Genetic Reproduction

Eva Diah Setijowati

Infertility : Definition
y Infertility is the inability of a sexually
active,
ti e non
non-contracepting
ont epting couple
o ple to
achieve pregnancy in one year
(
(WHO.,2000)
, )
y About 15% of couples do not achieve
pregnancy within 1 year and seek medical
t e tment for
treatment fo infertility
infe tilit
y Infertility affects both men and women.
y Affect one in six couples
y A physical cause can be identified in 90%
of cases: 30% in males, 60% in females
Causes of Infertility
y
Female Reproductive Organs
 Physiology
y gy

FSH E2
(+) ()
(-)

Developing follicle

FSH=Follicle
FSH F lli l Stimulating
Sti l ti Hormone
H E2=Estradiol
 Effects of Aging
g g on the Ovaryy

FSH E2
((+)) ((-))

FSH=Follicle Stimulating Hormone E2=Estradiol

Tubal/ Pelvic pathology
y Congenital y May occur as
anomalies sequelae of
PID
y Tubal occlusion
endometriosis
y Evaluated by: abdominal/pelvic
hysterosalpingogram surgery
laparoscopy peritonitis
it iti
hysteroscopy
Male factor
y Male partner should be evaluated
simultaneously
im lt neo l withith fem
femalele
y Causes of male infertility:
reversible
e e s b e conditions
co d t o s (varicocele,
( a coce e, obstructive
obst uct e
azoospermia)
not reversible, but viable sperm available
((ejaculatorydysfunction,
j y y , inoperative
p obstructive
azoospermia)
not reversible, no viable sperm (hypogonadism)
g genetic abnormalities
testicular or pituitary cancer
Male Reproductive Organs
Normal Sperm Morphology
Abnormal Morphology
Abnormal Morphology
 History
y and Physical
y - Female
y History y Physical
menarche
menarche, puberty weight/BMI
menstrual hx
thyroid
preganancies,
skin (striae?
abortions birth control
abortions,
Acanthosis
dysparenunia,
dysmenorrhea nigracans?)
STD
STDs
s, abdominal surg,
surg ppelvic ((vaginal
g
galactorrhea mucosa, masses,
Weight loss/gain pain)
Stress,
Stress exercise
exercise, drugs,
drugs rectal (uterosacral
alcohol, psychological nodularity)
History and Physical - Male
y History y Physical
prior fertility
f l habitus
habitus,
medications gynecomastia
h/o diabetes, mumps, sexual development
undescended testes testicular volume
genital surgery, trauma, (5x3 cm)
infections epididymis,
p y , vas,,
ED prostate by palpation
drug/alcohol use, stress check for varicocele
underwear, hot tubs,
frequent coitus
Normal Values for SA
Volume 2.0
2 0 ml or more
Sperm Concentration 20 million/ml or more
Motility 50% forward p progression
g
25% rapid progression
Viscosity Liquification in 30-60 min
Morphology 30% or more normal
pH forms
WBCC 7.2-7.8
72 78
Fewer than 1 million/ml
It is important to distinguish between the
following:
Oligozoospermia: < 15 million
spermatozoa/mL.
Asthenozoospermia:
A th i < 32% motiletil
spermatozoa.
y Teratozoospermia: < 4% normal forms.
forms
Ab
Abnormal
l Semen
S A
Analysis
l i
y Azospermia y Oligospermia
g p
Klinefelters (1 in Anatomic defects
1000) Endocrinopathies
Hypogonadotropic
Hypogonadotropic- Genetic factors
hypogonadism
Exogenous (e.g.
Ductal obstruction heat)
(absence of the Vas
deferens) y Abnormal volume
Retrograde
ejaculation
Infection
Ejaculatory failure
Evaluation of Abnormal SA
y Repeat semen analysis in 30 days
y Physical examination
Testicular size
Varicocele
y Laboratory
y tests
Testosterone level
FSH (spermatogenesis- Sertoli cells)
LH (testosterone-
(t t t L di cells)
Leydig ll )
y Referral to urology
Assisted
A i t dRReproductive
d ti Technologies
T h l i
(ARTs)

