-fold. With respect to ovarian function in exCGG-KI mice: (i) although the number of healthy growing follicles did not differ between wild-type and exCGG-KI mice, the number of atretic large antral follicles was increased by nearly 9-fold in 40-week old exCGG-KI mice (P < 0.001); (ii) at 40 weeks of age only 50% of exCGG-KI mice had recent ovulations compared with 89% in wild-type mice (P = 0.07) and (iii) those exCGG-KI mice with recent ovulations tended to have a reduced number of fresh corpora lutea (4.8 ± 1.74 versus 8.50 ± 0.98, exCGG-KI versus wild-type mice, respectively, P = 0.07). LIMITATIONS, REASONS FOR CAUTION Although FMRpolyG-positive inclusions were detected in ovaries of both a woman with FXPOI and a mouse model of the FMR1 PM, we only analyzed one ovary from a FXPOI subject. Caution is needed to extrapolate these results to all women with the FMR1 PM. Furthermore, the functional consequence of FMRpolyG-positive inclusions in the ovaries for reproduction remains to be determined. WIDER IMPLICATIONS OF THE FINDINGS Our results suggest that a dysfunctional hypothalamic-pituitary-gonadal-axis may contribute to FXPOI in FMR1 PM carriers. STUDY FUNDING/COMPETING INTERESTS This study was supported by grants from NFXF, ZonMW, the Netherlands Brain Foundation and NIH. The authors have no conflict of interest to declare.
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Affiliation(s)
- R A M Buijsen
- Department of Clinical Genetics, Erasmus Medical Center, 3015 CE Rotterdam, The Netherlands
| | - J A Visser
- Department of Internal Medicine, Erasmus Medical Center, 3015 CE Rotterdam, The Netherlands
| | - P Kramer
- Department of Internal Medicine, Erasmus Medical Center, 3015 CE Rotterdam, The Netherlands
| | - E A W F M Severijnen
- Department of Clinical Genetics, Erasmus Medical Center, 3015 CE Rotterdam, The Netherlands
| | - M Gearing
- Department of Pathology, Emory University School of Medicine, Atlanta, GA, USA
| | - N Charlet-Berguerand
- Department of Neurobiology and Genetics, IGBMC, INSERM U964, CNRS UMR7104, University of Strasbourg, Illkirch, France
| | - S L Sherman
- Department of Human Genetics, Emory University School of Medicine, Atlanta, GA, USA
| | - R F Berman
- Department of Neurological Surgery, UC Davis, Davis 95618, CA, USA
| | - R Willemsen
- Department of Clinical Genetics, Erasmus Medical Center, 3015 CE Rotterdam, The Netherlands
| | - R K Hukema
- Department of Clinical Genetics, Erasmus Medical Center, 3015 CE Rotterdam, The Netherlands
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10
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Gleicher N, Yu Y, Himaya E, Barad DH, Weghofer A, Wu YG, Albertini DF, Wang VQ, Kushnir VA. Early decline in functional ovarian reserve in young women with low (CGGn < 26) FMR1 gene alleles. Transl Res 2015. [PMID: 26209748 DOI: 10.1016/j.trsl.2015.06.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Mouse fmr1 models, and recent cross-sectional human data, suggest that different triple CGGn ranges of the fragile X mental retardation 1 (FMR1) gene are associated with variations in ovarian aging and infertility treatment outcomes. The FMR1 mutation affecting reproductive function most negatively in humans is the so-called low mutation, characterized by CGGn < 26. We here present a first longitudinal study of selected young women with normal functional ovarian reserve (FOR). In a prospective cohort study, we selected among 233 young oocyte donors (mean age 24.8 ± 3.3 years) as study population of 66 who had more than 1 anti-Müllerian hormone (AMH) level drawn over a 4-year period. AMH curves, as reflection of FOR, were then statistically compared between women with and without low FMR1 alleles. Biallelic low FMR1 (hom-low/low) donors already at initial presentation demonstrated significantly lower FOR than donors with biallelic normal (norm) FMR1 (CGGn = 26-34; P = 0.001). Although monoallelic low FMR1 at initial presentation was not yet associated with decreased FOR, it over 4 years did demonstrate significantly enhanced declines in FOR (P = 0.046). Including repeat measurements, low/low (P = 0.006) and high/high (CGGn > 34) alleles (P < 0.001) demonstrated lower FOR by AMH than norm donors. Even monoallelic low FMR1 alleles are, thus, already at young female ages associated with accelerated declines in FOR. Low FMR1 alleles, therefore, potentially represent a screening tool for women at genetic risk toward premature ovarian senescence, representing in all races circa 10% of the female population.
