Non-mosaic Klinefelter Syndrome Research Articles

Differences in clinical outcomes between men with mosaic Klinefelter syndrome and those with non-mosaic Klinefelter syndrome.

This study compared the clinical outcomes of men with Klinfelter syndrome based on karyotype. The authors analyzed the outcomes of microdissection testicular sperm extraction (micro-TESE) performed on 57 patients with Klinfelter syndrome (KS) at our clinic. The average ages of the non-mosaic and mosaic KS groups were 32.2 ± 4.8 and 45.9 ± 13.1 years, respectively. The sperm retrieval rates of the non-mosaic and mosaic KS groups were 46.5% (20/43) and 50.0% (7/14), respectively. The fertilization rates after intracytoplasmic sperm injection did not significantly differ between the non-mosaic and mosaic KS groups. The mosaic KS group had higher cleavage and blastocyst development rates than the non-mosaic KS group (72.2% vs. 96.2% and 30.5% vs. 44.7%, respectively). The group using motile sperm had better outcomes than the group using immotile sperm. The embryo transfer outcomes of the non-mosaic and mosaic KS groups did not significantly differ (clinical pregnancy rate: 28.0% vs. 20.7%, miscarriage rate: 14.3% vs. 33.3%, production rate per transfer: 22.0% vs. 13.8%, and production rate per case: 58.8% vs. 57.1%). Compared with the non-mosaic KS group, the mosaic KS group had significantly better intracytoplasmic sperm injection outcomes because of the higher utilization rate of motile sperm.

O-140 studying the effect of mosaicism on the outcome of micro-TESE among Klinefelter syndrome patients

Abstract Study question Does mosaicism affect sperm retrieval rate in Klinefelter patients? Summary answer Patients with mosaic Klinefelter syndrome (KS) have a higher success rate of sperm retrieval than those with non-mosaic KS. What is known already Klinefelter syndrome is characterised by the presence of an extra X chromosome in male individuals leading to a 47XXY karyotype and rarely to 46XY/47XXY Mosaicism; it is the most common sex chromosomal aneuploidy and the most common genetic cause of Azoospermia (Kanakis GA et al., 2018 and Gravholt CH et al.,2018). It accounts for 3–4% of male infertility cases and 10–12% of men with Azoospermia (Winters SJ,2018). Study design, size, duration After approval of the ethical committee of the faculty of medicine at Cairo University, This prospective study was conducted where 70 men who complained of primary infertility and azoospermia and were diagnosed with Klinefelter Syndrome were recruited for this study between 1/11/2021 and 30/11/2022. Patients with previous testicular disease (torsion, trauma) or who had a history of undescended testes or received chemotherapy or radiotherapy were excluded. Participants/materials, setting, methods Seventy patients (n = 70) aged between 20 and 50 who fit the inclusion criteria were recruited and underwent micro_TESE. Semen analysis (Azoospermia), hormonal profile, scrotal colour doppler ultrasonography, Karyotyping and FISH for Y and X chromosomes were performed. Statistical analysis was conducted using SPSS 22nd edition. Main results and the role of chance Our study groups comprised 14 patients with mosaic KS and 56 with non-mosaic KS. The clinical characteristics were not significantly different statistically between the two groups. Micro_TESE was performed in all 70 patients; in 26 patients (37.1%), mature sperm were found in the wet preparation. No statistically significant correlation was found between the presence of spermatozoa in the extraction specimen and age, serum follicle-stimulating hormone, serum testosterone, prolactin or oestradiol. The statistically significant predictor variable for sperm extraction was mosaicism, luteinising hormone, testicular volume and FISH. The sperm retrieval rate of the patients with mosaic and non-mosaic KS was 57.1% and 32.1%, respectively. Limitations, reasons for caution 1) Larger (n) number of patients was needed. 2) Despite our valuable findings, further studies should be performed to illuminate the relation between FISH for X and Y chromosomes and sperm retrieval rate success. Wider implications of the findings Klinefelter patients with mosaicism should be offered high sperm retrieval rate during IVF counselling. Trial registration number n/a

P-097 Embryological and Clinical Outcomes of Microdissection testicular sperm extraction combined with Intracytoplasmic sperm injection (microTESE-ICSI) in patients with and without Klinefelter syndrome

