Vol 47, No 1 (2019)
REVIEW ARTICLE
In search for an ideal marker of endometrial receptivity: from histology to comprehensive molecular genetics-based approaches
Abstract
Background: Despite significant improvements in the efficiency of assisted reproductive technologies (ART) for the past 10 years, proportion of unsuccessful cycles still remains significant and can reach up to 40%. Impairment of embryonic implantation is considered as one of the possible causes for low ART efficiency. Implantation failure may be a consequence of a shift in the “window of implantation”, i.e. the period of a cycle when endometrium is most receptive and ready for embryo implantation. Several methods have been developed to evaluate endometrial receptivity, but their accuracy and efficiency are quite different.
Aim: Review and efficiency evaluation of the methods used for endometrial receptivity assessment and the window of implantation determination.
Methods: We performed a comprehensive literature search (September 2018) with the key words “endometrial receptivity”, “endometrial receptivity evaluation”, “implantation window”, “window of implantation”, “pinopodes” from PubMed and E-library (Russian) databases. One hundred and thirty four (134) publications were selected for the analysis, including 101 original papers and 33 literature reviews.
Results: The methods of conventional histology, scanning electronic microscopy, immunohistochemistry, as well as techniques based on the measurement of prostaglandin levels in endometrial fluid and mRNA profiling in an endometrium biopsy sample to assess endometrial receptivity are reviewed. The issue of a search for an ideal endometrial receptivity marker is discussed.
Conclusion: At present, the most efficient and accurate methods to diagnose the window of implantation are those based on the mRNA profile assessment of an endometrial tissue sample. Аnalysis of mRNAs allows not only the accurate diagnosis of endometrial receptivity at the time of biopsy to be determined, but also the window of implantation shift to earlier or later periods to be reliably predicted.
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INVITED ARTICLE
Epidermolysis bullosa House Austria as a role model for the care of a rare disease
Abstract
The evolution of the Epidermolysis bullosa (EB) House Austria in Salzburg has demonstrated from its beginning in 2005 in an exceptional way the establishment of an optimized health care for a hitherto neglected group of patients, suffering from a rare but devastating skin disease: Epidermolysis bullosa. Patients with this hereditary mechanobullous skin disease, characterized by a heterogenous clinical course, multisystemic manifestations and increased morbidity and mortality, find in the EB House Austria a multidisciplinary, medical and psychosocial, family-centered support, optimally customized to this condition and individualized to each patient. Its unique structure of four divisions (Outpatient Unit, Research Laboratory, Academy, Clinical Research and Study Center) has set the basis for the delivery of best medical practice and state-of-the-art care as well as the establishment/ performance of high quality and patient centered research and translational medicine. Initially the (ongoing) close collaboration with the powerful patient group and medical research charity “DEBRA Austria” that is dedicated to a multidimensional support of EB patients and their relatives living in Austria and neighboring countries, has enabled the construction of the EB House Austria. The acknowledgement of this institution as a successful model has been officially obtained in 2017 by its designation as a national Center of Expertise for Genodermatoses with special focus on EB and its inclusion into the European Reference Network (ERN) for Rare Skin Disorders in September 2018. Therefore, the history of the EB house is worth reviewing since it can be regarded as a role model for the care of other rare and multisystemic diseases.
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ARTICLES
Reproductive system status and the algorithm to solve fertility issues in men with cystic fibrosis
Abstract
Rationale: Cystic fibrosis (CF) is a common hereditary disease related to the CFTR gene mutations and characterized by progression and multiple system involvement (primarily of the digestive tract and / or pulmonary system). Most men with CF are infertile. Due to new therapeutic options, the life expectancy of CF patients has increased, with reproductive issues becoming relevant.
Aim: A multifaceted assessment of the reproductive system status and fertility in male patients with CF and improvement of the strategies to resolve their reproduction issues.
Materials and methods: This cohort prospective study was performed 2006 to 2018 and included 81 unrelated Russian male patients with confirmed CF, aged from 15 to 69 years (mean age 25.6 ± 7.9 years). Forty two (42) patients had pancreatic sufficient and 39 pancreatic insufficient CF. The patients underwent clinical, andrological, laboratory and instrumental examination (scrotal ultrasonography, standard and biochemical semen examination and hormone levels).
