hCG Stimulation Test Research Articles

Diagnostic utility of testosterone priming prior to dynamic tests to differentiate constitutional delay in puberty from isolated hypogonadotropic hypogonadism in boys

BackgroundDifferentiation between isolated hypogonadotropic hypogonadism (IHH) and constitutional delay in puberty (CDP) throughout adolescence can be challenging for doctors. This study examines the withdrawal effects of short-term, low-dose testosterone treatment (testosterone priming) on the ability of dynamic testing to distinguish between CDP and IHH based on activation of the hypothalamo-pituitary–testicular axis.MethodsA case–control study included 20 boys with delayed puberty (group A) and 20 patients with IHH (group B). Both groups underwent Triptorelin and human chorionic gonadotropin (hCG) stimulation tests before and 2 months after testosterone injections (100 mg) intramuscularly every 4 weekly for 3 months.ResultsThe triptorelin-stimulated 4-h LH with a cutoff of 2.4 IU/L and the hCG-stimulated testosterone with a cutoff of 1.160 ng/mL had sensitivities of 65% each, and specificities of 90% and 95%, respectively, to diagnose CDP. After testosterone withdrawal, the cut-off values for 4-h LH were 8.850 IU/L and 3.190 ng/mL for hCG-stimulated testosterone. Basal inhibin B > 88.25 pg/ml was found to be a differentiating factor in diagnosing CDP after testosterone withdrawal.Conclusionsfollowing the withdrawal of testosterone therapy, Inhibin B levels or 4-h stimulated LH are the most effective discriminant assays to distinguish CDP from IHH.

7709 Ovotesticular Difference of Sex Development: Prognostic Evaluation, Sex Assignment, and Ethics

Abstract Disclosure: X. Xu: None. Y. Lin: None. B. Shivanna: None. A. Lee: None. J.C. Hakim: None. D.G. Mann: None. L.M. Noll: None. P. Georgiadis: None. S.K. Gunn: None. L.P. Karaviti: None. Background: Our case provides the identification and management of a newborn baby with ovotesticular syndrome, which was formerly known as true hermaphroditism. The term was classically derived from Greek mythology in which the deity 'Hermaphroditus', merging with the nymph Salamis, embodied both male and female attributes. The term 'true hermaphroditism' is now avoided due to its stigmatizing connotations. Ovotesticular difference of sex development (DSD) is an exceedingly rare condition, occurring in fewer than 1 in 20,000 births. This condition involves the coexistence of functional ovarian and testicular tissue within one individual, presenting a challenge in sex assignment due to unpredictable gender development. Clinical Case: This is a single case of the presence of ovarian and testicular differentiation on one side and a transitional zone of mixed pattern. Prenatal genetic testing consistent 46,XX karyotype. Initial ultrasound at the outside hospital revealed a uterus and right testicle. The baby exhibited Prader stage 4 genitalia, with a palpable gonad in the right labioscrotal area and the left gonad not palpable. Prophylactic hydrocortisone was started due to concerns regarding NR5A1/SF1 mutation. Further evaluations, including genetic tests, hormonal assessments, urinalysis and kidney ultrasound for the WT1 mutation, and scrotal and pelvic ultrasounds, were conducted. The high-dose ACTH stimulation test ruled out adrenal insufficiency. The testosterone level was in the male range, and the HCG stimulation test further confirmed functioning Leydig cells. The postnatal karyotype was 46,XX, and chromosome microarray analysis showed no abnormalities. Our approach to this case was multidisciplinary, including our endocrine experts, urologist, gynecologist, ethicist, and psychologist. We discussed the fluidity of sex assignment and addressed the degree of virilization, nature of the gonadal tissue, and emphasized the necessity of regular clinical follow-up. Our main concern was to educate the parents and protect the choices of the child. In this case, the child assumed a male sex assignment, as a result of the decision-making process between our team and the parents. In this context we did emphasize the fluidity of sex assignment. Clinical Lesson: Long-term outcomes for ovotesticular DSD remain understudied. Existing reports highlight varying rates of gender dysphoria, sexual function, and psychological well-being. Our approach to managing ovotesticular DSD involved a framework emphasizing ethical considerations and parental involvement. We advocated for and practiced a shared decision-making model involving healthcare providers, parents, and ultimately the patient. Presentation: 6/3/2024

Phenotypic and molecular characterizations of 46,XY disorders of sex development due to variants of NR5A1 gene