Abstract Study question This retrospective study aims to identify the embryo development and clinical outcomes in non-mosaic Klinefelter syndrome patients treated with microTESE-ICSI Summary answer Non-mosaic Klinefelter patients can retrieve their sperm using microTESE and can have their biological offsprings by combining microTESE with ICSI What is known already Klinefelter syndrome patients are classified into two main groups, namely non-mosaic Klinefelter (47, XXY) and mosaic Klinefelter (46, XY/47, XXY). To retrieve sperm from non-mosaic Klinefelter, microTESE is a crucial treatment that yields a successful rate of approximately 50%. Recent research reports that microTESE-ICSI is a treatment regime that brings a higher in-vitro fertilization (IVF) success rate for those with non-mosaic Klinefelter syndrome. However, most of the previous studies on this group focuses on sperm retrieval rate and male factors. Few studies have reported embryo development and clinical outcomes, especially, under the adjustment for female partner’s age and oocyte quantity Study design, size, duration This retrospective study was conducted to evaluate spermatozoa retrieval, embryo development, and clinical outcomes in 931 patients with microTESE treatment at Andrology and Fertility Hospital of Hanoi from 6/2019 to 9/2022. Patients were divided into two groups including 118 patients with non-mosaic Klinefelter syndrome (KS) and 813 patients without Klinefelter syndrome (non-KS). Participants/materials, setting, methods In 931 patients, 63 KS and 417 non-KS had spermatozoa retrieved from microTESE were carried out ICSI. In ICSI group, 59 KS and 319 non-KS patients whose partners were under 35 years old were selected to compare embryological and clinical outcomes. Outcomes included fertilization rate, day 3 usable embryo rate, usable blastocyst rate, pregnancy rate (positive beta-hCG test), biochemical pregnancy rate, ongoing pregnancy, and live-birth rate (calculated on the total number of IVF cycles). Main results and the role of chance Spermatozoa retrieval rate by microTESE in the KS group was 53.4% (63/118), while this rate in the non-KS group was 51.2% (417/813) (p > 0.05). The mean age of female partners was significantly lower in the KS group than in non-KS group (26.6 ± 4.0 vs. 28.0 ± 3.5; p = 0.006). The mean of mature oocytes between these two groups was similar (15.7 ± 8.1 vs 14.5 ± 7.2; p > 0.05). Fertilization rates in KS and non-KS groups were 62.7% and 65.3%, respectively. Day 3 usable embryo rate (embryo with over 6 blastomeres at day 3) in two groups was not significantly different (69% vs 69.5%, p > 0.05). Usable blastocyst rate (embryo quality is over 2BB, Gardner grading system) in the KS group (19.9%, n = 54) was significantly lower than in non-KS group (41.1%, n = 281) (p < 0.001). Pregnancy rate and biochemical pregnancy rate were 75.9% and 6.9% in KS group (n = 58), respectively. Those rates were 81.5% and 3.2% in non-KS group (n = 313), respectively. There was no significant difference in ongoing pregnancy rate between these two groups (61.1% vs 74.5%; p > 0.05). Live-birth rate in the KS group was 43.2% (16/37), while this rate in the non-KS group was 46.5% (67/145). Limitations, reasons for caution This research had limitations of a retrospective study. Male hormonal factors and baby health could not be thoroughly measured because of difficulties in contact with patients at the time of the study. Besides, day 3 top-quality embryos were directed to freeze, so usable blastocyst rate was low in this study. Wider implications of the findings These data confirmed that microTESE provides opportunities for non-mosaic Klinefelter syndrome patients to retrieve their own sperm. Combination of microTESE and ICSI is an effective treatment regimen that helps these patients to have their own usable embryos and babies. Trial registration number not applicable

O-139 Testicular mosaicism in non-mosaic Klinefelter Syndrome patients with focal spermatogenesis

