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Biochimica Clinica: VOL.41 N.4

Scarica intero fascicolo
Biochimica Clinica 2017; 41(4) 291
Il laboratorio nella medicina della riproduzione
Laboratory and Reproductive Medicine
Biochimica Clinica 2017; 41(4) 292-293
DOI: 10.19186/BC_2017.041
Pubblicato online il: 17.11.2017
Editoriale - Editorial
Individualization of treatment in controlled ovarian stimulation: myth or reality?

Variability in the infertile population excludes the possibility of a single approach to controlled ovarian stimulation. The modern technology has led to the development of new drugs, treatment options and quantitative methods that allow an individualized approach to in vitro fertilization. The personalization of treatments requires a comprehensive evaluation of several important aspects. Age still remains the best predictive factor of gametes euploidy rate. It was estimated that the percentage of abnormal embryos/oocytes increased dramatically in women >35 years old. Strategies to improve the number of vital and euploid embryos in those women represents the most intriguing challenge nowadays, considering that more and more women seeking assisted reproductive technologies are in advanced age. On the other hand, ovarian reserve markers, namely follicle stimulating hormone, anti-Mullerian hormone and antral follicle count are also considered the most accurate predictor of ovarian reserve and could be successfully used to guide controlled ovarian stimulation. Finally, there is an emerging evidence in literature which suggests that the ovarian sensitivity to exogenous gonadotropins could be also influenced by specific genotypes characteristics. If these data will be confirmed, a genetic screening might allow in the future a pharmacogenomic approach to better control ovarian stimulation.

Biochimica Clinica 2017; 41(4) 294-305
DOI: 10.19186/BC_2017.051
Pubblicato online il: 17.11.2017
Rassegne - Reviews
Prenatal screening in pregnancies achieved through assisted reproductive technologies

Pregnancies achieved through assisted reproductive technologies (ART) represent a group of high-risk pregnancies with special needs of antenatal care. With regard to the increased risk of chromosomal disorders, women conceived by assisted reproduction are confronted with different prenatal screening modalities. As the vast majority wish to avoid invasive testing because of the associated risk of abortion, prenatal evaluation of sonographic and biochemical markers is the preferred option. First-trimester measurement of fetal nuchal translucency in singleton and twin gestations in ART pregnancies is associated with similar screening results when compared with spontaneous conception. First-trimester maternal serum free β-human chorionic gonadotropin and pregnancy-associated plasma protein-A levels are more obviously altered in assisted conceptions and carry the risk of higher false positive rates if not adjusted accordingly. This may help to avoid the unnecessary uptake of invasive testing. It is likely that this problem will become less thorny in the coming years with increasing access to non invasive genetic tests on maternal blood.

Biochimica Clinica 2017; 41(4) 306-313
DOI: DOI: 10.19186/BC_2017.042
Pubblicato online il: 15.11.2017
Rassegne - Reviews
Indicazioni e limiti della diagnosi genetica preimpianto
Indications and limitations for preimplantation genetic diagnosis

The preimplantation genetic diagnosis allows to identify genetic disease and chromosomal alterations in early stages of embryonic development, giving the opportunity to overcome the risk of transmitting an inherited disease and to improve the efficiency of in vitro fertilization techniques. In this paper, we provide an overview of indications and of the advantages and limits of techniques used to perform the preimplantation genetic diagnosis. We describe the multiplex-polymerase chain reaction (PCR) and the karyomapping for the genetic diagnosis of inherited disease as well as the comparative genomic hybridization array, the qualitative real-time PCR and the next generation sequencing for the screening of chromosomal aneuploidy.

