Pregnancy achieved following ICSI from a man with Klinefelter's syndrome and spinal cord injury

Case report

Koichi Kyono1,3, Noritaka Fukunaga1, Kosuke Haigo1, Setsuyo Chiba1 and Yasuhisa Araki2

1 Ladies Clinic Kyono, Furukawa, Miyagi and 2 Institute for ARMT, Seta-gun, Gunma, Japan


    Abstract
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
Klinefelter's syndrome and spinal cord injury are major causes of male infertility. Intracytoplasmic sperm injection (ICSI) is a relatively new method of assisted reproduction. A testicular biopsy was obtained from a patient with the double complications of non-mosaic 47,XXY Klinefelter's syndrome and spinal cord damage, and motile spermatozoa were collected. ICSI was then performed. Of the four sperm-injected oocytes, three became fertilized and cleaved. Two embryos were implanted, resulting in a single pregnancy with visible evidence of a heartbeat appearing at 6 weeks gestation. The pregnancy is now entering its 20th week. To the best of our knowledge, this is the first case of a pregnancy resulting from the sperm of a patient with double complications.

Key words: azoospermia/Klinefelter's syndrome/spinal cord injury/testicular biopsy


    Introduction
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
Current assisted reproductive technology (ART) has advanced to the stage where intracytoplasmic sperm injection (ICSI) is an effective therapy for severe male subfertility, resulting in high fertilization and pregnancy rates. Patients having obstructive and non-obstructive azoospermia undergo testicular sperm extraction (TESE)–ICSI.

A major cause of male infertility is Klinefelter's syndrome. However, through ART, it is sometimes possible for patients with Klinefelter's to father healthy neonates despite the presence of this syndrome. This has been reported following ICSI using spermatozoa from a patient with non-mosaic Klinefelter's syndrome (Bourne et al., 1997Go; Tournaye et al., 1997Go; Reubinoff et al., 1998Go; Nodar et al., 1999Go; Palermo et al., 1999Go; Ron-El, 1999).

Another major cause of male infertility is spinal cord injury. Through TESE–ISCI, patients with spinal cord injury now have a good chance of having children of their own (Denil et al., 1996Go; Hulting et al., 1997; Yamamoto et al., 1997Go; Chen et al., 1998Go; Chung et al., 1998Go; Marina et al., 1999Go; Schatte et al., 2000Go).

We were presented with a very rare case involving an azoospermic patient with double complications: non-mosaic 47,XXY chromosome abnormality and spinal cord injury. We discussed, with the couple, the best method for obtaining spermatozoa from the patient. The couple strongly desired TESE–ICSI as the method of pregnancy.

This report is the first case in which pregnancy resulted from a patient with double complications.


    Case report
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
A 28-year-old male patient who injured his spinal cord at the age of 19 visited our clinic due to primary infertility. He married at 26 years of age and was diagnosed with retrogressive ejaculation by a different clinic. We twice-centrifuged urine from the patient for independent analysis, but no spermatozoa were detected.

The volume of the right testis was 4 ml, and that of the left testis was 5 ml. Serum analysis was performed to yield serum concentrations of FSH (18.7 mIU/ml), LH (8.4 mIU/ml), testosterone (372 ng/dl), and prolactin (15.8 ng/ml).

Chromosome analysis showed the 47,XXY karyotype in 27 blood cells.

Collection of sperm from the patient's testicular tissue was performed prior to the day on which the oocytes were retrieved. Biopsies were taken from the same bilateral location on each testes. A small piece (5x5 mm) of extruding testicular tissue was excised and minced using sterile glass slides in a dish with 1 ml modified–human tubal fluid medium (Irvine Scientific, Santa Ana, CA). An inverted microscope (x400) was used to check for motile sperm.

The minced specimen was incubated at 32°C under 5% CO2 in air overnight. We detected a few motile spermatozoa per field under a microscope at x400 magnification.

The patient's wife was a 31-year-old healthy woman with normal ovulatory cycles and a normal hysterosalpingography. She had delivered twice prior to marrying her present husband.

Ovarian stimulation was achieved though a combination of gonadotrophin-releasing hormone (GnRH agonist, Suprecure, Aventis, Japan) and human menopausal gonadotrophin (HMG, Humegon, Organon, The Netherlands). When the leading follicle reached a mean diameter of 18–20mm, 10000 units of human chorionic gonadotrophin (HCG, Profasi, Serono, Switzerland) were administered. Vaginal ultrasound-guided follicle puncture took place ~36 h after HCG injection. The cumulus corona cells were initially removed by exposure to 60 IU/ml of hyaluronidase for up to 1 min. Only metaphase II oocytes were injected.