- Intrauterine insemination
- Surrogate motherhood
- In vitro fertilization (IVF)
- Gamete intrafallopian transfer (GIFT)
- Zygote intrafallopian transfer (ZIFT)
- Oocyte banking and donation
- Preimplantation genetic diagnosis
In Vitro Fertilization (IVF)
Egg Retrieval
Egg Retrieval
Fertilization
F tili ti
Fertilization

y 2 Pronuclei (2PN)

y 1 dayy after egg

gg
retrieval
Embryo Transfer
Embryo Transfer
How
o Many y Embryos
yo are
Transferred?

y Related to age and embryo quality

<35 = 2
35-37 = 2-3
38-40 = 3-4
>40
40 = up to 5

For patients with 2 or more failed IVF

cycles, or a poor prognosis, can add more
based on clinical judgment
What Happens
pp to the Other
Embryos?

y Freeze Embryos
y Donate For Research/Stem Cells
y Embryo Adoption
y Discard
i d
Special IVF Procedures
y Assisted hatching
y Intracytoplasmic sperm injection
(ICSI)
y Preimplantation genetic diagnosis
(
(PGD) )
y Freezing
y Egg
gg donation
y Surrogacy
Assisted Hatching
In vitro Fertilization (IVF)
For in vitro fertilization, a sperm fertilizes an
oo te in a culture
oocyte lt e dish
di h
Embryos are transferred to the oocyte
donors
donor s uterus (or a surrogates
surrogate s uterus) for
implantation
1978: First IVF child born (Louise Joy
B
Brown))
- Since then, 4 million IVF children
Intracytoplasmic sperm injection (ICSI) is
more effective than IVF alone
Intracytoplasmic
y p Sperm
p Injection
j

For cases in which sperm cannot penetrate

the oocyte, IVF can be accompanied by
ICSI which injects sperm directly into the
oocyte

ICSI allows conception in cases of low

sperm count, abnormal sperm shape,
sperm
p motility
y problems,
p ,
- And in cases where male has spinal
cord injuries and cannot ejaculate
Intracytoplasmic Sperm Injection

Figure 21.3
Preimplantation Genetic
Diagnosis (PGD)
This PGD techniq
technique
e allo
allows
s detection of
genetic and chromosomal abnormalities
prior to implantation
p p

One cell or blastomere of an 8-celled

embryo
b can be
b removedd for
f testing
t ti
- The remaining cells will complete
normal development