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Affiliation(s)
- Norbert Gleicher
- Center for Human Reproduction, New York, NY; Foundation for Reproductive Medicine, New York, NY; Stem Cell Biology and Molecular Embryology Laboratory, The Rockefeller University, New York, NY.
| | - Yao Yu
- Center for Human Reproduction, New York, NY
| | - Erik Himaya
- Gatineau Hospital, McGill University, Montréal, Quebec, Canada
| | - David H Barad
- Center for Human Reproduction, New York, NY; Foundation for Reproductive Medicine, New York, NY; Department of Obstetrics and Gynecology, Albert Einstein College of Medicine, Bronx, NY
| | - Andrea Weghofer
- Center for Human Reproduction, New York, NY; Department of Obstetrics and Gynecology, University of Vienna School of Medicine, Vienna, Austria
| | | | - David F Albertini
- Center for Human Reproduction, New York, NY; Department of Molecular and Integrative Physiology, University of Kansas School of Medicine, Wichita, KS
| | | | - Vitaly A Kushnir
- Center for Human Reproduction, New York, NY; Department of Obstetrics and Gynecology, Wake Forest School of Medicine, Winston-Salem, NC
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11
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Alvarez-Mora MI, Rodriguez-Revenga L, Madrigal I, Garcia-Garcia F, Duran M, Dopazo J, Estivill X, Milà M. Deregulation of key signaling pathways involved in oocyte maturation in FMR1 premutation carriers with Fragile X-associated primary ovarian insufficiency. Gene 2015; 571:52-7. [PMID: 26095811 DOI: 10.1016/j.gene.2015.06.039] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 05/12/2015] [Accepted: 06/16/2015] [Indexed: 10/23/2022]
Abstract
FMR1 premutation female carriers are at risk for Fragile X-associated primary ovarian insufficiency (FXPOI). Insights from knock-in mouse model have recently demonstrated that FXPOI is due to an increased rate of follicle depletion or an impaired development of the growing follicles. Molecular mechanisms responsible for this reduced viability are still unknown. In an attempt to provide new data on the mechanisms that lead to FXPOI, we report the first investigation involving transcription profiling of total blood from FMR1 premutation female carriers with and without FXPOI. A total of 16 unrelated female individuals (6 FMR1 premutated females with FXPOI; 6 FMR1 premutated females without FXPOI; and 4 no-FXPOI females) were studied by whole human genome oligonucleotide microarray (Agilent Technologies). Fold change analysis did not show any genes with significant differential gene expression. However, functional profiling by gene set analysis showed large number of statistically significant deregulated GO annotations as well as numerous KEGG pathways in FXPOI females. These results suggest that the impairment of fertility in these females might be due to a generalized deregulation of key signaling pathways involved in oocyte maturation. In particular, the vasoendotelial growth factor signaling, the inositol phosphate metabolism, the cell cycle, and the MAPK signaling pathways were found to be down-regulated in FXPOI females. Furthermore, a high statistical enrichment of biological processes involved in cell death and survival were found deregulated among FXPOI females. Our results provide new strategic approaches to further investigate the molecular mechanisms and potential therapeutic targets for FXPOI not focused in a single gene but rather in the set of genes involved in these pathways.