The clinical and molecular genetic characteristics of 46,XY disorders of sex development caused by NR5A1 gene variants in 15 cases were analyzed to improve the understanding of this disease. The clinical data of children with NR5A1 gene variants diagnosed at the Children's Hospital Affiliated to Zhengzhou University from March 2016 to December 2021 were retrospectively analyzed. Whole exome sequencing was performed to confirm the candidate sites, and Sanger sequencing was performed for validation. The patients were treated and followed up according to their disease characteristics. At the initial diagnosis, 5 of the 15 cases were raised as females and 10 as males. The gonadal tissue was testis without residual Müllerian or ooticular structure, and all had various degrees of genital abnormalities. The average EMS masculinity score was 4.8 (1 ~ 9), including micropenis (100.0%), hypospadias (86.7%), unfused scrotum (46.7%), and abnormal testicular position (60.0%), in which the hypospadias was Ⅱ°~ Ⅳ°. There was no skin pigmentation in 5 patients with growth retardation. Chromosomal karyotypes were 46,XY, adrenocorticotropin and cortisol levels were normal, electrolyte levels were normal, HCG stimulation test in 5 cases had normal response, 9 cases had low response. Anti-Müllerian hormone and statin B had decreased abnormally with age. A total of 14 NR5A1 variants were detected in the 15 children, most of which occurred in exon 4, of which 9 variant loci were not included in the HGMD database as of December 2022. The clinical phenotype of 46,XY abnormal sexual development caused by NR5A1 gene variants is extensive, with the external genitals showing varying degrees of insufficient masculinization. Adrenal involvement is rare.

Clinical characteristics and surgical treatment of children with 45, X/46, XY differences of sex development

This study retrospectively analyzes the clinical data of 18 children with 45,X/46,XY differences of sex development (DSD), summarizes their clinical features and explores gonadal and Müllerian duct remnants surgical treatment methods. The clinical data of 18 children with karyotype 45,X/46,XY diagnosed in the Department of Urology of Hunan Children's Hospital from March 2011 to October 2021 were collected. All children underwent HCG stimulation testing, laparoscopic exploration, urethroscopy and bilateral gonadal biopsy. After DSD multidisciplinary team (MDT) meeting, some children underwent gonadectomy and genitalia reconstructive surgeries. The median age at first diagnosis was 1 year and 4 months (range: 10 months ∼ 16 years and 3 months). 5 children presented with female gender; they all maintained their gender assignment. The external masculinisation score (EMS) of patients raised as female was 1 (0∼3) [median (range)]. 13 children presented with male gender, 10 maintained a male gender, 3 were assigned a neutral gender. The EMS of the children raised as male was 5 (2-8) [median (range)], the EMS of the children raised as neutral gender was 4 (3.5-9.5) [median (range)]. The HCG stimulation test was positive in 11 cases, partially positive in 2 case, and negative in 5 cases. There was no relationship between the percentage of chimerism (45X ratio) and the appearance and severity of genital abnormalities. (t=-1.08, P=0.298). There was 1 case of complete gonadal dysgenesis (CGD), 10 cases of mixed gonadal dysgenesis (MGD), 5 cases of partial gonadal dysgenesis (PGD), 1 case of bilateral normal testes and 1 case of ovotesticular DSD (split-lateral type). No gonadal specimen showed germ cell tumor changes. Five cases selected to maintain the female gender, among which 3 cases underwent bilateral gonadectomy and genitalia reconstructive surgeries. Among the 10 children who chose to maintain the male gender, unilateral streak gonadectomy was performed in 4 (57.1%) with MGD, unilateral dysgenetic orchiectomy in 1 (25%) with PGD, and right ovariectomy in 1 with OTDSD. Nine of them underwent genitalia reconstructive surgeries. Four of them preserved their uterus and vagina did not have any complications during the follow-up period. Hypospadias combined with cryptorchidism and residual Müllerian duct structures is the most common phenotype of children with 45, X/46, XY DSD. Mixed gonadal dysgenesis (MGD) is the most common gonadal type. Gender assignment should be carefully selected after a thorough evaluation, while genitalia reconstructive surgery can be considered in selected patients. In children who choose the male gender, the Müllerian duct can be preserved.

