A successful pregnancy outcome using frozen testicular sperm from a chimeric infertile male with a 46, XX/46, XY karyotype: Case report

Nobuo Sugawara1,4, Yo Tokunaga2, Machiko Maeda1, Rie Komaba1 and Yasuhisa Araki3

1 Iwaki Women's Clinic, 3-2, Ookishita, Uchigo, Iwaki, Fukushima, 973-8403, 2 Iwakisaiseikai Foundation Matsumura General Hospital, 1-1, Tairakotaro, Iwaki, Fukushima, 970-8516 and 3 The Institute for ARMT, 909-21, Ishii, Fujimi, Setagun, Gunma, 371-0105, Japan

4 To whom correspondence should be addressed at: Iwaki Women's Clinic, 3-2, Ookishita, Uchigo, Iwaki, Fukushima, 973-8403, Japan. Email: sugawara{at}iwaki-fu.or.jp


    Abstract
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
BACKGROUND: We report a very rare case of the successful delivery of a healthy infant fathered by an infertile chimera. METHODS: ICSI was performed using frozen sperm. The karyotypes of peripheral lymphocytes were examined with a G-banding stain. RESULTS: Chromosomal analysis prior to ICSI revealed a 46, XX [28]/46, XY [2] karyotype chimera. As an infant, the subject was diagnosed as a true hermaphrodite, and underwent a hysterectomy and oophorectomy. A small number of sperm were found in minced testicular tissue, and they were stored for ICSI. CONCLUSION: To the best of our knowledge, this is the first case report of a successful pregnancy and delivery of a healthy infant fathered by an infertile chimera (46, XX/46, XY) following ICSI using frozen testicular sperm.

Key words: azoospermia/chimera/hermaphrodite/ICSI/XX/XY


    Introduction
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
Assisted reproductive technology has improved to the point of achieving pregnancies for severely infertile couples; in particular, ICSI has rescued severely infertile males, despite oligozoospermia or azoospermia. Recently, some case reports of healthy babies, which were the offspring of fathers who had a chromosomal abnormality, have been published. However, concern exists that defective paternal genes may be passed on to the next generation. It is known that defects in sperm production can be caused by genetic factors and that there is an inverse ratio between the incidence of chromosomal abnormalities and sperm count (Yoshida et al., 1996Go).

It is generally held that almost all hermaphrodites are infertile, however, German et al. (1962)Go observed spermatogenesis in a hermaphrodite. Furthermore, in abstracts, both Inatomi et al. (1973)Go and Manba et al. (1971)Go reported the delivery of infants fathered by a true hermaphrodite under natural conditions in Japan. In the true hermaphrodite case presented here, sperm were not present in an ejaculated specimen, however, a few sperm were found in a minced testicular biopsy specimen.

To the best of our knowledge, this is the first case report of a successful delivery of a healthy infant fathered by an infertile chimera (46, XX/46, XY) following ICSI using frozen testicular sperm.


    Case report
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
In October 2001, a 27-year-old woman and her 27-year-old husband were referred to our clinic (Iwaki Women's Clinic, Iwaki, Fukushima). The couple had been trying to achieve a pregnancy for more than a year. The woman's physical and gynecological examinations were within normal limits, including hysterosalpingography and hormonal studies. The husband was found to have azoospermia. The penis was relatively small and the right testis had a volume of approximately 10 ml and was soft to palpation; the left testicle was absent. Serum testosterone was 321 ng/dl, the LH was 10 mIU/ml, the FSH was 42 mIU/ml, the prolactin was 3.8 ng/ml, the progesterone was 0.8 ng/ml, and the estradiol (E2) was 20 pg/ml.

In January 2002, a testicular biopsy revealed a small number of non-motile sperm. The minced specimen was divided into several aliquots and cryopreserved in liquid nitrogen. At the time of the biopsy, we noted surgical scars on the abdomen and the groin, however, he was unaware of the indication for the surgery. His mother informed us that he had been diagnosed as a true hermaphrodite in infancy, and underwent a left oophorectomy, a hysterectomy and a right testicular fixation. We recommended chromosomal analysis of the peripheral lymphocytes prior to ICSI, and found that he was a 46, XX/46, XY chimera. Despite informed consent that the possibility of a good outcome was low, the couple was desirous of ICSI using frozen testicular sperm.

During the first treatment cycle in April 2002, we retrieved two oocytes, and one of two was fertilized via ICSI using frozen sperm from the testicular biopsy performed in January 2002. One embryo, which had developed to the 4-cell stage, was transferred; however, a pregnancy did not ensue.

A second attempt was made in September 2002; we retrieved only one oocyte, however the couple declined ICSI because they wanted to save the frozen sample for use with at least two oocytes; thus, treatment was cancelled.

A third attempt was made in December 2002; we retrieved three mature oocytes under the ultra-long protocol. Ovarian stimulation was achieved via combined administration of GnRH agonist (GnRH-a; Suprecur®; Mochida, Tokyo, Japan), FSH (Fertinorm P®; Serono Laboratory Co. Ltd, Switzerland), HMG (HMG-Fuji®, Fuji Phamaceutical Co. Ltd, Tokyo, Japan) and 10 000 units of HCG (HCG-10000-F® Fuji Phamaceutical Co. Ltd, Tokyo, Japan). GnRH-a was administered at 900 µg/day for 41 days beginning with the first day of menses, FSH/HMG was given until the dominant follicle reached a mean diameter of 20 mm, and then HCG was administered. Vaginal ultrasound-guided follicle puncture took place 36 h after the HCG injection. Retrieved oocytes were cultured for 8 h in the medium (IVC-Two®, Invitro Care Inc., MD) with 10% human serum albumin (HSA; Invitro Care Inc., MD) at 37°C in an atmosphere of 5% CO2 under humidified conditions (Sugawara et al., 2003Go).

