c Indian Academy of Sciences

RESEARCH ARTICLE

Maternal MTHFR polymorphism (677 C–T) and risk of Down’s

syndrome child: meta-analysis

AMANDEEP KAUR and ANUPAM KAUR∗

Department of Human Genetics, Guru Nanak Dev University, Amritsar 143 005, India

Abstract
Methylenetetrahydrofolate reductase (MTHFR) is the most important gene that participates in folate metabolism. Presence
of valine instead of alanine at position 677 and elevated levels of homocystein causes DNA hypomethylation which in turn
favours nondisjunction. In this study, we conducted a meta-analysis to establish link between maternal single-nucleotide
polymorphism (SNP) and birth of Down’s syndrome (DS) child. A total of 37 case–control studies were selected for analysis
including our own, in which we investigated 110 cases and 111 control mothers. Overall, the result of meta-analysis showed
significant risk of DS affected by the presence of maternal SNP (MTHFR 677 C–T OR = 0.816, 95% CI = 0.741–0.900,
P < 0.0001). Heterogeneity of high magnitude was observed among the studies. The chi-square value suggested a highly
significant association between homozygous mutant TT genotype and birth of DS child (χ 2 = 23.63, P = 0.000). Genetic
models suggested that ‘T’ allele possesses high risk for DS whether present in dominant (OR = 1.23, 95% CI = 1.13–1.34);
codominant (OR = 1.17, 95% CI = 1.10–1.25) or recessive (OR = 1.21, 95% CI = 1.05–1.38) form. The analysis from all
37 studies combined together suggested that MTHFR 677 C–T is a major risk factor for DS birth.

[Kaur A. and Kaur A. 2016 Maternal MTHFR polymorphism (677 C–T) and risk of Down’s syndrome child: meta-analysis. J. Genet. 95,
xx–xx]

Introduction
Down’s syndrome (DS) is the most common chromosomal
abnormality that occurs with the prevalence rate of about 1 in
1200 live births (Patel and Adhia 2005), due to nondisjunc-
tion during meiosis I or II. Many studies have reported that
increased homocystein levels and presence of MTHFR 677
C–T polymorphism impairs the folate metabolism and results
in DNA hypomethylation, which in turn favours nondisjunc-
tion of chromosome 21 (James et al. 1999; Fenech 2001).
The results seen in literature are quite contradictory, may be
due to small sample size, making it difficult to elucidate the
role of single-nucleotide polymorphism (SNP) for the risk of
DS child. The present meta-analysis was conducted to under-
stand whether mutation in MTHFR gene is a risk factor for
DS or not.
Materials and methods
Literature regarding DS was searched on electronic PubMed
database and Google scholar from 1999 to January 2015 for
the studies on MTHFR 677 C–T polymorphism (figure 1).
∗ For correspondence. E-mail: anupamkaur@yahoo.com.
Keywords. MTHFR gene; Down’s syndrome; folate metabolism.
All the selected reports were case–control studies. The key-
words used were: MTHFR 677 C–T, Down’s syndrome,
methylenetetrahydrofolate reductase and folate metabolism.
A total of 37 studies that evaluated the association between
the presence of MTHFR 677 C–T polymorphism and risk
of DS child were included. Only research article papers
were considred for this study. For each data, information
about author, country and year of publication along with total
number of cases and controls were extracted. Odds ratio, chi-
square values along with frequencies were calculated (table 1).
Inclusion criteria
The following criteria were considered. (i) Articles published
in English language; (ii) articles evaluated MTHFR 677 C–T
SNP; (iii) only those articles in which the mother had at least
two normal children, without miscarriages and abnormali-
ties; and (iv) reports with genotypic and allelic frequencies,
odds ratio and chi-square.
Statistical analysis
The meta-analysis was performed using StatsDirect 3.
Risk for the birth of DS child and presence of maternal