Value of the human chorionic gonadotropin stimulation test in the diagnosis of disorder of sexual development in children

To investigate the value of the human chorionic gonadotropin (hCG) stimulation test in the diagnosis of disorder of sexual development (DSD) in children. A retrospective analysis was conducted on 132 children with DSD. According to the karyotype, they were divided into three groups: 46,XX group (n=10), 46,XY group (n=87), and sex chromosome abnormality group (n=35). The above groups were compared in terms of sex hormone levels before and after hCG stimulation test, and the morphological manifestation of the impact of testicular tissue on the results of the hCG stimulation test was analyzed. There was no significant difference in the multiple increase of testosterone after stimulation among the three groups (P>0.05). In the 46,XY group, the children with 5α-reductase type 2 deficiency had a testosterone-to-dihydrotestosterone ratio higher than that of the 46,XY DSD children with other causes. Morphological analysis showed that DSD children with testicular tissue demonstrated a significantly higher multiple increase in testosterone after stimulation compared to children without testicular tissue (P<0.05). The hCG stimulation test has an important value in assessing the presence and function of testicular interstitial cells in children with different types of DSD, and it is recommended to perform the hCG stimulation test for DSD children with unclear gonadal type.

MP18-12 THE OUTCOME OF HORMONAL THERAPY IN PREPUBERTAL CHILDREN WITH MICROPENIS ACCORDING TO HCG STIMULATION TEST: A RETROSPECTIVE SINGLE CENTER COHORT STUDY

You have accessJournal of UrologyCME1 Apr 2023MP18-12 THE OUTCOME OF HORMONAL THERAPY IN PREPUBERTAL CHILDREN WITH MICROPENIS ACCORDING TO HCG STIMULATION TEST: A RETROSPECTIVE SINGLE CENTER COHORT STUDY Jae Min Chung and Sang Don Lee Yangsan Jae Min ChungJae Min Chung More articles by this author and Sang Don Lee YangsanSang Don Lee Yangsan More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003238.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: We report penile parameters and testicular volumes responses to testosterone enanthate (TE) therapy for micropenis according to hcg stimulation test. METHODS: A total of 63 boys with a micropenis (less than -2.0 SD) 5 to 13 years old, without any chromosomal anomalies and other genital disorders, were examined retrospectively. BMI with body weight and body height, penile parameters (baseline and stretched penile length (BPL, SPL), penile circumference (PC)), and testicular volumes were measured. Before hormonal therapy, hcg stimulation test was checked. TE was given 4 times every 3 weeks at a dosage of 25 mg intramuscularly, and PL and TV were measured at least 4 weeks after the final injection. RESULTS: The mean age before TE therapy was 9.9±1.9 years (5.6-13.2 years). (Table 1) In hcg stimulation test, 61.9% of patients showed normal testosterone response. (Table 2) All penile parameters (SPL, PC, and BPL) were improved after TE therapy except testicular volumes. The testicular volumes also improved 6 months later. There was no correlation between hcg stimulation response and improvement of penile parameters and testicular volumes. (Table 3) CONCLUSIONS: Our results suggest that administration of 25 mg TE is effective for micropenis in prepubertal boys. The penile and testicular responsiveness to TE therapy is independent of the hcg stimulation response. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e227 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jae Min Chung More articles by this author Sang Don Lee Yangsan More articles by this author Expand All Advertisement PDF downloadLoading ...

In Children with 46, XY DSD; HCG Testing is not always the Best Answer for Testicular Function Assessment

Hormonal levels are the hallmark for the assessment of testicular function in XY DSD (Disorders of sex development). Traditionally, it has relied on testosterone level increment after hCG (human Chorionic Gonadotropin) stimulation testing. More recently role of Sertoli cell hormones is more emphasized. Objectives: Evaluating the role of serum anti-mullerian hormone and inhibin B on function of the pre-pubertal testis without the need for hCG stimulation test. Method: The study was conducted in the Endocrinology Clinic in Alexandria University Children’s Hospital. All patients who present with XY DSD were tested for Testosterone (T), Dihydrotestosterone (DHT), Follicle Stimulating Hormone (FSH), Luteinizing Hormone (LH), Anti-Mullerian Hormone (AMH), inhibin B. All cases had hCG stimulation test. Results: The hCG stimulation test was done for 32 cases. There was significant positive correlation between serum testosterone levels before and after hCG stimulation test (p &lt;0.001). Similarly, significant correlation was identified between basal AMH and testosterone increment after hCG stimulation (p &lt;0.001) and between basal levels of AMH and inhibin (MCp= 0.025). Conclusion: Single measurement of basal AMH and/or inhibin B can detect the presence and function of testes by a reliable non-invasive way. Basal AMH assessment is an important tool to distinguish between cryptorchidism and anorchia. hCG test is needed in the work-up of patients with inconclusive results.

