Do partial AZFc deletions affect the sperm retrieval rate in non-mosaic Klinefelter patients undergoing microdissection testicular sperm extraction?

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I-Shen Huang, Richard J Fantus, Wei-Jen Chen, James Wren, Wei-Tang Kao, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.2.15379/v2 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 27 Feb, 2020 Read the published version in BMC Urology → Version 2 posted 9 You are reading this latest preprint version Show more versions Abstract Background The purpose of this study is to evaluate the prognostic factors for sperm retrieval and determine if Y chromosome deletion is associated with deleterious effects. Whether Y chromosome deletion determines the sperm retrieval rate in non-mosaic Klinefelter patients has not yet been addressed. Methods We retrospectively collected medical records of azoospermic patients from Sep 2009 to Dec 2018, and enrolled 66 non-mosaic 47, XXY patients who were receiving mTESE. The predictive values of patients age, serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), testosterone, prolactin, estradiol and Y chromosome deletion were assessed for successful sperm recovery. Results Testicular sperm recovery was successful in 24 (36.4%) of 66 men. The mean age (36.0 vs. 36.6 years), and levels of FSH (30.0 vs 36.9 IU/L), LH (17.7 vs 21.9 IU/L), testosterone (2.4 vs. 2.1 ng/ml), prolactin (9.1 vs. 8.8 ng/ml), and estradiol (19.4 vs. 22.3 pg/ml) did not show any significant difference when comparing patients with and without successful sperm retrieval. Partial deletion of azoospermic factor c (AZFc) was noted in 5 (20.8%) of 24 patients with successful sperm retrieval, including three b2/b3 and two gr/gr deletion cases, whereas 4 (9.5%) of 42 patients with unsuccessful sperm retrieval were noted to have AZFc partial deletion (one b2/b3 , one sY1206 and two gr/gr deletion), though the difference was not statistically significant (p=0.27) Conclusion According to present results, age and AZFc partial deletion status should not be a deterrent for azoospermic males with non-mosaic Klinefelter syndrome to undergo mTESE. Urology & Nephrology Klinefelter AZFc deletion age microdissection testicular sperm extraction Figures Figure 1 Figure 2 Background According to recommendations from the American Society for Reproductive Medicine (ASRM) and European Association of Urology (EAU), cytogenetic analysis is suggested for patients with azoospermia or oligozoospermia. However, the threshold of sperm count recommended for karyotype analysis differs between the two associations: spermatozoa count below 10 million/mL from the EAU and spermatozoa count below 5 million/mL from the ASRM (1, 2). The main purpose of performing cytogenetic analysis for patients with subfertility or infertility is to provide proper counselling before assisted reproductive technology and inform couples of possible inheritances of paternal genetic disorders in their offspring. Genetic mutation or chromosome abnormality is more common in infertile males than in the general population, and investigations have shown that the percentage of chromosome abnormalities and Y chromosome microdeletions is about 2-6% and 3-5% (3, 4) for oligospermic patients, 13-15% and 6-16% for non-obstructive azoospermia (NOA) patients (5, 6). Among all chromosome abnormalities, Klinefelter syndrome (KS) is the most common numerical chromosome abnormality found in infertile men with an incidence rate of about 1-in-500 to 1-in-1000 male birth (7). The majority of cases with 47, XXY non-mosaic Klinefelter karyotype will present as hypergonadotropic hypogonadism and azoospermia, regardless of age, as a sign of primary testicular failure (8). However, aside from the non-mosaic form, there is a strong probability of finding sperm in semen with mosaic form (46, XY/47, XXY) of KS, depending on the level of XXY cell line mosaicism in the gonads (9). In general, about 90% of patients have uniform 47, XXY karyotype (pure KS) in which an extra X chromosome is present in somatic and germ cells, while 10% of KS can present with higher-grade of X chromosome aneuploidies (48 or more chromosomes) as well as mosaicism (47, XXY/46, XY) (7). Mosaic KS men tend to be more androgenized than their non-mosaic KS counterparts in terms of hormone profile and sperm count in ejaculate, representing better fertility potential, especially in low-grade mosaicism form (9). The azoospermia factor (AZF) region on the Y chromosome long arm is crucial for spermatogenesis and is known for its unique nearly identical direct and indirect repeated palindromic sequences. In addition to KS, the deletion of AZF is another cause for male infertility (10). Removal of the spermatogenesis candidate gene located in the AZFa or AZFb, which is responsible for production of male gametes, namely the USP9Y, DDX3Y, RBMY and PRY genes, will inevitably lead to spermatogenic failure and therefore is not recommended for microdissection testicular sperm extraction (mTESE) due to the lack of identifiable regions of spermatogenesis in the testes (11). The result of semen analysis of men with AZFc deletion varies in comparison with azoospermia found in AZFa and AZFb men, ranging from azoospermia to moderate oligozoospermia. Despite causing detrimental effects in sperm production, AZFc deletion is still regarded as a good prognostic factor for azoospermic men; the sperm retrieval rate (SRR) is up to 70% in this population (12). The incidence of AZFc deletion is higher than incidence of AZFa or AZFb deletion in men, because the Y chromosome AZFc region is predisposed to intrachromosomal non-allelic homologous recombination owing to its composition of large repeat units called “amplicons” (13). Rearrangement of the AZFc region, including partial deletions, duplications and deletions followed by duplication(s) has been reported (13). Deletion of the entire AZFc locus on the Y chromosome by means of removing 3.5Mb segment, including eight multi-copy gene families, is consensually considered a cause for infertility (10, 14). As for AZFc partial deletion, Gr/gr deletion is the most common type, followed by b2/b3 and b1/b3 deletions. In particular, whether gr/gr deletion causes deleterious effects on spermatogenesis is still an ongoing debate. According to previous literature, the frequency of gr/gr deletion is only higher in certain azoospermia or oligozoospermia populations in Italy and China when compared to the control (15, 16). Researchers have attempted to find predictors for successful sperm retrieval in KS men; some have demonstrated that testosterone levels after medical treatment, including aromatase inhibitors, clomiphene or human chorionic gonadotropin (17) and age at time of mTESE are reliable prognostic factors (18). Therefore, they have recommended that patients receive mTESE for sperm retrieval under the age of 35 (18). To date, due to the limited number of KS men, there are a paucity of articles discussing sperm retrieval rate by mTESE. Moreover, previous study populations did not include Han-Chinese or whether Y chromosome microdeletion may serve as a prognostic factor for possible sperm retrieval. Some clinicians may infer the outcome of sperm retrieval is affected by Y chromosome microdeletion in Klinefelter patients. Our study aimed to analyze predictive factors for sperm retrieval in Han-Chinese KS men and discuss the association for Y chromosome microdeletion with successful sperm retrieval. Methods Studied populations We retrospectively reviewed the period between September 2009 to Dec 2018. A total of 66 non-mosaic Klinefelter patients who were receiving microdissection testicular sperm extraction were enrolled in our study. All subjects were genetically ethnic Han-Chinese from Taiwan. Each patient underwent a detailed examination to identify the etiology of azoospermia, including a detailed history, physical examination, two consecutive semen analyses, hormone profile (follicle stimulating hormone (FSH), leutinizing hormone (LH), testosterone and prolactin), chromosome karyotyping, and Y chromosome microdeletion. DNA samples of 107 fertile controls who had fathered at least one child were obtained from 2 medical centers in Taiwan as described by Lin et al. in 2007 (14). This study was performed according to the Taipei Veterans General Hospital approved Institutional Review Board protocol (IRB number: 2018-03-002CCF) DNA extraction Genomic DNA was extracted from peripheral blood using the QIAamp DNA minikit (Qiagen, Hilden, Germany) according to the manufacturer recommendations. In brief, 20 μl Qiagen protease was pipetted into the bottom of a 1.5 ml microcentrifuge tube, then up to 200 μl whole blood or buffy coat was added to the microcentrifuge tube. After the addition of 200 μl buffer AL to the sample, the sample was thoroughly mixed by vortex mixing and was incubated at 56 °C for 10 minutes until cell lysis was complete. Two hundred microliters of ethanol (100%) were added to precipitate the DNA. The mixture was carefully applied to the QIAamp spin column, placed inside a 2 ml collection tube, and centrifuged at 8000 rpm, 6000×g for 1 minute. The QIAamp Spin column was then placed in a new collection tube, and 500 µl of buffer, AW1 was added and centrifuged. This step was repeated with the buffer AW2 and a high spin was given for 3 minutes to dry the column membrane. The spin column was subsequently placed in a clean 1.5 ml microcentrifuge tube, and the DNA filtrate was recovered with 200 µl of buffer AE. Following centrifugation, DNA was eluted and stored at −20 °C until used. Cytogenetic analysis Chromosome analysis was performed using conventional trypsin-Giemsa banding technique. Twenty metaphases were analyzed for each patient, and in cases of suspected mosaicism, the number of metaphases was increased to a total of 50 for analysis. To achieve a more detailed analysis, a 500-550 band level was used for evaluation. Yq classical deletions and AZFc subdeletions Y microdeletion screening in Klinefelter patients was performed by multiplex polymerase chain reaction (PCR) that detects markers in the AZF regions, the sex determining region Y (SRY) gene, and the Y homologous gene pair zinc-finger Y (ZFY) (19). The sequence-tagged sites (STS) selected are listed in Figure 1 and Table 1. Six AZFc deletions (sY254, sY1161, sY1191, sY1201, sY1206, and sY1291) were used to identify the type of partial AZFc deletions in all subjects. In addition, DNA from fertile males and female served as positive and negative controls, respectively. Ambiguities in the multiplex PCR assays were resolved by following up with single PCR assays. Microdissection testicular sperm extraction A small incision (3 cm) was made longitudinally on the median raphe, and carried down to the fascia. The testis were mobilized after opening the tunica vaginalis as described in 1999 (20). We performed a longitudinal incision on the testis instead of open it widely in an equatorial plane along the mid portion of the testis. An operating microscope with 20x~24x magnification allow the surgeon to identify larger and opaquer seminiferous tubules, which are most likely to contain sperm. Tissue with possibility of spermatogenesis was removed and sent for real time analysis by experienced embryologists in our reproductive lab for further intracytoplasmic sperm injection (ICSI). Statistical analysis Outcome variables (age, serum FSH, LH, testosterone, prolactin and estradiol) of azoospermic non-mosaic KS men with successful surgical sperm retrieval were compared to those with unsuccessful sperm retrieval using the Student’s t test. The distributions of AZFc partial deletion of Klinefelter patient with or without sperm retrieval and the frequency of AZFc partial deletion comparing azoospermic non-mosaic Klinefelter men with controls were analyzed by the Fisher’s exact test. In these tests, values of p < 0.05 were regarded as statistically significant. Results Azoopsermic non-mosaic Klinefelter men and Y chromosome deletion The cohort of 66 azoospermic non-mosaic Klinefelter men with chromosome 47, XXY had a mean age of 36.4 ± 5.2 years (mean ± SD). Of these 66 men, 9 men (13.6%) had a deletion of one STS marker. More precisely, we identified 5 men with an absence of sY1291 (possible gr/gr deletion), 3 men with an absence of sY1191 (possible b2/b3 deletion) and 1 with an absence of sY1206 only. Of the 24 patients with successful sperm retrieval, 5 (20.8%) had partial AZFc deletion, including 2 possible gr/gr deletion and 3 possible b2/b3 deletion cases (Table 2). Partial AZFc deletion is identified in 4 (9.5%) of 42 patients without sperm retrieval by mTESE, (one possible b2/b3 , one sY1206, and two possible gr/gr deletion), though the difference of Y chromosome deletion was not statistically significant between the successful and non-successful sperm retrieval groups (p= 0.27). Impact of various parameters on mTESE success Of the non-mosaic KS patients, mTESE was successful in 24 out of 66 patients, representing 36.4% of cases. Table 2 lists the clinical factors analyzed to predict sperm retrieval, stratified by outcome. Age, partial AZFc deletions, and hormone parameter (LH, FSH, testosterone, prolactin, estradiol) were not predictive factors for successful sperm retrieval. Effect of age on sperm retrieval SRR for mTESE was 34.6% (9/26) at ages below 35 years and 37.5% (15/40) at 35 years and older. Four of 13 KS men older than 40 years of age had successful sperm retrieval; the oldest patient with successful mTESE was 47 years-old (Figure 2). Partial AZFc deletions distribution between the experimental and control groups The frequency of AZFc partial detection was 13.6% (9/66) in KS men and 6.5% (7/107) in the control, although a higher percentage was seen in KS men, however the difference was not statistically significant (p>0.05). The deletion pattern in 9 KS men with AZFc partial deletion included 4 men with possible gr/gr deletion, 4 with possible b2/b3 deletion, and