Androgen Insensitivity Research Articles

Clinicopathological Study of Testicular Lesions in a Tertiary Care Centre of Dakshina Kannada, India

Introduction: Testicular biopsies are performed for both diagnostic and therapeutic purposes. Diagnostic testicular biopsies are usually performed as a part of a male infertility work-up. Therapeutic testicular excision biopsies are performed for a wide range of disorders, including neoplastic lesions, inflammatory lesions, cryptorchidism, testicular trauma, and as a part of prophylactic treatment of carcinoma prostate. Aim: To evaluate the indications for orchidectomy and diagnostic testicular biopsies and to understand the histopathological spectrum of testicular lesions and concordance with clinical diagnosis. Materials and Methods: This was a retrospective study conducted in the Department of Pathology, Father Muller Medical College, Mangalore, Karnataka, India. The study period is from July 2017 to June 2020. Data was collected and analysed in August 2020. All testis’ biopsies, including excision and diagnostic biopsies, are included in the study. Histopathological findings and the clinical diagnosis were evaluated for concordance. Data were tabulated and statistically evaluated for age distribution, laterality, and frequency using Microsoft Excel 2021. Percentages for the variables and concordance rate were calculated. Results: A total of 139 cases (mean age 54.5 years) were included in the study. Prophylactic orchidectomy for carcinoma prostate (64/139=46.04%) was the most common clinical indication. Non neoplastic lesions account for 48.20% (67/139). Frequent non neoplastic lesions are testicular torsion (23/139=16.55%) and abscess (12/139=8.63%), followed by cryptorchidism (9/139=6.47%). Left-sided lesions are more frequent than right-sided lesions. Histopathology confirmed two cases of suspected male infertility and Androgen Insensitivity Syndrome (AIS). Neoplastic lesion accounts to 6.47% (9/139). Frequent neoplasm in the study was seminoma (3/139=2.16%), followed by lymphoma (2/139=1.44%). Other neoplasms included in the study were mixed germ cell tumours, post-pubertal teratoma, and spermatocytic tumour. Testicular tuberculosis accounts to 1.44% (2/139) in the present population. Conclusion: Non neoplastic lesions were common compared to testicular neoplasms. Testicular torsion, followed by abscess, was the most common indication for orchidectomy. Testicular Tuberculosis can mimic a neoplasm on clinical and radiological work-up. Hence, careful evaluation has to be performed in young suspected cases of tuberculosis.

P306: Characterization of clinically diagnosed androgen insensitivity syndrome (AIS) and its mimics

P306: Characterization of clinically diagnosed androgen insensitivity syndrome (AIS) and its mimics

Potential risk of inguinal hernia in complete androgen insensitivity syndrome

Potential risk of inguinal hernia in complete androgen insensitivity syndrome

Clinical and laboratory differences between chromosomal and undefined causes of non-obstructive azoospermia: A retrospective study.

Knowledge of clinical and laboratory differences between chromosomal and undefined causes aids etiological research on non-obstructive azoospermia. Compare clinical and laboratory differences between men with non-obstructive azoospermia due to chromosomal anomalies versus undefined causes. A cross-sectional retrospective study conducted at a public university hospital in Campinas (Brazil). All men aged 20-40 years with non-obstructive azoospermia were included in the analysis. The 107 cases included 14 with Klinefelter syndrome (KS) (13%), 1 with mosaic KS, 4 with sex development disorders (2 testicular XX, 1 NR5A1 gene mutation, and 1 mild androgen insensitivity syndrome) (4%), 9 with other non-obstructive azoospermia etiologies (8%), and 79 with undefined causes. The 22 chromosomal anomaly cases (14 KS, 1 mosaic KS, 2 testicular XX, 4 sex chromosome anomalies, and 1 autosomal anomaly) were compared with the 79 undefined cause cases. The KS group had lower average testicular volume, shorter penile length, and lower total testosterone levels but greater height, arm span, serum luteinizing hormone (LH) and follicle stimulating hormone (FSH) levels, and gynecomastia frequency (absent in the undefined group and affecting more than half of the KS group). Patients with testicular XX DSD had LH, FSH, and penile length data intermediate between the KS and undefined cause groups, testicular volume similar to the KS group, and other data similar to the undefined group. Clinical and laboratory data differentiate men with non-obstructive azoospermia and chromosomal anomalies, particularly KS and testicular XX, from those with undefined causes or other chromosomal anomalies.