Abstract 82: Rare case of 46XY OVO testicular DSD

A 5-month-old term baby was referred for ambiguous genitalia. Examination showed a right descended gonad, and an empty scrotum and an inguinal swelling on the left, no phallus and single external urogenital opening in the perinium with an EMS score of 2.5. Possibilities considered included ovo-testicular DSD, PAIS and testosterone biosynthetic defects. Beta HCG Stimulation test ruled out synthetic defects and with good testosterone response. USG abdomen/scrotum showed left inguinal undescended testes. Post Acton prolongatum stimulated cortisol was 43 mcg/dL and the Karyotyping was 46 XY. Diagnostic laparoscopy showed a left sided ovotestes with fallopian tube-like structure attached; and biopsy of gonad confirmed both ovarian and testicular tissue. Hence diagnosis of 46 XY Ovo testicular DSD was made; one which accounts for 3-10% of total DSD. We report this instance where absence of phallic structure is a rare presentation among cases of 46XY Ovo testicular DSD.

COMPARISON OF SINGLE DOSE AND MULTI-DOSE hCG STIMULATION TESTS

Objective: The human chorionic gonadotropin (hCG) stimulation test is widely used to assess testicular steroidogenesis. This test evaluates Leydig cell function and helps to evaluate testosterone synthesis in testicular enzyme defects, hypogonadism, 46,XY sexual development disorders (DSD), and micropenis. This study will compare testosterone responses to a single dose of 5000 IU/m2 and three consecutive days of 1500 IU/m2 hCG regimens. Materials and Methods: The study evaluated 18 patients who were admitted with micropenis, hypospadias, or undescended testis (Group 1) and 18 patients with a molecular diagnosis of androgen receptor insensitivity (56%) or 5α reductase deficiency (44%) (Group 2). The median (interquartile range; IQR) age of the patients were 1.4 (0.8-4.2) years for Group 1 and 0.7 (0.3-0.8) years for Group 2. Baseline testosterone levels were checked and after a single dose of hCG 5000 IU/m2 injection into the first group, testosterone levels were observed on day one and day four. In the second group, after the injection of hCG 1500 IU/m2 for three days, testosterone levels were checked on the fourth day. Results: There was no significant difference in height, weight, BMI SDS, and baseline testosterone levels between groups. After hCG, stimulation testosterone responses did not vary among the groups. Testosterone levels were increased 40-fold and 40.1- fold on day four compared to the baseline in Group 1 and Group 2. In Group 1, testosterone response was significantly higher on day four compared to day one (p=0.001). Conclusions: The hCG tests performed with a single dose or multidoses showed that there was no difference between testosterone responses and these two tests were applicable the 5000 IU/m2 hCG test requires fewer injections and is easy to administer, this test may be preferred to an evaluation of the Leydig cell function. For an adequate testosterone response, the researchers suggest measuring testosterone levels on the fourth day after the single dose of 5000 IU/m2 .

Selection of Hormonal Reference Values for Undescended Testicle Case in 8-Year-Old Boy with Abnormal Chromosome

Establishing the diagnosis of undescended testicles requires appropriate hormonal laboratory reference values basedon age and gender. An 8-year-old boy with an undescended testicle, mental retardation, and stunting had a blood test thatwas carried out at the Clinical Pathology Laboratory, dr. Cipto Mangunkusumo (RSCM) Hospital on February 6, 2020, withtestosterone levels of 0.69 nmol/L (N male: 4.94-32.01 nmol/L) indicating decreased testosterone levels. The patient wasconsulted from urological surgery to pediatric endocrinology to determine the presence or rudiment of the patient'stesticles. Using the reference range of testosterone values assists clinicians in determining the diagnosis, monitoringtherapy, and prognosis of a disease. There are some testosterone reference values, which are currently available, includingCanadian Laboratory Initiative on Pediatric Reference Intervals Database (CALIPER) and the Tanner stage reference value.Later is more applicable because it is based on chronological age and secondary sexual development in assessing pubertydevelopment. A case of an 8-year-old boy with a clinical diagnosis of an undescended testicle, the laboratory test resultsshowed normal-low testosterone levels using the CALIPER and Tanner stage ranges according to the patient's age. Noincrease of testosterone levels after the second HCG stimulation test might be due to differences in the HCG administrationprotocol; therefore, the diagnosis of anorchia had not been established, and chromosome abnormalities of 46 XY, +6 Mar,17 dmin on chromosome analysis suggested the suspected syndrome. These findings were consistent with the suspicion ofprimary hypogonadism in children with suspected syndrome caused by bilateral cryptorchidism with a suspectedseminiferous tubular defect.

