In 1875, Sir Francis Galton was the first to propose that by comparing the concordance of a specific trait or disorder in monozygotic (MZ) twins (assumed to be genetically identical) and dizygotic (DZ) twins (which were assumed to be as similar or as different as any other pair of sibs), it would be possible to distinguish between environmental and heritable effects. DZ twins are derived from the fertilization of two eggs by two sperm. MZ twins are the result of the fertilization of one egg by one sperm that then divides to form two embryos.

Genetic research has made amazing progress since 1875. Advances in molecular DNA techniques and developmental genetics have made it possible to differentiate unequivocally between MZ and DZ twins [1, 14]. It is in this new light that this manuscript will review the recent knowledge about twins and the twinning process.

The incidence of DZ twins differs between population [11, 18]. A DZ twin birth in North America is estimated to occur 9–11 times in every 1000 live births or 1 in 100 births; i.e. 1 in every 50 people is a DZ twin.

The DZ twinning rate is closely related to maternal age, parity, height, weight and gonadotropin levels. An increased DZ twinning rate is seen with increasing maternal age and peaks around 35–39 years; higher parity is also associated with a higher DZ twinning rate [19]. Tall heavy women are more likely to give birth to DZ twins than short thin women. A higher incidence of DZ twins has also been reported with the use of new reproductive techniques.

This paper summarizes our experience with Doppler velocimetry in survivors of intrauterine co-twin demise. In the first trimester, ten dichorionic deaths occurred; none of the survivors developed flow disorders. During the second trimester, there were three intrauterine demises, two of them were monochorionic and the survivors developed flow disorders: one presented transitory venous flow aberration, the other one an impaired development of diastolic flow. In the third trimester, two intrauterine deaths occurred. One case of twin to twin transfusion syndrome (TTTS) was complicated by the donor's death and the recipient showed a loss of diastolic flow. The second one happened during a dichorionic twin pregnancy. The survivor presented high systolic/diastolic daily ratio (S/D = 7.8).

Recent developments in molecular genetics and cytogenetics have allowed for better understanding of the inheritance and expression of genes. Many newly recognized mechanisms such as genomic imprinting, mosaicism, allelic expansion, cytoplasmic inheritance and uniparental disomy have been recognized to play an important role in human heredity.

Genomic imprinting refers to differences in the phenotype which are observed depending on whether the gene was inherited from the father or from the mother. Genomic imprinting is a difficult concept to understand because imprinting has been used loosely to refer to a number of different mechanisms including psychological development, endocrinological actions of cells and protein-protein interactions. Genomic imprinting produces parent-of-origin effects. Parent-of-origin effects is a term that encompasses many of the non-traditional types of inheritance and other genetic and non-genetic mechanisms which show an effect depending on whether they were paternally or maternally derived.

Our study reports five cases of prenatal ultrasound diagnosis of nuchal cystic hygroma and early diagnosis for both fetus and mother.

We observed that nuchal cystic hygroma is frequently associated to cytogenetic abnormalities, congenital structural anomalities and non-immune hydrops fetus universalis.

Tuberous sclerosis complex (TSC) is an autosomal dominant multisystem disorder with extensive clinical variability. Present estimates of the prevalence of TSC suggest that it may exceed 1:6,000. New mutations are frequent, as about 2/3 of all cases are apparently sporadic. Locus heterogeneity has been established, with one gene on chromosome 9q34 (TSC1) and the other on chromosome 16p13.3 (TSC2). The majority of TSC2 mutations are propably subtle alterations. In some cases, somatic and germline mosaicism might be explanations for intrafamilial phenotypic variation and apparent non penetrance. A role of the predicted protein product tuberin in growth suppression would be in agreement with allelic losses observed in tumors of TSC patients. Studies on tuberin using antibodies raised against various parts of the protein can be expected to provide insight into its normal and impaired function.

WBS is an overgrowth malformation syndrome characterized by highly variable expressivity, associated with predisposition to different types of pediatric tumors including Wilms' tumor (WT), adrenocortical carcinoma (ADCC), rhabdomyosarcoma (RMS) and hepatoblastoma (HEP). Most cases are sporadic, however 15% of the cases are familial. Cytogenetic, genetic and molecular analysis of the different forms of this syndrome and associated tumors have provided increasing evidence that the gene (or genes) map to 11p15.5 and that genomic imprinting can account for the strange genetics of this syndrome/tumors [1]. Two candidate genes, H19 and Igf2, which are both imprinted, but in opposite direction, map close to but not within one of the two smallest region(s) defined both by constitutional and tumoral rearrangements. These two genes, H19 and Igf2, and their specific parental imprint, may thus account for the pattern of inheritance observed, the variable expressivity, the specific loss of alleles and the loss of imprint. However, that these genes map 400 kb away from one cluster of breakpoints observed in the cytogenetic cases of WBS suggests that other genes could be involved. Indeed, although mapping to a different subregion, a sequence wit the properties of a tumor Suppressor (rhabdomyosarcoma cell line) has recently been isolated [2].