Psychological and family intervention with a person diagnosed with complete androgen insensitivity syndrome

Complete androgen insensitivity syndrome (CAIS) is a rare condition resulting due to the inability of the cell to respond to the masculine hormone (androgen). Often, CAIS patients identify themselves as female and may experience significant psychological distress on learning that they are genetically male with a female body with significantly reduced fertility. This is a report of a female patient with CAIS and intellectual development delay wanting to undergo mastectomy with multiple psychosocial issues.

Laparoscopic Inguinal Hernia Repair in a Young Female with Associated Multiple Congenital Defects: A Rare Case

Groin hernias are most common among patients presenting with hernia. Males have more predisposition mainly due to anatomy. However, females with groin hernia present with varied abdominal contents including ovaries and fallopian tubes. The worrisome feature of inguinal hernia with ovaries/fallopian tubes as content is torsion. Uncomplicated groin hernia with ovaries as content is managed with conventional laparoscopic or open hernia repair. Young females with groin hernias need to be evaluated thoroughly for features of androgen insensitivity syndrome or any underlying genetic disorder. A 12 years young female presented to our OPD with chief complaints of swelling in the right inguinal region for 6 months. Patient had not achieved menarche yet, however development milestones were found to be normal. On general physical examinations, deformities were noted in the right ear and left upper limb. On local examination, swelling of approximately 3x3 cm was noted in the right inguinal region. An ultrasonography scan of whole abdomen and pelvis which was suggestive of right inguinal hernia containing right ovary with malposition of the right kidney in the pelvis. Consequently, MRI whole abdomen with pelvis confirmed the findings of USG. Patient was taken for laparoscopic inguinal hernia repair. There was right sided indirect inguinal hernia with right ovary as content and a solid mass was also noted in the right pelvic region suggestive of right pelvic kidney. Right ovary was reduced back to the abdomen with transection of the right round ligament and the defect was closed back with interrupted 3’0 Vicryl sutures. Postoperative course was uneventful. Patient was counselled for genetic analysis to rule out any syndrome association. Uncomplicated groin hernia in young females and paediatric age groups with ovarian content can be easily managed with laparoscopic repair. Early intervention should be advised to prevent ovarian torsion and hence long term morbidity.

An Analogical Anthropology of Sex Difference: Erich Przywara, William Desmond, and the Imago Dei in Intersex Persons

This article argues that an analogical approach to the metaphysics of bodily sex difference, such as that found in Erich Przywara and William Desmond, offers a fruitful way forward in a fraught global discussion on sexed embodiment and the imago Dei. After discussing the unique ‘horizontal’ and ‘vertical’ dimensions of Przywara’s anthropology of sex difference, I discuss the common intersex condition called Androgen Insensitivity Syndrome and how Przywara’s system accommodates it as an authentic form of human being imaging God. I then draw from William Desmond’s metaxological approach to sexed bodies to show the great flexibility provided by analogical anthropologies and suggest that theology begin to rely more heavily on these models in future inquiries into sexed embodiment.

Compound K is a potential clinical anticancer agent in prostate cancer by arresting cell cycle

