CASE REPORT 2430.e1. a Section of Reproductive Medicine, First Department of Obstetrics and Gynaecology, Aristotle University Medical School,

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1 CASE REPORT Semen analysis by electron and fluorescence microscopy in a case of partial hydatidiform mole reveals a high incidence of abnormal morphology, diploidy, and tetraploidy Katerina Chatzimeletiou, M.Sc., Ph.D., a Antonia Sioga, Ph.D., b Louisa Oikonomou, M.D., Ph.D., b Sophia Charalampidou, M.D., c Persa Kantartzi, M.D., a Vasiliki Zournatzi, M.D., Ph.D., c Dimitrios Panidis, M.D., Ph.D., c Dimitrios G. Goulis, M.D., Ph.D., a Ioannis Papadimas, M.D., Ph.D., a and Basil C. Tarlatzis, M.D., Ph.D. a a Section of Reproductive Medicine, First Department of Obstetrics and Gynaecology, Aristotle University Medical School, Papageorgiou General Hospital; b Laboratory of Histology and Embryology, Aristotle University Medical School; and c Unit of Endocrinology and Human Reproduction, Second Department of Obstetrics and Gynaecology, Aristotle University Medical School, Hippokration General Hospital, Thessaloniki, Greece Objective: To perform a highly detailed semen analysis in a man whose wife had a partial mole. Design: Case report. Setting: Gynecology departments of two university hospitals and a laboratory of histology/embryology. Patient(s): A 32-year-old man whose wife had a partial mole. Intervention(s): Sperm characteristics were examined by light microscopy, morphology was analysed by electron microscopy (TEM), DNA fragmentation was evaluated by TUNEL using fluorescence microscopy, and chromosomal abnormalities were assessed by fluorescence in situ hybridization using probes for chromosomes 13, 15, 16, 18, 21, 22, X, and Y. Main Outcome Measure(s): Sperm count, motility, morphology, DNA fragmentation, and incidence of diploidy, tetraploidy, and aneuploidy. Result(s): Sperm concentration was 61 million/ml, with 31% progressive motility and 4% normal morphology. TEM revealed a high incidence of head, neck, and tail abnormalities as well as the presence of phagocytes. DNA fragmentation was within normal limits (11.6%). Aneuploidy levels were low for all chromosomes tested. However, there was a high level of diploidy, with XY, XX, and YY constitution. Tetraploid sperm (XXYY) were also noted. Conclusion(s): Semen analysis revealed a high incidence of abnormal morphology and increased diploidy. It may be important to perform FISH testing, to verify increased diploidy in sperm, in men whose wives have had partial moles. These couples could be informed of the option to have preimplantation genetic diagnosis as a means to distinguish between diploid and triploid embryos arising from fertilization of a haploid egg by diploid sperm. (Fertil Steril Ò 2011;95:2430.e1 e5. Ó2011 by American Society for Reproductive Medicine.) Key Words: Hydatidiform mole, sperm, electron microscopy, DNA fragmentation, TUNEL assay, aneuploidy screening, diploidy, tetraploidy Partial moles are characterized by focal trophoblastic hyperplasia with villous hydrops together with identifiable fetal tissues, and in 0.5% of cases persistent trophoblastic neoplasia occurs. They are Received December 16, 2010; revised January 12, 2011; accepted January 24, 2011; published online February 26, K.C. has nothing to disclose. A.S. has nothing to disclose. L.O. has nothing to disclose. S.C. has nothing to disclose. P.K. has nothing to disclose. V.Z. has nothing to disclose. D.P. has nothing to disclose. D.G.G. has nothing to disclose. I.P. has nothing to disclose. B.C.T. has nothing to disclose. Reprint requests: Katerina Chatzimeletiou, M.Sc., Ph.D., Section of Reproductive Medicine, First Department of Obstetrics and Gynaecology, Aristotle University Medical School, Papageorgiou General Hospital, Thessaloniki 56403, Greece ( katerinachatzime@hotmail.com). triploid conceptions with 69 chromosomes, of which 23 are of maternal and 46 of paternal origin, and are mainly thought to arise from fertilization of a normal egg by two spermatozoa (dispermy) (1). However, there have been reported cases of partial hydatidiform moles arising after IVF and intracytoplasmic sperm injection (ICSI), where it is impossible for polyspermy to be the causative mechanism (2, 3). In these cases it is suggested that the triploid chromosomal constitution arises from fertilization of a normal egg by a diploid spermatozoon. On average, 8.3% of diandric triploids originate from diploid sperm. The frequency of diploid sperm in the normal population has been estimated to be 0.2% 0.3%, while in infertile males the incidence is higher (1.1% 2.2%) (4 6). Diploid sperm are thought to arise from nonseparation of chromosomes in meiosis I (MI diploids), which 2430.e1 Fertility and Sterility â Vol. 95, No. 7, June /$36.00 Copyright ª2011 American Society for Reproductive Medicine, Published by Elsevier Inc. doi: /j.fertnstert

