Primary ovarian insufficiency, also known as premature ovarian failure, is characterized by loss of function of the ovaries before the age 40. Observational evidence of familial associations suggests a genetic basis for ovarian insufficiency. Despite extensive research, specific genetic causes have not been identified. A nuclear receptor, NR5A1, also called Ad4 binding protein or steroidogenic factor 1, is a protein that regulates the transcription of genes involved in the hypothalamic―pituitary―steroidogenic axis that play a key role in sexual development and reproduction. NR5A1 I is expressed in multiple ovarian cell types during fetal development, postnatal and prepubertal growth, and at maturity. In this study, the investigators tested the hypothesis that mutations in NR5A1 are associated with disorders of ovarian development and function. NR5A1 was sequenced in affected study subjects who were members of 4 families with a history of 46,XY disorders of sex development and 46,XX ovarian insufficiency and 25 women with 46,XX sporadic ovarian insufficiency. A panel of 1465 subjects of various ancestral origins who did not carry NRSA1 mutations served as controls. There was no clinical evidence of adrenal insufficiency among any of the affected patients. Mutations in the NR5A1 gene were found among members of each of the 4 families and 2 of the 25 subjects with isolated ovarian insufficiency. Analysis of the NRSA1 gene revealed a series of in-frame, frame-shift and missense mutations. Testing the effect of each of the NRSA1 mutations on protein function revealed a severe quantitative impairment of NRSA1 transactivational activity. A range of ovarian anomalies, including 46,XY gonadal dysgenesis and 46,XX primary ovarian insufficiency, were associated with the mutations. None of these mutations were found in any of the unaffected control subjects. These findings indicate that mutations in NRSA1 are associated with a number of ovarian anomalies characterized by loss of ovarian reproductive capacity.
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