Journal of Genetics, DOI 10.1007/s12041-016-0657-7

 Amandeep Kaur and Anupam Kaur
polymorphism was assessed by odds ratio with 95% CI.
Presence of heterogeneity was estimated using chi-square
based Q-statistics and I2 metrics. In case of higher hetero-
geneity (I2 > 50%), random effect model (DerSimonian and
Laird 1986) was used else fixed effect model (Mantel and
Haenszel 1959) was applied. To estimate publication bias,
Begg and Mazumdar rank correlation (Begg and Mazumdar
1994) and Egger’s regression intercept (Egger et al. 1997)
tests were performed.
Results
In this study, we identified 37 eligible reports from a total of
182 articles published between 1999 and 2015 (figure 1). The
reports were from different ethnic populations, i.e. Asians,
Americans, Europeans and others. A total of 3401 moth-
ers having DS children and 5277 mothers having normal
children were included in the study. Meta-analysis indicated
a highly significant difference between cases and controls
(χ 2 = 23.63, P = 0.000). The three genetic models (domi-
nant: OR = 1.23, 95% CI = 1.13–1.34; codominant: OR =
1.17, 95% CI = 1.10–1.25; recessive: OR = 1.21, 95% CI
= 1.05–1.38) suggested that presence of ‘TT’ genotype in
mothers significantly increased the risk of DS birth (table 2).
The frequency of heterozygote was highest among mothers
of Down’s syndrome children (MDS) (8.3–65.5%) as com-
pared to control mothers (0–55.3%) and a presence of TT
genotype was observed to be higher among cases (0–36.6%)
than the control mothers (0–21.5%) (table 1).
The present analysis revealed that occurrence of mater-
nal polymorphism 677 C–T significantly increases the risk
of birth of DS child (fixed effect model (OR = 0.816, 95%
CI = 0.741–0.900, P < 0.0001) (figure 2); random effect
model (OR = 0.776, 95% CI = 0.654−0.922, P = 0.003)
(figure 3)). The random model was used since the results
demonstrated high magnitude of heterogeneity among stud-
ies (I2 = 62.6%, P < 0.0001, Q = 96.26, df = 36). Sub-
group analysis revealed that MTHFR 677 C–T also found to
be significantly associated with the birth of DS child among
Asians (random model OR = 0.527, 95% CI = 0.355–0.782,
P = 0.001) (figure 4). Higher heterogeneity was observed
among Asian studies (I2 = 58.9%, Q = 29.17, df = 12,
Total articles searched=182
Mice models=5, Reviews=5, Case reports=7, Newsletters=10
Irrelevant articles, abstracts, foreign language articles,
Insufficient data=118
After exclusion
Articles included in the meta-analysis=37
Figure 1. Flow chart showing selection criteria for meta-analysis.
Journal of Genetics
P = 0.003). Similar results were obtained from American
population suggesting association between 677 C–T SNP
and DS child birth (fixed model OR = 0.658, 95% CI =