Of the four oocytes that were injected, three became fertilized zygotes. Two had two pronuclei (2PN) and the other had one pronucleus (1PN). All three fertilized zygotes cleaved. One of the two zygotes cleaved to produce eight cells that were similar in morphology, and the other zygote cleaved into five cells, with fragments >50%. The two embryos from the 2PN zygotes were transferred to the uterus, but the embryo from the 1PN zygote was not transferred. One of two embryos was implanted and a single visible heartbeat was seen at 6 weeks gestation. The pregnancy is now entering its 20th week.


    Discussion
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
With an incidence of about 1 in 600 newborn boys, Klinefelter's syndrome is one of the most common sex chromosomal abnormalities in humans and is usually associated with azoospermia or severe oligozoospermia. Current ART has advanced to the stage where the development of ICSI has provided an effective therapy for severe male subfertility. Despite having a 47,XXY karyotype, indicating the presence of Klinefelter's syndrome, a patient's spermatozoa can be used to produce a clinical pregnancy. Thus, ICSI increases the opportunity for patients with Klinefelter's syndrome to father children. Normal fertilization and embryo development, resulting in pregnancy and birth, have been achieved in mosaic and non-mosaic Klinefelter's syndrome patients, following ICSI using testicular extracted spermatozoa (Tournaye et al., 1997Go; Palermo et al., 1998Go; Ron-E1, 1999), or ejaculated spermatozoa (Bourne et al., 1997Go; Hinney et al., 1997Go).

Using fluorescence in-situ hybridization (FISH), 2.09% hyperploidy of spermatozoa was found in a male with mosaic Klinefelter's syndrome (Chevret et al., 1995Go). Guttenbach et al. reported a sex chromosome hyperhaploid rate of 2.67% in spermatozoa of non-mosaic Klinefelter's syndrome patients (Guttenbach et al., 1997Go). In a study that included diploid sperm, Foresta et al. observed a hyperploidy rate of 21.76% in spermatozoa of non-mosaic Klinefelter's syndrome patients (Foresta et al., 1998Go). These results suggest that the likelihood of a man with Klinefelter's syndrome passing it on to his child is low. The birth of healthy neonates after ICSI using spermatozoa from patients with non-mosaic Klinefelter's syndrome has been reported (Palermo et al., 1998Go; Kitamura et al., 2000Go; Ron-EI et al., 2000bGo). However, in a recent study, Ron-EI et al. reported that a 47,XXY fetus was conceived after ICSI using spermatozoa from a patient with non-mosaic Klinefelter's syndrome (Ron-EI et al. 2000aGo). Kitamura et al. suggested that the birth rate was very low, compared with the fertilization rate, in cases of ICSI using spermatozoa from patients with non-mosaic Klinefelter's syndrome, and also suggested that there was an increased risk of chromosomal abnormalities in such cases (Kitamura et al., 2000Go). Therefore, it is essential that the possibility be clearly discussed with a couple before therapy is initiated. Proper counselling in these matters is as important as providing efficacious treatment. Potential parents must be informed about the risks and benefits of pursuing treatment, as it can impact upon the future health of their child.

In this case, the patient injured his spinal cord when he was 19 years old, so not only did he have Klinefelter's syndrome, but also spinal cord damage. Informed consent was obtained from the patient, prior to using his testicular spermatozoa. The couple finally decided to attempt TESE–ICSI. Thus, we experienced a very rare case in which the patient had double complications leading to infertility. Motile spermatozoa were found in testicular tissue extracted from the patient and used in the first ICSI attempt. The couple wanted to allow their pregnancy to proceed without prenatal genetic diagnosis. They wanted to wait to assess the genetic health of their child until a blood test could be taken after birth.

This is the first reported case, to the best of our knowledge, of successful TESE–ICSI using testicular motile spermatozoa from a patient who has double complications leading to infertility. The resultant pregnancy is now entering its 20th week, there is visible evidence of a heartbeat, and the pregnancy is expected to continue without any major problems.


    Notes
 
3 To whom correspondence should be addressed at: Ladies Clinic Kyono, 3-8-6 Oomiya, Furukawa, Miyagi 989-6221, Japan.E-mail: a1951414{at}coral.ocn.ne.jp Back


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 Introduction
 Case report
 Discussion
 References
 
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Submitted on June 9, 2001; accepted on July 27, 2001.





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