Abstract Study question Do testis-specific cells have a normal karyotype in regions with spermatogonia (SPG) and ongoing spermatogenesis in non-mosaic Klinefelter Syndrome (KS) patients? Summary answer While SPG and Sertoli cells (SC) have 46,XY karyotype in regions with spermatogenesis, most Leydig cells (LC) and peritubular myoid cells (PTMC) have 47,XXY karyotype. What is known already Although the majority of non-mosaic KS patients is azoospermic, some patients with focal spermatogenesis (FS) can have children with artificial reproductive technologies. However, the genetic origin of FS is unknown. Independent of FS, dimorphism in sex chromatin has been reported amongst the seminiferous tubules of KS men. However, the karyotype of testis-specific cells in FS regions and other regions has not been clearly revealed so far. The histone-3-lysine-27-tri-methylation (H3K27me3) modification is involved in suppression of the extra X chromosome, and its immunohistochemical staining allows the analysis of the X chromosome aneuploidy. Study design, size, duration Testicular biopsies were taken from 7 patients in whom spermatozoa were found by testicular sperm extraction (TESE). Muscle cells of female colon samples were used as positive control. Participants/materials, setting, methods After tissue processing and paraffine embedding, sections were cut at 5 µm. Immunohistochemical staining was performed with antibodies for H3K27me3 (inactive X chromosome), and MAGE-A4 (SPG), SOX9 (SC) and CYP17A1 (LC). PMTC was evaluated according to their position around the tubules and elongated shape. Inactive X (Xi) positive (Xi+) and Xi negative (Xi-) cells were counted and, Xi+ cells were evaluated as having the 47,XXY karyotype; Xi- cells were evaluated as having the 46,XY karyotype. Main results and the role of chance A total of 25 SPG+ tubule sections were detected in 4 of 7 samples. Both SPG and SC were Xi-, i.e. 46,XY karyotype, in all of these tubules. In some of the Sertoli cell only (SCO) tubules, SCs were Xi+ (i.e. 47,XXY), while in others they were Xi- (i.e. 46,XY). The rate of Xi+ SC in SCO tubules containing Xi+ SCs was 31.6%. Similarly, the Xi+ ratio in muscle cells in the positive control was 31.0%. PTMCs surrounding tubules with SPG present, or ongoing FS were Xi+ (i.e. 47,XXY). LCs were Xi+ (i.e. 47,XXY) around all tubules. However, the percentage of Xi+ PTMCs (21.4%) and LC (24.6%) was low compared to the female control (31.0%), suggesting mosaicism for these cells as well. Limitations, reasons for caution The fact that not all of the cell nuclei coincide with the section plane and the cells are in the mitotic stage limit the detection of Xi with H3K27me3. To overcome this limitation, X chromosome analysis could be performed by different techniques on intact cells isolated from fresh tissue. Wider implications of the findings FS occurs only in tubules with 46,XY SPGs and 46,XY SCs. Non-mosaic 47,XXY (diagnosed on blood cells) KS patients may present with testicular mosaicism, increasing their chances for sperm retrieval. Trial registration number Not applicable

Repeat Microdissection Testicular Sperm Extraction in Azoospermic Men with Nonmosaic Klinefelter Syndrome

Introduction. To investigate the predictive factors for successful repeat microdissection testicular sperm extraction attempts in patients with Klinefelter syndrome. Methods. A total of 28 azoospermic men with nonmosaic Klinefelter syndrome who have received microdissection testicular sperm extraction twice with successful initial microdissection testicular sperm extraction attempts in our institute were studied. Outcome variables (age, serum follicle-stimulating hormone, luteinizing hormone, testosterone, prolactin, and estradiol) of azoospermic men with nonmosaic Klinefelter syndrome and a successful 2nd surgical sperm retrieval attempt (group A) were compared to those with an unsuccessful 2nd sperm retrieval attempt (group B). Results. Twenty-one patients (75%) had successful sperm recovery at the 2nd microdissection testicular sperm extraction attempt. The mean testosterone level at baseline and before the 1st microdissection testicular sperm extraction attempt was higher in group A than in group B (2.7 vs. 0.9 ng/mL, p < 0.01 , and 3.9 vs. 1.1 ng/mL, p = 0.02 ). Receiver operating characteristic curve analysis identified the threshold baseline testosterone concentration (1.5 ng/mL) of patients with Klinefelter syndrome in predicting successful 2nd sperm retrieval attempts and revealed positive and negative predictive values of 94.44% and 60%, respectively. Conclusion. Azoospermic men with Klinefelter syndrome presenting with low testosterone levels and successful sperm recovery during the first microdissection testicular sperm extraction procedure are unlikely to retrieve sperm on the 2nd microdissection testicular sperm extraction attempt. Hence, these patients should be properly counseled before sperm retrieval.

Factors influencing the sperm retrieval rate of microdissection testicular sperm extraction in patients with nonmosaic Klinefelter syndrome.

To investigate the factors affecting the sperm retrieval rate of microdissection testicular sperm extraction (micro-TESE) in patients with nonmosaic Klinefelter syndrome (KS), 64 patients with nonmosaic KS who underwent micro-TESE in the Center for Reproductive Medicine of Peking University Third Hospital (Beijing, China) between January 2016 and December 2017 were included in the study. Data on medical history, physical examination and laboratory examination results, and micro-TESE outcomes were collected. Patients were divided into two groups according to micro-TESE outcomes. The following factors were compared between the two groups by the Mann ‒ Whitney U test or Student's t-test based on the distribution (nonnormal or normal) of the factors: age, testicular size, follicle-stimulating hormone level, luteinizing hormone level, testosterone level, and anti-Müllerian hormone level. The overall success rate of sperm retrieval was 50.0%. Correlation analysis showed that testicular volume was positively correlated with testosterone level. Using a logistic regression model, age and anti-Müllerian hormone levels were found to be better predictors for the sperm retrieval rate than the other parameters.