one with sY1206 deletion. Seven men in the control group with AZFc partial deletion included 3 men with possible gr/gr deletion and 4 men with possible b2/b3 deletion. There was no significant difference between the frequencies of specific AZFc partial deletion pattern by means of possible gr/gr , possible b2/b3 , and sY1206 deletion, respectively (Table 3). Y chromosome partial deletion was detected in 5 KS men with successful sperm retrieval. Discussions The extra X chromosome in KS men causes germ cell degeneration and adverse effects to somatic cells, including Leydig and Sertoli cells, resulting in infertility. As a matter of fact, germ cell degeneration take place early in the fetal period, whereas the density and number of seminiferous tubules and mesenchymal tissues remain normal, without obvious pattern change (21). The hormone levels are unaffected until the onset of puberty, which is when the germ cell depletion, Sertoli cell degeneration, Leydig cell hyperplasia and seminiferous tubule hyalinization initiate and accelerate (22). Accelerated degeneration of the Sertoli cell is also evidenced by the sign of aberrant nuclear expression of the α-subunit in the Sertoli cells in older teenage KS boys (23). Based on the concept of early fertility deterioration, sperm banking at a younger age is recommended at puberty, according to their Tanner stage. The results, however, were not promising with regards to KS adolescent semen quality. Sperm in the ejaculate can only be detected in limited cases (8). If sperm cannot be traced in the semen, using mTESE for testicular sperm retrieval associated with assisted reproductive technology such as ICSI is a recommended option with a satisfactory outcome, and offers these patients the opportunity to father biological children. As shown in several studies, age is a predictive factor for successful sperm retrieval in KS men receiving mTESE; In adult men younger than 35 years old, sperm retrieval rate (SRR) is reported to range from 30% to 77%, with a higher SRR than subjects > 35 years. Consequently, experts recommend performing mTESE under the critical age of 35 or even 30 years to yield a better outcome (18, 24). However, age as a predictive factor for sperm retrieval was not unanimously proved in other literatures (25, 26). In our study, age was not a predictive factor for sperm retrieval, and SRR was comparable for KS men under or above the age of 35 (33.3% vs 37.5%, respectively). The mean age of our study population is 36.4 years; only two KS men (age 25 and 27 years) under the age of 30 was evaluated, which will limit the ability to evaluate the influence of age on successful sperm retrieval. Our Klinefelter cases with older age may be explained by the fact that a majority of cases coming to our center are either referral or consultation for infertility other than delayed puberty, which also implies that most of the Taiwanese KS men remained undiagnosed before marriage. According to Taiwanese government statistics, the average age of marriage for men has increased in the last decade and was 34.2 years in 2015. gr/gr deletion, the most common form of partial AZFc deletion, has been demonstrated a correlation with male infertility in many meta-analysis studies (27, 28). However, debates rage over whether gr/gr deletion and copy number reduction of AZFc genes influence spermatogenesis. The diverse phenotypes in gr/gr deletion prevent researchers from drawing definite conclusions on this topic, which is best shown in the Japanese population with 33.9% gr/gr deletion men in the control group, and 23.9% in the infertility group, although the controls have unknown fertility status (29). Based on ethnicity and region, Caucasians (OR=3.721), people from Europe (OR=2.465), and people from South Asia (OR=2.523) with gr/gr deletion had a higher risk of male infertility in comparison to those without deletions (28). But published literatures within the same ethnicity have drawn opposite conclusions. In China, Wu et al. pointed out that b2/b3 deletion was significantly associated with idiopathic male infertility (30), while in contrast, Yang et al. recorded gr/gr deletion, instead of b2/b3 deletion, serve as a more important anomaly in determining the susceptibility to spermatogenic failure (31). As a matter of fact, the results may vary without contradiction. Two study populations that were 1500 km apart belonged to different Y chromosome haplogroup, representing distinct paternal lineage. As demonstrated previously, Y lineages as defined by different haplotypes could influence the phenotypical expression of identical gr/gr deletion genotype (32). Gr/gr deletions and b2/b3 have been demonstrated fixed in haplogroup Q1 and haplogroup N; the prevalence of partial deletion will likely mask actual influence from other haplogroups (14, 27, 33, 34). In the Taiwanese population, Lin et al. found that 14% of men have deletions and duplications of AZFc and that the frequency of deletion vary between different Y haplogroups, ranging from 2.9% in O3e to 100% in N and Q (14). AZFc partial duplication other than partial deletion increases the risk of spermatogenic failure. Although, in our study, we did not perform quantitative PCR analysis to evaluate DAZ (Deleted in AZoospermia) dosage and duplication in our patients, with regard of the presence of AZFc, partial deletion did not seem to affect SRR. In Danish and Chinese populations, specific Y haplogroup has been suggested to be an “at risk Y haplogroup” by their over-presentation in the spermatogenic impairment population (31, 35). Until now, no study has looked into the relationship between different Y haplogroup and SRR in azoospermic cases. Hence, it would be interesting to understand the possible influence of Y haplogroup not only on semen parameters but also on spermatogenesis in the testes. We examined Y chromosome microdeletions in KS men using 10 sets of primers and detected 9 cases with partial AZFc deletion, including 4 men with possible gr/gr deletion, 4 with possible b2/b3 deletion, and one with sY1206 deletion KS. Our study did not detect complete AZFa, AZFb or AZFc deletion in KS men, which is compatible with the Lin et al. study, suggesting a low percentage of complete deletion pattern in Han Chinese in Taiwan (14). The incidence of AZFc partial deletion did not differ between the KS men and the fertility control men; the result is consistent with a recent study investigating AZF microdeletion in KS men (36). However, in a study of Han Chinese KS men in China, the proportion of partial AZFc deletion is higher than our population – 27 (24.3%) of 111 KS men and 11 (11.7%) of the 94 controls compared to our population of 13.6% in KS men and 6.5% in the control (36). The outcome of our study indicates that the possible gr/gr and b2/b3 deletions are not correlated with KS men in the Taiwan Han-Chinese population, suggesting that although formation of sperm with an extra copy of X chromosome by non-disjunction during meiosis I contributed to paternal error, it did not increase the chance of de novo Y chromosome partial microdeletion. Previous studies on the preoperative hCG or aromatase inhibitor on KS men have demonstrated varying results, therefore our KS cases were not routinely given hCG or aromatase inhibitors before mTESE. (17, 24, 26). Prior experience with mTESE in KS men with non-obstructive azoospermia reported SRR range from 16%-70% and cumulative SRR per TESE cycle of 44% (37). The SRR for KS men above 35 years of age in 3 series were 25%, 30% and 50%; it was 37.5% in our study (17, 18, 24). To our knowledge this is the first article looking into Y chromosome deletion in Klinefelter patients for SRR evaluation. Our results demonstrate that AZFc partial deletion, age, and endocrine variables do not predict sperm retrieval in KS men. Sperm retrieval rate is comparable for men below and above 35 years, and we should not discourage AZFc partial deletion men or men over the age of 35 from accepting mTESE for possible sperm retrieval. Conclusion According to present results, age and AZFc partial deletion status should not be a deterrent for azoospermic males with non-mosaic Klinefelter syndrome to undergo mTESE. Abbreviations American Society for Reproductive Medicine (ASRM) Azoospermia factor (AZF) DAZ (Deleted in AZoospermia) European Association of Urology (EAU) Follicle stimulating hormone (FSH) Intracytoplasmic sperm injection (ICSI). Klinefelter syndrome (KS) Leutinizing hormone (LH) Microsurgical testicular sperm extraction (mTESE) Non-allelic homologous recombination (NAHR) Non-obstructive azoospermia (NOA) Polymerase chain reaction (PCR) Sequence-tagged sites (STS) Sex determining region Y (SRY) Sperm retrieval rate (SRR) Zinc-finger Y (ZFY) Declarations Ethics approval and consent to participate All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This study was approved by the local ethics committee at the “Taipei Veterans General Hospital”, Taiwan, reference no. 2018-03-002-CCF. For this type of retrospective study formal consent is not required. Consent for publication Not applicable Availability of data and materials The data that support the findings of this study are available on request from the corresponding author W.H. The data are not publicly available due to them containing information that could compromise research participant privacy. Competing interests The authors declare that they have no competing interests. Funding Taipei Veterans General Hospital-National Yang-Ming University Excellent Physician Scientist Cultivation Program, No. 108-V-B-024 Taipei Veterans General Hospital V108C-141 Authors' contributions IH contributed to study conception and design. WC, JW, WK, EH contributed to data acquisition. IH contributed to analysis and interpretation of data. IH, RF contributed to drafting the manuscript. NB, RB, WH were involved in revising the manuscript. All authors have read and approved the manuscript. Acknowledgements Not applicable References Medicine PCoASfR. 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Repping S, van Daalen SK, Korver CM, Brown LG, Marszalek JD, Gianotten J, et al. A family of human Y chromosomes has dispersed throughout northern Eurasia despite a 1.8-Mb deletion in the azoospermia factor c region. Genomics. 2004;83(6):1046-52. Krausz C, Quintana-Murci L, Forti G. Y chromosome polymorphisms in medicine. Ann Med. 2004;36(8):573-83. Li LX, Dai HY, Ding XP, Zhang YP, Zhang XH, Ren HY, et al. Investigation of AZF microdeletions in patients with Klinefelter syndrome. Genet Mol Res. 2015;14(4):15140-7. Corona G, Pizzocaro A, Lanfranco F, Garolla A, Pelliccione F, Vignozzi L, et al. Sperm recovery and ICSI outcomes in Klinefelter syndrome: a systematic review and meta-analysis. Hum Reprod Update. 2017;23(3):265-75. Tables Table 1. Sequence of 10 sets of primer employed to identify Y-chromosome microdeletions STS/gene Primer sequence Product size (bp) Region SRY-F SRY-R 5' - GAA TAT TCC CGC TCT CCG GA - 3' 5' - GCT GGT GCT CCA TTC TTG AG - 3' 495 NRY ZFY-F 5' - ACC RCT GTA CTG ACT GTG ATT ACA C - 3' 472 NRY ZFY-R 5' - GCA CYT CTT TGG TAT CYG AGA AAG T - 3' sY86-F 5' - GTG ACA CAC AGA CTA TGC TTC - 3' 320 AZFa sY86-R 5' - ACA CAC AGA GGG ACA ACC CT - 3' sY127-F 5' - GGC TCA CAA ACG AAA AGA AA - 3' 274 AZFb sY127-R 5' - CTG CAG GCA GTA ATA AGG GA - 3' sY254-F 5' - GGG TGT TAC CAG AAG GCA AA - 3' 400 AZFc sY254-R 5' - GAA CCG TAT CTA CCA AAG CAG C - 3' sY1161-F 5' - CGA CAC TTT TGG GAA GTT TCA - 3' 377 AZFc sY1161-R 5' - TTG TGT CCA GTG GTG GCT TA- 3' sY1191-F 5' – CCA GAC GTT CTA CCC TTT CG - 3' 385 AZFc sY1191-R 5' – GAG CCG AGA TCC AGT TAC CA - 3' sY1201-F 5' – CCG ACT TCC ACA ATG GCT - 3' 677 AZFc sY1201-R 5' – GGG AGA AAA GTT CTG CAA CG - 3' sY1206-F 5' – ATT GAT CTC CTT GGT TCC CC - 3' 394 AZFc sY1206-R 5' – GAC ATG TGT GGC CAA TTT GA - 3 sY1291-F 5' – TAA AAG GCA GAA CTG CCA GG - 3' 527 AZFc sY1291-R 5' – GGG AGA AAA GTT CTG CAA CG - 3' Table 2. Demographic profile of nonmosaic Klinefelter men with positive and negative mTESE outcome Overall Mean ± SD mTESE ( +) Mean ± SD mTESE ( -) Mean ± SD p value Number n=66 n=24 n=42 Age (yr) 36.4 ± 5.2 36.0 ± 4.9 36.6 ± 5.4 0.67 FSH (IU/L) 34.3 ± 17.0 30.0 ± 13.1 36.9 ± 18.6 0.12 LH (IU/L) 20.4 ± 11.7 17.7 ± 9.7 21.9 ± 12.6 0.16 Testosterone (ng/nl) 2.2 ± 1.8 2.4 ± 2.0 2.1 ± 1.6 0.47 Prolactin 9.2 ± 3.7 8.7 ± 3.5 9.5 ± 3.8 0.39 Estradiol (pg/ml) 21.0 ± 9.9 19.5 ± 7.4 21.8 ± 11.0 0.41 Y partial deletion 9 (13.6%) 5 (20.8%) 4 (9.5%) 0.27 gr/gr deletion 4 (6.1%) 2 (8.3%) 2 (4.8%) 0.62 b2/b3 deletion 4 (6.1%) 3 (12.5%) 1 (2.4%) 0.13 sY1206 deletion 1 (1.5%) 0 (0%) 1 (2.4%) 1.00 Table 3. AZFc partial deletion in KS men and controls Fertile control Klinefelter men p value Total subjects 107 66 AZFc partial deletion 7 9 0.18 gr/gr deletion 3 4 0.43 b2/b3 deletion 4 4 0.48 sY1206 deletion 0 1 0.38 Cite Share Download PDF Status: Published Journal Publication published 27 Feb, 2020 Read the published version in BMC Urology → Version 2 posted Editorial decision: Accept 14 Feb, 2020 Reviewer # 2 agreed at journal 03 Feb, 2020 Review # 2 received at journal 03 Feb, 2020 Review # 1 received at journal 02 Feb, 2020 Reviewer # 1 agreed at journal 01 Feb, 2020 Reviewers invited by journal 30 Jan, 2020 Editor assigned by journal 21 Jan, 2020 Submission checks completed at journal 20 Jan, 2020 Editor invited by journal 20 Jan, 2020 You are reading this latest preprint version Show more versions Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Department of Physiology, School of Medicine, National Yang-Ming University","correspondingAuthor":false,"prefix":"","firstName":"I-Shen","middleName":"","lastName":"Huang","suffix":""},{"id":310094,"identity":"eb429a26-3f27-45a8-8d4a-0801b3cb4ac2","order_by":2,"name":"Richard J Fantus","email":"","orcid":"","institution":"Section of Urology, Department of Surgery, University of Chicago Medicine, IL","correspondingAuthor":false,"prefix":"","firstName":"Richard","middleName":"J","lastName":"Fantus","suffix":""},{"id":310095,"identity":"6a61f112-f485-4337-bc8a-73c22cc4ba74","order_by":3,"name":"Wei-Jen