0.551–0.786, P = 0.0001) (figure 5). However, heterogene-
ity was found to be of low magnitude (I2 = 39.9%, Q =
11.64, P = 0.113, df = 7). On the other hand, no association
and heterogeneity were found among European studies (fixed
model OR = 0.982, 95% CI = 0.851–1.133, P = 0.838,
I2 = 0%, Q = 8.264, P = 0.764, df = 12) (figure 6).
Publication bias
Publication bias was not observed among the studies as indi-
cated by Begg-Mazumdar bias P = 0.23 and Egger’s bias
P = 0.184 for CC versus CT+TT (figure 7).
Discussion
Literature search of individual reports suggest that the frequency
of MTHFR 677 TT distribution varies greatly worldwide. In
our previous study (Kaur and Kaur 2013), we observed
that 1.8% of cases exhibited ‘TT’ genotype, while con-
trol mothers did not exhibit homozygous mutant genotype.
No significant association was observed among cases and
controls (χ 2 − 2.047, P = 0.359) due to the absence of
homozygous mutant allele. Similar findings were observed
in other studies by Cyril et al. (2009), Mohanty et al.
(2012), Divyakolu et al. (2013) and Pandey et al. (2013).
Further, studies from other countries also corroborates with
our study like James et al. (1999), Acacia et al. (2005),
Biselli et al. (2008), Boduroglu et al. (2004), Bozovic et
al. (2011), Brandalize et al. (2009), Chadefaux-Vekeman
et al. (2002), Chango et al. (2005), Coppede et al. (2006,
2009, 2010), Cretu et al. (2010), Da Silva et al. (2005),
El-Gharib et al. (2012), Elsayed et al. (2014), Kokotas et
al. (2009), Martinez-Frias (2008), Meguid et al. (2008),
O’Leary et al. (2002), Pozzi et al. (2009), Santos-Rebaucas
et al. (2008), Scala et al. (2006), Stuppia et al. (2002), Tayeb
(2012), Vranekovic et al. (2010), Liao (2010) and Zampeiri
et al. (2012). The nonsignificant associations in these stud-
ies could be due to small sample size and further a single
polymorphism was not sufficient to establish any association.
James et al. (1999) was the first to report that mutant geno-
type ‘TT’ is associated with the increased risk of DS. In
their study, the frequency of heterozygote was much higher
(59.6%) when compared to controls (44%). It was suggested
that predominance of heterozygote among MDS was due to
foetal viability that may be lower in mothers with the ‘TT’
genotype. Several studies observed nonsignificant associa-
tion but the presence of mutant allele increased the risk of
DS ranging from 0.4–2.7% (table 1). The high intake of
folate may neutralize the metabolic impact of MTHFR poly-
morphism. Thus, SNPs in other genes in folate pathway,
combined with MTHFR and homocystein levels need to be
evaluated to see the overall association.
 Table 1. Comparison of genotypic frequencies, odds ratio and chi-square values.