2 may, however, undergo meiotic II (MII) chromatid separation followed by cleavage division or from nonpartitioning of chromatids during MII followed by defective cleavage division (MII diploids) (4, 5). Endoreduplication of chromosomes occurring before meiosis has also been suggested as a mechanism leading to tetraploid meiocytes, which subsequently can enter meiosis and produce diploid sperm (6 8). Here we present a highly detailed analysis on sperm count, motility, morphology, DNA fragmentation, and incidence of diploidy, tetraploidy, and aneuploidy in a male whose wife had a partial hydatidiform mole and was treated with methotrexate due to persistent hch levels. CASE REPORT A 32-year-old man presented for a semen analysis because his wife had a partial hydatidiform mole after natural conception. The partial mole was diagnosed at a routine ultrasound scan, and the female underwent evacuation of the products of conception. The female was also treated with methotrexate because of persistent hcg levels. MATERIALS AND METHODS Three milliliters of semen were collected and processed for standard semen analysis, DNA fragmentation, and molecular cytogenetic analysis. Sperm characteristics were examined by light microscopy, morphology was analyzed by transmission electron microscopy (TEM), fragmentation was evaluated by TdT-mediated dutp nick-end labeling (TUNEL) using fluorescence microscopy, and genetic abnormalites were assessed by fluorescence in situ hybridization (FISH) using probes for chromosomes 13, 15, 16, 18, 21, 22, X, and Y. Standard semen analysis, FISH, and DNA fragmentation assessment were performed as part of routine clinical practice. The electron microscopy analysis was approved by the Bioethics Committee of Aristotle University Medical School. Standard Semen Analysis Semen analysis was performed according to World Health Organization (WHO) criteria: lower reference limits 1.5 ml for volume, 15 millions/ml for concentration, 32% for progressive motility, and 4% for normal morphology (9). Fluorescence In Situ Hybridization (FISH) Ten microliters of fixed sperm suspension in 3:1 methanol:acetic acid were spread on poly-l-lysine slides (BDH, Poole, UK) and processed for FISH. Three sets of probes were used: [1] Multivysion PB (LSI13, Spectrum Red; CEP16, Spectrum Aqua; CEP18, Spectrum Blue; LSI21, Spectrum Green; CEP22, Spectrum Gold); [2] Aneuvysion (CEPX, Spectrum Green; CEPY, Spectrum Orange; CEP18, Spectrum Aqua); and [3] CEPX, Spectrum Green; CEPY, Spectrum Orange; CEP15, Spectrum Aqua (Abbott, Chicago). The codenaturation, hybridization, and wash conditions were according to the manufacturer s instructions. TUNEL Sperm DNA fragmentation was assessed in situ by TUNEL. Ten microliters of fixed sperm suspensions were spread on poly-l-lysine slides (BDH) and incubated in 0.1M Tris/DTT swelling solution for 30 minutes, washed in phosphate-buffered saline (PBS) and H 2 O, primed with TdT buffer, Cocl 2 (Roche Diagnostics GmbH, Mannheim, Germany), and incubated with TdT buffer, Cocl 2 TdT enzyme, and dutp (Roche) for 60 minutes in the dark. The slides TABLE 1 Standard semen analysis. Measurement Value Volume 3 ml ph 8.5 No /ml Total number /ejaculation Motility, % Linear progression 31 No progression - tail moving 30 Immotile 39 Morphology Normal, % 4 Abnormal, % 96 Big head 3 Small head 3 Long head 4 Pear-shaped head 27 Round head 1 Amorphous head 18 Vacuoles 36 Small acrosome 3 Short tail 1 Double tail 1 Fourchette 3 Broken tail 1 Spiral tail 9 Asymmetric tail extrusion 1 Broken neck 12 Cytoplasmic droplet 14 Thick midpiece 34 White blood cells 5% Round spermatids 8% were then placed in stop buffer and were washed twice in PBS (Sigma-Aldrich, Gillingham, Dorset, UK). After staining with Texas Red (Vector Laboratories, Burlingame, CA), the slides were washed in PBS (Sigma-Aldrich), air dried, and mounted in Vectarshield antifade medium with DAPI (4, 6-diamidino-2-phenylidole; Vector Laboratories, CA) under a coverslip and sealed with nail varnish. Fragmented sperm head nuclei were assessed by fluorescence microscopy using the Zeiss Axioimager, and images were captured using the Isis software (Metasystems, Altlussheim, Germany). Preparation of Sperm for Examination by TEM One milliliter of sperm was resuspended in 3% glutaraldehyde in sodium phosphate buffer (ph 7.4) at 4 C and centrifuged at 1,200 rpm for 5 minutes. The supernatant was discarded, and the pellet was resuspended in buffer. After two more centrifugations at 1,200 rpm for 5 minutes, the supernatant was discarded, and the pellet was fixed in 1% osmium tetroxide for 90 minutes, washed twice with buffer and distilled water, and stained with 1% aqueous uranyl acetate for hours. The pellet was then dehydrated in 30, 50, 70, 95, and 6 100% ethanol series and embedded in Epon 812 (Serve, Heidelberg, Germany). Ultrathin sections cut in a Reichert ultramicrotome EMUC6 (Leica, Vienna, Austria) were stained with lead citrate (Reynold s, Merck, Darmstadt, Germany) and were examined on a JEOL TEM 2000 FXII microscope (Jeol, Tokyo, Japan) at 80 KV. Fertility and Sterility â 2430.e2