Chen","email":"","orcid":"","institution":"Department of Urology, Taipei Veterans General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Wei-Jen","middleName":"","lastName":"Chen","suffix":""},{"id":310096,"identity":"3d16b52e-ba40-4fb9-8306-a9708702d56e","order_by":4,"name":"James Wren","email":"","orcid":"","institution":"Division of Male Reproductive and Men's Health, Department of Urology, Northwestern University Feinberg School of Medicine, Chicago","correspondingAuthor":false,"prefix":"","firstName":"James","middleName":"","lastName":"Wren","suffix":""},{"id":310097,"identity":"1056ea61-d777-4475-8231-b302eeeb84f4","order_by":5,"name":"Wei-Tang Kao","email":"","orcid":"","institution":"Taipei City University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Wei-Tang","middleName":"","lastName":"Kao","suffix":""},{"id":310098,"identity":"bec72fca-eba7-4b04-90ce-874720a21f6a","order_by":6,"name":"Eric Yi-Hsiu Huang","email":"","orcid":"","institution":"Department of Urolgoy, Taipei Veterans General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Eric","middleName":"Yi-Hsiu","lastName":"Huang","suffix":""},{"id":310099,"identity":"3a835f50-3d08-47cf-ba92-7d58b3586eae","order_by":7,"name":"Nelson E Bennett","email":"","orcid":"","institution":"Division of Male Reproductive Surgery and Men's Health, Department of Urology, Northwestern University Feinberg School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Nelson","middleName":"E","lastName":"Bennett","suffix":""},{"id":310100,"identity":"9317450a-ccb9-435d-b9fe-b749ffebaaa8","order_by":8,"name":"Robert E Brannigan","email":"","orcid":"","institution":"Division of Male Reproductive Surgery and Men's Health, Department of Urology, Northwerstern University Feinberg School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Robert","middleName":"E","lastName":"Brannigan","suffix":""},{"id":310101,"identity":"0fb72a3a-501b-4256-838a-f14e329e510c","order_by":9,"name":"William J 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14:23:17","currentVersionCode":2,"declarations":"","doi":"10.21203/rs.2.15379/v2","doiUrl":"https://doi.org/10.21203/rs.2.15379/v2","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12894-020-00587-5","type":"published","date":"2020-02-27T20:39:07+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":405238,"identity":"95fd8689-c8de-4eca-b428-f92dd3cc4342","added_by":"auto","created_at":"2020-01-24 14:15:01","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":37872,"visible":true,"origin":"","legend":"STS markers for Y chromosome microdeletion","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/1538eb73-ecb9-41e5-b7a6-770ee740b132/v2/1.png"},{"id":405239,"identity":"2fafbd9a-d90b-4fae-a0f5-fe5b82095263","added_by":"auto","created_at":"2020-01-24 14:15:01","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":47107,"visible":true,"origin":"","legend":"Percentage of KS men below and above 35 with Y chromosome deletion and sperm retrieval rate by mTESE","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/1538eb73-ecb9-41e5-b7a6-770ee740b132/v2/2.png"},{"id":13486636,"identity":"b6828886-d57f-47dc-aa10-3deddb210b22","added_by":"auto","created_at":"2021-09-16 22:07:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":354749,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6045/v2/1228ad0a-099a-4bd6-b1df-152e39471f06.pdf"}],"financialInterests":"","formattedTitle":"Do partial AZFc deletions affect the sperm retrieval rate in non-mosaic Klinefelter patients undergoing microdissection testicular sperm extraction?","fulltext":[{"header":"Background","content":"\u003cp\u003eAccording to recommendations from the American Society for Reproductive Medicine (ASRM) and European Association of Urology (EAU), cytogenetic analysis is suggested for patients with azoospermia or oligozoospermia. However, the threshold of sperm count recommended for karyotype analysis differs between the two associations: spermatozoa count below 10 million/mL from the EAU and spermatozoa count below 5 million/mL from the ASRM (1, 2). The main purpose of performing cytogenetic analysis for patients with subfertility or infertility is to provide proper counselling before assisted reproductive technology and inform couples of possible inheritances of paternal genetic disorders in their offspring.\u003c/p\u003e\n\u003cp\u003eGenetic mutation or chromosome abnormality is more common in infertile males than in the general population, and investigations have shown that the percentage of chromosome abnormalities and Y chromosome microdeletions is about 2-6% and 3-5% (3, 4) for oligospermic patients, 13-15% and 6-16% for non-obstructive azoospermia (NOA) patients (5, 6). Among all chromosome abnormalities, Klinefelter syndrome (KS) is the most common numerical chromosome abnormality found in infertile men with an incidence rate of about 1-in-500 to 1-in-1000 male birth (7). The majority of cases with 47, XXY non-mosaic Klinefelter karyotype will present as hypergonadotropic hypogonadism and azoospermia, regardless of age, as a sign of primary testicular failure (8). However, aside from the non-mosaic form, there is a strong probability of finding sperm in semen with mosaic form (46, XY/47, XXY)\u0026nbsp;of KS, depending on the level of XXY cell line mosaicism in the gonads (9). In general, about 90% of patients have uniform 47, XXY karyotype (pure KS) in which an extra X chromosome is present in somatic and germ cells, while 10% of KS can present with higher-grade of X chromosome aneuploidies (48 or more chromosomes) as well as mosaicism (47, XXY/46, XY) (7). Mosaic KS men tend to be more androgenized than their non-mosaic KS counterparts in terms of hormone profile and sperm count in ejaculate, representing better fertility potential, especially in low-grade mosaicism form (9).\u003c/p\u003e\n\u003cp\u003eThe azoospermia factor (AZF) region on the Y chromosome long arm is crucial for spermatogenesis and is known for its unique nearly identical direct and indirect repeated palindromic sequences. In addition to KS, the deletion of AZF is another cause for male infertility (10). Removal of the spermatogenesis candidate gene located in the AZFa or AZFb, which is responsible for production of male gametes, namely the USP9Y, DDX3Y, RBMY and PRY genes, will inevitably lead to spermatogenic failure and therefore is not recommended for microdissection testicular sperm extraction (mTESE) due to the lack of identifiable regions of spermatogenesis in the testes (11). The result of semen analysis of men with AZFc deletion varies in comparison with azoospermia found in AZFa and AZFb men, ranging from azoospermia to moderate oligozoospermia. Despite causing detrimental effects in sperm production, AZFc deletion is still regarded as a good prognostic factor for azoospermic men; the sperm retrieval rate (SRR) is up to 70% in this population (12). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe incidence of AZFc deletion is higher than incidence of AZFa or AZFb deletion in men, because the Y chromosome AZFc region is predisposed to intrachromosomal non-allelic homologous recombination owing to its composition of large repeat units called \u0026ldquo;amplicons\u0026rdquo; (13).\u003c/p\u003e\n\u003cp\u003eRearrangement of the AZFc region, including partial deletions, duplications and deletions followed by duplication(s) has been reported (13). Deletion of the entire AZFc locus on the Y chromosome by means of removing 3.5Mb segment, including eight multi-copy gene families, is consensually considered a cause for infertility (10, 14). As for AZFc partial deletion, Gr/gr deletion is the most common type, followed by b2/b3 and b1/b3 deletions. In particular, whether gr/gr deletion causes deleterious effects on spermatogenesis is still an ongoing debate. According to previous literature, the frequency of gr/gr deletion is only higher in certain azoospermia or oligozoospermia populations in Italy and China when compared to the control (15, 16).\u003c/p\u003e\n\u003cp\u003eResearchers have attempted to find predictors for successful sperm retrieval in KS men; some have demonstrated that testosterone levels after medical treatment, including aromatase inhibitors, clomiphene or human chorionic gonadotropin (17) and age at time of mTESE are reliable prognostic factors (18). Therefore, they have recommended that patients receive mTESE for sperm retrieval under the age of 35 (18). To date, due to the limited number of KS men, there are a paucity of articles discussing sperm retrieval rate by mTESE. Moreover, previous study populations did not include Han-Chinese or whether Y chromosome microdeletion may serve as a prognostic factor for possible sperm retrieval. Some clinicians may infer the outcome of sperm retrieval is affected by Y chromosome microdeletion in Klinefelter patients. Our study aimed to analyze predictive factors for sperm retrieval in Han-Chinese KS men and discuss the association for Y chromosome microdeletion with successful sperm retrieval.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cu\u003eStudied populations\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eWe retrospectively reviewed the period between September 2009 to Dec 2018. A total of 66 non-mosaic Klinefelter patients who were receiving microdissection testicular sperm extraction were enrolled in our study. All subjects were genetically ethnic Han-Chinese from Taiwan. Each patient underwent a detailed examination to identify the etiology of azoospermia, including a detailed history, physical examination, two consecutive semen analyses, hormone profile (follicle stimulating hormone (FSH), leutinizing hormone (LH), testosterone and prolactin), chromosome karyotyping, and Y chromosome microdeletion. DNA samples of 107 fertile controls who had fathered at least one child were obtained from 2 medical centers in Taiwan as described by Lin et al. in 2007 (14). This study was performed according to the Taipei Veterans General Hospital approved Institutional Review Board protocol (IRB number: 2018-03-002CCF)\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eDNA extraction\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eGenomic DNA was extracted from peripheral blood using the QIAamp DNA minikit (Qiagen, Hilden, Germany) according to the manufacturer recommendations. In brief, 20 \u0026mu;l Qiagen protease was pipetted into the bottom of a 1.5 ml microcentrifuge tube, then up to 200 \u0026mu;l whole blood or buffy coat was added to the microcentrifuge tube. After the addition of 200 \u0026mu;l buffer AL to the sample, the sample was thoroughly mixed by vortex mixing and was incubated at 56 \u0026deg;C for 10 minutes until cell lysis was complete. Two hundred microliters of ethanol (100%) were added to precipitate the DNA. The mixture was carefully applied to the QIAamp spin column, placed inside a 2 ml collection tube, and centrifuged at 8000 rpm, 6000\u0026times;g for 1 minute. The QIAamp Spin column was then placed in a new collection tube, and 500 \u0026micro;l of buffer, AW1 was added and centrifuged. This step was repeated with the buffer AW2 and a high spin was given for 3 minutes to dry the column membrane. The spin column was subsequently placed in a clean 1.5 ml microcentrifuge tube, and the DNA filtrate was recovered with 200 \u0026micro;l of buffer AE. Following centrifugation, DNA was eluted and stored at \u0026minus;20 \u0026deg;C until used.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCytogenetic analysis\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Chromosome analysis was performed using conventional trypsin-Giemsa banding technique. Twenty metaphases were analyzed for each patient, and in cases of suspected mosaicism, the number of metaphases was increased to a total of 50 for analysis. To achieve a more detailed analysis, a 500-550 band level was used for evaluation.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eYq classical deletions and AZFc subdeletions\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eY microdeletion screening in Klinefelter patients was performed by multiplex polymerase chain reaction (PCR) that detects markers in the AZF regions, the sex determining region Y (SRY) gene, and the Y homologous gene pair zinc-finger Y (ZFY) (19). The sequence-tagged sites (STS) selected are listed in Figure 1 and Table 1. Six AZFc deletions (sY254, sY1161, sY1191, sY1201, sY1206, and sY1291) were used to identify the type of partial AZFc deletions in all subjects. In addition, DNA from fertile males and female served as positive and negative controls, respectively. Ambiguities in the multiplex PCR assays were resolved by following up with single PCR assays.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eMicrodissection testicular sperm extraction\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eA small incision (3 cm) was made longitudinally on the median raphe, and carried down to the fascia. The testis were mobilized after opening the tunica vaginalis as described in 1999 (20). We performed a longitudinal incision on the testis instead of open it widely in an equatorial plane along the mid portion of the testis. An operating microscope with 20x~24x magnification allow the surgeon to identify larger and opaquer seminiferous tubules, which are most likely to contain sperm. Tissue with possibility of spermatogenesis was removed and sent for real time analysis by experienced embryologists in our reproductive lab for further intracytoplasmic sperm injection (ICSI).\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eStatistical analysis\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eOutcome variables (age, serum FSH, LH, testosterone, prolactin and estradiol) of azoospermic non-mosaic KS men with successful surgical sperm retrieval were compared to those with unsuccessful sperm retrieval using the Student\u0026rsquo;s t test. The distributions of AZFc partial deletion of Klinefelter patient with or without sperm retrieval and the frequency of AZFc partial deletion comparing azoospermic non-mosaic Klinefelter men with controls were analyzed by the Fisher\u0026rsquo;s exact test. In these tests, values of p \u0026lt; 0.05 were regarded as statistically significant.