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Familial ciliary dyskinesis: a cause of infertility without respiratory disease
Vol. 44, No.4, October 1985 Printed in U.SA.
FERTILITY AND STERILITY Copyright e 1985 The American Fertility Society
Familial ciliary dyskinesis: a cause of infertility without
respiratory disease
Anwar Moryan, M.D. Andre T. Guay, M.D. * Sanford Kurtz, M.D. Peter J. Nowak, B.S.t Section of Endocrinology and Department of Laboratory Medicine, Lahey Clinic Medical Center, Burlington, Massachusetts
The clinical constellation of chronic sinusitis, bronchiectasis, situs inversus, and defective microciliary transport is called Kartagener's syndrome. Men were found to have immotile but live sperm and specifically an abnormal ultrastructure of the sperm tails by electron microscopy, which was seen as absent or defective dynein arms. The same defect has been found in electron microscopic studies of both the nasal mucosal cilia and sperm tails. This was confirmed in patients not only with Kartagener's syndrome but also in patients who have chronic sinopulmonary infections without situs inversus. Thus the name of immotile cilia syndrome was recommended. l Another variation was observed in three siblings who had chronic respiratory disease but of whom only one had situs inversus. 2 Electron microscopic examination showed lack of radial spokes along with eccentric pairs of tubules in both the sperm and nasal mucosa. Because abnormal cilia may retain some motility, ciliary dyskinesis was proposed as a more accurate term, especially after the discovery of other structural abnormalities, such as transposition of ciliary microtubules,3 which was seen in two siblings in whom the cen-
Received March 14, 1985; revised and accepted June 10, 1985. *Reprint requests: Andre T. Guay, M.D., Section of Endocrinology, Lahey Clinic Medical Center, 41 Mall Road, Burlington, Massachusetts 01805. tPresent address: Department of Pathology, Tufts University Medical School, Boston, Massachusetts. Vol. 44, No.4, October 1985
tral doublet was absent, especially in the distal portion of the nasal cilia or sperm tail. Approximately 10% of the sperm were motile even with this defect; Subtypes of ciliary dyskinesis are listed according to the pathologic defects: type 1, defective dynein; type 2, defective radial spokes; and type 3, transposition of peripheral microtubules. 3 In a recent report,4 a patient with ciliary dyskinesis and no evidence of chronic sinobronchial disease had a semen analysis within normal limits except for lack of motility and a high percentage of abnormal forms (± 70%). Supernumerary microtubules, double axonemas, overabundant fibrous sheath, axonemal disorganization, abortive tail formation, and lack of a mitochondrial sheath were seen on electron microscopy. Results ofbiopsy of the testes were unremarkable. Preceding the report by McClure et aI., 4 Baccetti et al. 5 reported the case of one man with immotility of sperm without respiratory disease; the only defect described was absence of the central dQublet. We present the cases of two brothers with ciliary dyskinesis but without respiratory disease to show that this phenomenon can occur in a familial setting. CASE REPORTS CASE 1
A 30-year-old man was seen because of primary infertility of 4 years' duration. Evaluation of his Moryan et aL Communications-in-brief
539
Table 1. Semen Characteristics of Brothers with Ciliary Dyskinesis Case
Abnormal forms %
1 2
70 40
36 22
Sperm count x
]06
11
12 32 26
Motility
Viabil· ity
%
%
1 1 1 1
88 44
