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Birth of a healthy boy using fresh testicular sperm in a patient with Klinefelter syndrome combined with Kartagener syndrome
Birth of a healthy boy using fresh testicular sperm in a patient with Klinefelter syndrome combined with Kartagener syndrome Kubilay Vicdan, M.D., Ph.D.,a Cem Akarsu, M.D.,a Arzu Vicdan, M.D., Ph.D.,b Eran S€ ozen, M.D., Ph.D.,a € gul, Ph.D.d Burcu Buluc¸, M.Sc.,a Kutay Bibero glu, M.D.,c and Candan Ozo a
Private Ankara IVF Center, b Department of Genetics, Faculty of Medicine, Ankara University, and c Department of Reproductive Endocrinology and Infertility, and d Department of Histology and Embyology, Faculty of Medicine, Gazi University, Ankara, Turkey
Objective: To report a case of Klinefelter syndrome combined with Kartagener syndrome. Design: Case report. Setting: Private IVF center. Patient(s): A 35-year-old man with Klinefelter syndrome combined with Kartagener syndrome causing primary infertility. Intervention(s): Testicular sperm extraction (TESE) and intracytoplasmic sperm injection (ICSI). Main Outcome Measure(s): Sperm recovery, fertilization, and live birth. Result(s): Ovulation induction of the female partner, recovery of spermatozoa by TESE from the male partner and ICSI of 9 metaphase II oocytes resulted in two fertilized oocytes. The delivery of a healthy boy with normal anatomy and 46,XY karyotype was achieved after the transfer of only one 4-cell grade 1 embryo. Conclusion(s): To our knowledge, this case with nonmosaic Klinefelter syndrome combined with Kartagener’s syndrome is unique and demonstrates the revolutionary aspects of assisted reproductive technologies (ART) concerning male factor infertility. (Fertil Steril 2011;96:577–9. 2011 by American Society for Reproductive Medicine.) Key Words: Klinefelter syndrome, Kartagener syndrome, TESE, ICSI
In the past couples in whom the male partner had Klinefelter syndrome or Kartagener syndrome were inevitably sterile due to azoospermia and immotility of spermatozoa. Thanks to the progress in assisted reproduction technologies (ART) with intracytoplasmic sperm injection (ICSI) of ejaculated or testicular spermatozoa, these hopeless men have been provided with the opportunity to become biological fathers (1, 2). Klinefelter syndrome is characterized by small firm testes, hypogonadism, and elevated FSH levels. It is one of the most common forms of chromosomal aneuoploidy in humans. Genetic surveys have reported up to 0.7% of oligozoospermic and 11% of azoospermic men have an abnormal 47,XXY karyotype (3). Immotile cilia syndrome is defined as defective cilial ultrastructure in ciliated cells and spermatozoa. It is a genetically heterogeneous autosomal recessive disorder with an incidence of 1 in 20,000 live births (4) and characterized by recurrent infections of the respiratory tract, bronchiectasis, and male factor infertility. Approximately half of individuals with immotile cilia are known as having Kartagener syndrome, which is described as a familial form of bronchectasis with situs inversus and nasal polyps (5). Here we report the first case of nonmosaic Klinefelter syndrome combined with Received March 4, 2011; revised May 30, 2011; accepted June 2, 2011; published online June 30, 2011. K.V. has nothing to disclose. C.A. has nothing to disclose. A.V. has nothing to disclose. E.S. has nothing to disclose. B.B. has nothing to disclose. € has nothing to disclose. K.B. has nothing to disclose. C.O. Reprint requests: Kubilay Vicdan, M.D., Ph.D., Private Ankara IVF Center, € ¸ ler, Ankara, Turkey (E-mail: C¸etin Emec¸ Bulvarı, 2. Cadde, 2/A, Ovec [email protected]).
0015-0282/$36.00 doi:10.1016/j.fertnstert.2011.06.011
Kartagener syndrome succesfully treated by ICSI using testicular spermatozoa.