A dual-center study of predictive factors for sperm retrieval through microdissection testicular sperm extraction and intracytoplasmic sperm injection outcomes in men with non-mosaic Klinefelter syndrome.

This study evaluated the predictors of sperm retrieval (SR) in non-mosaic Klinefelter syndrome (KS) patients undergoing microsurgical testicular sperm extraction (mTESE). The cutoff values of the predictors of SR and overall pregnancy rates after intracytoplasmic sperm injection (ICSI) were analyzed for the positive SR (PSR) cases. The study was a dual-center retrospective study. Overall 118 patients with KS underwent mTESE between January 2011 and July 2021. Clinicopathological factors including comorbidities, endocrine profiles, and testicular volumes were analyzed. A total of 58 patients showed PSR (49.2%) and 60 patients (50.8%) had negative SR (NSR). The mean overall age of the patients was 32.5 years. The NSR patients had a significantly greater prevalence of obesity, diabetes mellitus, and cerebrovascular disease. The PSR group had a significantly higher left testis mean volume (p=0.039). The differences between the two study groups regarding follicular-stimulating hormone, luteinizing hormone, and testosterone variations at 1 and 3 months after mTESE were insignificant. Preoperative mean neutrophil-to-lymphocyte ratio was significantly greater in the NSR group (p=0.011), but the platelet-to-lymphocyte ratio showed no significant difference between the two study groups. A live child birth was achieved in 53.4% of the PSR patients. Multivariate logistic analysis showed that total testicular volume >3.93 mL, left testis volume >1.79 mL, and neutrophil-to-lymphocyte ratio ≤1.82 were significantly associated with PSR. mTESE-ICSI is a feasible method for KS patients to have a child, and total testicular volume, left testis volume, and neutrophil-to-lymphocyte ratio might be predictors of successful SR.

Testicular microlithiasis in paediatric patients with Klinefelter syndrome from infancy till adolescence: early start of degenerative process in the testes—preliminary results

To present the results of testicular ultrasonography supported by clinical and hormonal aspects in paediatric patients with Klinefelter syndrome (KS). Prospective analysis of medical files of 20 patients diagnosed with KS between 2016 and 2022. Assessed data included analysis of causes of referral, ultrasound, and clinical characterisation with hormonal evaluation of serum FSH, LH, testosterone, inhibin B, and anti-Müllerian hormone. Non-mosaic Klinefelter syndrome (47, XXY) was diagnosed in 65% of cases (13/20) by the geneticist (including 7 cases prenatally), in 25% (5/20) by the endocrinologist and in 10% (2/20) by the hematologist. Ultrasound assessment revealed bilateral testicular microlithiasis (TM) in all patients. The youngest KS patient with TM was 3 months old. TM patterns have not changed during follow-ups of up to 6 years in any of the patients. In all KS patients markedly reduced echogenicity and in pubertal KS patients, also irregular echostructure of the testes was observed. The hormonal patterns observed in the study group were typical for those already described in KS. Sertoli and Leydig cell function was intact in prepubertal patients and deteriorated after the start of puberty.Conclusion: Although the degenerative process in the testicular tissue starts very early in the testes in KS and is reflected in morphological changes seen in ultrasonography, Sertoli and Leydig cell hormonal function is normal in prepubertal KS patients.What is Known:• So far, normal Leydig and Sertoli cell function was observed in infants and prepubertal KS patients.What is New:• The morphological changes in the testes in KS may already be seen in early infancy.

In vitro propagation of XXY human Klinefelter spermatogonial stem cells: A step towards new fertility opportunities.

