BIRTH OF A HEALTHY CHILD AFTER PREIMPLANTATION GENETIC TESTING IN A FATHER WITH KLINEFELTER'S SYNDROME IN SERBIA ROĐENJE DETETA KLINFELTEROVIM SINDROMOM NAKON PREIMPLANTACIONOG TESTIRANJA

Introduction. The majority of Klinefelter syndrome cases with non-mosaic 47,XXY form have azoospemia and until recently they were considered completely infertile, with a markedly unfavorable and definitely poor male fertility prognosis. However, it has been confirmed that some non-mosaic patients have spermatozoa in the ejaculate deposition, although the form of severe oliogasthenoteratosoospermia is present in all of them. Although high fertilization rate with ICSI procedure using sperm from a non-mosaic patient and cumulative pregnancy rate following in-vitro fertilization constitutes 53%, the incidence of live birth rate after ICSI in cases of non-mosaic Klinefelter syndrome is very low. Case report. At the Clinic for Gynecology and Obstetrics of the Clinical Center of Vojvodina a successful in vitro fertilisation treatment was conducted in Klinefelter nonmosaic male, with the use of preimplantation genetic testing for embryo selection, and euploid embryo was transfered in the subsequent natural cycle. A healthy boy was born, delivery was spontaneous, vaginal, with head presentation , after 40 weeks and 3 days, by which Apgar scores were: 10/10, birth weight was 3950g and length 55cm. The psychomotor development scale of Brunet-Lézine was used when the boy reached 12 months of age and he was assessed as having normal psychomotor development. Conclusion. Due to the increased risk of chromosomal abnormalities in embryos (abnormalities of sex or autosomal chromosomes) from couples where a male partner is affected by Klinefelter syndrome, the use of preimplantation genetic testing involves selecting a chromosomally normal embryo which could shorten the time to the first live birth, decrease the risk of miscarriage and the chance of multiple pregnancy and its potential complications, reducing the need for invasive prenatal diagnostic procedures and the risks of some other complications, as well as the risk of late termination of pregnancy in case of pathological findings of the fetal karyotype using conventional diagnostics procedures.


Abstract
Introduction. The majority of Klinefelter syndrome cases with non-mosaic 47,XXY form have azoospemia and until recently they were considered completely infertile, with a markedly unfavorable and definitely poor male fertility prognosis. However, it has been confirmed that some non-mosaic patients have spermatozoa in the ejaculate deposition, although the form of severe oliogasthenoteratosoospermia is present in all of them.
Although high fertilization rate with ICSI procedure using sperm from a non-mosaic patient and cumulative pregnancy rate following in-vitro fertilization constitutes 53%, the incidence of live birth rate after ICSI in cases of non-mosaic Klinefelter syndrome is very low. Case report. At the Clinic for Gynecology and Obstetrics of the Clinical Center of Vojvodina a successful in vitro fertilisation treatment was conducted in Klinefelter nonmosaic male, with the use of preimplantation genetic testing for embryo selection, and euploid embryo was transfered in the subsequent natural cycle. A healthy boy was born, delivery was spontaneous, vaginal, with head presentation , after 40 weeks and 3 days, by which Apgar scores were: 10/10, birth weight was 3950g and length 55cm. The psychomotor development scale of Brunet-Lézine was used when the boy reached 12 months of age and he was assessed as having normal psychomotor development.
Conclusion. Due to the increased risk of chromosomal abnormalities in embryos (abnormalities of sex or autosomal chromosomes) from couples where a male partner is affected by Klinefelter syndrome, the use of preimplantation genetic testing involves selecting a chromosomally normal embryo which could shorten the time to the first live birth, decrease the risk of miscarriage and the chance of multiple pregnancy and its potential complications, reducing the need for invasive prenatal diagnostic procedures and the risks of some other complications, as well as the risk of late termination of pregnancy in case of pathological findings of the fetal karyotype using conventional diagnostics procedures.