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cu\u003eAzoopsermic non-mosaic Klinefelter men and Y chromosome deletion\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe cohort of 66 azoospermic non-mosaic Klinefelter men with chromosome 47, XXY had a mean age of 36.4 \u0026plusmn; 5.2 years (mean \u0026plusmn; SD). Of these 66 men, 9 men (13.6%) had a deletion of one STS marker. More precisely, we identified 5 men with an absence of sY1291 (possible \u003cem\u003egr/gr\u003c/em\u003e deletion), 3 men with an absence of sY1191 (possible \u003cem\u003eb2/b3\u003c/em\u003e deletion) and 1 with an absence of sY1206 only. Of the 24 patients with successful sperm retrieval, 5 (20.8%) had partial AZFc deletion, including 2 possible \u003cem\u003egr/gr\u003c/em\u003e deletion and 3 possible \u003cem\u003eb2/b3\u003c/em\u003e deletion cases (Table 2). Partial AZFc deletion is identified in 4 (9.5%) of 42 patients without sperm retrieval by mTESE, (one possible \u003cem\u003eb2/b3\u003c/em\u003e, one sY1206, and two possible \u003cem\u003egr/gr\u003c/em\u003e deletion), though the difference of Y chromosome deletion was not statistically significant between the successful and non-successful sperm retrieval groups (p= 0.27).\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eImpact of various parameters on mTESE success\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eOf the non-mosaic KS patients, mTESE was successful in 24 out of 66 patients, representing 36.4% of cases. Table 2 lists the clinical factors analyzed to predict sperm retrieval, stratified by outcome. Age, partial AZFc deletions, and hormone parameter (LH, FSH, testosterone, prolactin, estradiol) were not predictive factors for successful sperm retrieval.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eEffect of age on sperm retrieval\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eSRR for mTESE was 34.6% (9/26) at ages below 35 years and 37.5% (15/40) at 35 years and older. Four of 13 KS men older than 40 years of age had successful sperm retrieval; the oldest patient with successful mTESE was 47 years-old (Figure 2).\u003c/p\u003e\n\u003cp\u003e\u003cu\u003ePartial AZFc deletions distribution between the experimental and control groups\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe frequency of AZFc partial detection was 13.6% (9/66) in KS men and 6.5% (7/107) in the control, although a higher percentage was seen in KS men, however the difference was not statistically significant (p\u0026gt;0.05). The deletion pattern in 9 KS men with AZFc partial deletion included 4 men with possible \u003cem\u003egr/gr\u003c/em\u003e deletion, 4 with possible \u003cem\u003eb2/b3\u003c/em\u003e deletion, and one with sY1206 deletion. Seven men in the control group with AZFc partial deletion included 3 men with possible \u003cem\u003egr/gr\u003c/em\u003e deletion and 4 men with possible \u003cem\u003eb2/b3\u003c/em\u003e deletion. There was no significant difference between the frequencies of specific AZFc partial deletion pattern by means of possible \u003cem\u003egr/gr\u003c/em\u003e, possible \u003cem\u003eb2/b3\u003c/em\u003e, and sY1206 deletion, respectively (Table 3). Y chromosome partial deletion was detected in 5 KS men with successful sperm retrieval.\u003c/p\u003e"},{"header":"Discussions","content":"\u003cp\u003eThe extra X chromosome in KS men causes germ cell degeneration and adverse effects to somatic cells, including Leydig and Sertoli cells, resulting in infertility. As a matter of fact, germ cell degeneration take place early in the fetal period, whereas the density and number of seminiferous tubules and mesenchymal tissues remain normal, without obvious pattern change (21). The hormone levels are unaffected until the onset of puberty, which is when the germ cell depletion, Sertoli cell degeneration, Leydig cell hyperplasia and seminiferous tubule hyalinization initiate and accelerate (22). Accelerated degeneration of the Sertoli cell is also evidenced by the sign of aberrant nuclear expression of the \u0026alpha;-subunit in the Sertoli cells in older teenage KS boys (23). Based on the concept of early fertility deterioration, sperm banking at a younger age is recommended at puberty, according to their Tanner stage. The results, however, were not promising with regards to KS adolescent semen quality. Sperm in the ejaculate can only be detected in limited cases (8).\u003c/p\u003e\n\u003cp\u003eIf sperm cannot be traced in the semen, using mTESE for testicular sperm retrieval associated with assisted reproductive technology such as ICSI is a recommended option with a satisfactory outcome, and offers these patients the opportunity to father biological children. As shown in several studies, age is a predictive factor for successful sperm retrieval in KS men receiving mTESE; In adult men younger than 35 years old, sperm retrieval rate (SRR) is reported to range from 30% to 77%, with a higher SRR than subjects \u0026gt; 35 years. Consequently, experts recommend performing mTESE under the critical age of 35 or even 30 years to yield a better outcome (18, 24). However, age as a predictive factor for sperm retrieval was not unanimously proved in other literatures (25, 26). In our study, age was not a predictive factor for sperm retrieval, and SRR was comparable for KS men under or above the age of 35 (33.3% vs 37.5%, respectively). The mean age of our study population is 36.4 years; only two KS men (age 25 and 27 years) under the age of 30 was evaluated, which will limit the ability to evaluate the influence of age on successful sperm retrieval.\u003c/p\u003e\n\u003cp\u003eOur Klinefelter cases with older age may be explained by the fact that a majority of cases coming to our center are either referral or consultation for infertility other than delayed puberty, which also implies that most of the Taiwanese KS men remained undiagnosed before marriage. According to Taiwanese government statistics, the average age of marriage for men has increased in the last decade and was 34.2 years in 2015.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003egr/gr\u003c/em\u003e deletion, the most common form of partial AZFc deletion, has been demonstrated a correlation with male infertility in many meta-analysis studies (27, 28). However, debates rage over whether \u003cem\u003egr/gr\u003c/em\u003e deletion and copy number reduction of AZFc genes influence spermatogenesis. The diverse phenotypes in \u003cem\u003egr/gr\u003c/em\u003e deletion prevent researchers from drawing definite conclusions on this topic, which is best shown in the Japanese population with 33.9% \u003cem\u003egr/gr\u003c/em\u003e deletion men in the control group, and 23.9% in the infertility group, although the controls have unknown fertility status (29). Based on ethnicity and region, Caucasians (OR=3.721), people from Europe (OR=2.465), and people from South Asia (OR=2.523) with \u003cem\u003egr/gr\u003c/em\u003e deletion had a higher risk of male infertility in comparison to those without deletions (28). But published literatures within the same ethnicity have drawn opposite conclusions. In China, Wu et al. pointed out that \u003cem\u003eb2/b3\u003c/em\u003e deletion was significantly associated with idiopathic male infertility (30), while in contrast, Yang et al. recorded \u003cem\u003egr/gr\u003c/em\u003e deletion, instead of \u003cem\u003eb2/b3\u003c/em\u003e deletion, serve as a more important anomaly in determining the susceptibility to spermatogenic failure (31).\u003c/p\u003e\n\u003cp\u003eAs a matter of fact, the results may vary without contradiction. Two study populations that were 1500 km apart belonged to different Y chromosome haplogroup, representing distinct paternal lineage. As demonstrated previously, Y lineages as defined by different haplotypes could influence the phenotypical expression of identical \u003cem\u003egr/gr\u003c/em\u003e deletion genotype (32). \u003cem\u003eGr/gr\u003c/em\u003e deletions and \u003cem\u003eb2/b3\u003c/em\u003e have been demonstrated fixed in haplogroup Q1 and haplogroup N; the prevalence of partial deletion will likely mask actual influence from other haplogroups (14, 27, 33, 34). In the Taiwanese population, Lin et al. found that 14% of men have deletions and duplications of AZFc and that the frequency of deletion vary between different Y haplogroups, ranging from 2.9% in O3e to 100% in N and Q (14). AZFc partial duplication other than partial deletion increases the risk of spermatogenic failure. Although, in our study, we did not perform quantitative PCR analysis to evaluate DAZ (Deleted in AZoospermia) dosage and duplication in our patients, with regard of the presence of AZFc, partial deletion did not seem to affect SRR.\u003c/p\u003e\n\u003cp\u003eIn Danish and Chinese populations, specific Y haplogroup has been suggested to be an \u0026ldquo;at risk Y haplogroup\u0026rdquo; by their over-presentation in the spermatogenic impairment population (31, 35). Until now, no study has looked into the relationship between different Y haplogroup and SRR in azoospermic cases. Hence, it would be interesting to understand the possible influence of Y haplogroup not only on semen parameters but also on spermatogenesis in the testes.\u003c/p\u003e\n\u003cp\u003eWe examined Y chromosome microdeletions in KS men using 10 sets of primers and detected 9 cases with partial AZFc deletion, including 4 men with possible \u003cem\u003egr/gr\u003c/em\u003e deletion, 4 with possible \u003cem\u003eb2/b3\u003c/em\u003e deletion, and one with sY1206 deletion KS. Our study did not detect complete AZFa, AZFb or AZFc deletion in KS men, which is compatible with the Lin et al. study, suggesting a low percentage of complete deletion pattern in Han Chinese in Taiwan (14). The incidence of AZFc partial deletion did not differ between the KS men and the fertility control men; the result is consistent with a recent study investigating AZF microdeletion in KS men (36). However, in a study of Han Chinese KS men in China, the proportion of partial AZFc deletion is higher than our population \u0026ndash; 27 (24.3%) of 111 KS men and 11 (11.7%) of the 94 controls compared to our population of 13.6% in KS men and 6.5% in the control (36). The outcome of our study indicates that the possible \u003cem\u003egr/gr\u003c/em\u003e and \u003cem\u003eb2/b3\u003c/em\u003e deletions are not correlated with KS men in the Taiwan Han-Chinese population, suggesting that although formation of sperm with an extra copy of X chromosome by non-disjunction during meiosis I contributed to paternal error, it did not increase the chance of de novo Y chromosome partial microdeletion.\u003c/p\u003e\n\u003cp\u003ePrevious studies on the preoperative hCG or aromatase inhibitor on KS men have demonstrated varying results, therefore our KS cases were not routinely given hCG or aromatase inhibitors before mTESE. (17, 24, 26). Prior experience with mTESE in KS men with non-obstructive azoospermia reported SRR range from 16%-70% and cumulative SRR per TESE cycle of 44% (37). The SRR for KS men above 35 years of age in 3 series were 25%, 30% and 50%; it was 37.5% in our study (17, 18, 24).\u003c/p\u003e\n\u003cp\u003eTo our knowledge this is the first article looking into Y chromosome deletion in Klinefelter patients for SRR evaluation. Our results demonstrate that AZFc partial deletion, age, and endocrine variables do not predict sperm retrieval in KS men. Sperm retrieval rate is comparable for men below and above 35 years, and we should not discourage AZFc partial deletion men or men over the age of 35 from accepting mTESE for possible sperm retrieval.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAccording to present results, age and AZFc partial deletion status should not be a deterrent for azoospermic males with non-mosaic Klinefelter syndrome to undergo mTESE.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp class=\"p1\" style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003eAmerican Society for Reproductive Medicine (ASRM) \u003c/span\u003e\u003c/p\u003e\n\u003cp class=\"p1\" style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003eAzoospermia factor (AZF)\u003c/span\u003e\u003c/p\u003e\n\u003cp class=\"p1\" style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003eDAZ (Deleted in AZoospermia)\u003c/span\u003e\u003c/p\u003e\n\u003cp class=\"p1\" style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003eEuropean Association of Urology (EAU)\u003c/span\u003e\u003c/p\u003e\n\u003cp class=\"p1\" style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003eFollicle stimulating hormone (FSH)\u003c/span\u003e\u003c/p\u003e\n\u003cp class=\"p2\" style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003eIntracytoplasmic sperm injection (ICSI).\u003c/span\u003e\u003c/p\u003e\n\u003cp class=\"p1\" style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003eKlinefelter syndrome (KS)\u003c/span\u003e\u003c/p\u003e\n\u003cp class=\"p1\" style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003eLeutinizing hormone (LH)\u003c/span\u003e\u003c/p\u003e\n\u003cp class=\"p1\" style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003eMicrosurgical testicular sperm extraction (mTESE)\u003c/span\u003e\u003c/p\u003e\n\u003cp class=\"p1\" style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003eNon-allelic homologous recombination (NAHR)\u003c/span\u003e\u003c/p\u003e\n\u003cp class=\"p1\" style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003eNon-obstructive azoospermia (NOA)\u003c/span\u003e\u003c/p\u003e\n\u003cp class=\"p1\" style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003ePolymerase chain reaction (PCR)\u003c/span\u003e\u003c/p\u003e\n\u003cp class=\"p1\" style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003eSequence-tagged sites (STS)\u003c/span\u003e\u003c/p\u003e\n\u003cp class=\"p1\" style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003eSex determining region Y (SRY)\u003c/span\u003e\u003c/p\u003e\n\u003cp class=\"p1\" style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003eSperm retrieval rate (SRR)\u003c/span\u003e\u003c/p\u003e\n\u003cp class=\"p1\" style=\"line-height: 200%;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 200%; font-family: 'Times New Roman',serif;\"\u003eZinc-finger Y (ZFY)\u003c/span\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cu\u003eEthics approval and consent to participate\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This study was approved by the local ethics committee at the \u0026ldquo;Taipei Veterans General Hospital\u0026rdquo;, Taiwan, reference no. 2018-03-002-CCF. For this type of retrospective study formal consent is not required.