Klinefelter Syndrome (KS) is characterized by a masculine phenotype, supernumerary sex chromosomes (47, XXY), and impaired fertility due to loss of spermatogonial stem cells (SSCs). Early testicular cryopreservation could be an option for future fertility treatments in these patients, including SSCs transplantation or in vitro spermatogenesis. It is critically essential to adapt current in vitro SSCs propagation systems as a fertility option for KS patients. KS human testicular samples (13,15- and 17-year-old non-mosaic KS boys) were donated by patients enrolled in an experimental testicular tissue banking program. Testicular cells were isolated from cryopreserved tissue and propagated in long-term culture for 110 days. Cell-specific gene expression confirmed the presence of all four main cell types found in testes: Spermatogonia, Sertoli, Leydig, and Peritubular cells. A population of ZBTB16+ undifferentiated spermatogonia was identified throughout the culture using digital PCR. Flow cytometric analysis also detected an HLA-/CD9+/CD49f+ population, indicating maintenance of a stem cell subpopulation among the spermatogonial cells. FISH staining for chromosomes X and Y showed most cells containing an XXY karyotype with a smaller number containing either XY or XX. Both XY and XX populations were able to be enriched by magnetic sorting for CD9 as a spermatogonia marker. Molecular karyotyping demonstrated genomic stability of the cultured cells, over time. Finally, single-cell RNAseq analysis confirmed transcription of ID4, TCN2, and NANOS 3 within a population of putative SSCs population. This is the first study showing successful isolation and long-term in vitro propagation of human KS testicular cells. These findings could inform the development of therapeutic fertility options for KS patients, either through in vitro spermatogenesis or transplantation of SSC, in vivo.

Preoperative testosterone and follicle stimulating hormone levels are important predictors for sperm retrieval by microdissection testicular sperm extraction in non-mosaic Klinefelter syndrome.

This study aimed to assess outcomes of microdissection testicular sperm extraction (MD-TESE) and identify predictors for sperm retrieval (SR) in patients with non-mosaic Klinefelter syndrome (NM-KFS). We retrospectively evaluated 37 patients with NM-KFS who underwent MD-TESE. Data of age at operation, body mass index (BMI), testicular volume, serum luteinizing hormone (LH), follicle stimulating hormone (FSH), preoperative and postoperative testosterone levels with reduction ratio between the two values, and FSH/preoperative testosterone ratio were analysed. These patients were divided into two groups according to success or failure of SR: the successful and failure groups. Factors related to SR were evaluated by statistical analyses using the Mann-Whitney U test and logistic regression modelling. Regarding these factors, the cut-off level was specified using the receiver operating characteristics (ROC) curve. Moreover, the percentage of SR at that level was assessed. A simple scoring model was developed based on the multivariate analysis. Fourteen patients underwent successful SR, whereas 23 experienced failure SR. Statistical analysis found preoperative testosterone and FSH levels to be significant factors associated with SR. On the ROC curve, the cut-off levels for preoperative testosterone and FSH were 2.34 ng/ml and 33.2 mIU/ml respectively. A new scoring model was developed, consisting of preoperative testosterone (≥2.34 ng/ml) and FSH (≤33.2 mIU/ml). The sperm retrieval rates (SRRs) were clearly discriminated by stratification according to the scoring model. The SRR of the cases of scores of 2, 1 and 0 were 87.5%, 31.6% and 10% respectively. At our hospital, the SRR of MD-TESE in patients with NM-KFS was 37.8%. The patients with high testosterone and low FSH levels tended to demonstrate successful SR.

Successful live birth after intracytoplasmic sperm injection using testicular sperm in non-mosaic Klinefelter syndrome

Successful live birth after intracytoplasmic sperm injection using testicular sperm in non-mosaic Klinefelter syndrome

Monozygotic adult twins with nonmosaic Klinefelter syndrome with different results of sperm retrieval

Klinefelter syndrome and monozygotic twins are both rare. The reports of monozygotic twins with Klinefelter syndrome to have undergone fertility treatment are uncommon. This case report describes a case of 30-year-old monozygotic adult twin brothers diagnosed with nonmosaic Klinefelter syndrome following the complaint of infertility. The result of semen analysis showed cryptozoospermia (very low sperm count) and azoospermia (zero sperm count) with physical findings and lifestyles being very similar. They both underwent microtesticular sperm extraction. One had successful sperm retrieval and achieved pregnancy through intracytoplasmic sperm injection, whereas the other did not. Testicular pathological findings showed Sertoli cell-only syndrome. To the best of our knowledge, this is the first report on monozygotic adult twins both of whom underwent microtesticular sperm extraction and resulted in different outcomes.

The fertility preservation decision-making and testicular sperm retrieval outcome in older adolescents with nonmosaic Klinefelter syndrome and azoospermia.

