AbstractSTUDY QUESTIONWhat are some pathogenic mutations for non-obstructive azoospermia (NOA) and their effects on spermatogenesis?SUMMARY ANSWERBiallelic missense and frameshift mutations inADAD2disrupt the differentiation of round spermatids to spermatozoa causing azoospermia in humans and mice.WHAT IS KNOWN ALREADYNOA is the most severe cause of male infertility characterized by an absence of sperm in the ejaculate due to impairment of spermatogenesis. In mice, the lack of the RNA-binding protein ADAD2 leads to a complete absence of sperm in epididymides due to failure of spemiogenesis, but the spermatogenic effects ofADAD2mutations in human NOA-associated infertility require functional verification.STUDY DESIGN, SIZE, DURATIONSix infertile male patients from three unrelated families were diagnosed with NOA at local hospitals in Pakistan based on infertility history, sex hormone levels, two semen analyses and scrotal ultrasound. Testicular biopsies were performed in two of the six patients.Adad2mutant mice (Adad2Mut/Mut) carrying mutations similar to those found in NOA patients were generated using the CRISPR/Cas9 genome editing tool. Reproductive phenotypes ofAdad2Mut/Mutmice were verified at 2 months of age. Round spermatids from the littermates of wild-type (WT) andAdad2Mut/Mutmice were randomly selected and injected into stimulated WT oocytes. This round spermatid injection (ROSI) procedure was conducted with three biological replicates and >400 ROSI-derived zygotes were evaluated. The fertility of the ROSI-derived progeny was evaluated for three months in fourAdad2WT/Mutmale mice and sixAdad2WT/Mutfemale mice. A total of 120Adad2Mut/Mut,Adad2WT/Mut, and WT mice were used in this study. The entire study was conducted over 3 years.PARTICIPANTS/MATERIALS, SETTING, METHODSWhole-exome sequencing was performed to detect potentially pathogenic mutations in the six NOA-affected patients. The pathogenicity of the identifiedADAD2mutations was assessed and validated in human testicular tissues and in mouse models recapitulating the mutations in the NOA patients using quantitative PCR, western blotting, hematoxylin-eosin staining, Periodic acid-Schiff staining, and immunofluorescence. Round spermatids of WT andAdad2Mut/Mutmice were collected by fluorescence-activated cell sorting and injected into stimulated WT oocytes. The development of ROSI-derived offspring was evaluated in the embryonic and postnatal stages.MAIN RESULTS AND THE ROLE OF CHANCEThree recessive mutations were identified inADAD2(MT1: c.G829T, p.G277C; MT2: c.G1192A, p.D398N; MT3: c.917_918del, p.Q306Rfs*43) in patients from three unrelated Pakistani families. MT1 and MT2 dramatically reduced the testicular expression of ADAD2, likely causing spermiogenesis failure in the NOA patients. Immunofluorescence analysis of theAdad2Mut/Mutmale mice with the corresponding MT3 mutation showed instability and premature degradation of the ADAD2 protein, resulting in the spermiogenesis deficiency phenotype. Through ROSI, theAdad2Mut/Mutmice could produce pups with comparable embryonic development (46.7% inAdad2Mut/Mutversus 50% in WT) and birth rates (21.45 ± 10.43% inAdad2Mut/Mutversus 27.5 ± 3.536% in WT,P= 0.5044) to WT mice. TheAdad2WT/Mutprogeny from ROSI (17 pups in total via three ROSI replicates) did not show overt developmental defects and had normal fertility.LARGE SCALE DATAN/A.LIMITATIONS, REASONS FOR CAUTIONThis is a preliminary report suggesting that ROSI can be an effective treatment for infertileAdad2Mut/Mutmice. Further assisted reproductive attempts need to be carefully examined in humans during clinical trials.WIDER IMPLICATIONS OF THE FINDINGSOur work provides functional evidence that mutations in theADAD2gene are deleterious and cause consistent spermiogenic defects in both humans and mice. In addition, preliminary results show that ROSI can helpAdad2Mut/Mutto produce biological progeny. These findings provide valuable clues for genetic counselling on theADAD2mutants-associated infertility in human males.STUDY FUNDING/COMPETING INTEREST(S)This work was supported by the National Natural Science Foundation of China (32000587, U21A20204, and 32061143006), and the National Key Research and Developmental Program of China (2019YFA0802600 and 2021YFC2700202). This work was also supported by Institute of Health and Medicine, Hefei Comprehensive National Science Center, Hefei, China. The authors declare no competing interests.