wife did not reveal any contributory factors. Three years before being seen at the Lahey Clinic, the patient had had ligation of a left varicocele. Before this surgical procedure, the patient had sperm counts> 20 x 10B/ml and had constant motility readings of between 0% and 2%. These values did not change after the ligation even after 6 months of treatment with clomiphene citrate and after an empiric course of corticosteroid agents. The patient's past medical history did not reveal sinus disease, bronchiectasis, or any other pulmonary infections. The family history was also negative for these conditions. Physical examination revealed normal findings. Genital examination did not reveal recurrent varicoceles, and the testes measured 4 x 2.5 cm and were of normal consistency. Results of laboratory studies on the blood and urine were within normal limits. Serum levels of luteinizing hormone, folliclestimulating hormone, prolactin, testosterone, thyroxine, urinary hydroxysteroids, and ketosteroids were normal. Semen analyses are listed in Table 1. CASE 2
The 23-year-old brother of the patient whose case was just described had been married only 6 months and was not actively attempting fertility. Past medical history did not reveal sinobronchial disease. Results of recent physical and genital examinations were normal. Results of semen analysis were similar to his brother's findings (Table 1). MATERIALS AND METHODS HORMONAL ASSAYS
All hormonal assays were performed in the laboratory with standard radioimmunoassay kits. Viability staining was performed on the semen with eosin. The reagent used was 0.5% eosin Y 540
Moryan et aI. Communications· in· brief
stain. Two drops of cold stain were mixed with two drops of semen and were incubated for 2 minutes in a water bath at 37°C. Two hundred sperm were counted. Living sperm do not accept the dye, whereas dead sperm stain pink. The normal value is ~ 65% viability. ELECTRON MICROSCOPY
Immediately after an aliquot of semen was collected, it was placed in Karnovsky's buffered fixative. The specimen was spun down at 2000 rpm in a conical test tube for 15 minutes. The supernatant was removed, and a 25% gelatin solution was added to form a solid pellet. The pellet was cut into 1-mm pieces, placed in Karnovsky's fixative for 1 hour, and washed in 0.2 M cacodylate buffer, pH 7.4. It was postfixed in osmium tetroxide (1 %), dehydrated, and embedded in Poly sciences Polybed 812 medium (Poly sciences Inc., Warrington, PA). Sections were examined under a Philips 300 electron microscope (Philips Electronics, Eindhoven, The Netherlands).
RESULTS
Electron microscopic examination of specimens from both patients showed intact dynein arms and radial spokes. The main defect involved multiple abnormalities of microtubular arrangement. The central doublet was absent in both patients, and peripheral microtubular translocation was apparent in both patients (Fig. 1). One brother (case 1) had some sperm with peripheral doublets in the appropriate position but had two extra doublets. The other patient (case 2) had sperm with only eight peripheral doublets and two extra doublets. The sections examined from both brothers showed various microtubular disarray, but the findings were largely limited to the doublets. DISCUSSION
The electron microscopic findings were similar in both brothers, suggesting the idea of a familial nature of this defect. Although the ultrastructural defects of Kartagener's syndrome and its variants are known to be inherited, our report appears to be the first that supports an inherited defect of sperm tails in patients who have not had sinobronchial disease. In the absence of respiratory disease, we did not believe that performance of nasal ciliary biopsy was justified. Baccetti et Fertility and Sterility
c.......
A
c
Figure 1 (A), Cross-section of sperm tail with absence of central doublet and translocation of existing doublet. Longitudinal columns and outer dense fibrils appear normal. (B), Cross-section of sperm tail with absence of central doublet. (C), Cross-section of normal control with proper arrangement of nine pairs of outer microtubules and one central pair.