This study aims to analyze the fertility preservation decision-making and the sperm retrieval rate (SRR) in older adolescents (age 15-19 years) with nonmosaic Klinefelter syndrome (KS) and azoospermia in a male reproductive clinic, and to determine the accumulated SRR in older adolescents by literature review. Older adolescents with nonmosaic KS and azoospermia referred for hypogonadism and fertility concerns were enrolled. Reproductive counseling and fertility preservation options were offered to patients/parents. The acceptability and the reasons affecting the reproductive decision-making were analyzed. Patients/parents who agreed on fertility preservation received microdissection testicular sperm extraction (mTESE) and cryopreservation. A comprehensive literature review regarding the SRRs in older adolescents with KS was conducted. A total of eight older adolescents were enrolled. After fertility preservation counseling, three patients/parents (37.5%) agreed to receive mTESE, and spermatozoa were successfully retrieved in two. "Lack of interest" and "inconsistent sperm retrieval result" were the main reasons for refusal. A total of 89 older adolescents from nine articles, and ours were collected for SRR analysis. Most of the reports had a limited number of cases, and none of them described the acceptance rate of sperm retrieval in adolescents. Forty-three out of 89 older adolescents (48.3%) had successful sperm retrieval, and there was no significant difference in the SRR between the mTESE and conventional TESE. Successful testicular sperm retrieval in older adolescents with KS is not superior to those reported in adults. Adolescents and their parents should undergo a detailed reproductive consultation process and shared decision-making discussion before considering testicular sperm retrieval.

P–038 Clinical outcomes of 77 testicular sperm extraction treatment cycles in non-mosaic Klinefelter syndrome patients

Abstract Study question What are the clinical results of patients with azoospermia and nonmosaic Klinefelter syndrome, using fresh and cryopreserved sperm? Summary answer The results showed a recovery rate of testicular sperm in the order of 40% and a life newborn rate of 52% when using fresh sperm What is known already In Klinefelter syndrome (KS), the rates of successful testicular sperm retrieval were shown to be similar either using conventional TESE or micro-TESE (Corona et al., 2017), which highlights that the variability observed between studies is due to differences in patient characteristics. There are a few works with a large number of KS patients elucidating the clinical outcomes using fresh and cryopreserved testicular sperm. However, these studies revealed contradictory outcomes, either revealing better (Greco et al., 2013; Vicdan et al., 2016) or worst (Madureira et al., 2014) results with cryopreserved testicular sperm, or finding no differences (Chen et al, 2019). Study design, size, duration This study includes all patients up to 2019 presenting azoospermia due to non-mosaic Klinefelter syndrome (n = 76) that went for infertility consultations in a private fertility clinic. Patients were evaluated by the same Urologist. The genetic analysis of the patients was performed at an academic institution. At examination patients did not refer other complaints besides infertility, and referred to have not received any hormone replacement therapy in the past. Participants/materials, setting, methods The 76 azoospermic patients with non-mosaic Klinefelter syndrome (KS) were treated by testicular sperm extraction (TESE) followed by intracytoplasmic sperm injection (ICSI), using fresh and cryopreserved testicular sperm. Most patients used fresh testicular sperm, where others preferred to postpone ICSI treatment cycles and used cryopreserved testicular sperm. Aneuploidy screening in children was performed by prenatal diagnosis and MLPA (Multiplex ligation-dependent probe amplification). Full embryological, clinical and newborn outcomes are provided. Main results and the role of chance Of the 76 patients with non-mosaic Klinefelter syndrome, one repeated the testicular sperm extraction (TESE) procedure. Testicular sperm were recovered in 31/77 (40.3%) of the cases. Comparisons between the 31 cases with successful sperm recover (group–1) and the 46 cases without a successful TESE (group–2) revealed no significant differences regarding age, time of infertility, testicular volume, serum levels of FSH, LH and testosterone, total number of testicular fragments analyzed, and time of search in samples. The mean male age was 34 years. In most of the cases, the testicular volume was reduced (96.1%), the levels of FSH (98.3%) and LH (94.1%) were increased, and the levels of testosterone were normal (77.6%). There were 25 intracytoplasmic sperm injection (ICSI) treatment cycles using fresh testicular sperm and 22 ICSI treatment cycles using frozen testicular sperm. The rates of fertilization (63.5% fresh sperm vs 41.6% frozen sperm), implantation (37% fresh sperm vs 13.2% frozen sperm), clinical pregnancy (60.9% fresh sperm vs 19% frozen sperm), live birth delivery (52.2% fresh sperm vs 19% frozen sperm) and newborn (65.2% fresh sperm vs 23.8% frozen sperm) were higher in the group using fresh testicular sperm. Chromosome analysis of the 21 newborn was normal. Limitations, reasons for caution Although presenting a high number of cases with azoospermic non-mosaic Klinefelter syndrome treated with testicular sperm extraction and intracytoplasmic sperm injection, future studies are needed with a higher number of cycles using frozen testicular sperm, in order to confirm or rebut that the freezing methodology affects negatively the clinical outcomes. Wider implications of the findings: Data adds further information regarding testicular sperm retrieval rates and use of fresh or frozen testicular sperm in Klinefelter syndrome (KS) patients. High newborn rates were obtained only with fresh testicular sperm. Results also reassure KS patients about the safety relative to any abnormal chromosomal transmission to the born children. Trial registration number Not applicable

