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- Original Article -
Y-chromosomal microdeletions and partial deletions of the Azoospermia Factor c (AZFc) region in normozoospermic, severe oligozoospermic and azoospermic men in Sri Lanka
L. Fernando1,2, J. Gromoll1, T. R. Weerasooriya2, E. Nieschlag1, M. Simoni1
1Institute of Reproductive Medicine of the University, Münster University Hospital, D-48129 Münster, Germany
2Reproductive Biology Laboratory, Faculty of Medicine, Karapitiya, Galle, Sri Lanka
Abstract
Aim: To assess for the first time the occurrence of Y chromosomal microdeletions and partial deletions of the
Azoospermia Factor c (AZFc) region in Sri Lankan men and to correlate them with clinical parameters.
Methods: In a retrospective study, we analyzed 96 infertile men (78 with non-obstructive azoospermia) and 87 controls with
normal spermatogenesis. AZFa, AZFb,
AZFc and partial deletions within the
AZFc region were analyzed by multiplex polymerase chain reaction (PCR) according to established protocols.
Results: No AZFa, AZFb or
AZFc deletions were found in the control group. Seven patients in the group of infertile men were found to have deletions as following:
one AZFa, two AZFc, two AZFbc and two
AZFabc. The relative distribution of these patterns was significantly
different compared with that found in the German population. Extension analysis confirmed that the deletions
occurred according to the current pathogenic model. gr/gr deletions were found to be equally present both in the patients
(n = 4) and in the control group
(n = 4). One b2/b3 deletion was found in the patient group.
Conclusion: These results suggest that the frequency and pattern of microdeletions of the Y chromosome in Sri Lankan men are similar
to those found in other populations and confirm that gr/gr deletions are not sufficient to cause spermatogenetic failure.
(Asian J Androl 2006 Jan; 8: 39-44)
Keywords: Y chromosome; male infertility; gr/gr; b2/b3; microdeletion; normozoospermia; azoospermia factor c
Correspondence to: Prof. E. Nieschlag, FRCP, Institute of Reproductive Medicine of the University, Münster University Hospital,
Domagkstraße 11, D-48129 Münster, Germany
Tel: +49-251-835-6097, Fax: +49-251-835-6093
E-mail: eberhard.nieschlag@ukmuenster.de
Received 2005-02-29 Accepted 2005-09-26
DOI: 10.1111/j.1745-7262.2006.00100.x
1 Introduction
Infertility affects approximately 15 % of married
couples and, of these cases, approximately 50 % are due
to male factors [1]. Although the causes of male
infertility may vary with the geographical region and ethnic
make-up of the population, a reasonable number of male
infertility cases are related to genetic factors. The most
common chromosomal disorder in male infertility is
Klinefelter syndrome, which is responsible for
approximately 1.8 % of all cases [2]. The second most
common genetic cause is microdeletions in the azoospermia
factor (AZF) region of the Y chromosome [3].
The Y chromosome is the smallest chromosome in the human genome and is only transmitted from fathers
to sons. In addition to the testis determining factor (SRY),
located in the Yp region, the Y chromosome long arm (Yq
region) harbors genes which regulate spermatogenesis
[4]. Although the complete sequence of the Y
chromosome is now known [4], the pathophysiological
correlation between Y chromosomal microdeletions and the
resulting impairment of spermatogenesis has not been fully
established. Although it is difficult to establish precise
genotype/phenotype correlations in patients with Y
chromosomal microdeletions, deletions of
AZFa or AZFb and deletions involving more than one region
(AZFbc or AZFabc) have more severe effects on spermatogenesis
than deletions of the AZFc region [3, 5]. Furthermore,
different frequencies and different patterns of Yq
deletions, both microdeletions and partial deletions of the
AZFc region, have been reported in different
geographical regions and ethnic groups. In Europe, the overall
AZF deletion frequency is approximately 8 % of men with
non-obstructive azoospermia or severe oligozoospermia,
affecting the AZFc region in most cases [6].