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eConsent for publication\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAvailability of data and materials\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available on request from the corresponding author W.H. The data are not publicly available due to them containing information that could compromise research participant privacy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eCompeting interests\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eFunding\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTaipei Veterans General Hospital-National Yang-Ming University Excellent Physician Scientist Cultivation Program, No. 108-V-B-024\u003c/p\u003e\n\u003cp\u003eTaipei Veterans General Hospital V108C-141\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAuthors' contributions\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIH contributed to study conception and design. WC, JW, WK, EH contributed to data acquisition. IH contributed to analysis and interpretation of data. IH, RF contributed to drafting the manuscript. NB, RB, WH were involved in revising the manuscript. All authors have read and approved the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAcknowledgements\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMedicine PCoASfR. Diagnostic evaluation of the infertile male: a committee opinion. Fertil Steril. 2012;98(2):294-301.\u003c/li\u003e\n\u003cli\u003eJungwirth A, Giwercman A, Tournaye H, Diemer T, Kopa Z, Dohle G, et al. European Association of Urology guidelines on Male Infertility: the 2012 update. Eur Urol. 2012;62(2):324-32.\u003c/li\u003e\n\u003cli\u003eVan Assche E, Bonduelle M, Tournaye H, Joris H, Verheyen G, Devroey P, et al. Cytogenetics of infertile men. Hum Reprod. 1996;11 Suppl 4:1-24; discussion 5-6.\u003c/li\u003e\n\u003cli\u003eFu L, Xiong DK, Ding XP, Li C, Zhang LY, Ding M, et al. Genetic screening for chromosomal abnormalities and Y chromosome microdeletions in Chinese infertile men. J Assist Reprod Genet. 2012;29(6):521-7.\u003c/li\u003e\n\u003cli\u003eOliva R, Margarit E, Ballesc\u0026aacute; JL, Carri\u0026oacute; A, S\u0026aacute;nchez A, Mil\u0026agrave; M, et al. Prevalence of Y chromosome microdeletions in oligospermic and azoospermic candidates for intracytoplasmic sperm injection. Fertil Steril. 1998;70(3):506-10.\u003c/li\u003e\n\u003cli\u003eOates RD, Silber S, Brown LG, Page DC. Clinical characterization of 42 oligospermic or azoospermic men with microdeletion of the AZFc region of the Y chromosome, and of 18 children conceived via ICSI. Hum Reprod. 2002;17(11):2813-24.\u003c/li\u003e\n\u003cli\u003eBojesen A, Juul S, Gravholt CH. Prenatal and postnatal prevalence of Klinefelter syndrome: a national registry study. J Clin Endocrinol Metab. 2003;88(2):622-6.\u003c/li\u003e\n\u003cli\u003eRives N, Milazzo JP, Perdrix A, Castanet M, Joly-H\u0026eacute;las G, Sibert L, et al. The feasibility of fertility preservation in adolescents with Klinefelter syndrome. Hum Reprod. 2013;28(6):1468-79.\u003c/li\u003e\n\u003cli\u003eSamplaski MK, Lo KC, Grober ED, Millar A, Dimitromanolakis A, Jarvi KA. Phenotypic differences in mosaic Klinefelter patients as compared with non-mosaic Klinefelter patients. Fertil Steril. 2014;101(4):950-5.\u003c/li\u003e\n\u003cli\u003eKuroda-Kawaguchi T, Skaletsky H, Brown LG, Minx PJ, Cordum HS, Waterston RH, et al. The AZFc region of the Y chromosome features massive palindromes and uniform recurrent deletions in infertile men. Nat Genet. 2001;29(3):279-86.\u003c/li\u003e\n\u003cli\u003eKleiman SE, Almog R, Yogev L, Hauser R, Lehavi O, Paz G, et al. Screening for partial AZFa microdeletions in the Y chromosome of infertile men: is it of clinical relevance? Fertil Steril. 2012;98(1):43-7.\u003c/li\u003e\n\u003cli\u003eStahl PJ, Masson P, Mielnik A, Marean MB, Schlegel PN, Paduch DA. A decade of experience emphasizes that testing for Y microdeletions is essential in American men with azoospermia and severe oligozoospermia. Fertil Steril. 2010;94(5):1753-6.\u003c/li\u003e\n\u003cli\u003eRepping S, Skaletsky H, Lange J, Silber S, Van Der Veen F, Oates RD, et al. Recombination between palindromes P5 and P1 on the human Y chromosome causes massive deletions and spermatogenic failure. Am J Hum Genet. 2002;71(4):906-22.\u003c/li\u003e\n\u003cli\u003eLin YW, Hsu LC, Kuo PL, Huang WJ, Chiang HS, Yeh SD, et al. Partial duplication at AZFc on the Y chromosome is a risk factor for impaired spermatogenesis in Han Chinese in Taiwan. Hum Mutat. 2007;28(5):486-94.\u003c/li\u003e\n\u003cli\u003eGiachini C, Laface I, Guarducci E, Balercia G, Forti G, Krausz C. Partial AZFc deletions and duplications: clinical correlates in the Italian population. 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Age and markers of Leydig cell function, but not of Sertoli cell function predict the success of sperm retrieval in adolescents and adults with Klinefelter's syndrome. Andrology. 2015;3(5):868-75.\u003c/li\u003e\n\u003cli\u003eKoga M, Tsujimura A, Takeyama M, Kiuchi H, Takao T, Miyagawa Y, et al. Clinical comparison of successful and failed microdissection testicular sperm extraction in patients with nonmosaic Klinefelter syndrome. Urology. 2007;70(2):341-5.\u003c/li\u003e\n\u003cli\u003eSchiff JD, Palermo GD, Veeck LL, Goldstein M, Rosenwaks Z, Schlegel PN. Success of testicular sperm extraction [corrected] and intracytoplasmic sperm injection in men with Klinefelter syndrome. J Clin Endocrinol Metab. 2005;90(11):6263-7.\u003c/li\u003e\n\u003cli\u003eNavarro-Costa P, Gon\u0026ccedil;alves J, Plancha CE. The AZFc region of the Y chromosome: at the crossroads between genetic diversity and male infertility. Hum Reprod Update. 2010;16(5):525-42.\u003c/li\u003e\n\u003cli\u003eBansal SK, Jaiswal D, Gupta N, Singh K, Dada R, Sankhwar SN, et al. Gr/gr deletions on Y-chromosome correlate with male infertility: an original study, meta-analyses, and trial sequential analyses. Sci Rep. 2016;6:19798.\u003c/li\u003e\n\u003cli\u003ede Carvalho CM, Zuccherato LW, Fujisawa M, Shirakawa T, Ribeiro-dos-Santos AK, Santos SE, et al. Study of AZFc partial deletion gr/gr in fertile and infertile Japanese males. J Hum Genet. 2006;51(9):794-9.\u003c/li\u003e\n\u003cli\u003eWu B, Lu NX, Xia YK, Gu AH, Lu CC, Wang W, et al. A frequent Y chromosome b2/b3 subdeletion shows strong association with male infertility in Han-Chinese population. Hum Reprod. 2007;22(4):1107-13.\u003c/li\u003e\n\u003cli\u003eYang Y, Ma M, Li L, Zhang W, Xiao C, Li S, et al. Evidence for the association of Y-chromosome haplogroups with susceptibility to spermatogenic failure in a Chinese Han population. J Med Genet. 2008;45(4):210-5.\u003c/li\u003e\n\u003cli\u003eNavarro-Costa P, Pereira L, Alves C, Gusm\u0026atilde;o L, Proen\u0026ccedil;a C, Marques-Vidal P, et al. Characterizing partial AZFc deletions of the Y chromosome with amplicon-specific sequence markers. BMC Genomics. 2007;8:342.\u003c/li\u003e\n\u003cli\u003eZhang F, Lu C, Li Z, Xie P, Xia Y, Zhu X, et al. Partial deletions are associated with an increased risk of complete deletion in AZFc: a new insight into the role of partial AZFc deletions in male infertility. J Med Genet. 2007;44(7):437-44.\u003c/li\u003e\n\u003cli\u003eRepping S, van Daalen SK, Korver CM, Brown LG, Marszalek JD, Gianotten J, et al. A family of human Y chromosomes has dispersed throughout northern Eurasia despite a 1.8-Mb deletion in the azoospermia factor c region. Genomics. 2004;83(6):1046-52.\u003c/li\u003e\n\u003cli\u003eKrausz C, Quintana-Murci L, Forti G. Y chromosome polymorphisms in medicine. Ann Med. 2004;36(8):573-83.\u003c/li\u003e\n\u003cli\u003eLi LX, Dai HY, Ding XP, Zhang YP, Zhang XH, Ren HY, et al. Investigation of AZF microdeletions in patients with Klinefelter syndrome. Genet Mol Res. 2015;14(4):15140-7.\u003c/li\u003e\n\u003cli\u003eCorona G, Pizzocaro A, Lanfranco F, Garolla A, Pelliccione F, Vignozzi L, et al. Sperm recovery and ICSI outcomes in Klinefelter syndrome: a systematic review and meta-analysis. Hum Reprod Update. 2017;23(3):265-75.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eTable 1. Sequence of 10 sets of primer employed to identify Y-chromosome microdeletions\u003c/span\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" style=\"width:515.7pt;border-collapse:collapse;border:none;\" width=\"688\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62.1pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"12.063953488372093%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eSTS/gene\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 292.3pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"56.68604651162791%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003ePrimer sequence\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97.55pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"18.8953488372093%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eProduct size (bp)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"12.354651162790697%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eRegion\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62.1pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"12.063953488372093%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eSRY-F\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eSRY-R\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 292.3pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"56.68604651162791%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e5' - GAA TAT TCC CGC TCT CCG GA - 3'\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e5' - GCT GGT GCT CCA TTC TTG AG - 3'\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97.55pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"18.8953488372093%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e495\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"12.354651162790697%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eNRY\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62.1pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"12.063953488372093%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eZFY-F\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 292.3pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"56.68604651162791%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e5' - ACC RCT GTA CTG ACT GTG ATT ACA C - 3'\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97.55pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"18.8953488372093%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e472\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"12.354651162790697%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eNRY\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62.1pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"12.063953488372093%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eZFY-R\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 292.3pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"56.68604651162791%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e5' - GCA CYT CTT TGG TAT CYG AGA AAG T - 3'\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97.55pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"18.8953488372093%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"12.354651162790697%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62.1pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"12.063953488372093%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003esY86-F\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 292.3pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"56.68604651162791%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e5' - GTG ACA CAC AGA CTA TGC TTC - 3'\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97.55pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"18.8953488372093%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e320\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"12.354651162790697%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eAZFa\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62.1pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"12.063953488372093%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003esY86-R\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 292.3pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"56.68604651162791%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e5' - ACA CAC AGA GGG ACA ACC CT - 3'\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97.55pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"18.8953488372093%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"12.354651162790697%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62.1pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"12.063953488372093%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003esY127-F\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 292.3pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"56.68604651162791%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e5' - GGC TCA CAA ACG AAA AGA