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Affiliation(s)
- M I Alvarez-Mora
- CIBER de Enfermedades Raras, Hospital Clínic, 08036 Barcelona, Spain; Biochemistry and Molecular Genetics Department, Hospital Clinic, 08036 Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) 08036 Barcelona, Spain.
| | - L Rodriguez-Revenga
- CIBER de Enfermedades Raras, Hospital Clínic, 08036 Barcelona, Spain; Biochemistry and Molecular Genetics Department, Hospital Clinic, 08036 Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) 08036 Barcelona, Spain.
| | - I Madrigal
- CIBER de Enfermedades Raras, Hospital Clínic, 08036 Barcelona, Spain; Biochemistry and Molecular Genetics Department, Hospital Clinic, 08036 Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) 08036 Barcelona, Spain.
| | - F Garcia-Garcia
- Computational Genomics Department, Centro de Investigación Príncipe Felipe, 46012 Valencia, Spain.
| | - M Duran
- Obstetrics and Gynecology Department Hospital Clinic, 08036 Barcelona, Spain.
| | - J Dopazo
- Computational Genomics Department, Centro de Investigación Príncipe Felipe, 46012 Valencia, Spain; Functional Genomics Node, INB, Centro de Investigación Príncipe Felipe, Valencia, Spain; CIBER de Enfermedades Raras, Centro de Investigación Príncipe Felipe, 46012 Valencia, Spain.
| | - X Estivill
- Bioinformatics and Genomics Program, Centre for Genomic Regulation (CRG), 08003 Barcelona, Spain; Universitat Pompeu Fabra (UPF), 08005 Barcelona, Spain; Hospital del Mar Medical Research Institute (IMIM), 08003 Barcelona, Spain; CIBER de Epidemiología y Salud Pública (CIBERESP), Centre for Genomic Regulation, 08003 Barcelona, Spain; Genomics and Personalized Medicine Section, Dexeus Woman's Health, 08028 Barcelona, Spain.
| | - M Milà
- CIBER de Enfermedades Raras, Hospital Clínic, 08036 Barcelona, Spain; Biochemistry and Molecular Genetics Department, Hospital Clinic, 08036 Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) 08036 Barcelona, Spain.
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12
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Takahashi N, Tarumi W, Itoh MT, Ishizuka B. The Stage- and Cell Type-Specific Localization of Fragile X Mental Retardation Protein in Rat Ovaries. Reprod Sci 2015; 22:1524-9. [PMID: 26037301 DOI: 10.1177/1933719115589416] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Premutations of the fragile X mental retardation 1 (FMR1) gene are associated with increased risk of primary ovarian insufficiency. Here we examined the localization of the Fmr1 gene protein product, fragile X mental retardation protein (FMRP), in rat ovaries at different stages, including fetus, neonate, and old age. In ovaries dissected from 19 days postcoitum embryos, the germ cells were divided into 2 types: one with decondensed chromatin in the nucleus was FMRP positive in the cytoplasm, but the other with strongly condensed chromatin in the nucleus was FMRP negative in the cytoplasm. The FMRP was predominantly localized to the cytoplasm of oocytes in growing ovarian follicles. Levels of FMRP in oocytes from elderly (9 or 14 months of age) ovaries were lower than in those from younger ovaries. These results suggest that FMRP is associated with the activation of oogenesis and oocyte function. Especially, FMRP is likely to be implicated in germline development during oogenesis.
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Affiliation(s)
- Noriyuki Takahashi
- Department of Obstetrics and Gynecology, St Marianna University School of Medicine, Kawasaki, Japan
| | - Wataru Tarumi
- Department of Obstetrics and Gynecology, St Marianna University School of Medicine, Kawasaki, Japan
| | - Masanori T Itoh
- Department of Obstetrics and Gynecology, St Marianna University School of Medicine, Kawasaki, Japan Department of Biology, College of Liberal Arts and Sciences, Tokyo Medical and Dental University, Ichikawa, Japan
| | - Bunpei Ishizuka
- Department of Obstetrics and Gynecology, St Marianna University School of Medicine, Kawasaki, Japan
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13
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Gleicher N, Kushnir VA, Weghofer A, Barad DH. How the FMR1 gene became relevant to female fertility and reproductive medicine. Front Genet 2014; 5:284. [PMID: 25221568 PMCID: PMC4148646 DOI: 10.3389/fgene.2014.00284] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Accepted: 08/01/2014] [Indexed: 12/02/2022] Open
Abstract
This manuscript describes the 6 year evolution of our center’s research into ovarian functions of the FMR1 gene, which led to the identification of a new normal CGGn range of 26–34. This “new” normal range, in turn, led to definitions of different alleles (haplotypes) based on whether no, one or both alleles are within range. Specific alleles then were demonstrated to represent distinct ovarian aging patterns, suggesting an important FMR1 function in follicle recruitment and ovarian depletion of follicles. So called low alleles, characterized by CGGn<26, appear associated with most significant negative effects on reproductive success. Those include occult primary ovarian insufficiency (OPOI), characterized by prematurely elevated follicle stimulating hormone (FSH) and prematurely low anti-Müllerian hormone, and significantly reduced clinical pregnancy rates in association with in vitro fertilization (IVF) in comparison to women with normal (norm) and high (CGGn>34) alleles. Because low FMR1 alleles present in approximately 25% of all females, FMR1 testing at young ages may offer an opportunity for earlier diagnosis of OPOI than current practice allows. Earlier diagnosis of OPOI, in turn, would give young women the options of reassessing their reproductive schedules and/or pursue fertility preservation via oocyte cryopreservation when most effective.
