London Fertility Centre, Cozens House, 112a Harley Street, London W1G 7JH, UK
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Abstract |
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Key words: chromosomal anomalies/ICSI treatment
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Introduction |
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Case report |
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The wife then underwent a laparoscopy, hysteroscopy, bilateral ovarian drilling and laser vaporization of minimal endometriosis in the pouch of Douglas and on the surface of the right ovary. Intrauterine insemination with ovulation induction was then performed for two cycles and the sperm preparation was normal. But the treatment was not successful.
The couple underwent an IVFICSI treatment in June 2000. A follicular phase long protocol was used with leuprorelin acetate depot 3.75 mg (Prostap SR; Wyeth Laboratories, Maidenhead, Berkshire, UK) for down-regulation and recombinant FSH (Puregon; Organon, Oss, The Netherlands) 150 IU daily for 7 days, and 100 IU for 8 days for stimulation. hCG (Pregnyl; Organon Laboratories, Cambridge, UK) 10 000 IU was administered 36 h before oocyte collection. Transvaginal ultrasound-guided oocyte retrieval was performed under i.v. sedation using 600 mg of Alfentanil hydrochloride (Rapifen; Janssen-Cilag Ltd, Buckinghamshire, UK) and 240 mg of Propofol (Diprivan 1% w/v; Zeneca Ltd, Cheshire, UK) administered i.v. over 30 min. The patient received 100% oxygen throughout the procedure. Twelve oocytes were collected. The original plan was to perform IVF if the sperm parameters were within normal limits. However, on that day, the initial semen analysis revealed the sperm concentration to be 23x106/ml, motility 50% and progression score 2/4; after preparation the count was only 3x106/ml with a motility of 95%. In view of the low sperm count, ICSI was performed rather than IVF. Eight oocytes were suitable for microinjection and five fertilized. Of the five embryos, two did not divide on the third day. The other three embryos were at the 5-, 6- and 8-cell stage and two were graded 4/4 (4/4 being the best and 1/4 the poorest) and the other was compacted. The three embryos were placed into the uterus under ultrasound guidance; vaginal progesterone (Cyclogest pessaries; Shire Pharmaceuticals Ltd, Basingstoke, Hants, UK) 400 mg was administered twice daily in the luteal phase from the day of oocyte collection.
A positive (qualitative serum ß-hCG) pregnancy test resulted 12 days after embryo transfer and a transvaginal ultrasound scan at 7 weeks showed an intrauterine singleton live gestation equivalent to dates. The patient was advised to continue Cyclogest suppositories until 12 weeks gestation.
An ultrasound scan at 12 weeks gestation confirmed a viable pregnancy; however, the nuchal translucency measurement was 3.3 mm. This finding, combined with the free ß-hCG (33.0 IU/l) and pregnancy-associated plasma protein A 3060IU/ml measurements, predicted a 1 in 8 risk (at term) of having Downs syndrome.
An amniocentesis performed at 13 weeks identified the Triple-Y syndrome (48,XYYY). Blood samples confirmed a normal karyotype (46,XX and 46,XY) in the couple. After genetic counselling, the couple requested termination of pregnancy which was performed at 18 weeks using extra-amniotic prostaglandin gel 3 mg and i.v. oxytocin infusion (20 IU in 1 l of glucose). Abortion occurred after 22 h and the placenta and membranes appeared complete. However, heavy bleeding occurred after 5 days. A transvaginal ultrasound scan showed evidence of suspected retained products of conception. An evacuation of the uterus was carried out under general anaesthesia the next day.
Tissues were taken from kidney, lung, skin and gut of the fetus and cultured for chromosome analysis. Twenty-five metaphases were examined from each tissue and 100% cells confirmed a karyotype of 48,XYYY.
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Discussion |
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ICSI-independent problems may be due to: (i) male gamete carrying genetic anomalies such as cystic fibrosis mutations, Y-chromosome deletions and aneuploidy; (ii) male gamete with structural defects, e.g. lack of centrosome activity, deficit of cytoskeletal sperm proteins potentially responsible for round-headed sperm, severe forms of teratozoospermia and microtubule nucleation, elongation, sperm aster function and sperm nuclei ordered decondensation and lack of a particular isoform of certain phosphokinase; (iii) anomalies of sperm activating factors; (iv) potential for incorporating sperm mitochondrial DNA; (v) female gamete anomalies (oocyte ageing-related).