BackgroundGinsenosides, phenolic compounds, and polysaccharides are the bioactive constituents of Panax ginseng Meyer. Compound K (CK) is a secondary ginsenoside with better bioavailability. It is also a promising anticancer agent. PurposeWe aimed to evaluate the effect of CK on prostate cancer (PCa) and its potential mechanisms. Study designThe proliferation, migration and cell cycle of PCa cells after CK treatment were assessed in various PCa cell lines. Docetaxel was used as a positive control drug. Unlike other published studies, the potential mechanisms of CK (50 μM) were investigated by an unbiased global transcriptome sequencing in the current study. MethodsKey CK related genes (CRGs) with prognostic significance were identified and verified by bioinformatic methods using data from the TCGA dataset and GSE21034 dataset. The role of CDK1 in the effect of CK treatment on PCa cells was investigated by overexpression of CDK1. ResultsCK inhibited the proliferation and migration of PCa cells at concentrations (less than 25 μM) without obvious cytotoxicity. Five key CRGs with prognostic significance were identified, including CCNA2, CCNB2, CCNE2, CDK1, and PKMYT1, which are involved in cell cycle pathways. CK inhibited the expression of these 5 genes and the cell cycle of PCa cells. According to the results of bioinformatic analysis, the expression of the five key CRGs was strongly associated with poor prognosis and advanced pathological stage and grade of PCa. In addition, CK could restore androgen sensitivity in castration-resistant PCa cells, probably by inhibiting the expression of CDK1. After CDK1 overexpression, the inhibition of proliferation and migration of PCa cells by CK was decreased. The inhibition on the phosphorylation of AKT by CK was also reduced. ConclusionCK can inhibit PCa cells, and the mechanisms may be associated with the inhibition of cell cycle pathways through CDK1. CK is also a potential clinical anticancer agent for treating PCa.

Abstract 2

Background: The etiologies for ambiguous genitalia with palpable gonads include gonadal dysgenesis, congenital adrenal hyperplasia, androgen biosynthetic defects or androgen insensitivity. Klinefelter syndrome (1 in 500-1000 live male births) classically presents with hypergonadotropichypogonadism, infertility and neurocognitive deficits in adult men, and less frequently as isolated hypospadias and micropenis in infants. Klinefelter syndrome rarely can present with ambiguous genitalia. We detail a child with Klinefelter syndrome and associated androgen insensitivity presenting with genital ambiguity. Case Details: 3 year 5 months old child (DOB: 6/5/19), reared as male, presented with complaints of ambiguous genitalia and small-sized penis since birth. He was passing urine from a normally located urethralopening. Although gonads were noticed in the scrotum since birth, there was bifid scrotum. There was no history of hypoglycemia, salt-wasting crises or hyperpigmentation. Child was born out of non-consanguineous marriage, by cesarean delivery, at term, with a birth weight of 2.6 kg. Child had attained developmental milestones appropriate for age. On examination, Ht:92 cm (-1.96 Z), Wt:13kg (-1.33 Z), BP: 85/54mmhg (SBP: 50th centile, DBP: 90th centile), MPH:162.5 cm, US:LS:0.7, Arm Span: 89 cm. On examination, he had bilateral symmetric external genitalia with palpable gonads in the labio-scrotal folds. The labioscrotal folds were non-fused, but rugosity and pigmentation were present. Phallic length was 1.8 cm with a single urethral opening at the tip of phallus. EMS score was 6 and AG ratio was 0.5. Evaluation revealed Na:138, K:4.3, Cortisol:13.5 mcg/dl, LH: 0.862 mIU/ml, FSH:2.4 mIU/ml, Testosterone: 507 ng/dl. Post-hCG stimulation Testosterone/Dihydrotestosterone ratio was 12.43, while Testosterone/Androstenedione ratio was 22.96. Karyotype was 47,XXY. Genetic analysis revealed a pathogenic variant in the androgen receptor c.2495G>A (p.Arg832Gln), suggestive of androgen insensitivitysyndrome. Discussion: There have been isolated case reports of genital ambiguity in Klinefelter syndrome with associated AIS. The mechanisms suggested to explain genital ambiguity in Klinefelter syndrome include parental origin of the X chromosome, skewed inactivation of the X chromosome, CAG repeat polymorphism, double dosage of DAX-1 gene and androgen insensitivity. Although rare, it remains paramount to recognize Klinefelter syndrome as a cause of genital ambiguity. Genotypic-phenotypic discordance in Klinefelter syndrome should especially alert the clinician to look for associated androgen insensitivity as one of the mechanisms.

Aging and androgens: Physiology and clinical implications.