Whole exome sequencing and functional characterization increase diagnostic yield in siblings with a 46, XY difference of sexual development (DSD)

Pathogenic biallelic variants in HSD17B3 result in 17β-hydroxysteroid dehydrogenase 3 (17β-HSD3) deficiency, variable disruption of testosterone production, and phenotypic diversity among 46, XY individuals with differences of sexual development (DSDs). We performed quad whole exome sequencing (WES) on two male siblings with microphallus, perineal hypospadias, and bifid scrotum and their unaffected parents. Both male siblings were compound heterozygous for a rare pathogenic HSD17B3 variant (c.239 G > A, p.R80Q) previously identified among individuals with 17β-HSD3 deficiency and a HSD17B3 variant (c.641A > G, p.E214 G) of uncertain significance. Following WES, the siblings underwent hCG stimulation testing with measurement of testosterone, androstenedione, and dihydrotestosterone which was non-diagnostic. To confirm pathogenicity of the HSD17B3 variants, we performed transient transfection of HEK-293 cells and measured conversion of radiolabeled androstenedione to testosterone. Both HSD17B3 variants decreased conversion of radiolabeled androstenedione to testosterone. As pathogenic HSD17B3 variants are rare causes of 46, XY DSD and hCG stimulation testing may not be diagnostic for 17β-HSD3 deficiency, WES in 46, XY individuals with DSDs can increase diagnostic yield and identify genomic variants for functional characterization of disruption of testosterone production.

FSH Stimulated Inhibin B in Disorders of Puberty

Abstract Background: Predicting puberty is a clinical challenge. Available tests include basal gonadotropins, GnRH and GnRH analogue stimulation test, hCG stimulation test and basal inhibin B(INHB). Unlike GnRH and GnRH analogue stimulated LH, no study has investigated for possibility of rapidly releasable pool of inhibin B from gonads so far. Therefore, in quest of a better diagnostic test present study was undertaken to explore stimulability of inhibin B and if found stimulable, potential role of FSH stimulated inhibin B(FSH-INHB) as marker of entry into puberty. Methods: A total of forty-two subjects fulfilling eligibility criteria were enrolled into this prospective interventional study. Study cohort was divided into Cohort A (Healthy children in puberty; n=26) and Cohort B (Patients of hypogonadotropic hypogonadism; n=16). All participants were subjected to FSH stimulation test and GnRHa stimulation test as per study protocol. Data was analysed for male and female separately. Results: Mean delta change between INHB and FSH-INHB in cohort A (Male; n=18) was 188.8 pg/ml (p value-0.002) while in cohort B(Male; n=8) was 16.64 pg/ml (p value-0.076). Mean delta change in cohort A(Female; n=8) was 1065 pg/ml (p value- 0.023) while in cohort B (Female; n=8) was 9.8 pg/ml (p value-0.128). On ROC analysis, INHB of 68.88 pg/ml in male had 94.4 % sensitivity and 87.5% specificity while 51.47 pg/ml in female had 75% sensitivity and 100% specificity for entry into puberty. Cut off for FSH-INHB were 116.14 pg/ml and 116.50 pg/ml for male and female respectively (100% sensitivity/100% specificity). Conclusion: Inhibin B was stimulable in both male and female after entry into puberty, highlighting the presence of rapidly releasable pool in ovaries and testes. FSH stimulated inhibin B may emerge as promising tool for entry into puberty.