CASE REPORT A 35-year-old man and his 32-year-old wife were referred to our IVF center in June 2006 after 13 years of primary infertility due to azoospermia. The medical history of the man revealed that he had frequently been hospitalized for dyspnea, cough, and hemoptysis in the past. In one of the admission in 2001, his physical examination, chest roentgenogram, abdominal ultrasonography, computerized tomography (CT), and echocardiography revealed total situs inversus, bronchiectasis, and nasal polyp. He was diagnosed with Kartagener syndrome. He had a nasal polypectomy. He was consulted by an urologist because of his infertility problem and azoospermia in repeated semen analysis. Bilateral atrophic testes, and grade 3 varicocele with normal vasa and seminal vesicles, elevated FSH (51.4 mIUI/mL) and low T levels (0.4 ng/mL) were detected and the cytogenetic analysis of the man showed a 47, XXY karyotype. During infertility treatment, the nasal biopsy that we offered for electron microscopy (EM) to confirm the diagnosis was refused as it was invasive and had previously been done. His previous EM from nasal mucosa demonstrated degenerated microtubules and lack of dynein arms in microtubules as a definitive diagnosis of primary ciliary dyskinesia (Fig. 1). The female partner’s medical history and physical examination was uneventful. The couple received information on the outcome of the testicular sperm extraction (TESE) procedure and genetic counseling. After the female partner underwent down-regulation with GnRH analogue (Lucrin, Abbott), ovarian stimulation was
Fertility and Sterility Vol. 96, No. 3, September 2011 Copyright ª2011 American Society for Reproductive Medicine, Published by Elsevier Inc.
577
FIGURE 1 Degenerated microtubules (short arrow) and lack of internal and external dynein arms in microtubules (long arrow) (Carl Zeiss, 60.000).
four cells developed and was transferred on day 2. Luteal phase was supported by vaginal administration of P. A pregnancy test, carried out 12 days after transfer, showed a b-hCG level of 50.1 mIU/mL, which increased to 101 mIU/mL 2 days later. A singleton clinical pregnancy with visible heart beats was detected at the sixth gestational week. Amniocentesis for karyotyping was rejected by the couple. A cesarean section was performed and a healthy boy weighing 3,250 g was born at 39 weeks of gestation in July 2006. The newborn was healthy with no anatomical abnormalities. His cord blood chromosomal analysis revealed a normal karyotype of 46,XY.
DISCUSSION
Vicdan. Klinefelter and Kartagener syndromes. Fertil Steril 2011.
started on day 3 with 150 IU of recombinant FSH (Puregon; Organon) and ovulation was triggered by 10,000 U of hCG (Pregnyl, Organon). Before oocyte pick-up, the male partner underwent TESE using a surgical microscope at 15–20 power magnification and the tissues with dilated seminiferous tubules were extracted for sperm examination. They were minced under stereomicroscope by dissecting pincets and needles to obtain a homogenous testicular cell suspension. Suspensions were further mixed with a vortex. One drop of the cell suspension was examined under a phase contrast microscope at 200 magnification (BX50, Olympus) and results were recorded as the number of sperm cells per milliliter. Four of 15 tissue pieces were positive for spermatozoa and suspensions with mature sperm cells were prepared by discontinuous density gradients (SpermGrad; Vitrolife) for fertilization. The suspensions without any sperm cells were further investigated under the inverted microscope (IX70, Olympus) after centrifugation and concentrating the suspension at 2,500 g. Excess spermatozoa were kept for freezing. After obtaining spermatozoa, the female partner underwent oocyte pick-up under transvaginal ultrasound guidance 35 hours after the hCG administration and 11 oocytes were collected. Of these, nine were mature and two normally fertilized after ICSI. Only one grade 2 embryo with
Couples in which the male partner has Klinefelter syndrome are invariably infertile due to azoospermia with exceptional cases of proven spontaneous paternity (6). Although a few reports described successful pregnancies and deliveries after ICSI with ejaculated spermatozoa, ICSI with fresh or cryopreservedthawed testicular spermatozoa is now the treatment modality in these patients. Clinical pregnancy rates (PR) between 40% and 56.4% have been reported using the TESE-ICSI procedure with the transfer of fresh and frozen thawed embryos (1, 7–9). Men with Kartagener syndrome are also considered to be infertile due to totally immotile spermatozoa. Although ICSI, currently the only treatment option for these men, overcomes the factors related to impaired motility and bypasses the natural mechanisms for fertilization, the success of micromanipulation is unpredictable as the viability of immotile spermatozoa are unknown. Therefore, the use of immotile spermatozoa without the knowledge of viability of selected sperms for ICSI is the major concern and low or total failure of fertilization can frequently be seen in these cases after ICSI (10, 11). The use of testicular rather than ejaculated spermatozoa for ICSI and using the hypoosmotic swelling test for selection of viable spermatozoa were suggested to improve fertilization and PRs in cases with Kartagener syndrome (4, 12). The case presented had rare coincidental syndromes causing infertility that was treated successfully by ICSI using testicular spermatozoa. The probability of increased risks for chromosomal abnormalities were discussed with the couple but both opted to continue treatment without any preimplantation and prenatal diagnostic intervention. In conclusion, this couple with a unique cause of infertility benefited from the use of advanced ART and managed to take home a genotypically healthy baby boy.