Contribution of serum anti-M\xfcllerian hormone in the management of azoospermia and the prediction of testicular sperm retrieval outcomes: a study of 155 adult men

BackgroundTesticular sperm extraction (TESE) is the method of choice for recovering spermatozoa in patients with azoospermia. However, the lack of reliable biomarkers makes it impossible to predict sperm retrieval outcomes at TESE. To date, little attention has been given to anti-Müllerian hormone (AMH) serum levels in adult men with altered spermatogenesis. In this study we aimed to investigate whether serum concentrations of AMH and the AMH to total testosterone ratio (AMH/T) might be predictive factors for sperm retrieval outcomes during TESE in a cohort of 155 adult Caucasian men with azoospermia.ResultsAMH serum levels were significantly lower in nonobstructive azoospermia (NOA) that was unexplained, cryptorchidism-related, cytotoxic and genetic (medians [pmol/l] = 30.1; 21.8; 26.7; 7.3; and p = 0.02; 0.001; 0.04; <0.0001, respectively]) compared with obstructive azoospermia (OA) (median = 44.8 pmol/l). Lowest values were observed in cases of genetic NOA (p < 0.0001, compared with unexplained NOA) and especially in individuals with non-mosaic Klinefelter syndrome (median = 2.3 pmol/l, p <0.0001). Medians of AMH/T values were significantly lower in genetic NOA compared to unexplained, cryptorchidism-related NOA as well as OA. Only serum concentrations of AMH differed significantly between positive and negative groups in men with non-mosaic Klinefelter syndrome. The optimal cut-off of serum AMH was set at 2.5 pmol/l. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of this cut-off to predict negative outcomes of SR were 100 %, 76.9 %, 66.6 %, 100 and 84.2 %, respectively.ConclusionsSerum AMH levels, but not AMH/T values, are a good marker for Sertoli and germ cell population dysfunction in adult Caucasian men with non-mosaic Klinefelter syndrome and could help us to predict negative outcomes of SR at TESE with 100 % sensitivity when serum levels of AMH are below 2.5 pmol/l.

Endocrine, sexual and reproductive functions in patients with Klinefelter syndrome compared to non-obstructive azoospermic patients.

We aimed to investigate fertilisation rates, quality of embryo, pregnancy and live birth rates, endocrine, sexual function, psychological status and quality of life of cases diagnosed with Klinefelter syndrome (KS). Clinical findings, hormone values and semen analyses in patients with nonmosaic KS (Group 1, n=121) and those with non-genetic nonobstructive azoospermia (NOA) (Group 2, n=178) were retrospectively analysed. Sperm retrieval outcomes with microdissection testicular sperm extraction (micro-TESE), fertilisation rates and embryo quality, pregnancy, abortion and live birth rates were compared. Sexual functions were assessed using IIEF-15, quality of life was evaluated and psychological status was assessed. There was no difference in terms of age between groups. Sperm retrieval rates was 38% and 55.6% in Groups 1 and 2, respectively (P=.012). Sperm retrieval rates were higher in Group 1 before 31.5years than in Group 2 (AUC=0.620 and 0.578). Compared to Group 2, the fertilisation rate was low in Group 1, whereas embryo quality was similar. Live birth rates were 12.5% and 23% in Groups 1 and 2, respectively (P=.392). The education level, libido, erectile functions and general health satisfaction were lower in Group 1 than in Group 2 (P<.005). Depression and anxiety levels were higher in Group 2 than Group 1 (P<.001). Higher sperm retrieval rate has been achieved in Group 1 younger than 31.5years. Similar embryo quality is provided between groups. Sexual dysfunction and psychiatric problems were higher in Group 1, with lower satisfaction and general health than Group 2. Patients with KS should be monitored not only with their reproductive functions but also with their general health status.

PGT or ICSI? The impression of NGS-based PGT outcomes in nonmosaic Klinefelter syndrome.