Multi-region involvement (AZFbc or
AZFabc) and deletions of AZFa were recorded at very low frequencies in the
German population [7]. The published data for Asia
indicated a certain variability in the deletion frequency
depending on the selection criteria of the patients. When
patients with azoospermia or severe oligozoospermia are
considered together, the frequency of microdeletions varies
from 5 % in Eastern Uttar Pradesh in India [8], to
7.6 % in Japan [9], 8.5 % in Calcutta, India [10], 9 % in China [11]
and 10.6 % in Taiwan, China [12]. Interestingly, much
higher frequencies of AZFa deletions (17.2 % in India)
and AZFbc deletions (51.7 % in India and 36.6 % in
China) have been recorded, compared with those in Europe [10, 11].
Recently, partial deletions of the AZFc region (e.g.
gr/gr or b1/b3 resulting from homologous recombination between amplicons within the
AZFc region, and removing smaller numbers of genes compared to
complete AZFc deletions, have been described [13]. The
exact effects of these partial AZFc deletions on
spermatogenesis are still controversial. Some studies reported a
significant association between partial AZFc deletions and
spermatogenic failure [13, 14] but others did not [15, 16].
However, as the penetrance of these partial deletions is
far lower than that of deletions involving the entire
AZFc, it is to be expected that these partial deletions would not
have severe effects on spermatogenesis. Data on the
partial deletions of the AZFc region are still scant and
indicate frequencies of between 4 % and 6 % of men with
spermatogenetic failure [13-16]. In addition, some
deletion patterns are more common in some populations,
for example, in Eastern Siberian Yakuts [17], and are
compatible with normal spermatogenesis and fertility [15, 16].
These studies suggest that geographical and ethnic
differences might influence the frequencies of
AZF deletions and of partial deletions of the
AZFc region, as well as the deletion patterns and, possibly, the
phenotypic expression. In this study, the occurrence of Y
chromosomal microdeletions and partial deletions of the
AZFc region were assessed for the first time in Sri Lankan
men.
2 Material and methods
2.1 Study group
The study group, consisting of infertile patients and
semen donors attending the Reproductive Biology Laboratory, Faculty of Medicine, Galle, Sri Lanka, was
selected retrospectively. All men gave written consent
to voluntary participation in the study. Approval for the
study was given by the Ethics Committee, Faculty of
Medicine, Galle, Sri Lanka. Permission to use the
available clinic data was obtained by the Reproductive
Biology Laboratory administration.
Ninety-six patients were investigated, comprising two
oligozoospermic men (sperm concentration
< 20 × 106/mL
but > 1 × 106/mL), 15 severely oligozoospermic men
(sperm concentration
< 1 × 106/mL) and 79 men with
non-obstructive azoospermia. A questionnaire was
distributed to each patient to collect demographic data, past
medical and surgical history, including history of orchitis,
mumps, testicular maldescent, testicular injuries,
chemotherapy and radiotherapy, and habits concerning
smoking and alcohol consumption. All patients were examined
by a clinician for size, volume and consistency of
the testis, hydrocele, varicocele and secondary
sexual characteristics. Hormone profiles (serum follicle-stimulating hormone
[FSH], luteinizing hormone [LH] and testosterone) of all
patients were collected and, whenever available,
historical testicular biopsy reports were collected.
Eighty-seven men of Sri Lankan origin, who were
sperm donors for heterologous insemination with
normal ejaculate parameters, according to the World Health
Organization (WHO) criteria [18], were recruited as the
control group.
2.2 Molecular analysis
Five mL of ethylene diamine tetraacetic acid (EDTA)
blood was collected from each man in the study groups
and genomic DNA was extracted using the Wizard DNA
extraction kit (Promega, Madison, WI, USA) according
to the manufacturer¡¯s protocol. Microdeletion analysis
of the Y chromosome Yq AZF region involved two steps.