Biochimica Clinica 2017; 41(4) 314-321
DOI: DOI: 10.19186/BC_2017.043
Pubblicato online il: 15.11.2017
Rassegne - Reviews
Oncofertilità: dove siamo?
An update about oncofertility

Over the last years we are experiencing an increased incidence of cancer in young population. Chemotherapy and radiotherapy often result in reduced fertility in these patients. With increasing survival rates, fertility is becoming an important quality-of-life concern for young cancer patients. They may be interested in parenthood, but the number of patients who access fertility preservation techniques before treatment is low. There is a need for improvements in clinical care to ensure patients about infertility risks and fertility preservation options and to support them in their reproductive decision-making before cancer treatment. Nowadays, many opportunities exist for fertility preservation. Sperm cryopreservation is a well-established method in male. In female, there are several strategies such as ovarian suppression with gonadotropin-releasing hormone analogues, ovarian tissue cryopreservation, in vitro maturation or in vitro fertilization after ovulation induction. Recently, developed ovarian stimulation protocols using tamoxifen and letrozole have been applied to increase the margin of safety in breast cancer patients. This review is focused on the effect of cancer treatments on fertility and on the assisted-reproduction innovations devoted to the cancer survivors.

Biochimica Clinica 2017; 41(4) 322-334
DOI: 10.19186/BC_2017.044
Pubblicato online il: 15.11.2017
Rassegne - Reviews
The role of the laboratory in the evaluation of male factor in couple infertility

The evaluation of male factor in couple infertility aims at identifying risk factors and treatable causes of male infertility to offer an adequate counselling and to choose the best treatment options to improve fertility outcomes, including either the chance of a spontaneous conception or the outcome of assisted reproduction. The first approach to the infertile man requires an accurate assessment of medical history as well as a general and andrological anamnesis and physical examination. The evaluation is based on a series of laboratory procedures, comprising semen analysis, the assessment of hormone profile, the eventual microbiological tests for the investigation of urogenital tract infections and genetic testing. This is associated with scrotal ultrasound, aimed at investigating the structure of testis, funiculus, epididymis, vasa and pampiniform plexus, and transrectal ultrasound, aimed at providing information on prostate and seminal vesicles. Semen analysis, performed according to WHO 2010 guidelines, is fundamental to assess the male fertility potential. Hormone profile assessment evaluates the function of the hypothalamic-pituitarygonadal axis and is useful to establish a diagnosis of primary or secondary testis failure and to choose the most appropriate therapeutic approach. Microbiological assessment can be useful in case of clinical suspicion of urogenital tract infections, which might exert a detrimental effect on male fertility. Genetic testing, in particular karyotype analysis, and the assessment of Y chromosome microdeletions should be performed in case of clinical suspicion or in case of a severe reduction of sperm count.

Biochimica Clinica 2017; 41(4) 335-345
DOI: 10.19186/BC_2017.048
Pubblicato online il: 15.11.2017
Rassegne - Reviews
Validazione preclinica della tecnologia “next generation sequencing” per l’identificazione di embrioni a mosaico durante l’analisi genetica preimpianto
Preclinical validation of the next generation sequencing for the identification of mosaic embryos during preimplantation genetic screening

Aneuploidy screening of embryos at blastocyst stage can be jeopardized by the presence of chromosomal mosaicism, which is a phenomenon characterized by the presence a mixture of diploid and aneuploid cell lines in embryos. Although its significance for implantation and the developmental potential of embryos is still unclear, it is reasonable to assume that mosaicism is likely to influence in vitro fertilization success rates. In this study, we investigated whether next generation sequencing (NGS) technologies applied for preimplatation genetic screening (PGS) purposes have the potential to improve mosaicism detection in human embryos over conventional methods. The study was organized into two steps. The first involved 126 samples from mixing experiments with different ratios of euploid and aneuploid single cells, to mimic chromosomal mosaicims. The aim was to determine the minimum ratio of aneuploid to euploid cells that is needed to detect a copy number variation by NGS. The second step was a retrospective blinded assessment of 18 whole genome amplification products, selected from previously performed clinical PGS cycles, including embryos with mosaic aneuploidy results. Reconstitution experiments results demonstrated that chromosomal mosaicism can be consistently identified by NGS, with the lower representation of detectable aneuploid cells being at 10% level. In addition, NGS was able to detect all 18 embryos with mosaicism, accounting for a total of 31 chromosomes involved by mosaicism. In conclusion, NGS is a reliable methodology capable to detect mosaic embryos with low percentage of aneuploidy. NGS has the potential to improve chromosomal diagnosis on embryos, allowing the discrimination between aneuploidy and mosaic embryos.

