A clinical protocol for the detection of comorbidities associated with monogenic causes of male infertility.

study questionHow can comorbidities associated with monogenic forms of male infertility systematically be identified? SUMMARY ANSWER: Via a framework that consists of seven sequential steps, gene-specific phenotyping protocols can be generated for all monogenic causes of male infertility. WHAT IS KNOWN ALREADY: Infertility negatively impacts men's health. When loss of a single gene is causal for infertility (i.e. monogenic), the associated comorbidities are largely unknown. STUDY DESIGN, SIZE, DURATION: A framework was developed that allows the generation of gene-specific phenotyping protocols. The framework was applied to generate such protocols for two men, each with a different monogenic cause for their infertility. PARTICIPANTS/MATERIALS, SETTING,

methodsA multidisciplinary medical team formulated seven sequential steps to develop gene-specific phenotyping protocols. Gene-specificity was obtained by using a gene's expression pattern in the human body to identify tissues/cell types that show high levels of expression, as well as a literature search on the gene of interest, for potential morbidities. With these insights, tailored questionaries and tests are designed. We applied this framework to generate gene-specific protocols for two men in whom infertility was caused by the respective disruption of the genes MEI1 and DNAH17. These genes respectively show very high levels of expression in various types of immune cells and retinal cells. With gene-specific phenotyping protocols, we assessed the functionality of these cells in these men. MAIN RESULTS AND THE ROLE OF CHANCE: Our framework facilitated the generation of two gene-specific phenotyping protocols that were used to systematically identify potential comorbidities associated with two forms of monogenic male infertility. Analyses of the gene expression in the human body identified immune cells (MEI1) and retinal cells and oligodendrocytes (DNAH17) as somatic cell types with high expression. Gene-specific phenotyping protocols contained targeted questions as well as clinical tests for these tissues/cell types. The questionnaires indicated no increased susceptibility to infections, allergies nor autoimmune disease (MEI1) or visual problems (DNAH17). The clinical tests comprised extensive immune profiling for the MEI1-participant and functional evaluation and imaging of the retinal cells of the DNAH17-participant. None of the test results indicated clinically relevant alterations at present. To identify true comorbidities, or lack thereof, more men with the same monogenic cause should be phenotyped. LARGE SCALE DATA: Not applicable. LIMITATIONS, REASONS FOR CAUTION: The Human Protein Atlas database was used to assess the expression pattern of the causal gene. This database only contains expression data in adult tissues. Potential comorbidities due to a developmental function of a gene can therefore be missed. In addition, comorbidities might develop later in life and might not be present during the phenotyping. WIDER IMPLICATIONS OF THE

findingsKnowledge on the presence or absence of infertility-associated comorbidities allows clinicians to counsel patients on possible additional health risks for themselves and potential future offspring. As a consequence, medical care for infertile people extends beyond reproductive needs to general health. STUDY FUNDING/COMPETING INTEREST(S): J.A.V. was funded by an Investigator Award in Science from the Wellcome Trust (209451) and by The Netherlands Organization for Scientific Research (918-15-667). The authors declare no conflicts of interest. TRIAL REGISTRATION NUMBER: N/A.