In men > ~35years, aging is associated with perturbations in the hypothalamus-pituitary-testicular axis and declining serum testosterone concentrations. The major changes are decreased gonadotropin-releasing hormone (GnRH) outflow and decreased Leydig cell responsivity to stimulation by luteinizing hormone (LH). These physiologic changes increase the prevalence of biochemical secondary hypogonadism-a low serum testosterone concentration without an elevated serum LH concentration. Obesity, medications such as opioids or corticosteroids, and systemic disease further reduce GnRH and LH secretion and might result in biochemical or clinical secondary hypogonadism. Biochemical secondary hypogonadism related to aging often remits with weight reduction and avoidance or treatment of other factors that suppress GnRH and LH secretion. Starting at age ~65-70, progressive Leydig cell dysfunction increases the prevalence of biochemical primary hypogonadism-a low serum testosterone concentration with an elevated serum LH concentration. Unlike biochemical secondary hypogonadism in older men, biochemical primary hypogonadism is generally irreversible. The evaluation of low serum testosterone concentrations in older men requires a careful assessment for symptoms, signs and causes of male hypogonadism. In older men with a body mass index (BMI) ≥ 30, biochemical secondary hypogonadism and without an identifiable cause of hypothalamus or pituitary pathology, weight reduction and improvement of overall health might reverse biochemical hypogonadism. For older men with biochemical primary hypogonadism, testosterone replacement therapy might be beneficial. Because aging is associated with decreased metabolism of testosterone and increased tissue-specific androgen sensitivity, lower dosages of testosterone replacement therapy are often effective and safer in older men.

Androgen receptor polyQ alleles and COVID-19 severity in men: A replication study.

Ample evidence indicates a sex-related difference in severity of COVID-19, with less favorable outcomes observed in men. Genetic factors have been proposed as candidates to explain this difference. The polyglutamine (polyQ) polymorphism in the androgen receptor gene has been recently described as a genetic biomarker of COVID-19 severity. To test the association between the androgen receptor polyQ polymorphism and COVID-19 severity in a large cohort of COVID-19 male patients. This study included 1136 male patients infected with SARS-CoV-2 as confirmed by positive PCR. Patients were retrospectively and prospectively enrolled from March to November 2020. Patients were classified according to their severity into three categories: oligosymptomatic, hospitalized and severe patients requiring ventilatory support. The number of CAG repeats (polyQ polymorphism) at the androgen receptor was obtained by PCR and patients were classified as either short (<23 repeats) or long (≥23 repeats) allele carriers. The association between polyQ alleles (short or long) and COVID-19 severity was assessed by Chi-squared (Chi2 ) and logistic regression analysis. The mean number of polyQ CAG repeats was 22 (±3). Patients were classified as oligosymptomatic (15.5%), hospitalized (63.2%), and severe patients (21.3%) requiring substantial respiratory support. PolyQ alleles distribution did not show significant differences between severity classes in our cohort (Chi2 test p>0.05). Similar results were observed after adjusting by known risk factors such as age, comorbidities, and ethnicity (multivariate logistic regression analysis). Androgen sensitivity may be a critical factor in COVID-19 disease severity. However, we did not find an association between the polyQ polymorphism and the COVID-19 severity. Additional studies are needed to clarify the mechanism underlying the association between androgens and COVID-19 outcome. The results obtained in our study do not support the role of this polymorphism as biomarker of COVID-19 severity.

Challenges in the Diagnosis of XY Differences of Sexual Development

Background: We report the clinical case of female patient with 46,XY difference of sexual development (DSD) and discuss the challenges in the differential diagnosis between complete gonadal dysgenesis (also called Swyer syndrome) and complete androgen insensitivity syndrome. Case Presentation: The patient's with primary amenorrhea gynaecological examination and magnetic resonance imaging (MRI) revealed the absence of the uterus and a very short vagina. Two sclerotic structures, similar to ovaries, were recognised bilaterally in the iliac regions. Hormonal assay tests revealed hypergonadotropic hypogonadism and the testosterone level was above normal. The karyotype was 46,XY and a diagnosis of Swyer syndrome was made. At the age of 41, the patient underwent a gynaecological review and after evaluating her tests and medical history, the previous diagnosis was questioned. Therefore, a molecular analysis of sex-determining region Y (SRY) and androgen receptor (AR) genes was made and the results instead led to a definite diagnosis of complete androgen insensitivity syndrome. Conclusions: The presented case illustrates that differentiating between complete gonadal dysgenesis and complete androgen insensitivity can be challenging. A well-established diagnosis is crucial because the risk of malignancy is different in those two syndromes, as well as the timing and importance of gonadectomy.

