Genetic Reproduction

Eva Diah Setijowati

Infertility : Definition
y

y
y
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)
,
)
About 15% of couples do not achieve
pregnancy within 1 year and seek medical
t e tment for
treatment
fo infertility
infe tilit
Infertility affects both men and women.
Affect one in six couples
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

Congenital
anomalies
y Tubal occlusion
y Evaluated by:
y

hysterosalpingogram
laparoscopy
hysteroscopy

May occur as
sequelae of
PID
endometriosis
abdominal/pelvic
surgery
peritonitis
it iti

Male factor
y
y

Male partner should be evaluated

simultaneously
im lt neo l with
ith fem
female
le
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)
genetic abnormalities
g
testicular or pituitary cancer

Male Reproductive Organs

Normal Sperm Morphology

Abnormal Morphology

Abnormal Morphology

History
y and Physical
y
- Female
y

History
menarche
menarche, puberty
menstrual hx
preganancies,
abortions birth control
abortions,
dysparenunia,
dysmenorrhea
STD
STDs
s, abdominal surg,
surg
galactorrhea
Weight loss/gain
Stress,
Stress exercise
exercise, drugs,
drugs
alcohol, psychological

Physical
weight/BMI
thyroid
skin (striae?
Acanthosis
nigracans?)
p
pelvic ((vaginal
g
mucosa, masses,
pain)
rectal (uterosacral
nodularity)

History and Physical - Male

y

History
prior fertility
f
l
medications
h/o diabetes, mumps,
undescended testes
genital surgery, trauma,
infections
ED
drug/alcohol use, stress
underwear, hot tubs,
frequent coitus

Physical
habitus
habitus,
gynecomastia
sexual development
testicular volume
(5x3 cm)
epididymis,
p
y
, vas,,
prostate by palpation
check for varicocele

Normal Values for SA

2.0
2 0 ml or more
Volume
Sperm Concentration 20 million/ml or more
50% forward p
progression
g
Motility
25% rapid progression
Liquification in 30-60 min
Viscosity
30% or more normal
Morphology
forms
pH
7.2-7.8
72 78
WBC
C
Fewer than 1 million/ml

It is important to distinguish between the

following:
Oligozoospermia: < 15 million
spermatozoa/mL.
Asthenozoospermia:
A th
i < 32% motile
til
spermatozoa.
y Teratozoospermia: < 4% normal forms.
forms

Ab
Abnormal
l Semen
S
A
Analysis
l i
y

Azospermia
Klinefelters (1 in
1000)
Hypogonadotropic
Hypogonadotropichypogonadism
Ductal obstruction
(absence of the Vas
deferens)

Oligospermia
g p

Anatomic defects
Endocrinopathies
Genetic factors
Exogenous (e.g.
heat)

Abnormal volume
Retrograde
ejaculation
Infection
Ejaculatory failure

Evaluation of Abnormal SA
Repeat semen analysis in 30 days
y Physical examination
y

Testicular size
Varicocele
y

Laboratory
y tests
Testosterone level
FSH (spermatogenesis- Sertoli cells)
LH (testosterone(t t t
L di cells)
Leydig
ll )

Referral to urology

Assisted
A
i t dR
Reproductive
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

2 Pronuclei (2PN)

1 day
y 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
y
y
y

Freeze Embryos
Donate For Research/Stem Cells
Embryo Adoption
Discard
i
d

Special IVF Procedures

y
y
y
y
y
y

Assisted hatching
Intracytoplasmic sperm injection
(ICSI)
Preimplantation genetic diagnosis
(
(PGD)
)
Freezing
Egg
gg donation
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 removed
d 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

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

y
y

Sex chromosome anomalies

-Numerical
Numerical :ex : 47
47,XXY
XXY , 45 X
-Structural :ex : deletions of X or Y
Autosomal chromosome anomalies
-Structural :ex : Translocations
Single
g G
Gene d
disorders
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
y
y
y
y

Sex chromosome anomalies

-Numerical :ex : mosaics XY/XXY or X/XX
Autosomal chromosome anomalies
-Structural :ex : translocations, inversions
Single Gene disorders
-autosomal
t
ld
dominant
i
t :Steinert
St i
tM
Myotonic
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
AHC gene(XLR
(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)

IV Outflow tract
Androgene receptor gene(AR)

Cont

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 (812%) 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