Furthermore, neither reduplication of the active Igf2 paternal allele nor relaxation of Igf2 imprinting is sufficient for tumorigenesis, thus indicating that other mutation(s) must occur. The phenotypic consequences of these aberrant expressions will be better understood when the tissues, the stage of development or the state of differentiation are precisely identified [3-5].

Prader-Willi syndrome (PWS) and Angelman syndrome (AS) are distinct mental retardation disorders caused by paternal deficiency (PWS) or maternal deficiency (AS) of gene(s) in 15qll.2-ql3. We have constructed a 3.5 Mb yeast artificial chromosome (YAC) contig of the PWS/AS region and cosmid contigs of selected YACs at D15S13, SNRPN, S10, and S113. Cosmid clones have been used for fluorescence in situ hybridization (FISH) detection of deletions in PWS and AS patients. In addition, a total of 28 short tandem repeat polymorphisms (STRs) have been mapped to specific YACs in the contig, providing a highly informative set of markers for detection of deletion or uniparental disomy (UPD) in PWS and AS patients. Use of the 3 most informative markers in this region (S542, S128, and ASSCA-1) plus 3 markers distal on 15q (S123, S125, and S131) provide an efficient diagnostic strategy for UPD15.

A combination of FISH and STR analysis has identified small deletions in one sporadic and one familial case of PWS (family O). Both deletions involve all or part of the SNRPN gene but do not extend telomeric to PAR-5 or PAR-1, two novel transcripts expressed exclusively from the paternal chromosome. However, expression of SNRPN, PAR-5, and PAR-1 is lost in both cases, implying the presence of an imprinting control region near SNRPN. The smallest deletion in family O is estimated at approximately 30-40 kb in size and involves a newly identified CpG island at the 5′ end of SNRPN which is methylated on the maternal chromosome. This small deletion in two PWS affected siblings was present in the father and the paternal grandmother, both of whom were phenotypically normal.

In contrast to the random inactivation of either maternal or paternal X-chromosome in the somatic cells of eutherian mammals, in marsupials the paternal X-chromosome is preferentially inactivated in all cells. Similar exclusively paternal X-inactivation occurs in two extraembryonic cell lineages of mice and rats. Thus, genetic imprinting is an important feature of X-inactivation. In embryonic development the initiation of X-inactivation is thought to occur through the X-inactivation centre, located on the X-Chromosome, and thus imprinting probably acts through this centre. A candidate gene for a role in the inactivation centre is Xist (X inactive specific transcript) which is expressed only from the inactive X-Chromosome. The expression of Xist in the mouse embryo is appropriate for it to be a cause rather than a consequence of inactivation. It appears before inactivation, and only the paternal allele is expressed in the extraembryonic lineages. In the germ cells also changes in X-chromosome activity are accompanied by changes in Xist expression. Studies of methylation of the Xist gene have shown that in male tissues where Xist is not active it is fully methylated, whereas in the female the allele on the active X-chromosome only is methylated. In male germ cells, where Xist is expressed, it is demethylated and the demethylation persists in mature spermatozoa. Thus a methylation difference in germ cells could possibly be the imprint. In androgenotes, with paternally derived chromosomes, Xist is expressed at the 4-cell stage, whereas in gynogenotes and parthenogenotes expression does not appear until the blastocyst stage. Thus, Xist expression shows imprinting. When expression appears in parthenogenotes it is random, suggesting that the imprint has been lost. The Xist gene has no open reading frame and is thought to act through mRNA but its function is unknown.

Our studies aim to identify the mechanisms and genes involved in genomic imprinting in mammalian development and human disease. Imprinting refers to an epigenetic modification of DNA that results in parent-of-origin specific expression during embryogenesis and in the adult. This imprint is reset at each generation, depending on the sex of the parental gametogenesis. Prader-Willi (PWS) and Angelman (AS) syndromes are excellent models for the study of genomic imprinting in humans, since these distinct neurobehavioural disorders are both associated with genetic abnormalities (large deletions, uniparental disomy, and imprinting mutations) of inheritance in chromosome 15q11-q13, dependent on the parental origin (reviewed in ref. 1). Some AS patients have biparental inheritance, consistent with a single imprinted gene (active on the maternal chromosome), whereas similar PWS patients are not found suggesting that at least two imprinted genes (active on the paternal allele) may be necessary for classical PWS. We have previously shown that the small ribonucleoprotein associated protein SmN gene (SNRPN), located in the PWS critical region [2], is only expressed from the paternal allele and is differentially methylated on parental alleles [3]. Therefore, SNRPN may have a role in PWS. Methylation imprints have also been found at two other loci in 15q11-q13, PW71 [4] and D15S9 [5], which map 120 kb and 1.5 Mb proximal to SNRPN, respectively. We have now characterized in detail the gene structure and expression from two imprinted loci within 15q11-q13, SNRPN and D15S9, which suggests that both loci are surprisingly complex, with important implications for the pathogenesis of PWS.