REFERENCES 1. Tournaye H, Staessen C, Liebaers I, Van Assche E, Devroey P, Bonduelle M, et al. Testicular sperm recovery in nine 47, XXY Klinefelter patients. Hum Rep 1996;11:1644–9. 2. von Zumbusch A, Fiedler K, Mayerhofer A, Jessberger B, Ring J, Vogt HJ. Birth of healthy children after intracytoplasmic sperm injection in two couples with male Kartagener’s syndrome. Fertil Steril 1998;70:643–6. 3. Yoshida A, Kazukiyo M, Shirai M. Chromosome abnormalities and male infertility. Assist Rep Rev 1996;6:93–9.
578
Vicdan et al.
4. Cayan S, Conaghan J, Schriock ED, Ryan IP, Black LD, Turek PJ. Birth after intracytoplasmic sperm injection with use of testicular sperm from men with Kartegener/immotile cilia syndrome. Fertil Steril 2001;76:612–4. 5. Kartagener M, Horlacher A. Situs viscerum inversus und Polyposis nasi in einem Falle familiaerer Bronchiektasien. Beitr Klin Tuberk 1936;87: 331–3. 6. Lanfranco F, Kamischke A, Zitzmann M, Nieschlag E. Klinefelter’s syndrome. Lancet 2004;364:273–83. 7. Okada H, Goda K, Muto S, Maruyama O, Koshida M, Horie S. Four pregnancies in non-
Klinefelter and Kartagener syndromes
mosaic Klinefelter’s syndrome using cryopreservedthawed testicular spermatozoa. Fertil Steril 2005;5: 1508. 8. Vicdan K, Akarsu C, Vicdan A, Dingiloglu B, S€ozen E, Co¸skun Z, et al. Births using frozen-thawed spermatozoa and frozen-thawed embryos in two azoospermic patients with nonmosaic Klinefelter’s syndrome. J Turkish–German Assoc 2007;8:424–7. 9. Schiff JD, Palermo GD, Veeck LL, Goldstein M, Rosenwaks Z, Schlegel PN. Success of testicular sperm extraction and intracytoplasmic sperm injection in men with Klinefelter syndrome. J Clin Endocrinol Metab 2005;11:6263–7.
Vol. 96, No. 3, September 2011
10. Westlander G, Barry M, Petrucco O, Norman R. Different fertilization rates between immotile testicular spermatozoa and immotile ejaculated spermatozoa for ICSI in men with Kartagener’s syndrome: case reports. Hum Reprod 2003;18:1286–8.
Fertility and Sterility
11. Abu-Musa A, Hannoun A, Khabbaz A, Devroey P. Failure of fertilization after intracytoplasmic sperm injection in a patient with Kartagener’s syndrome and totally immotile spermatozoa: case report. Hum Reprod 1999;14:2517–8.