In the first step, aimed at detecting AZFa,
AZFb and AZFc microdeletions, two multiplex polymerase chain
reaction (PCR) systems (A and B) were carried out
according to the European Academy of
Andrology/European Molecular Genetics Quality Network (EAA/EMQN)
guidelines [3] using the recommended first choice
primers and the Qiagen Multiplex PCR kit (Qiagen, Hilden,
Germany). Each 50 µL PCR reaction mix contained 25 µL
2 × Qiagen Multiplex PCR MasterMix (containing
HotStarTaq DNA polymerase [Qiagen, Hilden, Germany],
Qiagen Multiplex PCR Buffer [containing
6 mmol/L MgCl2] and deoxyribonucleotide triphosphate mix), 5 µL
10 × Primer mix (2 µmol/L each primer), ~ 1 µg
template DNA, and sterile distilled water to
50 µL. Amplification started with an activation step of 15 min
at 95 ºC, followed by 35 cycles of 30 s denaturation
(94 ºC), 90 s annealing (57 ºC) and 60 s elongation
(72 ºC), ended by an elongation step of 10 min and cooling
to 4 ºC. Reaction products (30 µL) were
separated on 2 % agarose (Peqbold Universal Agarose, Peqlab, Erlangen,
Germany) plus 0.5 % DNA agar (Serva, Heidelberg,
Germany) gels in 1 ¡Á Tris borate EDTA (TBE) for
25 V overnight. Extension analysis was performed according
to the EAA/EMQN guidelines [3]. In the second step,
we used two multiplex systems, one including the
sequence tagged site (STS) primers sY1291, sY1191 and
sY1161 and the other including sY1201 and sY1206 to
screen the partial deletions of the AZFc region, as
described previously [15]. The samples, in which the
deletions were detected by the above multiplex systems, were
confirmed by repeating the single primer (simplex)
reactions.
2.3 Statistical analysis
Fisher¡¯s exact test and the c2 test were used to
compare the frequency of deletions by applying a
commercially available software package (GraphPad Prism
version 3; GraphPad Software, San Diego, CA,
USA). P < 0.05 was considered statistically significant.
3 Results
Seven of the 96 infertile men (7.3 %) were found to
have Y chromosome microdeletions in the AZF region
(Table 1). One of these seven men (case 18) had severe
oligozoospermia, and the rest had azoospermia. All men
with microdeletions had normal serum testosterone levels.
Five patients had high serum FSH levels. One patient
(case 96) showed increased serum FSH and LH levels;
the LH level was normal in the others.
The microdeletion patterns observed were
AZFc in two patients (cases 18 and 38),
AZFbc in two patients (cases 48 and 84),
AZFa in one patient (case 87) and
AZFabc in two patients (cases 20 and 96). The further
characterization of the microdeletions by extension
analysis showed a complete AZFa deletion in case 87 (sY82
and sY83 present, DBY, USP9Y and sY87 deleted, sY88
present) and deletion of the marker sY160 in cases 20
and 96, suggesting a large, terminal deletion in these two
patients. Due to a shortage of DNA we could further
analyze only one of the two patients with the
AZFbc deletion pattern. Using the STS markers, sY1264, sY1227,
sY1228, sY1283, sY117, sY1291, sY639, sY1206 and sY1201, case 84 showed a pattern corresponding to the
deletion model P4/distal P1 according to Repping
et al. [13]. No microdeletions were found in the control group.
Two different patterns of partial deletions within the
AZFc region were observed in five men in the patient
group. Four (4.17 %) had gr/gr deletions and one
(1.04 %) had a b2/b3 deletion pattern (Table 2). One man
with gr/gr deletion was oligozoospermic (sperm
concentration 4.2 × 106/mL) but the others were azoospermic.
Testicular biopsy reports were available for three of the
five patients with partial deletions of the
AZFc region. Two cases (cases 28 and 93) had Sertoli cell-only
syndrome (SCOS) and one patient (case 24) had
seminiferous tubule atrophy. Four subjects of the control group
were detected to have gr/gr deletions, which was the
only pattern of partial deletions of the
AZFc region observed in the control group. All of them had normal
ejaculate parameters (Table 3). The statistical analysis
of gr/gr deletions in the control group and the patient
group did not show any significant difference (Fisher¡¯s
exact test, P = 0.72).
A comparison of the relative frequency of the type
of microdeletions of the Y chromosome in Sri Lanka and
Germany, according to the authors¡¯ previously published
data [3], is shown in Table 4. A statistically significant
difference in the distribution of the deletion pattern was
observed. In particular, on the basis of the present results,
AZFc microdeletions seem to be less frequent than the
other patterns in Sri Lankan men compared to German men.
4 Discussion
Collecting demographic data is important in order to
assess the appropriateness of the current analysis
protocols [3], which might require adjustments of the STS
panel according to the ethnic origin of the patients [19].