al. 5 studied the nasal cilia in a patient with absent central doublets in the sperm tails, however, and found the nasal cilia perfectly normal. We presumed our patients would show similar features. The importance of a familial pattern is reinforced because of a report by Williamson et al.,6 who suggested that ultrastructural defects in sperm tails may be acquired. In the absence of respiratory disease, the implications were made because of antisperm antibodies, testicular injury, or genitourinary tract infection. One of the patients in the report by Williamson et a1. 6 showed some normal sperm tails, which is unusual but not impossible and may indicate the need for a more thorough study. Other abnormalities included absence of central doublets and supernumerary doublets, which is similar to findings in our patients. Although acquired defects have not been ruled out, it is possible that at least two of the patients of Williamson et al. 6 had a familial defect with later testicular injury, which was coincidental. It is interesting to speculate that if an acute episode can cause structurally abnormal sperm, these changes may be reversed after the offending episode has been resolved, especially in the presence of severe genitourinary tract infections. Although this theory is intriguing, more investigation is needed, especially in correlation of structural abnormalities to function. In our patients, the similarity of the defects in the siblings and the complete absence of sinopulmonary and genitourinary or testicular disease or both are consistent with a familial defect of ultrastructural formation of the sperm tail. Obviously, a wide spectrum of ultrastructural defects and a wider association of these defects with various Vol. 44, No.4, October 1985
clinical conditions are possi.ble. Studies of further detailed electron microscopic observations will have to be analyzed before the entire picture is better understood. Apart from a list of subpopulations of defects, the question of relating structural defects to function remains. Because the absence of outer dynein arms may not inhibit sperm motility, structural defects and loss offunction must be equated cautiously. This is especially important in the appropriate assessment of fertility potential. SUMMARY
Two brothers were found to have primary infertility and nonmotile sperm secondary to ultrastructural defects, which included absent central doublets and peripheral microtubular translocation. No personal or family history of sinobronchial disease was obtained. Although sporadic cases of this type of ciliary dyskinesis have been reported, our patients constitute the first known occurrence of familial association. REFERENCES 1. Eliasson R, Mossberg B, Camner P, Afzelius BA: The immotile-cilia syndrome: a congenital ciliary abnormality as an etiologic factor in chronic airway infections and male sterility. N Engl J Med 297:1, 1977 2. SturgessJM, ChaoJ, WongJ, Aspin N, TurnerJAP: Cilia with defective radial spokes: a cause of human respiratory disease. N Engl J Med 300:53, 1979 3. Sturgess JM, Chao J, Turner JAP: Transposition of ciliary microtubules: another cause of impaired ciliary motility. N Engl J Med 303:318, 1980 4. McClure RD, Brawer J, Robaire B: Ultrastructure of immotile spermatozoa in an infertile male: a spectrum of structural defects. Fertil Steril 40:395, 1983
Moryan et aL Communications-in-brief
541
5. Baccetti B, Burrini AG, Maver A, Pallini V, Renieri T: "9 + 0" immotile spermatozoa in an infertile man. Andrologia 11:437, 1979
542
Moryan et al.
Communications-in-brief
6. Williamson RA, Koehler JK, Smith WD, Stenchever MA: Ultrastructural sperm tail defects associated with sperm immotility. Fertil Steril 41:103, 1984
Fertility and Sterility
FERTILITY AND STERILITY Copyright e 1985 The American Fertility Society
Familial ciliary dyskinesis: a cause of infertility without
respiratory disease
Anwar Moryan, M.D. Andre T. Guay, M.D. * Sanford Kurtz, M.D. Peter J. Nowak, B.S.t Section of Endocrinology and Department of Laboratory Medicine, Lahey Clinic Medical Center, Burlington, Massachusetts
The clinical constellation of chronic sinusitis, bronchiectasis, situs inversus, and defective microciliary transport is called Kartagener's syndrome. Men were found to have immotile but live sperm and specifically an abnormal ultrastructure of the sperm tails by electron microscopy, which was seen as absent or defective dynein arms. The same defect has been found in electron microscopic studies of both the nasal mucosal cilia and sperm tails. This was confirmed in patients not only with Kartagener's syndrome but also in patients who have chronic sinopulmonary infections without situs inversus. Thus the name of immotile cilia syndrome was recommended. l Another variation was observed in three siblings who had chronic respiratory disease but of whom only one had situs inversus. 2 Electron microscopic examination showed lack of radial spokes along with eccentric pairs of tubules in both the sperm and nasal mucosa. Because abnormal cilia may retain some motility, ciliary dyskinesis was proposed as a more accurate term, especially after the discovery of other structural abnormalities, such as transposition of ciliary microtubules,3 which was seen in two siblings in whom the cen-