Mutational Screening of Androgen Receptor Gene in 8224 Men of Infertile Couples.

Mutations in the androgen receptor (AR) gene might be associated with infertility mainly because they cause various degrees of androgen insensitivity. The aim of the study was to evaluate the frequency and type of AR variants in a large cohort of infertile males. A total of 8224 males of Italian idiopathic infertile couples were referred to the University Hospital of Padova. The main outcome measures were mutational screening of AR, computational, and functional analyses. We found 131 patients (1.6%) harboring 45 variants in AR gene, of which 18 were novel missense AR variants. Patients with AR gene variants had lower sperm count (P = .048), higher testosterone (T) concentration (P < .0001), and higher androgen sensitivity index (ASI) (luteinizing hormone × T, P < .001) than patients without variants. Statistical analyses found T ≥ 15.38 nmol/L and ASI ≥ 180 IU × nmol/L2 as the threshold values to discriminate with good accuracy patients with AR variants. Patients with oligozoospermia and T ≥ 15.38 nmol/L had a 9-fold increased risk of harboring mutations compared with patients with normal sperm count and T < 15.38 nmol/L (odds ratio 9.29, 95% CI 5.07-17.02). Using computational and functional approaches, we identified 2 novel variants, L595P and L791I, as potentially pathogenic. This is the largest study screening AR gene variants in men of idiopathic infertile couples. We found that the prevalence of variants increased to 3.4% in oligozoospermic subjects with T ≥ 15.38 nmol/L. Conversely, more than 80% of men with AR gene variants had low sperm count and high T levels. Based on our findings, we suggest AR sequencing as a routine genetic test in cases of idiopathic oligozoospermia with T ≥ 15.38 nmol/L.

Characterization of a novel androgen receptor gene variant identified in an Iranian family with complete androgen insensitivity syndrome (CAIS): a molecular dynamics simulation study

Androgen insensitivity syndrome (AIS) is a common form of 46, XY disorder in sex development disease (DSD). It is due to the androgen receptor (AR) gene mutations and includes clinical subgroups of complete AIS (CAIS) and partial AIS (PAIS), along with a vast area of clinical heterogeneity of completely normal female external genitalia to male infertility. In this study, the Whole Exome Sequencing (WES) was utilized to detect the cause of DSD in a consanguineous Iranian family with two female patients with normal external genitalia and 46, XY karyotype. Sanger sequencing was applied to validate the candidate variant. Next, we predicted the structural alteration induced by the variant on AR protein using bioinformatics analysis such as molecular dynamic (MD) and molecular docking simulations. WES results identified a novel hemizygous p.L763V variant in the AR gene in the proband that was compatible with the X-linked recessive pattern of inheritance. Bioinformatics studies confirmed the loss of AR function. Based on the American College of Medical Genetics and Genomics (ACMG) guidelines, it was categorized as pathogenic. This study broadens the AR mutation spectrum and introduces the novel p.L763V missense pathogenic variant leading to AR failure to bind to its ligand, and the resulting CAIS clinical subgroup. This study presents a prosperous application of WES and bioinformatics analysis to recognize the underlying cause of DSD in Iran, necessary for its clinical/psychological management. Communicated by Ramaswamy H. Sarma

Vaginal Reconstruction in Patients with vaginal agenesis: Options and Outcome: A single-center experience.