In this study we analyzed for the first time microdeletions
of the Y chromosome in a small sample of Sri Lankan
men. We found AZF microdeletions in 7.3 % of a
selected group of infertile patients, a frequency similar to
that of 8 % recorded as the overall frequency for
AZF deletions among infertile patients [6]. Therefore, the
frequency of Y chromosomal microdeletions in Sri Lankan
men is similar to that observed in different regions of
India [8, 10, 20]. The frequency distribution of the
different types of AZF deletions, however, seems to be
different from that observed in European men of
German origin, suggesting that ethnic differences, possibly
reflected by Y chromosome haplogroups, might result in
a higher incidence of rare microdeletions in some populations. In a previous study conducted with Indian
men, a similar overall frequency of Y chromosomal microdeletions was found, with a very high incidence
(24.4 %) of AZFa microdeletions [10] and complex
patterns within this region which, however, were not
verified by Southern blotting. More data should be collected
in order to verify whether Indian men might be more
prone to AZFa deletions than European men.
Extension analysis of the two patients in our study
with AZFabc deletions showed that the heterocromatic
marker sY160 was absent in both cases, suggesting the
occurrence of a terminal deletion. Cytogenetic investigation,
however, was not performed in these men. The further
molecular analysis of one case with AZFa and one case
with AZFbc deletions confirmed the complete removal
of the entire AZFa region, including the two genes present
in it, and the deletion pattern P4/distal P1 in the latter
case. This suggests that the mechanism of microdeletions,
that is, homologous recombination between identical
sequences flanking the deletion, should be valid
independently of the ethnic origin of the Y chromosome.
The patients with AZFa or AZFabc deletion patterns
showed SCOS in their biopsy reports. One of the two
patients with an AZFbc deletion pattern showed
maturation arrest. The second patient had SCOS. These
findings are compatible with the recorded trend of
genotype/phenotype correlation reported in other studies [5] and
the concept that complete deletions of the
AZFa, or AZFb, or AZFbc region result in SCOS or maturation arrest
and the virtual impossibility of retrieving sperm by
testicular sperm extraction attempts. Of the two patients
with AZFc deletions, one was severely oligozoospermic
and the other was azoospermic with, surprisingly, a
normal testicular biopsy. The latter case suggests that an
obstruction might be present in this patient, compatible
with his normal serum FSH levels, and reinforces the
concept that AZFc deletions might be compatible with
spermatogenesis sufficient for fertility [21 and references
therein], provided that no obstructions are concomitantly
present.
In this study, we analyzed for the first time the
occurrence of partial deletions of the AZFc region in a small
sample of Sri Lankan men. The commonest partial
AZFc deletion pattern observed was the gr/gr pattern, which
was detected in four (4.2 %) patients and four (4.6 %)
control men, indicating no difference in the occurrence
of gr/gr deletions between patients and controls. Our Sri
Lankan data confirm previous findings in other
populations that partial deletions of the
AZFc region are not sufficient to cause spermatogenetic failure.
This finding is in contrast with some recent data reporting a significant
correlation between the presence of gr/gr deletion and
spermatogenic failure in Spanish men [14]. Similar to the
present finding, however, Hucklenbroich et
al. [15] and Machev et al. [16] found no significant differences
between the control group and the patient group. gr/gr
deletions have been associated with particular Y
chromosomal haplogroups [13]. Although the correct
distribution pattern of Y haplogroups in Asian populations is
still not known, haplogroup N, which is susceptible to
spontaneous gr/gr deletions, is reported to be common
in this region [22]. In any case, our results show clearly
that gr/gr deletions cannot be considered sufficient cause
for spermatogenic failure. Haplogroup and gr/gr
analysis in large groups of men of different ethnic origin with
normal spermatogenesis need to be performed to
characterize the role played by this type of chromosomal
rearrangement in male fertility. Meanwhile, we see no
basis to recommend screening for gr/gr deletions as a
routine investigation in male infertility.
Acknowledgment
This study was supported by the Special Programme
in Human Reproduction of the World Health
Organization with a fellowship to Dr L. Fernando. The excellent
technical assistance of Dr S. Borchert and the language
editing by Dr S. Nieschlag are gratefully acknowledged.
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