Received March 14, 1985; revised and accepted June 10, 1985. *Reprint requests: Andre T. Guay, M.D., Section of Endocrinology, Lahey Clinic Medical Center, 41 Mall Road, Burlington, Massachusetts 01805. tPresent address: Department of Pathology, Tufts University Medical School, Boston, Massachusetts. Vol. 44, No.4, October 1985
tral doublet was absent, especially in the distal portion of the nasal cilia or sperm tail. Approximately 10% of the sperm were motile even with this defect; Subtypes of ciliary dyskinesis are listed according to the pathologic defects: type 1, defective dynein; type 2, defective radial spokes; and type 3, transposition of peripheral microtubules. 3 In a recent report,4 a patient with ciliary dyskinesis and no evidence of chronic sinobronchial disease had a semen analysis within normal limits except for lack of motility and a high percentage of abnormal forms (± 70%). Supernumerary microtubules, double axonemas, overabundant fibrous sheath, axonemal disorganization, abortive tail formation, and lack of a mitochondrial sheath were seen on electron microscopy. Results ofbiopsy of the testes were unremarkable. Preceding the report by McClure et aI., 4 Baccetti et al. 5 reported the case of one man with immotility of sperm without respiratory disease; the only defect described was absence of the central dQublet. We present the cases of two brothers with ciliary dyskinesis but without respiratory disease to show that this phenomenon can occur in a familial setting. CASE REPORTS CASE 1
A 30-year-old man was seen because of primary infertility of 4 years' duration. Evaluation of his Moryan et aL Communications-in-brief
539
Table 1. Semen Characteristics of Brothers with Ciliary Dyskinesis Case
Abnormal forms %
1 2
70 40
36 22
Sperm count x
]06
11
12 32 26
Motility
Viabil· ity
%
%
1 1 1 1
88 44
wife did not reveal any contributory factors. Three years before being seen at the Lahey Clinic, the patient had had ligation of a left varicocele. Before this surgical procedure, the patient had sperm counts> 20 x 10B/ml and had constant motility readings of between 0% and 2%. These values did not change after the ligation even after 6 months of treatment with clomiphene citrate and after an empiric course of corticosteroid agents. The patient's past medical history did not reveal sinus disease, bronchiectasis, or any other pulmonary infections. The family history was also negative for these conditions. Physical examination revealed normal findings. Genital examination did not reveal recurrent varicoceles, and the testes measured 4 x 2.5 cm and were of normal consistency. Results of laboratory studies on the blood and urine were within normal limits. Serum levels of luteinizing hormone, folliclestimulating hormone, prolactin, testosterone, thyroxine, urinary hydroxysteroids, and ketosteroids were normal. Semen analyses are listed in Table 1. CASE 2
The 23-year-old brother of the patient whose case was just described had been married only 6 months and was not actively attempting fertility. Past medical history did not reveal sinobronchial disease. Results of recent physical and genital examinations were normal. Results of semen analysis were similar to his brother's findings (Table 1). MATERIALS AND METHODS HORMONAL ASSAYS
All hormonal assays were performed in the laboratory with standard radioimmunoassay kits. Viability staining was performed on the semen with eosin. The reagent used was 0.5% eosin Y 540
Moryan et aI. Communications· in· brief
stain. Two drops of cold stain were mixed with two drops of semen and were incubated for 2 minutes in a water bath at 37°C. Two hundred sperm were counted. Living sperm do not accept the dye, whereas dead sperm stain pink. The normal value is ~ 65% viability. ELECTRON MICROSCOPY
Immediately after an aliquot of semen was collected, it was placed in Karnovsky's buffered fixative. The specimen was spun down at 2000 rpm in a conical test tube for 15 minutes. The supernatant was removed, and a 25% gelatin solution was added to form a solid pellet. The pellet was cut into 1-mm pieces, placed in Karnovsky's fixative for 1 hour, and washed in 0.2 M cacodylate buffer, pH 7.4. It was postfixed in osmium tetroxide (1 %), dehydrated, and embedded in Poly sciences Polybed 812 medium (Poly sciences Inc., Warrington, PA). Sections were examined under a Philips 300 electron microscope (Philips Electronics, Eindhoven, The Netherlands).
