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<article article-type="research-article" dtd-version="1.3" xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xml:lang="ru"><front><journal-meta><journal-id journal-id-type="publisher-id">medgen</journal-id><journal-title-group><journal-title xml:lang="ru">Медицинская генетика</journal-title><trans-title-group xml:lang="en"><trans-title>Medical Genetics</trans-title></trans-title-group></journal-title-group><issn pub-type="ppub">2073-7998</issn><publisher><publisher-name>Publishing House «Genius Media» LLC</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="doi">10.25557/2073-7998.2018.02.46-52</article-id><article-id custom-type="elpub" pub-id-type="custom">medgen-398</article-id><article-categories><subj-group subj-group-type="heading"><subject>Research Article</subject></subj-group><subj-group subj-group-type="section-heading" xml:lang="ru"><subject>ОРИГИНАЛЬНЫЕ ИССЛЕДОВАНИЯ</subject></subj-group><subj-group subj-group-type="section-heading" xml:lang="en"><subject>ORIGINAL RESEARCH</subject></subj-group></article-categories><title-group><article-title>Сравнительная цитогенетика эмбриобласта, трофэктодермы и внутриполостной жидкости бластоцисты человека</article-title><trans-title-group xml:lang="en"><trans-title>Comparative cytogenetics of embryoblast, trophectoderm and blastocoele fluid of human blastocyst</trans-title></trans-title-group></title-group><contrib-group><contrib contrib-type="author" corresp="yes"><name-alternatives><name name-style="eastern" xml:lang="ru"><surname>Жигалина</surname><given-names>Д. И.</given-names></name><name name-style="western" xml:lang="en"><surname>Zhigalina</surname><given-names>D. I.</given-names></name></name-alternatives><email xlink:type="simple">darya.zhigalina@medgenetics.ru</email><xref ref-type="aff" rid="aff-1"/></contrib><contrib contrib-type="author" corresp="yes"><name-alternatives><name name-style="eastern" xml:lang="ru"><surname>Скрябин</surname><given-names>Н. А.</given-names></name><name name-style="western" xml:lang="en"><surname>Skryabin</surname><given-names>N. A.</given-names></name></name-alternatives><email xlink:type="simple">noemail@neicon.ru</email><xref ref-type="aff" rid="aff-2"/></contrib><contrib contrib-type="author" corresp="yes"><name-alternatives><name name-style="eastern" xml:lang="ru"><surname>Канбекова</surname><given-names>О. Р.</given-names></name><name name-style="western" xml:lang="en"><surname>Kanbekova</surname><given-names>O. R.</given-names></name></name-alternatives><email xlink:type="simple">noemail@neicon.ru</email><xref ref-type="aff" rid="aff-3"/></contrib><contrib contrib-type="author" corresp="yes"><name-alternatives><name name-style="eastern" xml:lang="ru"><surname>Артюхова</surname><given-names>В. Г.</given-names></name><name name-style="western" xml:lang="en"><surname>Artyukhova</surname><given-names>V. G.</given-names></name></name-alternatives><email xlink:type="simple">noemail@neicon.ru</email><xref ref-type="aff" rid="aff-4"/></contrib><contrib contrib-type="author" corresp="yes"><name-alternatives><name name-style="eastern" xml:lang="ru"><surname>Светлаков</surname><given-names>А. В.</given-names></name><name name-style="western" xml:lang="en"><surname>Svetlakov</surname><given-names>A. V.</given-names></name></name-alternatives><email xlink:type="simple">noemail@neicon.ru</email><xref ref-type="aff" rid="aff-4"/></contrib><contrib contrib-type="author" corresp="yes"><name-alternatives><name name-style="eastern" xml:lang="ru"><surname>Лебедев</surname><given-names>И. Н.</given-names></name><name name-style="western" xml:lang="en"><surname>Lebedev</surname><given-names>I. N.