Total no. Total no. Chi-square Odds

Study group of cases CC CT TT of controls CC CT TT (sig.) ratio 95% CI P

Kaur and Kaur (2013), 110 86 (78.2) 22 (20.0) 2 (1.8) 111 89 (80.1) 22 (19.8) 0 (0.0) 2.047 (0.359) – – –
present study (India)
James et al. (1999), USA 57 15 (26.3) 34 (59.6) 8 (14.0) 50 24 (48) 22 (44) 4 (8) 5.547 (0.062) 1.8776 0.529 to 6.658 0.32
Hobbs et al. (2000), USA 157 51 (32.4) 84 (53.5) 22 (14.0) 140 67 (47.8) 59 (42.1) 14 (10) 7.369 (0.025) 1.4667 0.719 to 2.991 0.29
O’Leary et al. (2002), Ireland 41 18 (43.9) 21 (51.2) 2 (4.8) 192 90 (46.8) 84 (43.7) 18 (9.3) 1.279 (0.527) 0.4957 0.110 to 2.225 0.35
Stuppia et al. (2002), Italy 64 20 (31.2) 32 (50) 12 (18.7) 112 27 (24.1) 62 (55.3) 23 (20.5) 1.062 (0.587) 0.893 0.410 to 1.942 0.77
Chadefaux-Vekeman et al. (2002), 85 36 (42.3) 42 (49.4) 7 (8.2) 70 29 (41.4) 30 (42.8) 11 (15.7) 2.212 (0.330) 0.4814 0.176 to 1.316 0.15
France
Boduroglu et al. (2004), Turkey 152 86 (56.5) 55 (36.1) 11 (7.2) 91 58 (63.7) 30 (32.9) 3 (3.2) 2.194 (0.333) 2.2884 0.621 to 8.431 0.21
Chango et al. (2005), France 119 43 (36.1) 64 (53.7) 12 (10.0) 119 49 (41.1) 58 (48.7) 12 (10.0) 0.686 (0.709) 1 0.430 to 2.325 1
Da Silva et al. (2005), Brazil 154 67 (43.5) 72 (46.7) 15 (9.7) 158 84 (53.1) 67 (42.4) 7 (4.4) 4.952 (0.084) 2.3279 0.921 to 5.878 0.07
Acacia et al. (2005), Brazil 70 35 (50) 30 (42.8) 5 (7.1) 88 54 (61.3) 25 (28.4) 9 (10.2) 3.650 (0.161) 0.6752 0.215 to 2.114 0.50
Liang et al. (2005), China 30 7 (23.3) 20 (66.67) 3 (10) 70 16 (22.8) 34 (48.57) 20 (28.57) 4.425 (0.109) 1.027 0.372 to 2.829 0.95
Coppede et al. (2006), Italy 79 20 (25.3) 43 (54.3) 16 (20.2) 111 39 (35.1) 54 (48.6) 18 (16.2) 2.155 (0.34) 1.3122 0.622 to 2.765 0.47
Scala et al. (2006), Italy 94 31 (32.9) 39 (41.4) 24 (25.5) 256 74 (28.0) 125 (47.3) 57 (21.5) 1.487 (0.475) 1.197 0.691 to 2.073 0.52
Rai et al. (2006), India 149 97 (65.1) 40 (26.8) 12 (8.0) 165 124 (75.1) 39 (23.6) 2 (1.2) 9.664 (0.008)∗ 7.1387 1.570 to 32.44 0.01∗
Wang et al. (2007), China 100 28 (28) 52 (52) 20 (20) 100 48 (48) 42 (42) 10 (10) 9.660 (0.008)∗ 2.25 0.994 to 5.091 0.05∗
Kohli et al. (2008), India 103 74 (71.8) 29 (28.1) 0 (0.0) 109 71 (65.1) 32 (29.3) 6 (5.5) 6.054 (0.048)∗ – – –
Meguid et al. (2008), Egypt 42 20 (47.6) 17 (40.4) 5 (11.9) 48 33 (68.7) 12 (25.0) 3 (6.2) 3.705 (0.156) 2.0721 0.464 to 9.243 0.33
Wang et al. (2008), China 64 14 (21.8) 32 (50) 18 (28.1) 70 36 (51.4) 29 (41.4) 5 (7.1) 16.941 (0.000)∗ 5.087 1.761 to 14.688 0.002∗
Biselli et al. (2008), Brazil 72 29 (40.2) 35 (48.6) 8 (11.1) 194 100 (51.5) 77 (39.6) 17 (8.7) 2.675 (0.262) 1.3015 0.535 to 3.161 0.56
Martinez-Frias (2008), Spain 146 61 (41.7) 61 (41.7) 24 (16.4) 188 76 (40.4) 85 (45.2) 27 (14.3) 0.490 (0.786) 1.173 0.645 to 2.133 0.60
Santos-Rebaucas et al. (2008), 103 51 (49.5) 43 (41.7) 9 (8.7) 108 49 (45.3) 47 (43.5) 12 (11.1) 0.528 (0.767) 0.766 0.308 to 1.902 0.56