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Affiliation(s)
- Norbert Gleicher
- Center for Human Reproduction New York, NY, USA ; Foundation for Reproductive Medicine New York, NY, USA
| | | | - Andrea Weghofer
- Center for Human Reproduction New York, NY, USA ; Department of Obstetrics and Gynecology, Medical University Vienna Vienna, Austria
| | - David H Barad
- Center for Human Reproduction New York, NY, USA ; Foundation for Reproductive Medicine New York, NY, USA
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14
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Sherman SL, Curnow EC, Easley CA, Jin P, Hukema RK, Tejada MI, Willemsen R, Usdin K. Use of model systems to understand the etiology of fragile X-associated primary ovarian insufficiency (FXPOI). J Neurodev Disord 2014; 6:26. [PMID: 25147583 PMCID: PMC4139715 DOI: 10.1186/1866-1955-6-26] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Accepted: 08/13/2014] [Indexed: 01/04/2023] Open
Abstract
Fragile X-associated primary ovarian insufficiency (FXPOI) is among the family of disorders caused by the expansion of a CGG repeat sequence in the 5' untranslated region of the X-linked gene FMR1. About 20% of women who carry the premutation allele (55 to 200 unmethylated CGG repeats) develop hypergonadotropic hypogonadism and cease menstruating before age 40. Some proportion of those who are still cycling show hormonal profiles indicative of ovarian dysfunction. FXPOI leads to subfertility and an increased risk of medical conditions associated with early estrogen deficiency. Little progress has been made in understanding the etiology of this clinically significant disorder. Understanding the molecular mechanisms of FXPOI requires a detailed knowledge of ovarian FMR1 mRNA and FMRP’s function. In humans, non-invasive methods to discriminate the mechanisms of the premutation on ovarian function are not available, thus necessitating the development of model systems. Vertebrate (mouse and rat) and invertebrate (Drosophila melanogaster) animal studies for the FMR1 premutation and ovarian function exist and have been instrumental in advancing our understanding of the disease phenotype. For example, rodent models have shown that FMRP is highly expressed in oocytes where it is important for folliculogenesis. The two premutation mouse models studied to date show evidence of ovarian dysfunction and, together, suggest that the long repeat in the transcript itself may have some pathological effect quite apart from any effect of the toxic protein. Further, ovarian morphology in young animals appears normal and the primordial follicle pool size does not differ from that of wild-type animals. However, there is a progressive premature decline in the levels of most follicle classes. Observations also include granulosa cell abnormalities and altered gene expression patterns. Further comparisons of these models are now needed to gain insight into the etiology of the ovarian dysfunction. Premutation model systems in non-human primates and those based on induced pluripotent stem cells show particular promise and will complement current models. Here, we review the characterization of the current models and describe the development and potential of the new models. Finally, we will discuss some of the molecular mechanisms that might be responsible for FXPOI.