</given-names></name></name-alternatives><email xlink:type="simple">noemail@neicon.ru</email><xref ref-type="aff" rid="aff-2"/></contrib></contrib-group><aff-alternatives id="aff-1"><aff xml:lang="ru"><institution>Национальный исследовательский Томский государственный университет</institution><country>Россия</country></aff><aff xml:lang="en"><institution>National Research Tomsk State University</institution><country>Russian Federation</country></aff></aff-alternatives><aff-alternatives id="aff-2"><aff xml:lang="ru"><institution>Научно-исследовательский институт медицинской генетики, Томский национальный исследовательский медицинский центр Российской академии наук</institution><country>Россия</country></aff><aff xml:lang="en"><institution>Research Institute of Medical Genetics, Tomsk National Research Medical Center of Russian Academy of Sciences</institution><country>Russian Federation</country></aff></aff-alternatives><aff-alternatives id="aff-3"><aff xml:lang="ru"><institution>ОГАУЗ «Томский областной перинатальный центр»</institution><country>Россия</country></aff><aff xml:lang="en"><institution>Tomsk Regional Perinatal Center</institution><country>Russian Federation</country></aff></aff-alternatives><aff-alternatives id="aff-4"><aff xml:lang="ru"><institution>ООО «Красноярский центр репродуктивной медицины»</institution><country>Россия</country></aff><aff xml:lang="en"><institution>Krasnoyarsk Center for Reproductive Medicine</institution><country>Russian Federation</country></aff></aff-alternatives><pub-date pub-type="collection"><year>2018</year></pub-date><pub-date pub-type="epub"><day>03</day><month>04</month><year>2018</year></pub-date><volume>17</volume><issue>2</issue><fpage>46</fpage><lpage>52</lpage><permissions><copyright-statement>Copyright &amp;#x00A9; Жигалина Д.И., Скрябин Н.А., Канбекова О.Р., Артюхова В.Г., Светлаков А.В., Лебедев И.Н., 2018</copyright-statement><copyright-year>2018</copyright-year><copyright-holder xml:lang="ru">Жигалина Д.И., Скрябин Н.А., Канбекова О.Р., Артюхова В.Г., Светлаков А.В., Лебедев И.Н.</copyright-holder><copyright-holder xml:lang="en">Zhigalina D.I., Skryabin N.A., Kanbekova O.R., Artyukhova V.G., Svetlakov A.V., Lebedev I.N.</copyright-holder><license xml:lang="ru" license-type="creative-commons-attribution" xlink:href="https://creativecommons.org/licenses/by/4.0/" xlink:type="simple"><license-p>Данная работа распространяется под лицензией Creative Commons Attribution 4.0.</license-p></license><license xml:lang="en" license-type="creative-commons-attribution" xlink:href="https://creativecommons.org/licenses/by/4.0/" xlink:type="simple"><license-p>This work is licensed under a Creative Commons Attribution 4.0 License.</license-p></license></permissions><self-uri xlink:href="https://www.medgen-journal.ru/jour/article/view/398">https://www.medgen-journal.ru/jour/article/view/398</self-uri><abstract><p>Сравнение молекулярных кариотипов внеклеточной ДНК из внутриполостной жидкости бластоцисты, клеток эмбриобласта и трофэктодермы открывает новые перспективы для изучения цитогенетических механизмов формирования числовых хромосомных нарушений в преимплантационном периоде развития человека. Кроме того, такой анализ позволяет оценить диагностическую ценность внеклеточной ДНК как дополнительного источника информации об эмбриональном кариотипе при преимплантационной генетической диагностике. Цель исследования - сравнительное молекулярно-цитогенетическое кариотипирование эмбриобласта, трофэктодермы и внеклеточной ДНК из внутриполостной жидкости бластоцисты. Методами метафазной и микроматричной сравнительной геномной гибридизации проанализировано 29 бластоцист человека 5 дня развития. Внеклеточная ДНК была успешно амплифицирована в 86,2% (25/29) образцов. По результатам анализа трофэктодермы, эмбриобласта и внеклеточной ДНК, бластоцисты были эуплоидными в 31%, 36% и 28% случаев соответственно. Лишь 3 бластоцисты из 29 (10,3%) имели нормальный кариотип по данным анализа всех трех образцов. Всего было выявлено 175 