Journal of Genetics
Brazil
Cyril et al. (2009), India 36 33 (91.6) 3 (8.3) 0 60 60 (100) 0 0 2.776 (0.095) – – –
Kokotas et al. (2009), Denmark 177 92 (51.9) 72 (40.6) 13 (7.3) 1084 545 (50.2) 449 (41.4) 90 (8.3) 0.278 (0.870) 0.8755 0.478 to 1.602 0.66
Coppede et al. (2009), Italy 94 25 (26.5) 52 (55.3) 17 (18.0) 113 40 (35.3) 55 (48.6) 18 (15.9) 1.846 (0.379) 1.1652 0.562 to 2.412 0.68
MTHFR 677 C–T: a meta-analysis

Brandalize et al. (2009), Brazil 239 94 (39.3) 113 (47.2) 32 (13.3) 197 86 (43.6) 93 (47.2) 18 (9.1) 2.192 (0.334) 1.5373 0.834 to 2.832 0.16
Pozzi et al. (2009), Danish 74 28 (37.8) 30 (40.5) 16 (21.6) 184 62 (33.6) 93 (50.5) 29 (15.7) 2.407 (0.300) 1.4744 0.746 to 2.912 0.26
Coppede et al. (2010), Italy 29 5 (17.2) 19 (65.5) 5 (17.2) 32 11 (34.3) 17 (53.1) 4 (12.5) 2.330 (0.31) 1.4583 0.351 to 6.053 0.60
Cretu et al. (2010), Rome 26 14 (53.8) 10 (38.4) 2 (7.6) 46 18 (39.1) 21 (45.6) 7 (15.2) 1.761 (0.414) 0.4643 0.089 to 2.421 0.36
Vranekovic et al. (2010), Crotia 111 49 (44.1) 49 (44.1) 13 (11.7) 141 66 (47.1) 64 (45.3) 11 (7.8) 1.115 (0.572) 1.5677 0.673 to 3.648 0.29
Liao et al. (2010), China 60 12 (20) 26 (43.3) 22 (36.6) 68 23 (33.8) 33 (48.5) 12 (17.6) 6.755 (0.345) 2.7018 1.195 to 6.104 0.01∗
Sadiq et al. (2011), Jordan 53 23 (43.3) 27 (50.9) 3 (5.6) 29 23 (79.3) 5 (17.2) 1 (3.4) 9.953 (0.006)∗ 1.68 0.166 to 16.925 0.65
Bozovic et al. (2011), Crotia 112 46 (41.0) 55 (49.1) 11 (9.8) 221 101 (45.7) 97 (43.8) 23 (10.4) 0.829 (0.660) 0.9376 0.439 to 1.999 0.86
El-Gharib et al. (2012), Egypt 80 18 (22.5) 48 (60) 14 (17.5) 30 13 (43.3) 12 (40) 5 (16.6) 4.969 (0.083) 1.0606 0.346 to 3.250 0.91
Tayeb (2012), Saudi Arabia 30 16 (53.3) 10 (33.3) 4 (13.3) 40 22 (55) 14 (35) 4 (10) 0.189 (0.909) 1.3846 0.316 to 6.051 0.66
Mohanty et al. (2012), India 52 44 (84.6) 8 (15.4) 0 52 49 (94.2) 3 (5.9) 0 1.627 (0.202) – – –
Zampeiri et al. (2012), Brazil 105 40 (38.1) 55 (52.4) 10 (9.5) 185 94 (51.0) 73 (39.4) 18 (9.7) 4.881 (0.087) 0.9766 0.433 to 2.202 0.95
Pandey et al. (2013), India 81 67 (83.7) 12 (15) 2 (2.5) 99 87 (87) 9 (9) 3 (3) 1.440 (0.486) 0.8101 0.132 to 4.969 0.82
Divyakolu et al. (2013), India 25 21 (84) 4 (16) 0 50 42 (84) 8 (16) 0 0.112 (0.738) – – –
Elsayed et al. (2014), Egypt 26 11 (42.3) 12 (46.1) 3 (11.5) 61 30 (49.1) 24 (39.3) 7 (11.4) 0.387 (0.824) 1.0062 0.238 to 4.237 0.99
Total 3401 1527 (44.89) 1472 (43.28) 402 (11.82) 5277 2643 (50.08) 2106 (39.94) 528 (10.00) 23.631 (0.000)∗ 0.8121 0.744 to 0.885 0.0001∗
∗ Significant association.
 Amandeep Kaur and Anupam Kaur

Indian reports by Kohli et al. (2008) (χ 2 − 6.054, P − frequency of TT genotype in a study by Rai et al. (2006) was
0.048) and Rai et al. (2006) (χ 2 − 9.664, P − 0.008) showed 8% and showed a 7.13-fold increase risk of DS birth in moth-
a significant association among cases and controls. The ers less than 31 years of age. Similarly, other reports also

Table 2. Genetic models showing odds ratio and chi-square values.

Model Odds ratio 95% CI Chi-square

Dominant (CT/TT versus CC) 1.23 1.13–1.34 22.313, P = 0.000

Codominant (TT/CT versus CT/CC) 1.17 1.10–1.25 22.533, P = 0.000
Recessive (TT versus CC/CT) 1.21 1.05–1.38 7.047, P = 0.008

James et al. (1999), USA 0.39 (0.16, 0.94)

Hobbs et al. (2000), USA 0.52 (0.32, 0.86)

O’Leary et al. (2002), Ireland 0.89 (0.42, 1.84)

Stuppia et al. (2002), Italy 1.43 (0.68, 2.98)

Chadeaux-Vekemans et al. (2002), France 1.04 (0.52, 2.08)

Boduroglu et al. (2004), Turkey 0.74 (0.42, 1.31)