Introduction
Klinefelter's syndrome (KS) is one of the most common chromosomal aberrations of human sex chromosomes, often resulting in hypogonadism and male infertilityazoospermia or severe oligospermia. Accordingly, KS is one the most common genetic causes of male infertility found in approximately 10% of all men who suffer from azoospermia. Epidemiological data show that Klinefelter's syndrome has an estimated prevalence of between 1:400 and 1:1000 male births. The prevalence of Klinefelter's syndrome was reported to be 0.1% to 0.2% in the general population and 0.15% to 0.17% in prenatally detected cases (1, 2).
Since Klinefelter's syndrome may have a variable phenotypic features, a large number of males remain undiagnosed until they are well into adulthood and have fertility problems.
Nowadays, besides prenatal invasive procedures (chorionic villi sampling, amnio/cordocentesis), there is a noninvasive testing used in prenatal diagnostics for detecting cell-free DNA in maternal blood in order to establish diagnosis of fetal chromosomal disorders in an early pregnancy. In the Autonomous Province of Vojvodina, a high percentage of pregnant women (over 90%) and their partners choose an option of pregnancy termination after they receive prenatal diagnosis of KS and become familiar with the clinical presentation and the diagnosis of KS.
Azoospermia is diagnosed when no spermatozoa are detected upon microscopic evaluation (the absence of spermatozoa) in more than 90% of cases, although there is also a possibility of the emergence of oligospermia (low sperm count and motility) which provides a reasonable probability of parenthood by in vitro fertilisation (3).
At present, data available in the literature demonstrate that spermatozoa can be found by TESE technique (testicular sperm extraction) in about 40-50% of males with KS, with the incidence of pregnancy and live birth rates achieved in approximately 50% (3).
Progress in the field of assisted reproduction techniques and the advent of intracytoplasmic sperm injection (ICSI) improves the chances for normal fertilization and embryo development in men with severe oligozoospermia and azoospermia. In spite of the pathological karyotype (47, XXY), the retrieved spermatozoa can be used for the ICSI procedure in males with KS, which can be used to enable genetic fatherhood.
Both normal fertilization of the ovum and normal development of the embryo, with subsequent pregnancy and childbirth were achieved in both mosaic and non-mosaic KS patients, after successful sperm retrievals using the TESE procedure (4).
According to the publications of the 90', the use of fluorescent in situ hybridization technique (FISH), 2.09-2.7% hyperdiploid sperm were found in mosaic and non-mosaic males with KS (4.5). There is a little chance of passing extra chromosomes on to their offspring. Accordingly, healthy children were born after the TESE procedure with ICSI in cases of non-mosaic KS patients. (4.5). Moreover, cases of embryos conceived in KS patients who have a non-mosaic 47, XXY karyotype were published during that period.
Before accessing the procedure itself, it is necessary for the couples to be able to obtain all the necessary information, as well as to show that sperm retrieval is necessary, and

Discussion
First subsequent pregnancy outcomes after PGD were reported in 1990 and they were performed with the aim of preventing the transmission of X-linked diseases (14). Since In general, in mosaic and non-mosaic KS patients, the possibility of sperm retrieval is about 30-50%, although predictive value for sperm retrieval is higher in mosaic KS (17).
For successful in vitro fertilization it is crucial to retrieve sperm, either by evaluating deposition of an ejaculate semen or by testicular biopsy. It is also noteworthy to mention that spermatozoids derived from testicular tissue can be cryopreserved for later use but there is a risk of about 20% that the retrieved sperm counts will not survive defrosting. That is why testicular biopsy is repeated on the day of oocyte retrieval, although it must be emphasized that it is sometimes technically difficult due to the smallsize-testis .
The majority of KS cases with non-mosaic 47,XXY Klinefelter's syndrome have azoospmeria and until recently they were considered completely infertile, with a markedly unfavorable and definitely poor male fertility prognosis. However, it has been confirmed that some non-mosaic KS patients have spermatozoa in the ejaculate deposition, although the form of severe oliogasthenoteratosoospermia is present in all of them. A high fertilization rate with ICSI procedure using sperm from a patient with non-mosaic KS was published in 1995. (18).
However, the incidence of live birth rate after ICSI in cases of non-mosaic Klinefelter syndrome is very low and clinical pregnancy rates were detected in 7 out of 10 cases. (4,20,21,22,23) It has been described earlier that only normal 46, XY cells can complete the meiotic process, and therefore every spermatozoid produced by KS patients (24) has a high probability of having an abnormal karyotype. The inequality of number of X chromosomes can lead to cell death (25). Literature citations suggest that meiotic progression is possible as well as sperm production in males with non-maosaic KS.
The use of PGT is now additional practice for couples with KS in order to shorten time to pregnancy. According to the available literature data, 54% of embryos from KS patients were found to be euploid and the study included 113 embryos of couples at different age in which the male suffers from Klinefelter's syndrome, which is less than in normal population constituting 77 %, evenly represented in both males and females (7). First trimester combined screening test has been the gold standard for calculation of the risk for Trisomy 21, 13 and 18 with a detection rate of 95% when nuchal translucency, nasal bone, ductus venosus and tricuspid valve blood flow are assessed.
The management plan for IVF patient with PGT should be first trimester screening test, followed by comprehensive counselling and reassurance or recommendation for NIPT or invasive testing depending on the findings. The role of the IVF specialist is to recommend the correct test for the correct patient.

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After achieving pregnancy, with or without PGT, it is always advisable to confirm the results of PGT with different non-invasive or invasive prenatal tests, of which amniocentesis provides for higher diagnostic certainty.
So far there is no indication that embryo biopsy causes an increased risk for adverse neonatal outcome. (31).

Conclusion
PGT is suggested part of the analysis of embryos from the couples in which a male is affected by Klinefelter syndrome in order to shorten time to pregnancy and enhance chances to success.