About 29% success rate

Preimplantation Genetic
Diagnosis (PGD)
1989: First children who had PGD
- Used to select females who could not
inherit X-linked disease from mother
1992: First child born following PGD to
screen for cystic fibrosis allele present in
her family
PGD can be
b combined
bi d with
ith IVF for
f women
who have had multiple miscarriages
Preimplantation Genetic
Diagnosis (PGD)
GENETIC DISORDERS IN
INFERTILITY
y Chromosomal abnormalities
Sperm chromosomal abnormalities
Sex chromosome abnormalities (Klinefelters syndrome
and variants [47,XXY;
[47 XXY; 46,XY/
46 XY/ 47,XXY
47 XXY mosaicism])
Autosomal abnormalities
Translocations
y G
Genetic
i defects
d f
X-linked genetic disorders and male fertility
Kallmanns syndrome
Mild Androgen Insensitivity syndrome
Other X-disorders
Primary
y Infertility
y and Genetics
y Sex chromosome anomalies
-Numerical
Numerical :ex : 47
47,XXY
XXY , 45 X
-Structural :ex : deletions of X or Y
y Autosomal chromosome anomalies
-Structural :ex : Translocations
y Single
g G Gene ddisorders
so d s
-autosomal dominant : Steinert Myotonic
Dystrophy in males
-autosomal
t l recessive
i :Cystic
C ti Fib
Fibrosis
i
-X-linked :Androgen Resistance
Secondary Infertility and Genetics
y Sex chromosome anomalies
y -Numerical :ex : mosaics XY/XXY or X/XX
y Autosomal chromosome anomalies
y -Structural :ex : translocations, inversions
y Single Gene disorders
-autosomal
t ld
dominant
i t :Steinert
St i tMMyotonic
t i
Dystrophy in females
-autosomal recessive :Sickle cell anaemia
-X-linked :Fragile X syndrome
Genetic causes of Male and Female
I f tilit
Infertility:
I Hypothalamic
KAL1 gene(XLR hypogonadotrophic
hypogonadism in males)
AHC gene(XLR
AHC (XLR cong.adrenal
d l hypoplasia
h l i
in males)
II Pituitary
GNRHR gene(AR gonadotrophin
releasing hormone receptor)
FSHgene, LHand hCGgene complexe
Successful therapy for pituitary causes =
replace missing trophic factor (LH, FSH)
 Cont
III Gonadal(major factor)
Genes
involved in Gonadotrophin receptors
receptors, steroid
hormone receptors, steroid synthesis (poor
prognosis donor), autosomal genes (SOX9,
WT1 can cause sexuall ambiguity+infert.)
bi it i f t )
X Chromosomal causes :
-whole X deletions (45,X cell line with/without
mosaicism (46,XY/ 46,XX/ 47,XXX), when
fertile beware POF -partial X deletions (Xp11,
Xp21 Xq13 putative POF1 region,
Xp21, region Xq26
putative POF2 region
-X;autosome translocations (rare)
 Cont
IV Outflow tract
Androgene receptor gene(AR)
46,XY male with androgene insensitivity
female phenotype)
CFTR gene: cystic fibrosis (AR)
congenital bilateral absence of vas deferens
found in 1-2 % infertile males, around 90% of
which carry one or two CFTR mutations :
normal but immotile testicular sperm
reproduction by biopsy+ICSI.
Test partner + Genetic counseling, other family
members at risk?
HOXA 13 gene
only known single gene causing uterine
anomalies
In male:
Chromosomal abnormality 15 % (azoo),
5 % (oligo)
De novo deletion of azoosp factor region
(AZF) 13% (a/oligo)
Cong.
C Bilat.
Bil t Abs.
Ab off vas deferens
d f (CBAVD)
1-2% (azoo)
Currently Gene and Chromosomal
abnormalities are known to affect count
and
a d motility,
ot ty, yet unknown
u o gene
ge e mutations
utat o s
are expected to affect morphology
Y chromosome and male infertility
y
Clinical implications of Y microdeletions
o The highest frequency is found in azoospermic men (8-
12%) followed
f ll d by
b oligospermic
li i (3-7%)
(3 7%) men
o The most frequently deleted region is AZFc
(approximately 65-70%), followed by deletions of the
AZFb and AZFb+c or AZFa+b+c regions (25-30
(25 30 %)
whereas deletions of the AZFa region are extremely rare
(5%)
o The complete removal of the AZFa and AZFb regions are
associated with severe testicular phenotype, Sertoli Cell
Only syndrome and spermatogenic arrest
o The complete removal of the AZFc region causes a
variable phenotype which may range from azoospermia
to oligozoospermia
Autosomal defects with severe
phenotypic abnormalities and
infertility
Genetic Consultation in Infertility
Genetic testing
Identify the etiology
Identify
d f syndromic
d causes off reproduction
d failure
f l

Genetic counseling
Implications of syndromic causes
Other family members at risk? Offer counseling
Expose
E reproduction
d ti options
ti (d
(donor, adoption),
d ti ) ART
methods (Artif.reprod.techniques): IVF, ICSI, chances
of success, technique, limits, genetic risks
Prenatal Diagnosis
Risk / implications of transmission (ex. Y
microdeletion))
Psychological and ethical implications