Chango et al. (2005), France 0.81 (0.46, 1.41)

Da Silva et al. (2005), Brazil 7.38 (3.23, 18.83)

Acacio et al. (2005), Brazil 0.39 (0.20, 0.75)

Liang et al. (2006), China 1.03 (0.31, 3.09)

Scala et al. (2006), Italy 1.21 (0.70, 2.06)

Rai et al. (2006), India 0.62 (0.37, 1.03)

Wang et al. (2007), China 0.42 (0.22, 0.79)

Kohli et al. (2008), India 1.37 (0.73, 2.56)

Meguid et al. (2008), Egypt 0.44 (0.17, 1.12)

Wang et al. (2007), China 0.26 (0.11, 0.60)

Biselli et al. (2008), Brazil 0.63 (0.35, 1.14)

Martinez-Frias et al. (2008), Spain 1.06 (0.67, 1.68)

Santos et al. (2008), Brazil 1.18 (0.66, 2.10)

Cyril et al. (2009), India 0.08 (0.00, 1.42)

Kokotas et al. (2009), Denmark 1.07 (0.77, 1.49)

Coppede et al. (2009), Italy 0.66 (0.35, 1.25)

Brandalize et al. (2009), Brazil 0.84 (0.56, 1.25)

Pozzi et al. (2009), Danish 1.20 (0.65, 2.17)

Cretu et al. (2010), Rome 1.81 (0.62, 5.37)

Vrenekovic et al. (2010), Crotia 0.90 (0.53, 1.53)

Lio et al. (2010), China 0.49 (0.20, 1.17)

Sadiq 2011 (Jordan) 0.20 (0.06, 0.62)

Bozovic et al. (2011), Crotia 0.83 (0.51, 1.34)

Gharib et al. (2012), Egypt 0.38 (0.14, 1.03)

T a y e b 2 0 12 ( S au d i A r ab i a) 0.94 (0.33, 2.69)

Mohanty et al. (2012), India 0.34 (0.05, 1.53)

Zampeiri et al. (2012), Brazil 0.60 (0.35, 1.00)

Pandey et al. (2013), India 0.66 (0.26, 1.65)

Divyakolu et al. (2013), India 1.00 (0.23, 5.07)

Elsayed et al. (2014), Egypt 0.76 (0.27, 2.10)

Kaur and Kaur 2013 (India)our study 0.89 (0.44, 1.79)

combined [fixed] 0.82 (0.74, 0.90)

0.01 0.1 0.2 0.5 1 2 5 10 100

Figure 2. Forest plot (fixed effect) showing significant association between maternal
SNP MTHFR 677 C–T and birth of DS child (CC vs CT+TT).

Journal of Genetics
 MTHFR 677 C–T: a meta-analysis

James et al. (1999), USA 0.39 (0.16, 0.94)

Hobbs et al. (2000), USA 0.52 (0.32, 0.86)

O’Leary et al. (2002), Ireland 0.89 (0.42, 1.84)

Stuppia et al. (2002), Italy 1.43 (0.68, 2.98)

Chadeaux-Vekemans et al. (2002), France 1.04 (0.52, 2.08)

Boduroglu et al. (2004), Turkey 0.74 (0.42, 1.31)

Chango et al. (2005), France 0.81 (0.46, 1.41)

Da Silva et al. (2005), Brazil 7.38 (3.23, 18.83)

Acacio et al. (2005), Brazil 0.39 (0.20, 0.75)

Liang et al. (2006), China 1.03 (0.31, 3.09)

Scala et al. (2006), Italy 1.21 (0.70, 2.06)

Rai et al. (2006), India 0.62 (0.37, 1.03)

Wang et al. (2007), China 0.42 (0.22, 0.79)

Kohli et al. (2008), India 1.37 (0.73, 2.56)

Meguid et al. (2008), Egypt 0.44 (0.17, 1.12)

Wang et al. (2008), China 0.26 (0.11, 0.60)

Biselli et al. (2008), Brazil 0.63 (0.35, 1.14)

Martinez-Frias et al. (2008), Spain 1.06 (0.67, 1.68)