анеуплоидий, при этом трисомии, моносомии, частичные три- и моносомии встречались с частотой 47,4%, 46,9%, 5,1% и 0,5% соответственно. Отмечено преобладание трисомий в эмбриобласте, недоступном для преимплантационного генетического скрининга. Хромосомный мозаицизм выявлен в 14 обследованных бластоцистах (48,2%), а в 44,8% бластоцист описаны реципрокные анеуплоидии, представленные сочетанием трисомии и моносомии по одной паре гомологичных хромосом. Всего зафиксировано 25 реципрокных анеуплоидий, в формирование которых было вовлечено 50 из 175 анеуплоидий (28,5%). Таким образом, внеклеточная ДНК может быть успешно амплифицирована и проанализирована современными молекулярно-цитогенетическими методами. Результаты сравнительного молекулярного кариотипирования внеклеточной ДНК, клеток эмбриобласта и трофэктодермы в целом свидетельствуют о недооценке частоты анеуплоидных и мозаичных бластоцист. Установлено, что в 72,4% случаев молекулярные кариотипы эмбриобласта и трофэктодермы не являются идентичными, что говорит о невозможности прямой экстраполяции результатов преимплантационного генетического скрининга биопсированных клеток трофэктодермы на внутреннюю клеточную массу. Соответственно, внеклеточная ДНК в полости бластоцист человека может рассматриваться как важный дополнительный источник информации о кариотипе эмбриона при проведении преимплантационной генетической диагностики.</p></abstract><trans-abstract xml:lang="en"><p>Relevance. A comparison of the molecular karyotypes of the cell-free DNA from the blastocoele fluid of the blastocyst, the embryoblast and trophectoderm cells provides new possibilities for studying of the cytogenetic mechanisms of the formation of numerical chromosomal abnormalities at the preimplantation stage of human development. In addition, such analysis allows us to evaluate the diagnostic yield of cell-free DNA as an additional source of information about the embryo karyotype for preimplantation genetic diagnosis. Aim. Comparative molecular cytogenetic karyotyping of embryoblast, trophectoderm and the cell-free DNA from the blastocoele fluid of the blastocyst. Materials and methods. Twenty-nine human blastocysts of the 5th day of development were analyzed by metaphase and array comparative genomic hybridization. Results. Cell-free DNA was successfully amplified in 86.2% (25/29) of the samples. Blastocysts were euploid in 31%, 36% and 28% of cases according to the results of analysis of trophectoderm, embryoblast and сell-free DNA, respectively. Only 3 out of 29 (10.3%) blastocysts had a normal karyotype according to the analysis of all three samples. A total of 175 aneuploidies were detected. Trisomies, monosomies, partial tri- and monosomies were observed at a frequency of 47.4%, 46.9%, 5.1%, and 0.5%, respectively. The prevalence of trisomy was noticed in the embryoblast, which is not available for preimplantation genetic screening. Chromosomal mosaicism was detected in 14 examined blastocysts (48.2%). The reciprocal aneuploidies presented by combination of trisomy and monosomy with one pair of homologous chromosomes were described in 44.8% of blastocysts. A total of 25 reciprocal aneuploidies were observed with involvement of 50 from 175 (28.5%) detected aneuploidies. Conclusions. The cell-free DNA can be successfully amplified and analyzed by current molecular cytogenetic techniques. The results of comparative molecular karyotyping of cell-free DNA, embryoblast and trophectoderm cells indicate an underestimation of the frequency of aneuploid and mosaic blastocysts. It was found that in 72.4% of cases the molecular karyotypes of the embryoblast and trophectoderm are not identical. This finding provides evidence for impossibility of a direct extrapolation of the results of preimplantation genetic screening of trophectoderm cells to the inner cell mass. Accordingly, the cell-free DNA from the blastocoele fluid can be considered as an important additional source of information about the embryo karyotype in preimplantation genetic diagnosis.