To assess the postoperative functional, anatomical outcome and complications of various surgical procedures of vaginoplasty performed for patients with vaginal agenesis at our institution. This was a cross-sectional study of 14 patients (age range 17-40 years), who underwent vaginoplasty at the Aga Khan University Hospital, Karachi, Pakistan between January 2008 to December 2018. We aimed to assess the anatomical outcomes in terms of vaginal depth, axis and functional outcome as painless and satisfactory vaginal intercourse. The mean age and mean body mass index (BMI) of the cases were 26.8 ± 8.1 years and 27.7143 ± 4.6 respectively. All were phenotypically female, with only two cases of XY genotype. Two patients were married on presentation. On evaluation, four cases had Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome, three had androgen insensitivity syndrome (AIS), one case had congenital adrenal hyperplasia and six cases did not fit into any diagnosis. Associated renal anomalies were diagnosed in 14.3% of cases. The performed procedures were; Singaporean flap vaginoplasty (in four patients), Lee's, modified McIndoe and pull-through vaginoplasty (in three each patients), and Davydov vaginoplasty (in one patient). One patient was complicated by intraoperative bladder injury (p<0.63) and two cases by vaginal stenosis (p<0.43). The mean operative time was 120 minutes and the mean estimated blood loss was 200mls. Postoperatively, the vaginal length varied from 6-10 cm with a normal vaginal axis and satisfactory sexual activity. Vaginal agenesis is associated with several sexual disorders and despite the various surgical options available, the best procedure in terms of fewer complications and best surgical outcome is yet to be determined.

MRI Features of Androgen Insensitivity Syndrome: Case Report

Androgen insensitivity syndrome or testicular feminization is a genetic condition caused by the defect of androgen receptors and resulting in a lack of response to androgen. In the complete form patients have a female phenotype with a male karyotype (XY). In most cases it is revealed by primary amenorrhea. Imaging modalities are very contributive in the initial diagnosis but also to localize gonads. We report the case of complete androgen insensitivity in a 12 years old girl, discovered accidentally during an ultrasound for acute abdominal pain.

OR07-6 Disrupting DNA-binding Domain Dimerization In The Androgen Receptor In Mice Results In a Partial Androgen Insensitivity Model

Abstract The androgen receptor (AR) plays a crucial role in the development and maintenance of the male phenotype, as shown in patients with androgen insensitivity syndrome (AIS). The AR is a nuclear receptor that needs to homodimerize to execute its role as transcription factor. Dimerization can occur through three different modes: via the DNA-binding domain (DBD), via the ligand-binding domain and via an interaction between the LBD and the aminoterminal domain. Dimerization via the DBD is very well known and occurs through the D-box located in the second zinc finger. DBD dimerization is generally accepted for all steroid receptors, but some of them show that D-box mutations do not inactivate them completely. However, for the AR, no monomeric transactivation capacity was described yet. To study the role of D-box independent activity of the AR, we introduced a double point mutation in the D-box that is predicted to disrupt DBD dimerization (ARDmon). These two point mutations were found in separate patients suffering from partial AIS. In vitro studies with this mutant suggest that the remaining activity depends on the androgen response element under investigation. We show that ligand binding was not affected by the D-box mutation. Furthermore, BioID assays indicated no changes in coregulatory interactions. When introducing the corresponding mutation in mice, this led to a phenotype that is intermediate between global ARKO and wild type (WT) males. Based on their anogenital distance (AGD) and the absence of nipples at early age, the ARDmon/Y mice were identified as males. Follow-up of their AGD and body weight, however, revealed clear differences with both WT males and females. Furthermore, hypospadias was observed in the ARDmon/Y mice. Testes were smaller in size compared to the WT males and first analysis showed almost no expression of well-known AR regulated genes. Reminiscent structures of the epididymis were found. In summary, the ARDmon mouse model shows an intermediate AIS phenotype. Via orchidectomy in combination with androgen replacement therapy, we will now investigate remaining androgen responses in the ARDmon/Y mice and elucidate response elements on which the AR can act in a D-box independent way. Additionally, we generated the first rodent PAIS model with a genetic cause of hypospadias. Presentation: Saturday, June 11, 2022 12:45 p.m. - 1:00 p.m.