Santos et al. (2008), Brazil 1.18 (0.66, 2.10)

Cyril et al. (2009), India 0.08 (0.00, 1.42)

Kokotas et al. (2009), Denmark 1.07 (0.77, 1.49)

Coppede et al. (2009), Italy 0.66 (0.35, 1.25)

Brandalize et al. (2009), Brazil 0.84 (0.56, 1.25)

Pozzi et al. (2009), Danish 1.20 (0.65, 2.17)

Cretu et al. (2010), Rome 1.81 (0.62, 5.37)

Vrenekovic et al. (2010), Crotia 0.90 (0.53, 1.53)

Lio et al. (2010), China 0.49 (0.20, 1.17)

Sadiq 2011 (Jordan) 0.20 (0.06, 0.62)

Bozovic et al. (2011), Crotia 0.83 (0.51, 1.34)

Gharib et al. (2012), Egypt 0.38 (0.14, 1.03)

Tayeb 2012 (Saudi Arabia) 0.94 (0.33, 2.69)

Mohanty et al. (2012), India 0.34 (0.05, 1.53)

Zampeiri et al. (2012), Brazil 0.60 (0.35, 1.00)

Pandey et al. (2013), India 0.66 (0.26, 1.65)

Divyakolu et al. (2013), India 1.00 (0.23, 5.07)

Elsayed et al. (2014), Egypt 0.76 (0.27, 2.10)

Kaur and Kaur 2013 (India)our study 0.89 (0.44, 1.79)

combined [random] 0.78 (0.65, 0.92)

0.01 0.1 0.2 0.5 1 2 5 10 100

Figure 3. Forest plot (random effect) showing significant association between MTHFR 677 C–T and DS child (CC vs CT+TT).

suggested that homozygous mutant (TT) genotype is a risk
factor for DS and its presence increases the risk of DS by
1.4–5.0 folds (Hobbs et al. 2000; Wang et al. 2007, 2008;
Sadiq et al. 2011).
Some Indian and international reports failed to show any
significant association between cases and controls when
analysed individually. However, the genetic models were
best fit for this analysis, demonstrating the presence of
MTHFR 677 C–T polymorphism either in dominant or reces-
sive form, playing a significant role as one of the risk factor
for the birth of DS (table 2). The variation in frequency of
‘T’ allele may be due to ethnicity, lifestyle and availability of
dietary folate that minimizes the effect of MTHFR 677 C–T
polymorphism. Large-scale studies are needed to rule out
the exact mechanism behind the role of homocystein, folate,
vitamin B levels in combination with other polymorphisms
in folate pathway.
Literatures of various meta-analysis suggest significant
association between presence of maternal polymorphism and
birth of DS child. Wu et al. (2014) provided the result on
28 publications that included 2806 cases and 4597 control
mothers for MTHFR 677 C–T analysis. They also performed

Journal of Genetics
 Amandeep Kaur and Anupam Kaur

Rai et al. (2006), India 0.62 (0.37, 1.03)

Liang et al. (2006), China 1.03 (0.31, 3.09)

Wang et al. (2007), China 0.42 (0.22, 0.79)

Kohli et al. (2008), India 1.37 (0.73, 2.56)

Wang et al. (2008), China 0.26 (0.11, 0.60)

Cyril et al. (2009), India 0.08 (0.00, 1.42)

Lio et al. (2010), China 0.49 (0.20, 1.17)

Sadiq 2011 (Jordan) 0.20 (0.06, 0.62)

Tayeb 2012 (Saudi Arabia) 0.94 (0.33, 2.69)

Mohanty et al. (2012), India 0.34 (0.05, 1.53)

Pandey et al. (2013), India 0.66 (0.26, 1.65)

Divyakolu et al. (2013), India 1.00 (0.23, 5.07)

Kaur and Kaur 2013 (India) our study 0.02 (0.00, 0.17)

combined [random] 0.53 (0.36, 0.78)

0.01 0.1 0.2 0.5 1 2 5 10

Figure 4. Forest plot (random plot) showing significant association between MTHFR
677 C–T and DS child among Asians (CC vs CT+TT).

