Do alterations in the sex ratio occur at fertilization? A case report using fluorescent in situ hybridization

Purpose: The mechanisms by which the sex ratio might be altered at fertilization were reviewed, following a case of preimplantation gender analysis revealing a significantly skewed proportion of male-to-female embryos. Methods: The case of a known carrier of X-linked hydrocephalus with a history of three affected male pregnancies is presented. Her husband's family history consisted of a strong increase in the number of males relative to females. She had four cycles of stimulated in vitro fertilization, with sex chromosome analysis using fluorescent in situ hybridization (FISH) on suitable cleavage-stage embryos. The difference in the sex ratio of normal male-to-female embryos was compared using a significance probabilities test for sex ratio. The sex ratio of sperm from a semen sample from the male partner was determined by FISH. Results: Fifty embryos were suitable for analysis. A significantly higher number of normal male (n = 20) than normal female (n = 8) embryos was obtained (P < 0.05). The FISH assessment of the husband's semen analysis revealed no alteration in the normal X:Y ratio. Conclusions: As the sperm analysis revealed a normal X: Y ratio, an alteration in the embryo sex ratio might he explained by the preferential binding of Y-bearing sperm to the oocyte, an oocyte-related "discouragement" of binding of X-bearing sperm, or a postfertilization event.