This retrospective study demonstrates the clinical outcomes of patients with nonmosaic Klinefelter’s syndrome (KS) who underwent preimplantation genetic testing (PGT) with frozen-thawed testicular spermatozoa. Microdissection testicular sperm extraction (micro-TESE) was performed for sperm retrieval. Next-generation sequencing (NGS) was conducted for embryo analysis. A total of 18 couples aged ≤35 years were included, and 22 oocyte retrieval cycles were completed. Euploidy was detected in 29 of 45 (64.4%) embryos. Additionally, the numbers of aneuploid and mosaic embryos detected were 8 (17.8%) and 8 (17.8%), respectively, regardless of a lack of sex chromosome abnormalities. Finally, 13 couples with euploid embryos completed 14 frozen embryo transfer (FET) cycles. Ten couples had clinical pregnancies, and 6 of them had already delivered 5 healthy babies and 1 monozygotic twin. There were also 4 ongoing pregnancies and 2 biochemical pregnancies, but no early pregnancy loss was reported. Based on our results, we speculate that for KS patients, when sperm can be obtained by micro-TESE, the cryopreservation strategy makes the ovarian stimulation procedure more favorable for female partners. The paternal genetic risk of sex chromosome abnormalities in their offspring is extremely low in men with KS. In addition to PGT, the intracytoplasmic sperm injection (ICSI) procedure is comparably effective but more economical for young nonmosaic KS couples. ICSI should be offered as an option for such couples, but monitoring by prenatal genetic diagnosis is recommended.

Clinical outcomes of 77 TESE treatment cycles in non-mosaic Klinefelter syndrome patients.

ObjectiveThe current study aimed to present the clinical outcomes of 76 azoospermic patients with non-mosaic Klinefelter syndrome (KS), treated with testicular spermatozoa extraction (TESE) followed by intracytoplasmic sperm injection (ICSI) using either fresh or cryopreserved testicular spermatozoa.MethodsWe retrospectively evaluated 76 patients with non-mosaic KS belonging to a special group of cases that besides infertility did not present the classical signs and symptoms of testosterone deficiency. One of the patients repeated the TESE procedure (76 patients, 77 TESE cycles). Sixty of these 76 patients accepted to undergo TESE associated with ovarian stimulation, while 16 patients underwent TESE followed by testicular spermatozoa cryopreservation. Aneuploidy screening of the offspring was performed by Multiplex ligation-dependent probe amplification and by amniotic fluid karyotyping. Statistical analysis used the Chi-Squared Test, Fisher's Exact Test, 2-sided, for rates, and the Independent Samples T-test for equality of means, 2-sided.ResultsTesticular spermatozoa were recovered in 31 (40.3%) of the attempts. The patients underwent 47 ICSI cycles, 25 with fresh testicular spermatozoa and 22 with cryopreserved testicular spermatozoa. Fertilization (63.5% vs. 41.6%, p=0.000), implantation (37% vs. 13.2%, p=0.014), clinical pregnancy (60.9% vs. 19%, p=0.005) and live birth (65.2% vs. 23.8%, p=0.006) rates were higher with fresh testicular spermatozoa. Chromosome analysis of the 21 newborns was normal.ConclusionsThe present data adds further information regarding the recovery rate of spermatozoa after TESE and the embryological and clinical outcomes with fresh and cryopreserved testicular spermatozoa, besides reassuring the safety concerning chromosomal transmission of KS from parents to their offspring.

Commentary on "PGT or ICSI? The impression of NGS-based PGT outcomes in nonmosaic Klinefelter syndrome".

Commentary on "PGT or ICSI? The impression of NGS-based PGT outcomes in nonmosaic Klinefelter syndrome".

Generation of an iPSC cohort of isogenic iPSC lines (46-XY and 47-XXY) from a non-mosaic Klinefelter Syndrome patient (47-XXY) (KAUSTi008-A, KAUSTi008-B, KAUSTi008-C, KAUSTi008-D, KAUSTi008-E, KAUSTi008-F, KAUSTi008-G).

Klinefelter Syndrome (KS) is the most commonXchromosome aneuploidy in males characterized by highly heterogeneous clinical manifestations including a subtle cognitive impairment and multisystemic disorders such as infertility, metabolic syndrome, gynecomastia and cardiovascular diseases. To date dosage-dependent correlation studies of X-linked genes and low- and high-grade KS clinical phenotypes have not been performed. Here we generated multiple isogenic 47-XXY and 46-XY iPSC lines from one 47-XXY patient. Leveraging on a fully matched genetic background, our cohort represents a highly informative tool to study the impact ofXchromosome dosage on KS pathophysiology.