ICSI-dependent problems include: (i) injection of foreign, sperm-associated plasmid DNA into the ooplasm and the risk of transgenic offspring or assimilation of infectious particles; (ii) injection of biochemical contaminants (from medium); (iii) mechanical oocyte activation (parthenogenesis); (iv) physical and biochemical disturbance of ooplasm; (v) damage to the separating chromosomes in the second meiotic spindle; (vi) human errors in sperm selection and site of injection.
Among the ICSI-independent problems, injection of sperm with a chromosomal abnormality is a major factor. There have been several reports of significantly increased frequency of autosomal and sex chromosomal aneuploidy in sperm from oligoasthenoteratozoospermic (OAT) patients undergoing ICSI (Moosani et al., 1995; Egozcue et al., 1997
, 2000
; Storeng et al., 1998
; Ushijima et al., 2000
). A study was conducted in 1999 to determine the incidence of aneuploidy in sperm from OAT patients using fluorescence in-situ hybridization (Pang et al., 1999
). It revealed that per chromosome disomy frequencies for autosomes and sex chromosomes in OAT males were 05.4% (0.052% in controls) and the frequency of diploid sperm in OAT patients was 0.49.6% (controls showed a mean frequency of 0.04%). The total aneuploidy in the sperm of the OAT patient population was estimated to be 3374% and in controls 4.17.7%. This suggests that there may be some risk of aneuploidy in children conceived by the ICSI technique.
It has long been noted that the frequency of chromosomal abnormality is increased in subfertile males and the trend is inversely proportional to the sperm concentration (Kjessler, 1974; Chandley, 1979
). A study from Tokyo reviewed the frequency of karyotypic abnormalities in infertile males. The incidence of chromosomal abnormality, in the Tokyo study, rose from 2.2% with a normal sperm concentration, to 5% in the oligozoospermic group, 14.6% for azoospermia and 20.3% with non-obstructive azoospermia. It increased significantly when serum FSH concentrations were raised (Yoshida et al., 1997
).
Karyotyping the male with OAT before ICSI treatment would enable one to divide infertile males into two categories: euploid low risk and aneuploid high risk groups (Persson et al., 1996).
Several studies have now been published after evaluation of parental karyotypes from couples (both men and women) undergoing ICSI (Givens, 2000). A study of 1792 men with oligozoospermia and azoospermia showed that 72 men (4.4%) had chromosomal aberrations, predominantly sex chromosome abnormalities and Robertsonian translocations (Tuerlings et al., 1998
). A similar conclusion was reached by another study of 781 couples (1562 patients) prior to ICSI treatment (Peschka et al., 1999
). A surprisingly high percentage of genetic abnormalities in the female partners in couples undergoing ICSI treatment have been reported: 6% in one study (Mau et al., 1997
) and 9.7% in another study (Scholtes et al., 1998
). Meschede et al. reported that 24 out of 436 female partners of couples presenting for ICSI treatments (5.5%) were found to have karyotyping abnormalities (Meschede et al., 1998
). Of all constitutional chromosomal aberrations, 54.2% were contributed by female partners (Peschka et al., 1999
). In view of this, a chromosomal analysis should be performed on both partners before ICSI treatment is initiated.
In the case reported, both partners had a normal karyotype (46,XX and 46,XY). An XYYY genotype might arise from the fertilization of a normal ovum by a YYY sperm, as suggested by the absence of Y chromosomes in the female partner. The mechanism by which the fetus received the extra Y chromosomes is unknown, probably from a sperm with an extra Y chromosome. A sperm containing three Y chromosomes could theoretically be produced by secondary non-disjunction or anaphase lagging in meiosis II from an XYY primary spermatocyte. Recurrent non-disjunction of the Y chromosome in a normal zygote might be expected to produce a mosaic of at least three cell lines X, XY and XYYY. A familial tendency to non-disjunction has been described (Hauschka et al., 1962). There was no evidence of a mosaicism in this case.