12. C ¸ aglar G, Vicdan K, I¸sık AZ, Akarsu Cem, S€ozen Eran. Kartagener’s syndrome and intracytoplasmic injection of ejaculated immotile spermatazoa selected by hypo-osmotic swelling test. J TurkishGerman Gynecol Assoc 2007;8:211–4.
579
Private Ankara IVF Center, b Department of Genetics, Faculty of Medicine, Ankara University, and c Department of Reproductive Endocrinology and Infertility, and d Department of Histology and Embyology, Faculty of Medicine, Gazi University, Ankara, Turkey
Objective: To report a case of Klinefelter syndrome combined with Kartagener syndrome. Design: Case report. Setting: Private IVF center. Patient(s): A 35-year-old man with Klinefelter syndrome combined with Kartagener syndrome causing primary infertility. Intervention(s): Testicular sperm extraction (TESE) and intracytoplasmic sperm injection (ICSI). Main Outcome Measure(s): Sperm recovery, fertilization, and live birth. Result(s): Ovulation induction of the female partner, recovery of spermatozoa by TESE from the male partner and ICSI of 9 metaphase II oocytes resulted in two fertilized oocytes. The delivery of a healthy boy with normal anatomy and 46,XY karyotype was achieved after the transfer of only one 4-cell grade 1 embryo. Conclusion(s): To our knowledge, this case with nonmosaic Klinefelter syndrome combined with Kartagener’s syndrome is unique and demonstrates the revolutionary aspects of assisted reproductive technologies (ART) concerning male factor infertility. (Fertil Steril 2011;96:577–9. 2011 by American Society for Reproductive Medicine.) Key Words: Klinefelter syndrome, Kartagener syndrome, TESE, ICSI
In the past couples in whom the male partner had Klinefelter syndrome or Kartagener syndrome were inevitably sterile due to azoospermia and immotility of spermatozoa. Thanks to the progress in assisted reproduction technologies (ART) with intracytoplasmic sperm injection (ICSI) of ejaculated or testicular spermatozoa, these hopeless men have been provided with the opportunity to become biological fathers (1, 2). Klinefelter syndrome is characterized by small firm testes, hypogonadism, and elevated FSH levels. It is one of the most common forms of chromosomal aneuoploidy in humans. Genetic surveys have reported up to 0.7% of oligozoospermic and 11% of azoospermic men have an abnormal 47,XXY karyotype (3). Immotile cilia syndrome is defined as defective cilial ultrastructure in ciliated cells and spermatozoa. It is a genetically heterogeneous autosomal recessive disorder with an incidence of 1 in 20,000 live births (4) and characterized by recurrent infections of the respiratory tract, bronchiectasis, and male factor infertility. Approximately half of individuals with immotile cilia are known as having Kartagener syndrome, which is described as a familial form of bronchectasis with situs inversus and nasal polyps (5). Here we report the first case of nonmosaic Klinefelter syndrome combined with Received March 4, 2011; revised May 30, 2011; accepted June 2, 2011; published online June 30, 2011. K.V. has nothing to disclose. C.A. has nothing to disclose. A.V. has nothing to disclose. E.S. has nothing to disclose. B.B. has nothing to disclose. € has nothing to disclose. K.B. has nothing to disclose. C.O. Reprint requests: Kubilay Vicdan, M.D., Ph.D., Private Ankara IVF Center, € ¸ ler, Ankara, Turkey (E-mail: C¸etin Emec¸ Bulvarı, 2. Cadde, 2/A, Ovec [email protected]).
0015-0282/$36.00 doi:10.1016/j.fertnstert.2011.06.011
Kartagener syndrome succesfully treated by ICSI using testicular spermatozoa.