Biochimica Clinica 2017; 41(4) 346-352
DOI: 10.19186/BC_2017.045
Pubblicato online il: 15.11.2017
Contributi scientifici - Scientific papers
The improvement of oocyte selection for social freezing application

Lifestyle, educational opportunities, career choices and new unions lead to pregnancy in more advanced age, increasing the emerging preventive solution to freeze oocytes at a young age for later use. In this scenario, the oocyte selection has a great importance in order to choose the best ones capable of a good subsequent embryo development and implantation. The aim of this study was to develop a decision support system, able to classify oocytes according to a score based on morphological features and patients’ clinical data. The approach would offer a more effective selection method because it is not dependent on the doctor’s experience or on an “at-first-sight” impression. As a first step, a prototype system able to support embryologists in oocyte selection was presented and an experimental evaluation on a real set of data provided. The developed pipeline included the identification of main morphological features influencing oocyte quality and the assignment of a weight and of a better way of measuring them. After that, a standard data format collecting in an organized way all morphological features of oocytes, zigote and embryos and patients’ clinical data was developed. More than 150 oocytes images, taken in standard and comparable conditions, from 35 women were collected. Morphological features were extracted manually and automatically. A preliminary version of the scoring algorithm was tested on these data.

Biochimica Clinica 2017; 41(4) 353-357
DOI: 10.19186/BC_2017.046
Pubblicato online il: 15.11.2017
Contributi scientifici - Scientific papers
Human papillomavirus infection and male infertility

Human papillomavirus (HPV) is one of the most common sexually transmitted infection in females and males. More than 100 different HPV types have been isolated and they can be subgrouped in cutaneous or mucosal according to their ability to infect the skin or the mucosa of the genital tract. Recently, many studies have found an association between HPV infection and male infertility. The purpose of this study was to investigate the implication of HPV sperm infection on male fertility and the impairment of principal sperm parameters. Moreover, we evaluated the reproductive outcome of infertile couples undergoing assisted reproduction techniques in presence or absence of HPV in semen.

Biochimica Clinica 2017; 41(4) 358-363
DOI: 10.19186/BC_2017.052
Pubblicato online il: 20.11.2017
Contributi scientifici - Scientific papers
Male infertility and ageing: two faces of the same coin?
A. Alfano  |  M. Nebuloni  |  P. Zerbi  |  A. Salonia  | 

Couple infertility has become a common condition in Western societies, with important medical, psychological and socio-economical consequences. Female conditions related to infertility have been extensively investigated. On the contrary, despite infertility affects 7% of all men and 50% of cases are of idiopathic nature, there is still a lack in terms of knowledge about etiology and pathophysiology behind male factor infertility. Clinically, infertile men are sicker than fertile men, as they experience higher rate of developing neoplastic disease and age-related comorbidities. Moreover, histological modifications of testicular parenchima of elder men are very similar to that observed in younger infertile male. Thereof, infertile male could be considered as an individual characterized by a faster ageing process. As a whole, a poorer health status appears to be associated to a malfunctioning male reproductive system, with the worst clinical picture in azoospermic individuals. We could considerate that an infertile male is an individual who grows old sooner and speculate that the same mechanisms leading to clinical and testicular histopathological modification of the elder lead to infertility in the young man. On the whole, male infertility could be considered as a proxy of general male health, with the etiological factors for infertility possibly representing markers of male healthiness and therapeutic intervention. Better understanding of the pathological bases of one condition could lighten the comprehension of the other one.