The type of chromosomal abnormality observed here is in line with previous reports. Data from the VUB University, Brussels, showed that all five non-familial chromosomal abnormalities encountered in 384 ICSI pregnancy amniocenteses were of a sex chromosomal nature (Bonduelle et al., 1994). Data from another group reported that five out of 12 ICSI pregnancies who underwent prenatal diagnosis because of advanced maternal age had sex chromosomal abnormalities (Int Veld et al., 1995
). A study involving 7 years of ICSI and follow-up of 1987 subsequent children compiled data on karyotypes, congenital malformations, growth parameters and developmental milestones. Abnormal fetal karyotype was found in 28 cases out of 1082 karyotypes determined by prenatal diagnosis; 18 (1.66%) were de-novo chromosomal aberrations: nine (0.83%) were sex chromosomal aberrations and the other nine (0.83%) were autosomal aberrations. Ten (0.92%) were inherited structural abnormalities (Bonduelle et al., 1999
).
Poly-Y karyotypes with three or more chromosomes are rare. Townes et al. reported the first case of a 5-year old boy with 48,XYYY karyotype (Townes et al., 1965). Subsequently eight cases of 48,XYYY without mosaicism (Pozsonyi and Sergovich, 1970; Schoepflin and Centerwall, 1972
; Hunter and Quaife, 1973
; Ridler et al., 1973
; Hori et al., 1988
) and three cases with mosaicism have been reported (Cox and Berry, 1967
; Sele et al., 1975
; Gigliani et al., 1980
).
Patients with mosaicism demonstrated a spectrum from multiple anomalies to an apparently normal phenotype, while those without mosaicism had no conspicuous physical anomalies. Minor malformations such as transverse palmar creases, clinodactyly and abnormal teeth have been reported. They exhibited mild mental retardation, recurrent upper respiratory infection during childhood, tall stature and azoospermia in adulthood. Psychomotor retardation in the boys consisted of delayed walking and delayed speech. Their intelligence quotients (IQ) were said to be generally in the lownormal range with a span of 6586 and performance IQ was greater than verbal IQ. Behaviour has been reportedly troublesome, characterized by impulsivity and a low frustration tolerance. Occasional aggressive outbursts and poor emotional stability seem to be fairly consistent in 48,XYYY males (Hori et al., 1988; Linden et al., 1995
). It has been reported that raised performance:verbal IQ ratio is also seen in other sex chromosome disorders in males and in psychopathic behaviour disorders (Hunter and Quaife, 1973
).
All these features of the Triple-Y syndrome were explained to the couple by us and by genetic counsellors. After these discussions, the couple opted for termination.
In view of the increased risk of sex chromosomal abnormalities in ICSI pregnancies, many clinicians have recommended karyotyping of both partners prior to a planned treatment with ICSI (Meschede et al., 1995, 1998
; Int Veld et al., 1997
; Peschka et al., 1999
; Givens, 2000
). However, it is still not a routine practice to perform chromosomal analysis on patients before ICSI treatment.
We feel that the patients undergoing ICSI treatment should be offered karyotyping (of both male and female partners) and be informed about the increased risk of chromosomal abnormalities. This is particularly important in the high risk group due to the karyotypic anomalies in the parents, most often the fathers with either sex chromosomal aberrations or structural anomalies (4.8%). This can also lead to a higher miscarriage rate and perhaps a lower implantation rate (Bonduelle et al., 1999).
Couples should be informed of the risk of transmitting chromosomal aberrations, the risk of de-novo, mainly sex chromosomal, aberrations and the risk of transmitting fertility problems to the offspring (Bonduelle et al., 1999). Patients should however, be reassured that there seems to be no increased risk of major congenital malformations and neonatal complications in children born after ICSI (Bonduelle et al., 2002
).
In view of the above risks we think that it is necessary to offer prenatal diagnostic tests such as amniocentesis and chorion villous sampling to all ICSI couples. The risk of miscarriage (1% with amniocentesis and 2% with chorionic villous sampling) with these invasive tests should be discussed with them.
If a sex chromosomal anomaly is diagnosed by one of the prenatal tests, detailed information about the condition under discussion should be given to the couple, with careful genetic counselling. Sex chromosomal anomalies in most cases are not associated with malformations or other major congenital handicaps and the long term developmental prognosis is fairly good, but significant medical and educational problems do occur in some affected individuals. While the final choice about continuation or termination of a pregnancy should always remain with the parents, it is the obligation of the counsellor to have an unbiased and detailed discussion of the developmental perspectives (Meschede and Horst, 1997).
Preimplantation genetic diagnosis would be an alternative option in future for all ICSI procedures or in selected high risk cases at least.
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Acknowledgements |
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Notes |
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References |
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Submitted on August 15, 2001; resubmitted on May 2, 2002; accepted on June 6, 2002.