RESULTS
Electron microscopic examination of specimens from both patients showed intact dynein arms and radial spokes. The main defect involved multiple abnormalities of microtubular arrangement. The central doublet was absent in both patients, and peripheral microtubular translocation was apparent in both patients (Fig. 1). One brother (case 1) had some sperm with peripheral doublets in the appropriate position but had two extra doublets. The other patient (case 2) had sperm with only eight peripheral doublets and two extra doublets. The sections examined from both brothers showed various microtubular disarray, but the findings were largely limited to the doublets. DISCUSSION
The electron microscopic findings were similar in both brothers, suggesting the idea of a familial nature of this defect. Although the ultrastructural defects of Kartagener's syndrome and its variants are known to be inherited, our report appears to be the first that supports an inherited defect of sperm tails in patients who have not had sinobronchial disease. In the absence of respiratory disease, we did not believe that performance of nasal ciliary biopsy was justified. Baccetti et Fertility and Sterility
c.......
A
c
Figure 1 (A), Cross-section of sperm tail with absence of central doublet and translocation of existing doublet. Longitudinal columns and outer dense fibrils appear normal. (B), Cross-section of sperm tail with absence of central doublet. (C), Cross-section of normal control with proper arrangement of nine pairs of outer microtubules and one central pair.
al. 5 studied the nasal cilia in a patient with absent central doublets in the sperm tails, however, and found the nasal cilia perfectly normal. We presumed our patients would show similar features. The importance of a familial pattern is reinforced because of a report by Williamson et al.,6 who suggested that ultrastructural defects in sperm tails may be acquired. In the absence of respiratory disease, the implications were made because of antisperm antibodies, testicular injury, or genitourinary tract infection. One of the patients in the report by Williamson et a1. 6 showed some normal sperm tails, which is unusual but not impossible and may indicate the need for a more thorough study. Other abnormalities included absence of central doublets and supernumerary doublets, which is similar to findings in our patients. Although acquired defects have not been ruled out, it is possible that at least two of the patients of Williamson et al. 6 had a familial defect with later testicular injury, which was coincidental. It is interesting to speculate that if an acute episode can cause structurally abnormal sperm, these changes may be reversed after the offending episode has been resolved, especially in the presence of severe genitourinary tract infections. Although this theory is intriguing, more investigation is needed, especially in correlation of structural abnormalities to function. In our patients, the similarity of the defects in the siblings and the complete absence of sinopulmonary and genitourinary or testicular disease or both are consistent with a familial defect of ultrastructural formation of the sperm tail. Obviously, a wide spectrum of ultrastructural defects and a wider association of these defects with various Vol. 44, No.4, October 1985
clinical conditions are possi.ble. Studies of further detailed electron microscopic observations will have to be analyzed before the entire picture is better understood. Apart from a list of subpopulations of defects, the question of relating structural defects to function remains. Because the absence of outer dynein arms may not inhibit sperm motility, structural defects and loss offunction must be equated cautiously. This is especially important in the appropriate assessment of fertility potential. SUMMARY
Two brothers were found to have primary infertility and nonmotile sperm secondary to ultrastructural defects, which included absent central doublets and peripheral microtubular translocation. No personal or family history of sinobronchial disease was obtained. Although sporadic cases of this type of ciliary dyskinesis have been reported, our patients constitute the first known occurrence of familial association. REFERENCES 1. Eliasson R, Mossberg B, Camner P, Afzelius BA: The immotile-cilia syndrome: a congenital ciliary abnormality as an etiologic factor in chronic airway infections and male sterility. N Engl J Med 297:1, 1977 2. SturgessJM, ChaoJ, WongJ, Aspin N, TurnerJAP: Cilia with defective radial spokes: a cause of human respiratory disease. N Engl J Med 300:53, 1979 3. Sturgess JM, Chao J, Turner JAP: Transposition of ciliary microtubules: another cause of impaired ciliary motility. N Engl J Med 303:318, 1980 4. McClure RD, Brawer J, Robaire B: Ultrastructure of immotile spermatozoa in an infertile male: a spectrum of structural defects. Fertil Steril 40:395, 1983
Moryan et aL Communications-in-brief
541
5. Baccetti B, Burrini AG, Maver A, Pallini V, Renieri T: "9 + 0" immotile spermatozoa in an infertile man. Andrologia 11:437, 1979
542
Moryan et al.
Communications-in-brief
6. Williamson RA, Koehler JK, Smith WD, Stenchever MA: Ultrastructural sperm tail defects associated with sperm immotility. Fertil Steril 41:103, 1984
Fertility and Sterility