Results: Reproductive disorders and semen abnormalities found in CF patients varied from preserved fertility to infertility. The following andrological abnormalities were found: delayed puberty (48%), urological disorders (26%), uni- or bilateral testicular hypoplasia (42%), diffuse lesions and cysts of the epididymis (70%), diffuse lesions /calcifications of the prostate (50%), and decreased testosterone levels (24.2%). Azoospermia was diagnosed in 87.5% of the patients, “moderate” or “mild” pathozoospermia (oligo-/astheno-/teratozoospermia) in 11.1%, and normozoospermia in 1.4% of the patients. There were significant differences between the patients with pancreatic sufficient and pancreatic insufficient CF in the ejaculate volume (1.4 ± 1.5 ml vs. 0.6 ± 0.5 ml; р = 0.006), ejaculate pH (6.7 ± 0.7 vs. 6.1 ± 0.4; р < 0.0001), and sperm concentration (19.6 ± 56.0 Mio/mL vs. 0.001 ± 0.008 Mio/ mL; p = 0.011). Normal ejaculate volume was more frequent (21.1% vs 14.7%; p > 0.05) in patients under the age of 25. No bilateral obstruction of vas deferens was found in 71.4% patients with 3849+10kbC>T mutation. There was a significant difference (p < 0.00001) in the frequency of 3849+10kbC>T mutation between the patients with vas deferens obstruction (9.5%) and without it (93.8%). We developed an algorithm to resolve infertility issues (including assisted reproductive technologies) in male CF patients depending on their fertility / presence and type of pathozoospermia and some other factors that may influence the conception and CF risk in the offspring. We also suggested practical recommendations for the andrological assessment, maintenance of reproductive health, and planning of childbirth in these patients.
Conclusion: Male CF patients require a multifaceted assessment of their reproductive system. The prognosis of their reproductive functions, the strategy to maintain their reproductive health and making a decision on childbirth depends on the CF type, the CFTR genotype, the results of semen analysis, and the patient’s age. Pancreatic sufficient CF type, 3849+10kbС>T mutation of the CFTR gene and younger age are favorable factors for potential maintenance of vas deferens patency and male fertility in CF patients.
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Characteristics of the mutation spectrum identified by comprehensive investigation of the CFTR gene in the Russian patients
Abstract
Rationale: Cystic fibrosis (CF; OMIM 219700) is a common hereditary disease caused by mutations in the CFTR gene (OMIM 602421). The distribution and frequencies of the CFTR gene mutations vary considerably between countries and ethnic groups. By now about 11% alleles of the CFTR gene remain unidentified after testing for frequent mutations in the Russian patients. A full determination of the mutation spectrum in the CFTR gene is necessary to optimize medical and genetic assistance to the population and to implement the achievements of targeted therapy in the treatment of CF patients.
Materials and methods: The sample included 121 Russian CF patients, in whom testing for 34 routinely analyzed mutations did not identify one (n = 107) or both (n = 14) mutant alleles. Assessment of the coding sequence of the CFTR gene, including the regions of exon-intron junctions, 5’- and 3’-untranslated regions was performed by the Sanger sequencing method; in addition, the search for large rearrangements was conducted by the multiplex ligation-dependent probe amplification (MLPA) method.
Results: In addition to the previously identified, 88 more variants were determined, including 28 missense mutations, 15 nonsense mutations, 18 frameshift mutations (14 deletions, 4 insertions), 14 splicing mutations, 1 in-frame insertion, 1 in-frame deletion, 1 in/del mutation, and 10 large rearrangements (7 deletions, 3 duplications). Twenty three (23) novel variants were sequenced. Four (4) complex mutant alleles were found. Sixty (60) variants are found once each. One hundred and thirty four (134) of 135 tested mutant alleles were identified.
Conclusion: Consequent use of the sequencing and MLPA methods has allowed for identification of a high proportion of the tested mutant alleles in CF patients from Russia (134/135, > 99%), to detect a significant diversity of the CFTR mutation spectrum (88 additional variants, 32 of them novel), a number of repeated mutations (c.2353C>T, c.1240_1244delCAAAA, c.1766+1G>A and c.3929G>A) encountered in 5 or more unrelated patients, which could be included in the panel of routinely analyzed variants in the Russian CF patients; and a high proportion of large rearrangements of the CFTR gene.