CASE REPORT A 35-year-old man and his 32-year-old wife were referred to our IVF center in June 2006 after 13 years of primary infertility due to azoospermia. The medical history of the man revealed that he had frequently been hospitalized for dyspnea, cough, and hemoptysis in the past. In one of the admission in 2001, his physical examination, chest roentgenogram, abdominal ultrasonography, computerized tomography (CT), and echocardiography revealed total situs inversus, bronchiectasis, and nasal polyp. He was diagnosed with Kartagener syndrome. He had a nasal polypectomy. He was consulted by an urologist because of his infertility problem and azoospermia in repeated semen analysis. Bilateral atrophic testes, and grade 3 varicocele with normal vasa and seminal vesicles, elevated FSH (51.4 mIUI/mL) and low T levels (0.4 ng/mL) were detected and the cytogenetic analysis of the man showed a 47, XXY karyotype. During infertility treatment, the nasal biopsy that we offered for electron microscopy (EM) to confirm the diagnosis was refused as it was invasive and had previously been done. His previous EM from nasal mucosa demonstrated degenerated microtubules and lack of dynein arms in microtubules as a definitive diagnosis of primary ciliary dyskinesia (Fig. 1). The female partner’s medical history and physical examination was uneventful. The couple received information on the outcome of the testicular sperm extraction (TESE) procedure and genetic counseling. After the female partner underwent down-regulation with GnRH analogue (Lucrin, Abbott), ovarian stimulation was
Fertility and Sterility Vol. 96, No. 3, September 2011 Copyright ª2011 American Society for Reproductive Medicine, Published by Elsevier Inc.
577
FIGURE 1 Degenerated microtubules (short arrow) and lack of internal and external dynein arms in microtubules (long arrow) (Carl Zeiss, 60.000).
four cells developed and was transferred on day 2. Luteal phase was supported by vaginal administration of P. A pregnancy test, carried out 12 days after transfer, showed a b-hCG level of 50.1 mIU/mL, which increased to 101 mIU/mL 2 days later. A singleton clinical pregnancy with visible heart beats was detected at the sixth gestational week. Amniocentesis for karyotyping was rejected by the couple. A cesarean section was performed and a healthy boy weighing 3,250 g was born at 39 weeks of gestation in July 2006. The newborn was healthy with no anatomical abnormalities. His cord blood chromosomal analysis revealed a normal karyotype of 46,XY.
DISCUSSION
Vicdan. Klinefelter and Kartagener syndromes. Fertil Steril 2011.
started on day 3 with 150 IU of recombinant FSH (Puregon; Organon) and ovulation was triggered by 10,000 U of hCG (Pregnyl, Organon). Before oocyte pick-up, the male partner underwent TESE using a surgical microscope at 15–20 power magnification and the tissues with dilated seminiferous tubules were extracted for sperm examination. They were minced under stereomicroscope by dissecting pincets and needles to obtain a homogenous testicular cell suspension. Suspensions were further mixed with a vortex. One drop of the cell suspension was examined under a phase contrast microscope at 200 magnification (BX50, Olympus) and results were recorded as the number of sperm cells per milliliter. Four of 15 tissue pieces were positive for spermatozoa and suspensions with mature sperm cells were prepared by discontinuous density gradients (SpermGrad; Vitrolife) for fertilization. The suspensions without any sperm cells were further investigated under the inverted microscope (IX70, Olympus) after centrifugation and concentrating the suspension at 2,500 g. Excess spermatozoa were kept for freezing. After obtaining spermatozoa, the female partner underwent oocyte pick-up under transvaginal ultrasound guidance 35 hours after the hCG administration and 11 oocytes were collected. Of these, nine were mature and two normally fertilized after ICSI. Only one grade 2 embryo with
Couples in which the male partner has Klinefelter syndrome are invariably infertile due to azoospermia with exceptional cases of proven spontaneous paternity (6). Although a few reports described successful pregnancies and deliveries after ICSI with ejaculated spermatozoa, ICSI with fresh or cryopreservedthawed testicular spermatozoa is now the treatment modality in these patients. Clinical pregnancy rates (PR) between 40% and 56.4% have been reported using the TESE-ICSI procedure with the transfer of fresh and frozen thawed embryos (1, 7–9). Men with Kartagener syndrome are also considered to be infertile due to totally immotile spermatozoa. Although ICSI, currently the only treatment option for these men, overcomes the factors related to impaired motility and bypasses the natural mechanisms for fertilization, the success of micromanipulation is unpredictable as the viability of immotile spermatozoa are unknown. Therefore, the use of immotile spermatozoa without the knowledge of viability of selected sperms for ICSI is the major concern and low or total failure of fertilization can frequently be seen in these cases after ICSI (10, 11). The use of testicular rather than ejaculated spermatozoa for ICSI and using the hypoosmotic swelling test for selection of viable spermatozoa were suggested to improve fertilization and PRs in cases with Kartagener syndrome (4, 12). The case presented had rare coincidental syndromes causing infertility that was treated successfully by ICSI using testicular spermatozoa. The probability of increased risks for chromosomal abnormalities were discussed with the couple but both opted to continue treatment without any preimplantation and prenatal diagnostic intervention. In conclusion, this couple with a unique cause of infertility benefited from the use of advanced ART and managed to take home a genotypically healthy baby boy.