A Novel Mutation of the AR Androgen Receptor Gene

Abstract Androgen insensitivity syndrome (AIS), formerly known as testicular feminization, is an X-linked recessive condition resulting in a failure of normal masculinization of the external genitalia in chromosomally male individuals. The basic etiology of androgen insensitivity syndrome is a loss-of-function mutation in the androgen receptor (AR) gene. Loss of AR function means that, despite normal levels of androgen synthesis, the typical postreceptor events that mediate the effects of hormones on tissues do not occur. This results in the phenotype of prenatal undervirilization of external genitalia, absence of pubic and axillary hair, lack of acne, and absence of voice changes at puberty We present This baby reffered at age of 2 months from pediatric surgery as a case of bilateral inguinal hernia and chromosomes 46xy. Phenotypically female no male structures no phallus and single opening and visible labia, both test are in the inguinal canals. HCG stimulation test shows: Testosterone: the level at (0) time: 0.8 nmol/l then 3 days: 31.4 nmol/l. DHT dihydrotetostrerone: the level at (0) time: 13 NG/L then 3 days: 485 The baby was given 3 doses of Testosterone injections 150mg but no response at the genetalia. Radiological investigations shows ultrasound both tests at the inguinal canals and no uterus Also MRI of pelvis shows absence of uterus and both test at the inguinal canals Molecular genetics analysis for Androgen receptor gene: Exon 7 c.2512 G &amp;gt;A hem. P.Glu838lys missense, novel VUS,likely pathogenic. The segregations analysis test in the process. Her we present a novel mutation of the AR gene not reported yet in literature.

Changes in circulating concentrations of testosterone and estrone sulfate after human chorionic gonadotropin administration and subsequent to castration of 2-year-old stallions

Reproductive steroids testosterone (T) and estrone sulfate (E1S) are used as diagnostic markers for cryptorchidism in horses. The human chorionic gonadotropin (hCG) stimulation test is used as a diagnostic aid because administration of this hormone results in greater incremental differences in circulating steroid concentrations. Thoughts regarding optimal sampling times following hCG administration, however, are inconsistent. Additionally, determination of half-life of these steroids is important in postsurgical samples to confirm complete removal of testicular tissue. Objectives of this study, therefore, were to determine optimal sampling periods for peak T and E1S after hCG administration and half-life of these steroids after castration. Eight pony stallions were randomly assigned to control or treatment groups (5000 IU hCG). Blood samples were collected following hCG administration. Subsequently, stallions were castrated and blood samples were collected post-castration. The T concentrations were greatest at 72 h after hCG and were greater (P < 0.02) in samples from hCG-treated than control animals: 9,903.4 ± 384 and 784.0 ± 192 pg/mL, respectively (Mean ± SEM). The T concentrations were also greater at 1, 12, 24, 48 and 96 h. The E1S concentrations did not change after administration of hCG. The T response to hCG administration was biphasic with a maximal response between 48–96 h after administration. Half-lives of T and E1S were 1.1 and 0.7 h, respectively, and concentration of T and E1S was similar to that of geldings at 24 h post-castration, which, therefore, should be considered an optimal time to ensure complete castration has occurred.

Molecular Characteristics of Sequence Variants in GATA4 in Patients with 46,XY Disorders of Sex Development without Cardiac Defects

A GATA4 haploinsufficiency has been well described in patients with congenital heart defects (CHDs), whilst only a few studies have reported mutations related to a 46,XY disorder of sex development (DSD) phenotype. This study investigated the clinical phenotypes and molecular characteristics of two 46,XY DSD patients harboring GATA4 variants. Mutation analysis was performed using a targeted gene panel or whole-exome sequencing. The transactivation activity of each variant protein was examined by in vitro luciferase reporter assay using the AMH and SRY promoters. Subject 1 presented with a micropenis and hypospadias. Subject 2 showed complete female external genitalia with a 46,XY karyotype. Both patients were responsive to hCG stimulation tests and did not manifest CHD. A novel heterozygous variant, c.643A>G (p.R215G), in GATA4 was identified in Subject 1, whereas Subject 2 harbored a previously reported variant, c.1220C>A (p.P407Q), in GATA4 and a previously known pathogenic mutation, i.e., c.226C>T (p.Q76*) in the AR gene. The reporter assays using the SRY and AMH promoters revealed decreased transcriptional activity of both p.P407Q and p.R215G. However, the GATA4 p.P407Q variant was classified as likely benign. In conclusion, it is essential to integrate clinical features and endocrine findings when interpreting sequence variants.

Distinguishing between hidden testes and anorchia: the role of endocrine evaluation in infancy and childhood