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Affiliation(s)
- Stephanie L Sherman
- Department of Human Genetics, Emory University, 615 Michael St, Emory University, Atlanta, GA 30322, USA
| | - Eliza C Curnow
- Washington National Primate Center, University of Washington, Seattle, WA, USA
| | - Charles A Easley
- Laboratory of Translational Cell Biology, Department of Cell Biology, Emory University, Atlanta, GA, USA
| | - Peng Jin
- Department of Human Genetics, Emory University, 615 Michael St, Emory University, Atlanta, GA 30322, USA
| | - Renate K Hukema
- Department of Clinical Genetics, Erasmus MC, Rotterdam, The Netherlands
| | - Maria Isabel Tejada
- Molecular Genetics Laboratory, Genetics Service, BioCruces Health Research Institute, Hospital Universitario Cruces, Barakaldo, Biscay, Spain
| | - Rob Willemsen
- Department of Clinical Genetics, Erasmus MC, Rotterdam, The Netherlands
| | - Karen Usdin
- Laboratory of Molecular and Cellular Biology, NIDDK, National Institutes of Health, Bethesda, MD, USA
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15
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Kushnir VA, Yu Y, Barad DH, Weghofer A, Himaya E, Lee HJ, Wu YG, Shohat-Tal A, Lazzaroni-Tealdi E, Gleicher N. Utilizing FMR1 gene mutations as predictors of treatment success in human in vitro fertilization. PLoS One 2014; 9:e102274. [PMID: 25019151 PMCID: PMC4096763 DOI: 10.1371/journal.pone.0102274] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 06/16/2014] [Indexed: 11/18/2022] Open
Abstract
CONTEXT Mutations of the fragile X mental retardation 1 (FMR1) gene are associated with distinct ovarian aging patterns. OBJECTIVE To confirm in human in vitro fertilization (IVF) that FMR1 affects outcomes, and to determine whether this reflects differences in ovarian aging between FMR1 mutations, egg/embryo quality or an effect on implantation. DESIGN, SETTING, PATIENTS IVF outcomes were investigated in a private infertility center in reference to patients' FMR1 mutations based on a normal range of CGG(n = 26-34) and sub-genotypes high (CGG(n>34)) and low (CGG(<26)). The study included 3 distinct sections and study populations: (i) A generalized mixed-effects model of morphology (777 embryos, 168 IVF cycles, 125 infertile women at all ages) investigated whether embryo quality is associated with FMR1; (ii) 1041 embryos in 149 IVF cycles in presumed fertile women assessed whether the FMR1 gene is associated with aneuploidy; (iii) 352 infertile patients (< age 38; in 1st IVF cycles) and 179 donor-recipient cycles, assessed whether the FMR1 gene affects IVF pregnancy chances via oocyte/embryo quality or non-oocyte maternal factors. INTERVENTIONS Standardized IVF protocols. MAIN OUTCOME MEASURES Morphologic embryo quality, ploidy and pregnancy rates. RESULTS (i) Embryo morphology was reduced in presence of a low FMR1 allele (P = 0.032). In absence of a low allele, the odds ratio (OR) of chance of good (vs. fair/poor) embryos was 1.637. (ii) FMR1 was not associated with aneuploidy, though aneuploidy increased with female age. (iii) Recipient pregnancy rates were neither associated with donor age or donor FMR1. In absence of a low FMR1 allele, OR of clinical pregnancy (vs. chemical or no pregnancy) was 2.244 in middle-aged infertility patients. CONCLUSIONS A low FMR1 allele (CGG(<26)) is associated with significantly poorer morphologic embryo quality and pregnancy chance. As women age, low FMR1 alleles affect IVF pregnancy chances by reducing egg/embryo quality by mechanisms other than embryo aneuploidy.
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Affiliation(s)
- Vitaly A Kushnir
- Center for Human Reproduction, New York, New York, United States of America
| | - Yao Yu
- Center for Human Reproduction, New York, New York, United States of America
| | - David H Barad
- Center for Human Reproduction, New York, New York, United States of America; Foundation for Reproductive Medicine, New York, New York, United States of America
| | - Andrea Weghofer
- Center for Human Reproduction, New York, New York, United States of America; Department of Obstetrics and Gynecology, University of Vienna School of Medicine, Vienna, Austria
| | - Eric Himaya
- Gatineau Hospital, McGill University, Quebec, Canada
| | - Ho-Joon Lee
- Center for Human Reproduction, New York, New York, United States of America
| | - Yan-Guang Wu
- Center for Human Reproduction, New York, New York, United States of America
| | - Aya Shohat-Tal
- Center for Human Reproduction, New York, New York, United States of America
| | | | - Norbert Gleicher
- Center for Human Reproduction, New York, New York, United States of America; Foundation for Reproductive Medicine, New York, New York, United States of America
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