</p></trans-abstract><kwd-group xml:lang="ru"><kwd>внеклеточная ДНК</kwd><kwd>внутриполостная жидкость бластоцисты</kwd><kwd>эмбриобласт</kwd><kwd>трофэктодерма</kwd><kwd>хромосомный мозаицизм</kwd><kwd>реципрокные анеуплоидии</kwd><kwd>cell-free DNA</kwd><kwd>blastocoele fluid</kwd><kwd>embryoblast</kwd><kwd>trophectoderm</kwd><kwd>chromosomal mosaicism</kwd><kwd>reciprocal aneuploidy</kwd></kwd-group></article-meta></front><back><ref-list><title>References</title><ref id="cit1"><label>1</label><citation-alternatives><mixed-citation xml:lang="ru">Handyside AH, Kontogianni EH, Hardy K, Winston RML. Pregnancies from biopsied human preimplantation embryos sexed by Y specific DNA amplification. Nature. 1990;344:768-770.</mixed-citation><mixed-citation xml:lang="en">Handyside AH, Kontogianni EH, Hardy K, Winston RML. Pregnancies from biopsied human preimplantation embryos sexed by Y specific DNA amplification. Nature. 1990;344:768-770.</mixed-citation></citation-alternatives></ref><ref id="cit2"><label>2</label><citation-alternatives><mixed-citation xml:lang="ru">Montag M, Kоster M, Strowitzki T, Toth B. Polar body biopsy. Review article. Fertil Steril. 2013;100(3): 603-607.</mixed-citation><mixed-citation xml:lang="en">Montag M, Kоster M, Strowitzki T, Toth B. Polar body biopsy. Review article. Fertil Steril. 2013;100(3): 603-607.</mixed-citation></citation-alternatives></ref><ref id="cit3"><label>3</label><citation-alternatives><mixed-citation xml:lang="ru">Kuliev A, Zlatopolsky Z, Kirillova I et al. Meiosis errors in over 20,000 oocytes studied in the practice of preimplantation aneuploidy testing. Reprod Biomed Online. 2011;22(1): 2-8.</mixed-citation><mixed-citation xml:lang="en">Kuliev A, Zlatopolsky Z, Kirillova I et al. Meiosis errors in over 20,000 oocytes studied in the practice of preimplantation aneuploidy testing. Reprod Biomed Online. 2011;22(1): 2-8.</mixed-citation></citation-alternatives></ref><ref id="cit4"><label>4</label><citation-alternatives><mixed-citation xml:lang="ru">Gianaroli L, Magli MC, Pomante A et al. Blastocentesis: a source of DNA for preimplantation genetic testing. Results from a pilot study. Fertil Steril. 2014;102(6): 1692-1699. e6.</mixed-citation><mixed-citation xml:lang="en">Gianaroli L, Magli MC, Pomante A et al. Blastocentesis: a source of DNA for preimplantation genetic testing. Results from a pilot study. Fertil Steril. 2014;102(6): 1692-1699. e6.</mixed-citation></citation-alternatives></ref><ref id="cit5"><label>5</label><citation-alternatives><mixed-citation xml:lang="ru">Harper JC, Coonen E, De Rycke M et al. ESHRE PGD Consortium data collection X: Cycles from January to December 2007 with pregnancy follow-up to October 2008. Hum Reprod. Hum. Reprod. 2010;25(11):2685-2707.</mixed-citation><mixed-citation xml:lang="en">Harper JC, Coonen E, De Rycke M et al. ESHRE PGD Consortium data collection X: Cycles from January to December 2007 with pregnancy follow-up to October 2008. Hum Reprod. Hum. Reprod. 2010;25(11):2685-2707.</mixed-citation></citation-alternatives></ref><ref id="cit6"><label>6</label><citation-alternatives><mixed-citation xml:lang="ru">Harton GL, Magli MC, Lundin K et al. ESHRE PGD Consortium/Embryology Special Interest Group-best practice guidelines for polar body and embryo biopsy for preimplantation genetic diagnosis/screening (PGD/PGS). Hum Reprod. 2011;26(1):41-46.</mixed-citation><mixed-citation xml:lang="en">Harton GL, Magli MC, Lundin K et al. ESHRE PGD Consortium/Embryology Special Interest Group-best practice guidelines for polar body and embryo biopsy for preimplantation genetic diagnosis/screening (PGD/PGS). Hum Reprod. 2011;26(1):41-46.