Non-palpable testes remain a diagnostic challenge, often involving exploratory laparoscopy. We evaluated the diagnostic value of a wide range of reproductive hormones in order to distinguish between bilateral cryptorchidism and bilateral anorchia. In this retrospective study, we identified and included 36 boys with non-palpable testes (20 with cryptorchidism, 3 with congenital hypogonadotropic hypogonadism (CHH), and 13 with anorchia) at first examination during childhood. Information on karyotype, phenotype, surgical results from laparoscopy, and biochemistry was retrieved from patient files. We compared serum concentrations of AMH, inhibin B, FSH, LH, testosterone, estradiol, and hCG stimulation testing in cryptorchid and anorchid boys to serum concentrations in a large, age-matched control group. Receiver-operating characteristic curves were used to determine the cut-off values of each reproductive hormone as a predictor of the presence of functional testicular tissue. Concentrations of AMH in 0-1 year olds: ≥155 pmol/L and >1-15 year olds: ≥19 pmol/L, inhibin B (≥22 pg/mL and ≥4 pg/mL), FSH (≤28.9 IU/L and ≤20.3 IU/L) and hCG-induced testosterone (>1-15 year olds: ≥2 nmol/L) were significantly sensitive and specific markers in predicting the presence of functional testicular tissue in boys with non-palpable testes. In infancy, anorchid infants had significantly elevated gonadotropin levels, while CHH had low levels. Our findings suggest that laparoscopy may not be necessary in all boys with non-palpable testes if reproductive hormones unequivocally confirm the presence of functional testicular tissue. However, proving the absence may still be a diagnostic challenge.

SUN-159 17-beta Hydroxysteroid Dehydrogenase 3 Deficiency in 1 Month Old Infant

Background: 17-beta hydroxysteroid dehydrogenase 3 deficiency is a rare autosomal recessive disorder caused by mutations in HSD17B3 encoding the enzyme which converts androstenedione to testosterone. It is characterized in 46, XY males by incomplete virilization, including micropenis and hypospadias. Clinical Case: We report a 1 month old infant who presented with ambiguous genitalia. Prenatal non-invasive screening showed a Y chromosome, however, fetal ultrasound revealed female genitalia. The infant was born with micropenis (~1.4 cm in length) and proximal hypospadius, with enlarged labioscrotal folds and palpable gonads bilaterally. The urethral meatus had been relocated surgically to the glans. There was an apparent vaginal orifice with a normally positioned anus. Initial testing revealed a normal serum 17-OHP (90 ng/dl, n<200 ng/dl) and normal electrolytes. Abdominal US showed normal kidneys. Pelvic US demonstrated no Mullerian structures; gonads thought to be testes were identified in the labioscrotal folds. At 3 months of age, the infant underwent a 3 day HCG stimulation testing with a borderline testosterone response to 132 ng/dl, androstenedione 78 ng/dl and DHT 25 ng/dl. T/A ratio was unremarkable at 1.7 (n>0.8). Thus, hormonal testing was unsupportive of a testicular steroidogenic enzyme deficiency or androgen insensitivity syndrome. Karyotype was confirmed as 46, XY with microarray evidence of multiple regions of homozygosity. Genotyping with a 46, XY DSD panel (GeneDx) revealed a homozygous pathogenic variant c.608 C>T (p.A203V) in exon 9 of the HSD17B3 gene, consistent with a diagnosis of autosomal recessive 17-beta hydroxysteroid dehydrogenase 3 deficiency. Parents are of Arabic descent and are consanguineous. An older brother was also born with ambiguous genital and was later found to be homozygous for the same mutation. This mutation has been identified in the homozygous state in several unrelated affected patients. Previously published functional studies demonstrated loss of enzymatic activity with this missense mutation (1). Male gender was assigned at birth, and parents wish to continue male sex of rearing. Conclusion: Molecular genetic analysis utilizing a commercially available candidate gene panel for 46, XY disorders of sex development diagnosed 17 beta-HSD3 deficiency in this case where hormonal testing was not informative. Early and correct diagnosis is key in planning medical treatment to facilitate pubertal development.

SUN-074 Loss-Of-Function Mutations in GATA4 in Patients with 46,XY Disorders of Sex Development Without Cardiac Defects