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Hypermethylation of the microRNA miR-124, miR-125b, miR-127, and miR-129 in ovarian carcinoma is involved in suppression of their expression and associated with both the development and progression of ovarian cancer
Abstract
Rationale: We have previously identified a group of microRNA genes (MIR-107, MIR-1258, MIR-130b, MIR-34b/c, MIR-9-1, MIR-9-3 et al.), whose methylation was involved into the development and progression of ovarian cancer. Aim: To expand the range of microRNA genes hypermethylated in ovarian cancer and to study the role of this modification in the pathogenesis and progression of ovarian cancer. Materials and methods: The study was performed on a series of 76 ovarian cancer and 13 peritoneal metastases samples. The method of bisulfite DNA conversion followed by methylation-specific polymerase chain reaction (PCR) was used to assess the methylation status of the microRNA genes; the expression of these genes was measured by quantitative real-time PCR. Results: Compared to histologically unchanged ovarian tissue, there was a significant increase in methylation frequencies in the tumor samples for 6 microRNA genes studied: MIR-124-1, MIR-124-2, MIR-124-3, MIR-125B-1, MIR-127, and MIR-129-2 (p ≤ 10-3). The expression level of 4 microRNAs (miR-124-3p, miR-125b-5p, miR-127-5p, miR-129-5p) encoded by these genes was suppressed, with a significant correlation between changes in their expression levels and the gene methylation (rs = 0.63–0.94, p ≤ 10-4). In addition, there were statistically significant associations between methylation of 5 genes (MIR-124-2, MIR-124-3, MIR-125B-1, MIR-127, and MIR-129-2) and the parameters of cancer progression, such as its clinical stage, metastatic spread, tumor size and invasion, and to a lesser extent with a decrease in the differentiation grade. The association of 5 microRNA genes with metastatic spread was confirmed by the analysis of peritoneal macro-metastases from 13 patients. Conclusion: We have demonstrated the functional significance of aberrant methylation in a group of microRNA genes for suppression of their expression in ovarian carcinomas. There is an association of microRNA gene hypermethylation with the progression of ovarian cancer, including metastatic spread to the peritoneum.
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Algorithm of molecular genetic investigation to identify hereditary BRCA-associated breast cancer
Abstract
Background: About 30% of cases of hereditary breast cancer (BC) are associated with the BRCA1 and BRCA2 gene mutations. The absence of the programs of mandatory genetic screening for hereditary BRCA-associated BC in Russia, as well as of an algorithm for molecular genetic testing does not allow fully accomplishing the necessary preventive, diagnostic and medical measures.
Aim: To elaborate an algorithm for molecular genetic testing of BC patients in order to improve the efficacy of identification of the hereditary nature of the disease.
Materials and methods: The study is based on the analysis of the results of molecular genetic testing of 3826 BC patients aged from 22 to 90 years, who were examined and treated in the Russian Research Center of Roentgenoradiology (Moscow) from 2010 to 2016. At the first stage of the study, germinal mutation in the BRCA1 and BRCA2 genes prevalent in the Russian population were identified by the real-time polymerase chain reaction (PCR). At the second stage, we searched for rare genetic variants of these genes by the ‘next generation sequencing’ (NGS) method.
Results: The real-time PCR (the first stage) showed that the prevalence of the most typical for the Russian population mutations in the BRCA1 gene, associated with BC risk, was 3.5% (132/3826 BC patients). No carriers of the BRCA2 mutations were identified. Based on the analysis of a questionnaire survey and primary medical documentation, a group of 717 patients was selected from the total cohort, who had clinical features of the hereditary disease (CFHD). In this group, the BRCA1 and BRCA2 gene mutations were found in 126 patients (17.6%). At the second stage, a group of 193 patients with CFHD and no BRCA1 and BRCA2 mutations prevalent in the Russian population was investigated by NGS. Rare pathogenic mutations of these genes were found in 27 patients (14%). In total, it may be concluded that at least 30% of the BC patients with CFHD have germinal mutations in the BRCA1 and BRCA2 genes. Based on the data obtained, we have developed the algorithm of molecular genetic testing of BC patients aimed at identification of the hereditary nature of the disease.
Conclusion: The high frequency of mutations in the BRCA1 and BRCA2 genes found in this study in BC patients with CFHD confirms the necessity of genetic testing for this hereditary disease. The information on its hereditary nature allows for the introduction of essential therapy modification with a personalized approach. Regular follow-up of patients with hereditary BC and prevention of new BC cases and other cancers (ovarian, gastric, pancreatic and prostate cancer, as well as melanoma) in their relatives with BRCA1 and BRCA2 mutations have to be implemented by a multidisciplinary team (specialists in mammology, gynecology, oncology, medical genetics, chemotherapy and psychotherapy).
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The study on the modifying role of mitochondrial DNA polymorphism in the Brugada syndrome manifestation
Abstract
Background: Brugada syndrome is a hereditary disease with genetic and phenotypic variability characterized by a high risk for arrhythmia and sudden cardiac death. It is assumed that modifying genetic factors contribute to the variability of the phenotype. Mitochondrial DNA (mtDNA) polymorphism can be considered among such factors, since mitochondrial dysfunction, including that associated with mtDNA variants, can have an arrhythmogenic effect. Aim: To study possible association between mtDNA polymorphism with the phenotype in the Russian patients with Brugada syndrome. Materials and methods: We have studied mtDNA polymorphism in 36 Russian probands with Brugada syndrome. Common “European” haplogroups of mtDNA were assigned using sequencing of the hypervariable segment 1 in mtDNA D-loop. Results: In the study sample, the frequencies of the mtDNA haplogroups generally correspond to the distribution common for the Russian populations, except the J haplogroup, which was not found in the studied probands. The results contradict with previously published data on the J and T haplogroups as risk factors for Brugada syndrome manifestation. Conclusion: The study did not reveal the role of mtDNA polymorphism (J and T haplogroups) in the formation of the Brugada syndrome phenotype.