FIGURE 1 TEM photomicrographs showing sperm with (A) abnormalities in the acrosome and the midpiece, (B) higher magnification of the sperm in (A), and (C) abnormal acrosome (arrow).

3 FIGURE 1 TEM photomicrographs showing sperm with (A) abnormalities in the acrosome and the midpiece, (B) higher magnification of the sperm in (A), and (C) abnormal acrosome (arrow). Also note the normal tails around the sperm head (arrow heads), (D) abnormal tail and cytoplasmic remnants, (E) immature spermatid, and (F I) abnormal spermiogenesis. Note that only part of the tail is created in H (arrow), while only the head and acrosome is created in I. (J) Sperm that has been phagocytosed by a macrophage. TABLE 2 Incidence of chromosomal abnormalities in sperm assessed by FISH (total number of sperm analyzed in each probe set used [ 400). Haploid, n (%) Aneuploid, n (%) Diploid, n (%) Tetraploid, n (%) Probe: Multivysion PB Chromosomes 13, 16, 18, 21, (93.25) 5 (1.25) 21 (5.25) 1 (0.25) Probe: CEPX/Y/18 Chromosomes X, Y, (93.5) 4 (1.0) 6 (XY), 14 (XX,YY) (5.0) 2 (0.5) Probe: CEPX/Y/15 Chromosomes X, Y, (93.75) 2 (0.5) 7 (XY), 15 (XX, YY) (5.5) 1 (0.25) 2430.e3 Chatzimeletiou et al. Semen analysis in a case of partial mole Vol. 95, No. 7, June 2011

FIGURE 2 FISH photomicrographs showing sperm hybridized with the (A C) Multivysion PB probe (chromosomes 13-red, 16-aqua, 18-blue, 21-green, 22-gold) and the (D I) Aneuvysion probe (chromosomes

4 FIGURE 2 FISH photomicrographs showing sperm hybridized with the (A C) Multivysion PB probe (chromosomes 13-red, 16-aqua, 18-blue, 21-green, 22-gold) and the (D I) Aneuvysion probe (chromosomes X-green, Y-red, 18-aqua). (A) Normal haploid sperm, (B) aneuploid sperm showing no signal for chromosome 13 (red) and two signals for chromosome 21 (green), (C) diploid sperm showing two signals for all five chromosomes tested, (D) normal sperm (X, 18), (E) normal sperm (Y, 18), (F) diploid sperm (XY1818), (G) diploid sperm (XX1818), (H) diploid sperm (YY1818), and (I) tetraploid sperm (XXYY ). RESULTS Standard semen analysis is shown in Table 1. TEM revealed a high incidence of abnormalities on the sperm head, neck, and tail as well as the presence of several phagocytes (Fig. 1). Sperm DNA fragmentation as assessed by TUNEL-labeled nuclei was within the normal limits (11.6%; 58/500; normal range 0 29%). Aneuploidy levels were low for all chromosomes tested (Table 2, Fig. 2). However, there was a high level of diploidy (5% 5.5%), with XY, XX, and YY chromosomal constitution (Table 2). The incidence of XX-bearing sperm was higher than that of YY- or XYbearing sperm. Tetraploid sperm chromosomal constitutions (XXYY) were also noted at low levels. Figure 2D 2I shows representative images of the haploid, diploid, and tetraploid sperm observed using the Aneuvysion X, Y, 18 probe panel. The same pattern of chromosomal abnormalities was also observed with the X, Y, 15 and the Multivysion probe set used. DISCUSSION The semen sample analyzed had a high incidence of abnormal morphology and increased diploidy. Diploid XX- or YY-bearing sperm may be due to failure of second meiosis or to endoreduplication. Diploid XY-bearing sperm may be immature round spermatids. Fertility and Sterility â 2430.e4