Background: Disorders of sex development (DSD) encompass a wide range of conditions associated with numerous causative genes. In about 50-60% of 46,XY DSD individuals, the underlying molecular cause remains uncertain. GATA4 haploinsufficiency has been described in patients with congenital heart defects (CHD), while only a few studies reported mutations related to 46,XY DSD phenotype. This study investigated clinical phenotypes and molecular characteristics of two 46,XY DSD patients with GATA4 mutations. Methods: Mutation analysis was performed in patients with 46,XY DSD by whole exome sequencing (WES) using Illumina NextSeq platform. Clinical and endocrine characteristics were reviewed retrospectively. GATA4 variants identified by WES were verified by Sanger sequencing. Functional activity of GATA4 variants was tested by luciferase reporter assay on the SRY and AMH promoter using two different cell systems including HEK293 and NCI-H295R. Results: Subject 1 presented with micropenis and hypospadias at the age of 5 months. Karyotype was 46,XY. Mullerian duct remnants were not found in pelvic ultrasound. The patient underwent urethroplasty at the age of 10 months and was reared as a male. Subject 2 with complete female external genitalia was referred to our hospital because of 46,XY karyotype on G-scanning. The patient underwent laparoscopic orchiectomy at the age of 1.8 years and was assigned as a female. Both patients were responsive to hCG stimulation tests and did not have CHD. Subject 1 harbored a novel heterozygous variant of c.643A>G (p.R215G)] in GATA4, whereas a previously reported variant of c.1220C>A (p.P407Q) was identified in Subject 2. In vitro luciferase reporter assays using SRY and AMH promoter revealed decreased transcriptional activity of both p.P407Q and p.R215G. Conclusions: This study expanded phenotypic spectrum of mutations in GATA4 in patients with 46,XY DSD without CHD. GATA4 mutations in patients with 46,XY DSD may not be associated with CHD. Possible explanations for phenotypical variability comprise incomplete penetrance, variable expressivity, and oligogenic mechanisms.

Serum Anti-Müllerian Hormone in the Prediction of Response to hCG Stimulation in Children With DSD

The relationship between serum anti-Müllerian hormone (AMH) and the testosterone response to human chorionic gonadotropin (hCG) stimulation test is unclear. Children who had hCG stimulation tests in one tertiary centre from 2001 to 2018 were included (n = 138). Serum testosterone was measured before (day 1 [D1]) and after 3 days (D4) of hCG stimulation. Sixty-one of these children also had prolonged hCG stimulation for 2 more weeks and serum testosterone measured after 21 days (D22). All children had a serum AMH measured on D1. Of the 138 children, D4 testosterone was normal in 104 (75%). AMH was low in 24/138 (17%) children, and 16 (67%) of these had a low D4 testosterone. Median AMH in those who had a normal vs low D4 testosterone was 850 pmol/L (24, 2280) and 54 pmol/L (0.4, 1664), respectively (P < 0.0001). An AMH > 5th centile was associated with a low D4 testosterone in 18/118 (13%; P < 0.0001). Of the 61 children who had prolonged hCG stimulation, D22 testosterone was normal in 39 (64%). AMH was low in 10/61(16%) children and 9 (90%) of these had a low D22 testosterone. Median AMH in children who responded and did not respond by D22 was 639 pmol/L (107, 2280) and 261 pmol/L (15, 1034) (P < 0.0001). A normal AMH may provide valuable information on overall testicular function. However, a low AMH does not necessarily predict a suboptimal testosterone response to hCG stimulation.

Disorders of Sexual Development in Proximal Hypospadias in Children

Background: Hypospadias is seen in around one in 300 live births, making it the most prevalent congenital penile abnormality. Objective: to evaluate of the incidence and diagnosis of disorders of sexual development in proximal hypospadias. Patients and Methods: This prospective study was conducted on 44 children attending the Pediatric Surgery Department, Al-Azhar University Hospitals during the period from Dec 2018 to Nov 2019. Detailed history taking; including complete physical examination, examination with special focus on external genitalia and gonads; routine and specific laboratory investigation as genetic karyotyping, serum testosterone (T), dihydrotestosterone, dehydroandrostenedione,17 OH progesterone, HCG stimulation test, serum levels of luteinizing hormone (LH) and follicle-stimulating hormone (FSH), Adrenal hormones “serum cortisol & plasma adrenocorticotropic hormone (ACTH) “to exclude congenital adrenal hyperplasia. Ultrasound abdomen and pelvis was routinely done to assess the internal genital organs uterus, fallopian tubes and gonads testis, ovaries . Results: there are (5) patients diagnosed as DSD: Three cases (6.8 %) have Karyotyping (46, XX), diagnosed as CAH. One case (2.2%) has Karyotyping (46XY (70%)/45X (30) sex chromosome DSD (45, X/46, XY PGD) or “mixed gonadal dysgenesis”. One case (2.2%) has Karyotyping (46, xy), diagnosed as complete Androgen insensitivity syndrome. Conclusion: Patients presenting with proximal hypospadias and one or more of the co-existing anomalies of micro penis, undescended/impalpable testes, and penoscrotal transposition/bifid scrotum should warrant DSD evaluation. Presence of bilaterally descended testes in scrotum does not preclude the possibility of DSD.