</mixed-citation></citation-alternatives></ref><ref id="cit7"><label>7</label><citation-alternatives><mixed-citation xml:lang="ru">Chow JF, Yeung WS, Lau EY et al. Array comparative genomic hybridization analyses of all blastomeres of a cohort of embryos from young IVF patients revealed significant contribution of mitotic errors to embryo mosaicism at the cleavage stage. Reprod Biol Endocrinol. 2014;12(1):105. DOI: 10.1186/1477-7827-12-105.</mixed-citation><mixed-citation xml:lang="en">Chow JF, Yeung WS, Lau EY et al. Array comparative genomic hybridization analyses of all blastomeres of a cohort of embryos from young IVF patients revealed significant contribution of mitotic errors to embryo mosaicism at the cleavage stage. Reprod Biol Endocrinol. 2014;12(1):105. DOI: 10.1186/1477-7827-12-105.</mixed-citation></citation-alternatives></ref><ref id="cit8"><label>8</label><citation-alternatives><mixed-citation xml:lang="ru">Mertzanidou A, Spits C, Nguyen HT et al. Evolution of aneuploidy up to Day 4 of human preimplantation development. Hum Reprod. 2013;28(6):1716-1724.</mixed-citation><mixed-citation xml:lang="en">Mertzanidou A, Spits C, Nguyen HT et al. Evolution of aneuploidy up to Day 4 of human preimplantation development. Hum Reprod. 2013;28(6):1716-1724.</mixed-citation></citation-alternatives></ref><ref id="cit9"><label>9</label><citation-alternatives><mixed-citation xml:lang="ru">Evsikov S, Verlinsky Y. Mosaicism in the inner cell mass of human blastocysts. Hum Reprod. 1998;13:3151-3155.</mixed-citation><mixed-citation xml:lang="en">Evsikov S, Verlinsky Y. Mosaicism in the inner cell mass of human blastocysts. Hum Reprod. 1998;13:3151-3155.</mixed-citation></citation-alternatives></ref><ref id="cit10"><label>10</label><citation-alternatives><mixed-citation xml:lang="ru">Johnson DS, Cinnioglu C, Ross R et al. Comprehensive analysis of karyotypic mosaicism between trophectoderm and inner cell mass. Mol Hum Reprod. 2010;16:944-949.</mixed-citation><mixed-citation xml:lang="en">Johnson DS, Cinnioglu C, Ross R et al. Comprehensive analysis of karyotypic mosaicism between trophectoderm and inner cell mass. Mol Hum Reprod. 2010;16:944-949.</mixed-citation></citation-alternatives></ref><ref id="cit11"><label>11</label><citation-alternatives><mixed-citation xml:lang="ru">Esfandiari N, Bunnell ME, Casper RF. Human embryo mosaicism: did we drop the ball on chromosomal testing? J Assist Reprod Genet. 2016;33(11):1439-1444.</mixed-citation><mixed-citation xml:lang="en">Esfandiari N, Bunnell ME, Casper RF. Human embryo mosaicism: did we drop the ball on chromosomal testing? J Assist Reprod Genet. 2016;33(11):1439-1444.</mixed-citation></citation-alternatives></ref><ref id="cit12"><label>12</label><citation-alternatives><mixed-citation xml:lang="ru">Bolton H, Graham SJ, Van der Aa N. et al. Mouse model of chromosome mosaicism reveals lineage-specific depletion of aneuploid cells and normal developmental potential. Nature communications. 2016;7:11165. DOI:10.1038/ncomms11165.</mixed-citation><mixed-citation xml:lang="en">Bolton H, Graham SJ, Van der Aa N. et al. Mouse model of chromosome mosaicism reveals lineage-specific depletion of aneuploid cells and normal developmental potential. Nature communications. 2016;7:11165. DOI:10.1038/ncomms11165.</mixed-citation></citation-alternatives></ref><ref id="cit13"><label>13</label><citation-alternatives><mixed-citation xml:lang="ru">Lledо B, Morales R, Ortiz JA et al. Implantation potential of mosaic embryos. Syst Biol Reprod Med. 2017;63(3):206-208. DOI: 10.1080/19396368.2017.1296045.</mixed-citation><mixed-citation xml:lang="en">Lledо B, Morales R, Ortiz JA et al. Implantation potential of mosaic embryos. Syst Biol Reprod Med. 2017;63(3):206-208. DOI: 10.1080/19396368.2017.1296045.