James et al. (1999), USA 0.39 (0.16, 0.94)

Hobbs et al. (2000), USA 0.52 (0.32, 0.86)

Da Silva et al. (2005), Brazil 0.68 (0.42, 1.09)

Acacio et al. (2005), Brazil 0.39 (0.20, 0.75)

Biselli et al. (2008), Brazil 0.63 (0.35, 1.14)

Santos et al. (2008), Brazil 1.18 (0.66, 2.10)

Brandalize et al. (2009), Brazil 0.84 (0.56, 1.25)

Zamoeiri et al. (2012), Brazil 0.60 (0.35, 1.00)

combined [fixed] 0.66 (0.55, 0.79)

0.1 0.2 0.5 1 2 5

Figure 5. Forest plot (fixed effect) showing significant association between

MTHFR 677 C–T and risk of DS child in American studies (CC vs Ct+TT).

subgroup analysis and revealed significant association. Other
analyses by Medica et al. (2009), Rai et al. (2014) and
Victorino et al. (2014) have suggested similar findings. Yang
et al. (2013) also reported significant association but did not
perform subgroup analysis. In our meta-analysis, a strong
association of MTHFR 677 C–T was observed and we have
also performed subgroup analysis and genetic models to esti-
mate the association. On the other hand, Zintazaras (2007)
did not observe significant involvement of MTHFR 677
C–T polymorphism. Similarly, Costa-Lima et al. (2013)
conducted meta-analysis on 20 publications and reported
moderate relationship for maternal MTHFR 677 C–T using
codominant model only. The difference in the results may be
due to difference in the number of publications included and
various approaches used to demonstrate the association.
Our study have few limitations: we analysed only sin-
gle polymorphism, unadjusted OR in the analysis was used,
no environmental factors were considered, foreign language
and unpublished reports were not included. However, advan-
tages were: there were more number of studies in this meta-
analysis (37 studies), overlapping studies were excluded and
subgroup analysis was also conducted.
In conclusion, our meta-analysis suggests that exhibit-
ing TT genotype significantly increases the risk for DS.
However, this risk varies across different ethnicities and DS
results from the interaction of genetic and environmental

Journal of Genetics
 MTHFR 677 C–T: a meta-analysis

O’leary et al. (2002), Ireland 0.89 (0.42, 1.84)

Stuppia et al. (2002), Italy 1.43 (0.68, 2.98)

Chadeaux-Vekemans et al. (2002), France 1.04 (0.52, 2.08)

Boduroglu et al. (2004), Turkey 0.74 (0.42, 1.31)

Chango et al. (2005), France 0.81 (0.46, 1.41)

Scala et al. (2006), Italy 1.21 (0.70, 2.06)

Martinez-Frias et al. (2008), Spain 1.06 (0.67, 1.68)

Kokotas et al. (2009), Denmark 1.07 (0.77, 1.49)

Coppede et al. (2009), Italy 0.66 (0.35, 1.25)

Pozzi et al. (2009), Danish 1.20 (0.65, 2.17)

Cretu et al. (2010), Rome 1.81 (0.62, 5.37)

Vrenekovic et al. (2010), Crotia 0.90 (0.53, 1.53)

Bozovic et al. (2011), Crotia 0.83 (0.51, 1.34)

combined [fixed] 0.98 (0.85, 1.13)

0.2 0.5 1 2 5 10

Figure 6. Forest plot (fixed effect) showing significant association between MTHFR
677 C–T and birth of DS child among European studies (CC versus CT+TT).

Figure 7. Standard error by log odds ratio for dominant model.

factors as well. Considering all such factors in future stu-
dies will lead to better understanding of association between
SNPs and birth of DS child.
Acknowledgements
We gratefully acknowledge the support from DST grant and fellow-
ship (SR/WOS-A/LS-348/2013) awarded to Amandeep Kaur and in
part (UGC) grant no. F.37190/2009 (SR) awarded to Anupam Kaur.
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Received 23 June 2015, in revised form 23 September 2015; accepted 24 November 2015
Unedited version published online: 30 November 2015
Final version published online: 4 July 2016

Journal of Genetics