Genetic imprinting implies the preferential or exclusive expression of one of the parental alleles of a subset of autosomal loci. The insulin-like growth factor II (IGF2) and H19 loci are particularly interesting examples of this phenomenon since their products appear to display growth agonistic and antagonistic properties, respectively. In addition, IGF2 and H19 are only 90 kb apart, are expressed from opposite parental alleles [1,2] and show a striking similarity in their spatial expression patterns during human prenatal development [3]. One exception is the choroid plexus and leptomeninges which express 1GF2 biallically with no detectable H19 expression [3]. Observations like these have fuelled ideas that there is an enhancer competition between the IGF2 and H19 loci [4]. The imprinting status of the H19 locus would then indirectly control the expressivity of IGF2. This model is likely to be too simple since the P1 promoter of IGF2 is not functionally imprinted during liver development in humans [4]. Moreover, while the liver P2-P4 promoters are expressed primarily from the paternally derived allele during human prenatal development, the P2-P4 promoters can be expressed from both parental alleles in complex patterns during postnatal human development [5]. The enhancer competition model might be put to the test in human and mouse uniparental embryos since the parental origin of their diploid genomes cannot be discerned. Unexpectedly, H19 which is expressed preferentially from the maternal allele in mouse [6] and human [7] placenta is expressed in both mouse and human trophoblasts (in complete hydatidiform moles) lacking the maternal genome. In the normal human placenta, the repressed paternal H19 allele is more methylated. Interestingly, the CpG methylation pattern of H19 is strikingly similar between normal placenta and complete moles. Hence, both paternal H19 alleles are similarly methylated indicating that postzygotic modification events typical of normal development have taken place in complete moles as well in spite of the absence of the maternal genome. In contrast to the normal placenta, H19 is expressed biallelically in complete moles as assessed by allele-specific in situ hybridisation analysis of dispermie moles [8]. We discuss these results in relation to current models of IGF2/H19 imprinting mechanism(s).

Fragile X syndrome is the most common cause of interited mental retardation in humans, with a frequency of approximately 1 in 1200 males and 1 in 2500 females [1]. It is second only to Down syndrome as a genetic cause of mental retardation, which has an overall frequency of 1 in 600. These frequency estimates suggest that fragile X syndrome accounts for approximately 3% of mental retardation in males, and perhaps as much as 20% in males with IQs between 30 and 55 [2]. The disease derives its name from the observation of a fragile site at Xq27.3 in cultured lymphocytes, fibroblasts and amniocytes [3].

The phenotype of the fragile X syndrome is mental retardation, usually with an IQ in the 4-70 range [4] and a number of dysmorphic features: long face, everted ears and large testicles [for review see ref. 5] (Fig. 1). Not every patient shows all the physical symptoms, which are generally more apparent after childhood. Macroorchidism is a common feature of fragile X syndrome in more than 90% of postpuberal males. Some patients show hyperactivity and attention deficits as well as avoidance behaviour similar to autism. Affected females generally have a less severe clinical presentation, and their IQ scores are generally higher, with typically borderline IQs or mild mental retardation.

No gross pathological abnormalities have been described in the brains of fragile X patients. Only a few post-mortem brain studies of fragile X males have been described and the information is very limited, presenting only non-specific findings such as brain atrophy, ventricular dilatation and pyramidal neurons with abnormal dendritic spines. It has been shown that the volume of the hippocampus was enlarged compared to controls [6], while a significantly decreased size of the posterior cerebellar vermis and increased size of the fourth ventricle was found [7]. Using magnetic resonance imaging it was shown that fragile X patients have an increased volume of the caudate nucleus [8]. The caudate volume is correlated with IQ and methylation status of the FMR1 gene.

With a population incidence of about 1 in 15.000 retinoblastoma is the most frequent intraocular tumor in infancy and early childhood. It occurs in a hereditary form due to a germline mutation in about 40% of patients (30% de novo mutation and 10% transmission from an affected parent) and in a non-hereditary form due to a somatic mutation. The retinoblastoma gene is located on chromosome 13q14. This large gene of about 180 kb, consists of 27 exons of rather different sizes and encodes a 4.7 kb transcript with important function in cell cycle regulation. Individuals with bilateral, multifocal tumors are assumed to carry a germline mutation, whereas unilateral and unifocal tumors are generally due to the somatic form. Both copies of the RB1 gene must be in inactivated before a tumor develops. In about half of patients with the germline mutation the second event inactivating the second allele can be shown by loss of heterozygosity in tumor tissues compared to surrounding somatic tissues.

Knowledge of the RB1 gene locus affords an opportunity to specify the type of mutation in many patients and arrive at a definitive molecular diagnosis. This is the basis for clinical evaluation and genetic counseling. The types of mutation are large scale deletions, small deletions and insertions, and base substitutions. There is no hot-spot for mutations.

During the last several years we have studied more than 200 patients in search for large scale and small deletions and insertions, and missense mutations. Using intragenic polymorphic DNA markers we were able to identify the mutant haplotype in all familial cases. Direct DNA analysis identified a mutation in about 25% of patients. The distribution of lesions will be described in relation to the clinical situation.