The frozen sperm specimen was thawed and cultured in IVC-Two® medium with 10% HSA for 7 h in 5% CO2 under humidified conditions. We found two slightly motile sperm, and only one had normal membrane morphology, using the hypo-osmotic swelling test. Two of the three oocytes were fertilized via ICSI and they developed to the 8-cell cleavage stage 72 h after insemination, and were subsequently transferred. After oocyte retrieval for luteal support, the patient was given an intramuscular injection of 50 mg of progesterone (Progestone 50®; Fuji Phamaceutical Co. Ltd, Tokyo, Japan) daily for 16 days; in addition, she received one injection of progesterone depo (Progestone Depot-S®; Fuji Phamaceutical Co. Ltd, Tokyo, Japan).

The qualitative urinary HCG level 14 days after embryo transfer was borderline positive and 5 days later the urinary HCG level was >25 mIU/ml by qualitative analysis. At 7 weeks of gestation, a singleton pregnancy and a fetal heartbeat were confirmed by transvaginal ultrasound. In September 2003, at 40 weeks and 5 days of gestation, the patient vaginally delivered a healthy female (3026 g; 46, XX).


    Discussion
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
Artificial chimerism can arise from transfused blood stem cells, either by intrauterine transfusion or by allogenic bone marrow transplantation, as well as other organ transplantations. Tetragametic chimerism is very rare in humans, and this type of chimerism can be the cause of true hermaphroiditism (Tippett, 1983Go). Twin chimerism confined to blood cells has been thought to be an exceptional case in humans, while it is frequently reported in cattle (Tippett, 1983Go). Almost all true hermaphrodites are infertile; however, rare case reports have described a natural delivery of an infant fathered by a true hermaphrodite (Manba et al., 1971Go; Inatomi et al., 1973Go).

In our case, the patient had an oophorectomy and hysterectomy at 1 year of age, and was never apprised of the surgical indication. He was diagnosed as a true hermaphrodite. Sperm were never detected in either an ejaculated specimen or urine; therefore, we performed a testicular biopsy and found a small number of sperm. Histology revealed the presence of Sertoli cells in the seminiferous tubules, and only one of them contained sperm heads. We diagnosed the patient as a chimera because of the 46, XX/46, XY karyotype of the peripheral blood (we had not yet tested body tissues). Inasmuch as we detected a small number of sperm, we expected to find a spermatogenesis process from 46, XY chromosome germinal cells. We fixed a testicular tissue block in paraffin for histology and determined that if we found an X- or Y-bearing probe, additional examination would be required to determine whether sperm produced from the spermatogonia were XY normal or XX/XY chimeric germinal cells.

The origin and pathogenesis of chimerism in our patient was obviously quite difficult to determine. Informed consent was given by this couple prior to undergoing ICSI; however, they refused chromosomal analysis prior to delivery. Proper counseling in cases such as this is as important as providing efficacious treatment. In the future we expect to treat a higher number of women or men who are severely infertile; therefore, we must inform the patients of the risks and benefits of undergoing fertility treatment.

In conclusion, to our knowledge, this is the first report of a successful pregnancy and delivery of a healthy female infant (46, XX), using frozen testicular sperm from a 46, XX/46, XY chimera via ICSI. Despite the fact that the likelihood of a successful pregnancy outcome is low for patients with severe infertility, this case study should provide encouragement.


    References
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
German JL, Bearn AG and McGovern JH (1962) Chromosomal studies of three hermaphrodites. Am J Med 33, 83–87.[CrossRef][ISI][Medline]

Inatomi K, Oka S, Nomura Y, Ta N, Tsuhata K, Yoshida T, Fukui Y, Takagi S, Umashima K and Sawazaki C (1973) Two cases of true hermaphrodite (in Japanese). Japn Sco Ob Gyn 25, 720.

Manba S, Adachi T, Narita S, Nakanishi O and Ishihara N (1971) The pregnancy and derivery from true hermaphrodite (in Japanese). Japn Fertil Steril 16, 110.

Sugawara N, Yanagida K, Maeda M, Suzuki N, Tokunaga Y and Sato A (2003) Conjoined twin in triplet pregnancy occurring after ICSI, cryopreservation, and assisted hatching. J Mamm Ova Res 20, 41–44.[CrossRef]

Tippett P (1983) Blood group chimeras. Vox Sang 44, 333–359.[ISI][Medline]

Yoshida A, Miura K and Shirai M (1996) Chromosome abnormalities and male infertility. Assist Reprod Rev 6, 93–99.

Submitted on February 6, 2004; resubmitted on August 5, 2004; accepted on October 4, 2004.





This Article
Abstract
Full Text (PDF )
All Versions of this Article:
20/1/147    most recent
deh587v1
Alert me when this article is cited
Alert me if a correction is posted
Services
Email this article to a friend
Similar articles in this journal
Similar articles in ISI Web of Science
Similar articles in PubMed
Alert me to new issues of the journal
Add to My Personal Archive
Download to citation manager
Search for citing articles in:
ISI Web of Science (1)
Request Permissions
Google Scholar
Articles by Sugawara, N.
Articles by Araki, Y.
PubMed
PubMed Citation
Articles by Sugawara, N.
Articles by Araki, Y.