5 Alternatively, they may originate from nonseparation of chromosomes during MI. Devillard et al. (7) suggested that incomplete partition of homologous chromosomes/chromatids during both MI and MII is associated with the failure of nuclear cleavage. However Egozcue et al. (5) reported that diploid sperm with X- and Y-chromosomes that originate from MI owing to chromosomal nonseparation (MI diploids) may undergo MII chromatid separation plus nuclear cleavage. Dominance of either the MI diploids or the MII diploids can occur in sperm with higher than average diploidy rates. This suggests that in most cases with moderately elevated frequencies of diploid sperm, chromosomal nonseparation during MI and defective nuclear cleavage during MII occur separately (5, 7, 8). Endoreduplication of chromosomes occurring before meiosis has also been suggested as a mechanism leading to tetraploid meiocytes, which subsequently can enter meiosis and produce diploid sperm (6). Tetraploid sperm (XXYY) were noted in this case at low levels. Apart from the mechanism mentioned above, these may have resulted from two successive failed meiotic cleavage divisions or endoreduplication of a diploid sperm. These meiotic errors may indicate an inherent abnormality of the sperm, which causes it to become diploid, thus providing another mechanism beyond polyspermy that may lead to partial hydatidiform moles. This mechanism may explain the formation of hydatidiform moles in pregnancies established from embryos created after ICSI (10). It may be important to perform molecular cytogenetic analysis in the sperm of males whose wives had partial hydatidiform moles in the past to verify whether there is an increased diploidy level. If it is present, patients can be informed of the option to have preimplantation genetic diagnosis as a means to distinguish between diploid 2-pronuclear embryos and triploid 2-pronuclear embryos arising from fertilization of a normal egg by diploid sperm (11). REFERENCES 1. Slim R, Mehio A. The genetics of hydatidiform moles: new lights on an ancient disease. Clin Genet 2007;71: Ulug U, Ciray NH, Tuzlali P, Bahçeci M. Partial hydatidiform mole following the transfer of single frozen-thawed embryo subsequent to ICSI. Reprod Biomed Online 2004;9: Dalmia R, Young P, Sunanda GV. A case of triploidy. Fertil Steril 2005;83: Egozcue S, Blanco J, Vidal F, Egozcue J. Diploid sperm and the origin of triploidy. Hum Reprod 2002;17: Egozcue S, Blanco J, Vendrell JM, Garcıa F, Veiga A, Aran B, et al. Human male infertility: chromosome anomalies, meiotic disorders, abnormal spermatozoa and recurrent abortion. Hum Reprod Update 2000;6: Codina-Pascual M, Navarro J, Egozcue J, Benet J. A human tetraploid pachytene spermatocyte as the possible origin of diploid sperm: a case report. Hum Reprod 2006;21: Devillard F, Metzler-Guillemain C, Pelletier R, DeRobertis C, Bergues U, Hennebicq S, et al. Polyploidy in large-headed sperm: FISH study of three cases. Hum Reprod 2002;17: Jakab A, Kovacs T, Celik C, Huszar G. Origin of sperm with extra chromosome set. Hum Reprod 2003;18: Cooper TG, Noonan E, von Eckardstein S, Auger J, Baker HW, Behre HM, et al. World Health Organization reference values for human semen characteristics. Hum Reprod Update 2010;16: Rosenbusch BE. Mechanisms giving rise to triploid zygotes during assisted reproduction. Fertil Steril 2008;90: Reubinoff BE, Lewin A, Verner M, Safran A, Schenker JG, Abeliovich D. Intracytoplasmic sperm injection combined with preimplantation genetic diagnosis for the prevention of recurrent gestational trophoblastic disease. Hum Reprod 1997;12: e5 Chatzimeletiou et al. Semen analysis in a case of partial mole Vol. 95, No. 7, June 2011

Article Case report: Partial hydatidiform mole following the transfer of single frozen thawed embryo subsequent to ICSI

RBMOnline - Vol 9. No 4. 442-446 Reproductive BioMedicine Online; www.rbmonline.com/article/1405 on web 4 August 2004 Article Case report: Partial hydatidiform mole following the transfer of single frozen