</mixed-citation></citation-alternatives></ref><ref id="cit14"><label>14</label><citation-alternatives><mixed-citation xml:lang="ru">Bazrgar M, Gourabi H, Valojerdi MR et al. Self-correction of chromosomal abnormalities in human preimplantation embryos and embryonic stem cells. Stem Cells Dev. 2013;22(17):2449-2456.</mixed-citation><mixed-citation xml:lang="en">Bazrgar M, Gourabi H, Valojerdi MR et al. Self-correction of chromosomal abnormalities in human preimplantation embryos and embryonic stem cells. Stem Cells Dev. 2013;22(17):2449-2456.</mixed-citation></citation-alternatives></ref><ref id="cit15"><label>15</label><citation-alternatives><mixed-citation xml:lang="ru">Palini S, Galluzzi L, DeStefani S et al. Genomic DNA in human blastocoele fluid. Reprod Biomed Online. 2013;26(6):603-610.</mixed-citation><mixed-citation xml:lang="en">Palini S, Galluzzi L, DeStefani S et al. Genomic DNA in human blastocoele fluid. Reprod Biomed Online. 2013;26(6):603-610.</mixed-citation></citation-alternatives></ref><ref id="cit16"><label>16</label><citation-alternatives><mixed-citation xml:lang="ru">Tobler KJ, Zhao Y, Ross R et al. Blastocoel fluid from differentiated blastocysts harbors embryonic genomic material capable of a whole-genome deoxyribonucleic acid amplification and comprehensive chromosome microarray analysis. Fertil Steril. 2015;104(2):418-425.</mixed-citation><mixed-citation xml:lang="en">Tobler KJ, Zhao Y, Ross R et al. Blastocoel fluid from differentiated blastocysts harbors embryonic genomic material capable of a whole-genome deoxyribonucleic acid amplification and comprehensive chromosome microarray analysis. Fertil Steril. 2015;104(2):418-425.</mixed-citation></citation-alternatives></ref><ref id="cit17"><label>17</label><citation-alternatives><mixed-citation xml:lang="ru">Mantikou E, Wong KM, Repping S, Mastenbroek S. Molecular origin of mitotic aneuploidies in preimplantation embryos. Biochim Biophys Acta. 2012;1822:1921-1930.</mixed-citation><mixed-citation xml:lang="en">Mantikou E, Wong KM, Repping S, Mastenbroek S. Molecular origin of mitotic aneuploidies in preimplantation embryos. Biochim Biophys Acta. 2012;1822:1921-1930.</mixed-citation></citation-alternatives></ref><ref id="cit18"><label>18</label><citation-alternatives><mixed-citation xml:lang="ru">Taylor TH, Gitlin SA, Patrick JL et al. The origin, mechanisms, incidence and clinical consequences of chromosomal mosaicism in humans. Hum Reprod Update. 2014;20: 571-581</mixed-citation><mixed-citation xml:lang="en">Taylor TH, Gitlin SA, Patrick JL et al. The origin, mechanisms, incidence and clinical consequences of chromosomal mosaicism in humans. Hum Reprod Update. 2014;20: 571-581</mixed-citation></citation-alternatives></ref><ref id="cit19"><label>19</label><citation-alternatives><mixed-citation xml:lang="ru">Gleicher N, Vidali A, Braverman J et al. Accuracy of preimplantation genetic screening (PGS) is compromised by degree of mosaicism of human embryos. Reprod Biol Endocrinol. 2016;14(1):54.</mixed-citation><mixed-citation xml:lang="en">Gleicher N, Vidali A, Braverman J et al. Accuracy of preimplantation genetic screening (PGS) is compromised by degree of mosaicism of human embryos. Reprod Biol Endocrinol. 2016;14(1):54.</mixed-citation></citation-alternatives></ref><ref id="cit20"><label>20</label><citation-alternatives><mixed-citation xml:lang="ru">Van Echten-Arends J, Mastenbroek S, Sikkema-Raddatz B et al. Chromosomal mosaicism in human preimplantation embryos: a systematic review. Hum Reprod Update. 2011;17:620-627.</mixed-citation><mixed-citation xml:lang="en">Van Echten-Arends J, Mastenbroek S, Sikkema-Raddatz B et al. Chromosomal mosaicism in human preimplantation embryos: a systematic review. Hum Reprod Update. 2011;17:620-627.</mixed-citation></citation-alternatives></ref></ref-list><fn-group><fn fn-type="conflict"><p>The authors declare that there are no conflicts of interest present.</p></fn></fn-group></back></article>