REFERENCES 1. Tournaye H, Staessen C, Liebaers I, Van Assche E, Devroey P, Bonduelle M, et al. Testicular sperm recovery in nine 47, XXY Klinefelter patients. Hum Rep 1996;11:1644–9. 2. von Zumbusch A, Fiedler K, Mayerhofer A, Jessberger B, Ring J, Vogt HJ. Birth of healthy children after intracytoplasmic sperm injection in two couples with male Kartagener’s syndrome. Fertil Steril 1998;70:643–6. 3. Yoshida A, Kazukiyo M, Shirai M. Chromosome abnormalities and male infertility. Assist Rep Rev 1996;6:93–9.
578
Vicdan et al.
4. Cayan S, Conaghan J, Schriock ED, Ryan IP, Black LD, Turek PJ. Birth after intracytoplasmic sperm injection with use of testicular sperm from men with Kartegener/immotile cilia syndrome. Fertil Steril 2001;76:612–4. 5. Kartagener M, Horlacher A. Situs viscerum inversus und Polyposis nasi in einem Falle familiaerer Bronchiektasien. Beitr Klin Tuberk 1936;87: 331–3. 6. Lanfranco F, Kamischke A, Zitzmann M, Nieschlag E. Klinefelter’s syndrome. Lancet 2004;364:273–83. 7. Okada H, Goda K, Muto S, Maruyama O, Koshida M, Horie S. Four pregnancies in non-
Klinefelter and Kartagener syndromes
mosaic Klinefelter’s syndrome using cryopreservedthawed testicular spermatozoa. Fertil Steril 2005;5: 1508. 8. Vicdan K, Akarsu C, Vicdan A, Dingiloglu B, S€ozen E, Co¸skun Z, et al. Births using frozen-thawed spermatozoa and frozen-thawed embryos in two azoospermic patients with nonmosaic Klinefelter’s syndrome. J Turkish–German Assoc 2007;8:424–7. 9. Schiff JD, Palermo GD, Veeck LL, Goldstein M, Rosenwaks Z, Schlegel PN. Success of testicular sperm extraction and intracytoplasmic sperm injection in men with Klinefelter syndrome. J Clin Endocrinol Metab 2005;11:6263–7.
Vol. 96, No. 3, September 2011
10. Westlander G, Barry M, Petrucco O, Norman R. Different fertilization rates between immotile testicular spermatozoa and immotile ejaculated spermatozoa for ICSI in men with Kartagener’s syndrome: case reports. Hum Reprod 2003;18:1286–8.
Fertility and Sterility
11. Abu-Musa A, Hannoun A, Khabbaz A, Devroey P. Failure of fertilization after intracytoplasmic sperm injection in a patient with Kartagener’s syndrome and totally immotile spermatozoa: case report. Hum Reprod 1999;14:2517–8.
12. C ¸ aglar G, Vicdan K, I¸sık AZ, Akarsu Cem, S€ozen Eran. Kartagener’s syndrome and intracytoplasmic injection of ejaculated immotile spermatazoa selected by hypo-osmotic swelling test. J TurkishGerman Gynecol Assoc 2007;8:211–4.
579