OR06-3 ESR1 Pathogenic Variant With Incomplete Estrogen Insensitivity

Abstract Introduction Estrogen is vital to human reproduction and acts primarily through two receptors: estrogen receptor alpha (ERα, encoded by ESR1) and estrogen receptor beta (ERβ, encoded by ESR2). Surprisingly, very few human ESR1 pathogenic variants have been recognized, despite the existence of &amp;gt;1000 different androgen receptor pathogenic variants causing androgen insensitivity syndrome. Functional analysis of an ESR1 homozygous missense variant (p.Glu375His) in the ERα ligand-binding domain (LBD) showed a 240-fold decrease in estrogen response in a patient with complete estrogen insensitivity and abnormal pubertal development. We predict that less severe ESR1 variants will present with unexplained infertility. Previously, we performed whole exome sequencing on 200 females with unexplained infertility and identified 4 likely pathogenic ESR1 heterozygous missense variants confirmed by Sanger sequencing, including one variant (p.Thr313Met) in the LBD. In this study, we performed in vitro functional analysis to evaluate if the p.Thr313Met likely pathogenic variant found in a patient with unexplained infertility causes incomplete estrogen insensitivity. Hypothesis We hypothesize that the p.Thr313Met likely pathogenic variant in the ERa LBD will result in incomplete estrogen insensitivity. Methods The p.Thr313Met variant plasmid was constructed using site-directed mutagenesis (SDM), and confirmed by Sanger sequencing. An in vitro cell model was used to evaluate estrogenic activity. HepG2 cells were transiently transfected with WT ESR1, p.Thr313Met, or p.Glu375His plasmid, along with the Firefly estrogen response element (ERE) luciferase reporter (3X ERE TATA luc) and Renilla luciferase (pRL-TK luc) plasmids using the Effectene transfection protocol. Cells were treated with 17β-estradiol (0.01, 0.1, 1, 10, and 100 nM). A dual luciferase reporter assay was used to compare relative Firefly and Renilla luciferase activity between WT ESR1, p.Thr313Met, and p.Glu375His plasmids using a luminometer. Estrogen dose response curves were generated, and a two-way ANOVA with Tukey's test was performed to compare the relative luciferase activity across WT and variant plasmids using GraphPad Prism v.9. Differences were considered significant at p&amp;lt;0.05. Results Estrogen response curves were generated for WT, p.Thr313Met, and p.Glu375His plasmids. The p.Thr313Met variant showed lower overall activity with a right shifted dose response curve with a statistically significant decrease in relative luciferase activity in comparison to WT (p&amp;lt;0.05). The p.Thr313Met variant was more active at higher doses (1 and 10 nM) with a left shifted dose curve when compared to the p.Glu375His variant (p&amp;lt;0.05). Conclusion We have identified a human ESR1 variant that impairs estrogen signaling in vitro, suggesting incomplete estrogen insensitivity as a putative mechanism for unexplained infertility. The identification of ESR1 pathogenic variants and the evaluation of their functionality could provide improved diagnosis and genetic counseling for patients with unexplained infertility. Presentation: Saturday, June 11, 2022 12:00 p.m. - 12:15 p.m.

ODP381 Changes in Perceptions of Pediatric Endocrinologists (PE) and Urologists (PU) to Infants and Children regarding care of individuals with 46,XY DSD