AA - 3'\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97.55pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"18.8953488372093%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e274\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"12.354651162790697%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eAZFb\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62.1pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"12.063953488372093%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003esY127-R\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 292.3pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"56.68604651162791%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e5' - CTG CAG GCA GTA ATA AGG GA - 3'\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97.55pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"18.8953488372093%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"12.354651162790697%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62.1pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"12.063953488372093%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003esY254-F\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 292.3pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"56.68604651162791%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e5' - GGG TGT TAC CAG AAG GCA AA - 3'\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97.55pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"18.8953488372093%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e400\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"12.354651162790697%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eAZFc\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62.1pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"12.063953488372093%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003esY254-R\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 292.3pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"56.68604651162791%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e5' - GAA CCG TAT CTA CCA AAG CAG C - 3'\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97.55pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"18.8953488372093%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"12.354651162790697%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62.1pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"12.063953488372093%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003esY1161-F\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 292.3pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"56.68604651162791%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e5' - CGA CAC TTT TGG GAA GTT TCA - 3'\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97.55pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"18.8953488372093%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e377\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"12.354651162790697%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eAZFc\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62.1pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"12.063953488372093%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003esY1161-R\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 292.3pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"56.68604651162791%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e5' - TTG TGT CCA GTG GTG GCT TA- 3'\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97.55pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"18.8953488372093%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"12.354651162790697%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62.1pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"12.063953488372093%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003esY1191-F\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 292.3pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"56.68604651162791%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e5' – \u003cspan style=\"background: white;\"\u003eCCA GAC GTT CTA CCC TTT CG\u003c/span\u003e - 3'\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97.55pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"18.8953488372093%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e385\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"12.354651162790697%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eAZFc\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62.1pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"12.063953488372093%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003esY1191-R\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 292.3pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"56.68604651162791%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e5' – \u003cspan style=\"background: white;\"\u003eGAG CCG AGA TCC AGT TAC CA\u003c/span\u003e - 3'\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97.55pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"18.8953488372093%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"12.354651162790697%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62.1pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"12.063953488372093%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003esY1201-F\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 292.3pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"56.68604651162791%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e5' – CCG ACT TCC ACA ATG GCT - 3'\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97.55pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"18.8953488372093%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e677\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"12.354651162790697%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eAZFc\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62.1pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"12.063953488372093%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003esY1201-R\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 292.3pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"56.68604651162791%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e5' – GGG AGA AAA GTT CTG CAA CG - 3'\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97.55pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"18.8953488372093%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"12.354651162790697%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62.1pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"12.063953488372093%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003esY1206-F\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 292.3pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"56.68604651162791%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e5' – ATT GAT CTC CTT GGT TCC CC - 3'\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97.55pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"18.8953488372093%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e394\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"12.354651162790697%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eAZFc\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62.1pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"12.063953488372093%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003esY1206-R\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 292.3pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"56.68604651162791%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e5' – GAC ATG TGT GGC CAA TTT GA - 3\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97.55pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"18.8953488372093%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"12.354651162790697%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62.1pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"12.063953488372093%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003esY1291-F\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 292.3pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"56.68604651162791%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e5' – \u003cspan style=\"background: white;\"\u003eTAA AAG GCA GAA CTG CCA GG\u003c/span\u003e - 3'\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97.55pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"18.8953488372093%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e527\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"12.354651162790697%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eAZFc\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 62.1pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;height: 18.75pt;vertical-align: top;\" valign=\"top\" width=\"12.063953488372093%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003esY1291-R\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 292.3pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;height: 18.75pt;vertical-align: top;\" valign=\"top\" width=\"56.68604651162791%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e5' – \u003cspan style=\"background: white;\"\u003eGGG AGA AAA GTT CTG CAA CG\u003c/span\u003e - 3'\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97.55pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;height: 18.75pt;vertical-align: top;\" valign=\"top\" width=\"18.8953488372093%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 63.75pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;height: 18.75pt;vertical-align: top;\" valign=\"top\" width=\"12.354651162790697%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 16px; font-family: \u0026quot;Times New Roman\u0026quot;, serif;\"\u003e\n \u003cbr\u003e\u0026nbsp;\n \u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eTable 2. Demographic profile of nonmosaic Klinefelter men with positive and negative mTESE outcome\u003c/span\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" style=\"border-collapse:collapse;border:none;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 111.75pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"24.50657894736842%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.05pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"18.585526315789473%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:center;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eOverall\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:center;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eMean \u003cspan style=\"background: white;\"\u003e±\u003c/span\u003e SD\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93.8pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"20.55921052631579%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:center;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003emTESE (\u003cstrong\u003e+)\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:center;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eMean \u003cspan style=\"background: white;\"\u003e±\u003c/span\u003e SD\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92.15pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"20.230263157894736%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:center;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003emTESE (\u003cstrong\u003e-)\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:center;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eMean \u003cspan style=\"background: white;\"\u003e±\u003c/span\u003e SD\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73.25pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"16.11842105263158%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cem\u003ep\u003c/em\u003e value\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 111.75pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"24.50657894736842%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eNumber\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.05pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"18.585526315789473%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003en=66\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93.8pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"20.55921052631579%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003en=24\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92.15pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"20.230263157894736%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003en=42\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73.25pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"16.11842105263158%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 111.75pt;border: none;padding: 0in 5.4pt;height: 26.2pt;vertical-align: top;\" valign=\"top\" width=\"24.50657894736842%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eAge (yr)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.05pt;border: none;padding: 0in 5.4pt;height: 26.2pt;vertical-align: top;\" valign=\"top\" width=\"18.585526315789473%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e36.4\u0026nbsp;\u003cspan style=\"background: white;\"\u003e± 5.2\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93.8pt;border: none;padding: 0in 5.4pt;height: 26.2pt;vertical-align: top;\" valign=\"top\" width=\"20.55921052631579%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e36.0\u0026nbsp;\u003cspan style=\"background: white;\"\u003e± 4.9\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92.15pt;border: none;padding: 0in 5.4pt;height: 26.2pt;vertical-align: top;\" valign=\"top\" width=\"20.230263157894736%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e36.6\u0026nbsp;\u003cspan style=\"background: white;\"\u003e± 5.4\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73.25pt;border: none;padding: 0in 5.4pt;height: 26.2pt;vertical-align: top;\" valign=\"top\" width=\"16.11842105263158%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e0.67\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 