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Association of celiac disease genetic markers with reproduction disorders
Abstract
Background: Numerous studies have shown a link between genes involved in the immune response and infertility and miscarriage. The most significant associations have been established for the cytokine genes (IL1B, IL6, IL10, IL18), chemokine genes (CXCL9, CXCL10, CXCL11), and genes of the major histocompatibility complex HLA II class (DQA1, DQB1, DRB1). HLA genes are associated with celiac disease, a genetically determined autoimmune disorder, where male and female reproduction impairment is one of the symptoms. Aim: To assess the prevalence of polymorphic variants of the immune response genes (HLA: DQA1 DQB1, DRB1; TNF, IL10, CXCL10) in patients with reproduction disorders. Materials and methods: This pilot study involved assessment of the following gene polymorphisms: IL10 (rs1800872), TNF (rs1800629), CXCL10 (rs4386624), and HLA class II (DQA1, DQB1, DRB1) in couples (n = 220) with reproduction disorders (infertility and miscarriage). Genotyping was performed by real-time polymerase chain reaction (PCR) and polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) methods. The genotypes and alleles population data were used for comparison with the studied variants of the genes IL10 (rs1800872), TNF (rs1800629), and CXCL10 (rs4386624). Differences in the prevalence of alleles and genotypes were assessed by χ2 test. The differences were considered significant at p < 0.05. Haplotype diversity was calculated by the Arlequin software, version 3.5.x. Results: Compared to the populational data, there was significant re-distribution of the genotypes and alleles to the TNF gene (rs1800629) variant in men with impaired reproductive functions. No differences were found for other gene variants studied. The frequency of HLA class II gene (DQA1, DQB1, DRB1) haplotypes associated with celiac disease (DQ2 and DQ8) in the study sample was 23.8%. Conclusion: The results indicate the important role of genes associated with celiac disease in the development of reproduction disorders.
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CLINICAL CASES
Challenges of the differential diagnosis between the subtypes of the junctional epidermolysis bullosa: presentation of two clinical cases
Abstract
Background: Epidermolysis bullosa (EB) is a rare hereditary skin disease. It is subdivided into EB simplex (EBS), junctional EB (JEB), dystrophic EB (DEB) and Kindler syndrome. JEB is diagnosed in 2 per 1,000,000 of the population. There are few descriptions of clinical JEB cases in the literature. Clinical diagnosis of JEB and its subtypes is a challenge, especially in the early age. The paper presents 2 clinical cases of JEB in patients of the West Slavonic origin. Clinical case No. 1 was a girl of Ukrainian ethnicity, with confirmed definitive diagnosis of severe generalized JEB. Molecular genetic tests identified mutations of the LAMA3 gene that had not been described previously. The patient died at the age of 24 months from acute respiratory failure. When the patient was alive, her EB type and subtype was not possible to identify, because she had a combination of clinical manifestations typical for various JEB subtypes. Despite such symptoms as hoarse voice, stenoses, granulation tissue of typical location, laryngeal granulations, the girl was steadily gaining weight, with some periods of relative stabilization of the skin disease; she also had longer life longevity than was common for patients with severe generalized JEB. All this made a precise diagnosis difficult. Clinical case No. 2: an ethnic Russian boy with non-classified JEB. Molecular genetic testing helped to identify a homozygote mutation in the LAMA3 gene that had not been previously described; reliable determination of the subtype was not possible. The patient had mixed clinical manifestation similar both to generalized severe JEB and to laryngo-onycho-cutaneous (LOC) syndrome. During his lifetime, the patient was clinically diagnosed with Hallopeau acrodermatitis and LOC syndrome. The differential diagnostic problems were associated with the presence of signs not typical for each of the subtypes. Significant life longevity of the proband is not characteristic for severe generalized JEB (at the time of the publication the patient is 13 years old), whereas for LOC syndrome the absence of eye involvement is not typical, as well as severe laryngeal involvement at adolescence.
Conclusion: Detailed descriptions of phenotype of JEB subtypes including rare and minimal clinical signs can be useful to study the clinical manifestations and natural course of the disease, including its differential diagnosis.
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