Biochimica Clinica 2017; 41(4) 364-367
DOI: 10.19186/BC_2017.049
Pubblicato online il: 17.11.2017
Opinioni - Opinions
Tutela della dignità umana e libertà di ricerca scientifica: una possibile soluzione al conflitto in tema di embrioni sovrannumerari
Human dignity and freedom of scientific research: a balancing approach for surplus embryos

The new challenges posed by biotechnology for legal science have led to unprecedented dilemmas as regards legal subjectivity and the beginning of life. Notably, biotechnology has rearticulated the existential project concerning procreation and parenting. In this process, biotechnology expands the existential prerogatives of the involved parties, but it also radicalizes ethical positions impinging on crucial issues posed by the need to define, in philosophical and legal terms, the status of entities produced but not necessarily involved in the procreative process, as in the case of embryos. This dilemma is crucial in the field of assisted reproductive techniques, as witnessed by the Italian regulatory framework (art. 1 co.1, L. 40/2004). The Italian “Rules Governing Assisted Fertilization” have been extensively modified by the Constitutional Court that, in recent years, declared many of its parts unconstitutional. The Court’s judgment finally permits a diagnostic survey of the health of the embryo, thereby allowing couples to transfer only “healthy” embryos in the uterus. The production of surplus embryos (so-called because they exceed the number of embryos transferred to the uterus) poses ethical and legal dilemmas about their destiny, especially in the case of embryos whose growth is arrested in vitro or who are affected by a severe disease and thus are excluded from becoming individuals. Considering the recent Constitutional Court’s judgment on art. 13 L. 40/2004 (84/2016), this paper analyses the current open dilemma on the destiny of the surplus embryos, even in the light of the European framework offered both by National legislations and Higher European Courts on this topic.

Biochimica Clinica 2017; 41(4) 368-370
DOI: 10.19186/BC_2017.053
Pubblicato online il: 20.11.2017
Opinioni - Opinions
La legge sulla procreazione medicalmente assistita: dall’emanazione alla demolizione
The assisted reproductive technology law: from enactment to demolition
G. Gallo  |  F. Re  | 

13 years after the enactment of the law no. 40/2004 regulating the assisted reproductive technologies in Italy, this paper focuses on the current status of the law after a number of National and International judgments that have modified the nature and the structure of the law. This paper discusses not only the positive amendments introduced by the Courts, but also the catastrophic effects produced by the law from 2004 up today. Several Italian couples have been forced to expatriate to overcome illegitimate and unfair legislative limits. One of the major limits is the production of a maximum of 3 embryos per cycle and then the contextual implantation in the uterus of all 3 embryos, without considering the differences among patients, with the risk of serious injuries. The Italian Constitutional Court has established that the choice of the number of embryos to be implanted should be made by physicians on a case-by-case basis, depending on the patient’s condition. This amendment produced several benefits, like the decrease of number of miscarriages and diseases and the increase of successful pregnancies. The hope is that the remaining unfair limits will be quickly fixed by the Italian Parliament instead of keeping on delegating legislative functions to National and International Courts.

Biochimica Clinica 2017; 41(4) 371-374
DOI: 10.19186/BC_2017.050
Pubblicato online il: 17.11.2017
Opinioni - Opinions
Gravidanza gemellare dizigotica in una donna affetta da diabete MODY3
Twin dizygotic pregnancy in a MODY3 patient

Maturity Onset Diabetes of the young (MODY) is an autosomal dominant disease that includes clinically heterogeneous forms of not autoimmune diabetes that are caused by mutations in different genes. To date at least thirteen subtypes of MODY have been described. Hepatocyte Nuclear Factor-1α (HNF-1α) gene mutations (MODY3) lead to a severe form of diabetes during adolescence, with glycosuria and progressive reduction of insulin secretion. The management of pregnancies in women with familial diseases could be difficult. We reported a case of a 36-year-old woman at the 5th week of a twin, bicorial, biamniotic pregnancy, diagnosed with diabetes at 18 years of age, with negative autoimmunity and diabetes family history. Genetic tests on woman and on her family showed father, sister, first daughter and one of the twins, carriers of c.812G>A HNF-1α mutation. This case of a twin pregnancy, with only one fetus inheriting the disease, allowed us to evaluate the genotype influence in a shared metabolic environment.

Biochimica Clinica 2017; 41(4) e25-e28
DOI: 10.19186/BC_2017.047
Pubblicato online il: 17.11.2017
Casi clinici - Case report