111.75pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"24.50657894736842%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eFSH (IU/L)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.05pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"18.585526315789473%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e34.3\u0026nbsp;\u003cspan style=\"background: white;\"\u003e± 17.0\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93.8pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"20.55921052631579%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e30.0\u0026nbsp;\u003cspan style=\"background: white;\"\u003e± 13.1\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92.15pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"20.230263157894736%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e36.9\u0026nbsp;\u003cspan style=\"background: white;\"\u003e± 18.6\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73.25pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"16.11842105263158%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e0.12\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 111.75pt;border: none;padding: 0in 5.4pt;height: 25.55pt;vertical-align: top;\" valign=\"top\" width=\"24.50657894736842%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eLH (IU/L)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.05pt;border: none;padding: 0in 5.4pt;height: 25.55pt;vertical-align: top;\" valign=\"top\" width=\"18.585526315789473%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e20.4\u0026nbsp;\u003cspan style=\"background: white;\"\u003e±\u003c/span\u003e\u0026nbsp;11.7\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93.8pt;border: none;padding: 0in 5.4pt;height: 25.55pt;vertical-align: top;\" valign=\"top\" width=\"20.55921052631579%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e17.7\u0026nbsp;\u003cspan style=\"background: white;\"\u003e± 9.7\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92.15pt;border: none;padding: 0in 5.4pt;height: 25.55pt;vertical-align: top;\" valign=\"top\" width=\"20.230263157894736%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e21.9\u0026nbsp;\u003cspan style=\"background: white;\"\u003e± 12.6\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73.25pt;border: none;padding: 0in 5.4pt;height: 25.55pt;vertical-align: top;\" valign=\"top\" width=\"16.11842105263158%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e0.16\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 111.75pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"24.50657894736842%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eTestosterone (ng/nl)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.05pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"18.585526315789473%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e2.2 \u003cspan style=\"background: white;\"\u003e±\u003c/span\u003e 1.8\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93.8pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"20.55921052631579%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e2.4\u0026nbsp;\u003cspan style=\"background: white;\"\u003e± 2.0\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92.15pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"20.230263157894736%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e2.1\u0026nbsp;\u003cspan style=\"background: white;\"\u003e± 1.6\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73.25pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"16.11842105263158%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e0.47\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 111.75pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"24.50657894736842%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eProlactin\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.05pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"18.585526315789473%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e9.2\u0026nbsp;\u003cspan style=\"background: white;\"\u003e±\u0026nbsp;\u003c/span\u003e3.7\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93.8pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"20.55921052631579%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e8.7\u0026nbsp;\u003cspan style=\"background: white;\"\u003e± 3.5\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92.15pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"20.230263157894736%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e9.5\u0026nbsp;\u003cspan style=\"background: white;\"\u003e± 3.8\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73.25pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"16.11842105263158%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e0.39\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 111.75pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"24.50657894736842%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eEstradiol (pg/ml)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.05pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"18.585526315789473%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e21.0\u0026nbsp;\u003cspan style=\"background: white;\"\u003e± 9.9\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93.8pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"20.55921052631579%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e19.5\u0026nbsp;\u003cspan style=\"background: white;\"\u003e± 7.4\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92.15pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"20.230263157894736%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e21.8\u0026nbsp;\u003cspan style=\"background: white;\"\u003e± 11.0\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73.25pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"16.11842105263158%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e0.41\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 111.75pt;border: none;padding: 0in 5.4pt;height: 26.2pt;vertical-align: top;\" valign=\"top\" width=\"24.50657894736842%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eY partial deletion\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.05pt;border: none;padding: 0in 5.4pt;height: 26.2pt;vertical-align: top;\" valign=\"top\" width=\"18.585526315789473%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e9 (13.6%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93.8pt;border: none;padding: 0in 5.4pt;height: 26.2pt;vertical-align: top;\" valign=\"top\" width=\"20.55921052631579%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e5 (20.8%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92.15pt;border: none;padding: 0in 5.4pt;height: 26.2pt;vertical-align: top;\" valign=\"top\" width=\"20.230263157894736%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e4 (9.5%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73.25pt;border: none;padding: 0in 5.4pt;height: 26.2pt;vertical-align: top;\" valign=\"top\" width=\"16.11842105263158%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e0.27\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 111.75pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"24.50657894736842%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp; gr/gr deletion\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.05pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"18.585526315789473%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e4 (6.1%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93.8pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"20.55921052631579%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e2 (8.3%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92.15pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"20.230263157894736%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e2 (4.8%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73.25pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"16.11842105263158%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e0.62\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 111.75pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"24.50657894736842%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp; b2/b3 deletion\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.05pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"18.585526315789473%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e4 (6.1%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93.8pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"20.55921052631579%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e3 (12.5%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92.15pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"20.230263157894736%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e1 (2.4%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73.25pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"16.11842105263158%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e0.13\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 111.75pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"24.50657894736842%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp; sY1206 deletion\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85.05pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"18.585526315789473%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e1 (1.5%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93.8pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"20.55921052631579%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e0 (0%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92.15pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"20.230263157894736%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e1 (2.4%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73.25pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"16.11842105263158%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e1.00\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 16px; font-family: \u0026quot;Times New Roman\u0026quot;, serif;\"\u003e\n \u003cbr\u003e\u0026nbsp;\n \u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eTable 3. AZFc partial deletion in KS men and controls\u003c/span\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" style=\"border-collapse:collapse;border:none;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 133pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;height: 20.8pt;vertical-align: top;\" valign=\"top\" width=\"29.159802306425043%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113.4pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;height: 20.8pt;vertical-align: top;\" valign=\"top\" width=\"24.87644151565074%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eFertile control\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113.4pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;height: 20.8pt;vertical-align: top;\" valign=\"top\" width=\"24.87644151565074%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eKlinefelter men\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96.2pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;height: 20.8pt;vertical-align: top;\" valign=\"top\" width=\"21.087314662273474%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cem\u003ep\u003c/em\u003e\u0026nbsp;value\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 133pt;border: none;padding: 0in 5.4pt;height: 21.55pt;vertical-align: top;\" valign=\"top\" width=\"29.159802306425043%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eTotal subjects\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113.4pt;border: none;padding: 0in 5.4pt;height: 21.55pt;vertical-align: top;\" valign=\"top\" width=\"24.87644151565074%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e107\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113.4pt;border: none;padding: 0in 5.4pt;height: 21.55pt;vertical-align: top;\" valign=\"top\" width=\"24.87644151565074%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e66\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96.2pt;border: none;padding: 0in 5.4pt;height: 21.55pt;vertical-align: top;\" valign=\"top\" width=\"21.087314662273474%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 133pt;border: none;padding: 0in 5.4pt;height: 20.7pt;vertical-align: top;\" valign=\"top\" width=\"29.159802306425043%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003eAZFc partial deletion\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113.4pt;border: none;padding: 0in 5.4pt;height: 20.7pt;vertical-align: top;\" valign=\"top\" width=\"24.87644151565074%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp; 7\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113.4pt;border: none;padding: 0in 5.4pt;height: 20.7pt;vertical-align: top;\" valign=\"top\" width=\"24.87644151565074%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;9\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96.2pt;border: none;padding: 0in 5.4pt;height: 20.7pt;vertical-align: top;\" valign=\"top\" width=\"21.087314662273474%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e0.18\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 133pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"29.159802306425043%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp; \u0026nbsp;gr/gr deletion\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113.4pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"24.87644151565074%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp; 3\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113.4pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"24.87644151565074%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;4\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96.2pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"21.087314662273474%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e0.43\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 133pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"29.159802306425043%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp; \u0026nbsp;b2/b3 deletion\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113.4pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"24.87644151565074%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp; 4\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113.4pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"24.87644151565074%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;4\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96.2pt;border: none;padding: 0in 5.4pt;vertical-align: top;\" valign=\"top\" width=\"21.087314662273474%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e0.48\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 133pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;height: 11.85pt;vertical-align: top;\" valign=\"top\" width=\"29.159802306425043%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp; \u0026nbsp;sY1206 deletion\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113.4pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;height: 11.85pt;vertical-align: top;\" valign=\"top\" width=\"24.87644151565074%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp; 0\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113.4pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;height: 11.85pt;vertical-align: top;\" valign=\"top\" width=\"24.87644151565074%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u0026nbsp;1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96.2pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;height: 11.85pt;vertical-align: top;\" valign=\"top\" width=\"21.087314662273474%\"\u003e\n \u003cp style=\"margin:0in;margin-bottom:.0001pt;font-size:16px;font-family:\u0026quot;Times New Roman\u0026quot;,serif;text-align:justify;line-height:12.0pt;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e0.38\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Klinefelter, AZFc deletion, age, microdissection testicular sperm extraction","lastPublishedDoi":"10.21203/rs.2.15379/v2","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.2.15379/v2","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground The purpose of this study is to evaluate the prognostic factors for sperm retrieval and determine if Y chromosome deletion is associated with deleterious effects. Whether Y chromosome deletion determines the sperm retrieval rate in non-mosaic Klinefelter patients has not yet been addressed. Methods We retrospectively collected medical records of azoospermic patients from Sep 2009 to Dec 2018, and enrolled 66 non-mosaic 47, XXY patients who were receiving mTESE. The predictive values of patients age, serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), testosterone, prolactin, estradiol and Y chromosome deletion were assessed for successful sperm recovery. Results Testicular sperm recovery was successful in 24 (36.4%) of 66 men. The mean age (36.0 vs. 36.6 years), and levels of FSH (30.0 vs 36.9 IU/L), LH (17.7 vs 21.9 IU/L), testosterone (2.4 vs. 2.1 ng/ml), prolactin (9.1 vs. 8.8 ng/ml), and estradiol (19.4 vs. 22.3 pg/ml) did not show any significant difference when comparing patients with and without successful sperm retrieval. Partial deletion of azoospermic factor c (AZFc) was noted in 5 (20.8%) of 24 patients with successful sperm retrieval, including three b2/b3 and two gr/gr deletion cases, whereas 4 (9.5%) of 42 patients with unsuccessful sperm retrieval were noted to have AZFc partial deletion (one b2/b3 , one sY1206 and two gr/gr deletion), though the difference was not statistically significant (p=0.27) Conclusion According to present results, age and AZFc partial deletion status should not be a deterrent for azoospermic males with non-mosaic Klinefelter syndrome to undergo mTESE.\u003c/p\u003e","manuscriptTitle":"Do partial AZFc deletions affect the sperm retrieval rate in non-mosaic Klinefelter patients undergoing microdissection testicular sperm extraction?","msid":"","msnumber":"","nonDraftVersions":[{"code":2,"date":"2020-01-24 14:15:00","doi":"10.21203/rs.2.15379/v2","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accept","date":"2020-02-14T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-02-03T12:00:00+00:00","index":2,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-02-03T12:00:00+00:00","index":2,"fulltext":"Recommendation: Accept without revision\nForm responses:\n---\n* Please confirm that you have included your review in the ‘Comments to Author’ box?: ** Yes**\n* Are the methods appropriate and well described to allow independent reproduction of experiments?: **Yes**\n* Does the work include the necessary controls?: **Yes**\n* Are you able to assess the statistics?: ** I have been able to assess all of the statistics in this manuscript (please refer to checklist above)**\n* Are the conclusions drawn adequately supported by the data shown?: **Yes**\n* Quality of written English: **Acceptable**\n* Should the manuscript be highlighted for promotional activity?: **No**\n* Declaration of competing interests: **I declare that I have no competing interests**\n\nComments to Author:\n---\n"},{"type":"editorInvitedReview","content":"","date":"2020-02-02T12:00:00+00:00","index":1,"fulltext":"Recommendation: Accept without revision\nForm responses:\n---\n* Please confirm that you have included your review in the ‘Comments to Author’ box?: ** Yes**\n* Are the methods appropriate and well described to allow independent reproduction of experiments?: **Yes**\n* Does the work include the necessary controls?: **Yes**\n* Are you able to assess the statistics?: ** There are statistical tests that I am unable to assess and recommend seeking additional advice (please specify which tests these are in the ‘Comments to Editor’ box)**\n* Are the conclusions drawn adequately supported by the data shown?: **Yes**\n* Quality of written English: **Acceptable**\n* Should the manuscript be highlighted for promotional activity?: **No**\n* Declaration of competing interests: **I declare that I have no competing interests**\n\nComments to Author:\n---\nThe manuscript is improved and is suitable for publication."},{"type":"reviewerAgreed","content":"","date":"2020-02-01T12:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-01-30T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-01-21T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-01-20T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-01-20T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":1,"date":"2019-10-01 18:39:16","doi":"10.21203/rs.2.15379/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2020-01-08T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-01-06T12:00:00+00:00","index":2,"fulltext":"Recommendation: Accept after discretionary revisions\nForm responses:\n---\n* Please confirm that you have included your review in the ‘Comments to Author’ box?: ** Yes**\n* Are the methods appropriate and well described to allow independent reproduction of experiments?: **Yes**\n* Does the work include the necessary controls?: **Yes**\n* Are you able to assess the statistics?: ** I have been able to assess all of the statistics in this manuscript (please refer to checklist above)**\n* Are the conclusions drawn adequately supported by the data shown?: **Yes**\n* Quality of written English: **Acceptable**\n* Should the manuscript be highlighted for promotional activity?: **No**\n* Declaration of competing interests: **I declare that I have no competing interests**\n\nComments to Author:\n---\nThank you for this interesting manuscript.\nI congratulate the authors on their work.\nI have only one question: 'During laboratory management, how mTESE samples were processed?"},{"type":"reviewerAgreed","content":"","date":"2019-12-24T12:00:00+00:00","index":2,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2019-11-27T12:00:00+00:00","index":1,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n* Please confirm that you have included your review in the ‘Comments to Author’ box?: ** Yes**\n* Are the methods appropriate and well described to allow independent reproduction of experiments?: **Yes**\n* Does the work include the necessary controls?: **Yes**\n* Are you able to assess the statistics?: ** There are statistical tests that I am unable to assess and recommend seeking additional advice (please specify which tests these are in the ‘Comments to Editor’ box)**\n* Are the conclusions drawn adequately supported by the data shown?: **Yes**\n* Quality of written English: **Not suitable for publication unless extensively edited**\n* Should the manuscript be highlighted for promotional activity?: **No**\n* Declaration of competing interests: **I declare that I have no competing interests**\n\nComments to Author:\n---\nThe manuscript submitted by I-shen et al., entitled \"Do partial AZFc deletions affect the sperm retrieval rate in non-mosaic Klinefelter patients undergoing microdissection testicular sperm extraction?\" and summarizes the authors findings of any deleterious effects of partial AZFc region deletions on sperm retrieval rate in 66 non-mosaic 47, XXY patients with and without successful sperm retrieval.\nFinding predictive factors that help improving the sperm retrieval rate in KS patients is an interesting topic for sure; however there are a number of issues for consideration.\n\n1- Page number is missing.\nhttps://bmcurol.biomedcentral.com/submission-guidelines/preparing-your-manuscript\n\n2- The manuscript would strongly benefit from being read by one of the native English authors\n3- \"…Y chromosome deletion is associated with deleterious effects\" on/including what?\n4- The authors noted that the rate of partial AZFc deletion is 20.8% and 9.5% in those with successful and unsuccessful sperm recovery, respectively. Does the difference was not significant?!\n5- The references of 14-15 are published 10-12 years before; so, they should not be considered recent literature.\n6- In p.6 L.46 the authors state that \"…after treatment...\". what kind of treatment the authors mean? Are they denoting to medical therapy with aromatase inhibitors, clomiphene or human chorionic gonadotropin before microdissection testicular sperm extraction?\n7- In p.6 paragraph 3 the authors imply that 2 factors of testosterone and age are reliable prognostic factors, but the only recommendation is about age. Needs to add a sentence about the role of testosterone, as well.\n8- What was the inclusion criteria for fertile group?\n9- It is noted that \"107 fertile controls who had fathered at least one child were obtained\". However, considering a time-limit after fathering is a must, as age can affect male infertility, adversely.\n10- The discussion needs to be reduced in size. The first paragraph of Discussion doesn't any relevance to the main purpose of the article. Some sentences may be transferred to the Introduction section.\n11- In p.13 L.16 it is state that \"10% of KS can present with an additional X chromosome\"; it should be change to higher-grade of X chromosome aneuploidies.\n12- In p.14 L.7 the authors referred to references of 16-17 and discuss that \"In men younger than 35 years old, sperm retrieval rate (SRR) is reported to range from 55% to 86%\"; however, the issue is there is no 55% in these references:\nAccording to Ref. 16- Ramasamy, R., et al., \"SRR for micro-dissection TESE was 71% at ages 22 to 30 years, 86% at 31 to 35 years and 50% at 36 to 52 years\" and based on Ref. 17- Okada, H., et al., \"The success rates in TESE were 81% (25 to 29 years); 73% (30 to 34 years)\".\n13- The fifth paragraph of discussion needs to be transferred to introduction.\n14- In p.14 L.53 the authors discuss that \"Gr/gr deletion, the clinically most relevant and common form of AZFc deletion, has gained attention worldwide\". It is also not entirely clear that deletion is clinically most relevant to what? Do authors mean the correlation with male infertility? But in p.6 of the manuscript they indicated that \"... the frequency of gr/gr deletion is only higher in certain azoospermia or oligozoospermia populations in Italy and China...\"\n15- In p.15 L.53 it is stated that \"(18). AZFc partial duplication other than partial deletion increase the risk of spermatogenic failure\"; it is unclear to what they are referring.\n16- What is the reference for \"the result is consistent with a recent study investigating AZF microdeletion in KS men\".\n17- The 10th paragraph of discussion should be reduced in size. The Pros and Cons of preoperative hCG or aromatase on SRR is out of aims of the current study.\n18- It would be more informative if the authors use a Boxplot for presenting the \"percentage of sperm retrieval rate by microscopic testicular sperm extractions\" in Fig 2.\n"},{"type":"reviewerAgreed","content":"","date":"2019-11-16T12:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2019-11-15T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2019-10-30T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2019-09-25T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2019-09-25T12:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"","date":"2019-09-18T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6b6a5699-22e6-4781-b43c-4a610727f56b","owner":[],"postedDate":"January 24th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":29417,"name":"Urology \u0026 Nephrology"}],"tags":[],"updatedAt":"2021-08-09T17:58:16+00:00","versionOfRecord":{"articleIdentity":"rs-6045","link":"https://doi.org/10.1186/s12894-020-00587-5","journal":{"identity":"bmc-urology","isVorOnly":false,"title":"BMC Urology"},"publishedOn":"2020-02-27 20:39:07","publishedOnDateReadable":"February 27th, 2020"},"versionCreatedAt":"2020-01-24 14:15:00","video":"","vorDoi":"10.1186/s12894-020-00587-5","vorDoiUrl":"https://doi.org/10.1186/s12894-020-00587-5","workflowStages":[]},"version":"v2","identity":"rs-6045","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"identity":"rs-6045","version":["v2"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}