Abstract Introduction Over recent decades, controversy regarding standards of care has contributed to questioning past management recommendations for infants and children with a 46,XY DSD. Surveys conducted in 3 waves (2003, 2010, 2020) provide evidence of changes in recommendations for care have changed over this period. Methods Online surveys of the members of the Pediatric Endocrine Society (PE) and Societies for Pediatric Urology (PU) included case vignettes representing partial androgen insensitivity syndrome (PAIS), micropenis resulting from primary testicular failure, and penile ablation (non-DSD). Survey items included questions regarding recommended gender of rearing (GoR), genital surgery (and timing), and disclosure of diagnostic details to patient. Results The newborn PAIS vignette included elevated LH and FSH and a 1.2 cm. phallus that increased to 1.7 after exogenous testosterone. Male GoR was chosen by 47, 55 &amp; 55% PE and 81, 83 &amp; 69% of PU in waves 1 to 3, respectively; 27 PE and 28% PU chose an added "non-binary" option in 2020. The recommendation that parents, rather than patients, should decide about perineal hypospadias repair was chosen by 70, 60 &amp; 50% of PE and 93, 90 &amp; 79% of PU. Recommending against surgery were 25, 22 &amp; 10% PE and 23, 13 &amp; 8% PU. Recommending surgery be completed at &amp;lt;1 year of age: 56, 59, 66% PE and 69, 78, 84% PU. Recommendation against disclosure of the underlying condition to the patient 12, 17 &amp; 28% PE and 17, 19 &amp; 22% PU, while 35, 28 to 32% PE and 34, 43 &amp; 30% PU recommended that disclosure occur by 11 years of age. For the penile ablation vignette, 78, 92 &amp; 92% PE and 98, 95 &amp; 97% PU recommended male GoR. The 2020 non-binary option was chosen by 4 and 2% PE and PU. The majority of both groups recommended male GoR for the micropenis vignette with testicular failure; 94, 94 &amp; 89% PE and 96, 97 &amp; 88% PU. The decline in 2020 resulted from the recommendation of the non-binary option by 9% PE and 8% PU. Conclusions It seems clear that a female GoR recommendation is currently rare across 46,XY vignettes with evidence of testicular function during at least some of fetal life. It is also apparent that the current emphasis/controversy regarding GoR has resulted in confusion as to how to apply this poorly understood concept. The resulting shift of delaying decisions regarding surgery until the patient can decide is inconsistent with the recommendation that hypospadias repair occur before age 1 year. Finally, lack of or delayed disclosure is inconsistent with patient centered care recommendations. Presentation: No date and time listed

OR18-3 Case Series of 16 Patients With 17β-Hydroxysteroid Dehydrogenase Type 3 Deficiency at Five Children's Hospitals in the United States

Abstract Objectives The 17β-hydroxysteroid dehydrogenase type 3 (17βHSD3) enzyme, expressed in the testes, converts androstenedione to testosterone. Deficiency of 17βHSD3 causes a 46,XY difference of sex development (DSD). Until recently, just 12 cases of 17βHSD3 deficiency had been reported in the literature in the United States. We report a series of 16 patients diagnosed at five children's hospitals in the United States. Methods We performed a multi-center chart review of patients with 17βHSD3 deficiency diagnosed based on hormone values and/or sequencing and deletion/duplication analysis of the HSD17B3 gene. Results Sixteen patients were identified, ranging in age at diagnosis from birth to 22.3 years (average age 9.5 years). One patient, assigned female at birth, was diagnosed due to a positive family history of the condition. Three patients underwent testing due to discordance between the sex predicted by prenatal cell-free DNA testing and the external genital appearance on prenatal ultrasound or at birth (two were assigned female, one was assigned male). An additional four patients had non-binary (atypical) appearing external genitalia at birth (two assigned female, two assigned male). Two children assigned female at birth were diagnosed after undescended testes were identified during hernia repair in early childhood. Six patients who were assigned female at birth came to medical attention peri-pubertally due to signs of excess/undesired androgen effects and/or primary amenorrhea. Data on gender identity is limited by the current age of many of the patients, but as of most recent follow-up, one patient assigned male and one assigned female are reported to be exploring their gender identities. Four patients had a prior diagnosis of complete or partial androgen insensitivity syndrome and 8 had a prior diagnosis of 46,XY DSD of unknown etiology. Eleven patients had genetic testing confirming pathogenic or likely pathogenic variants in the HSD17B3 gene (two identified on whole exome, one on a DSD-specific multi-gene panel, and the remaining 8 on single gene testing). Of the patients without genetically confirmed 17βHSD3 deficiency, one had a clinical diagnosis due to a genetically-confirmed diagnosis in a sibling. The remaining four declined or have not completed genetic testing, but had hormonal testing consistent with the diagnosis. Conclusions 17βHSD3 deficiency is likely much more common in the US than previously appreciated, and can present at any age with a range of physical findings. Accurate diagnosis is important, as the broad category of 46,XY DSD encompasses a wide spectrum of gonadal malignancy risk, potential for pubertal hormone function and fertility, and gender identity outcomes. We suggest evaluating for this potential diagnosis with genetic and/or hormonal testing in cases of 46,XY DSD with absent uterus. Presentation: Monday, June 13, 2022 11:30 a.m. - 11:45 a.m.