Molecular biologic analyses of tetragametic chimerism in a true hermaphrodite with 46,XX/46,XY

OBJECTIVE

To investigate the mechanism of the formation of a tetragametic chimera with true hermaphroditism (46,XX/46,XY).

DESIGN

Molecular biologic analyses.

SETTING

Outpatient clinic and laboratories of a university hospital.

SUBJECTS

A true hermaphrodite with 46,XX/46,XY and the parents. MAIN OUTCOME ANALYSIS: Restriction fragment length polymorphism (RFLP) of the pseudoautosomal region on sex chromosomes.

RESULTS

Whereas a normal diploid individual showed two bands, the true hermaphrodite showed four bands in the RFLP analyses. Evaluation of the molecular weights of the bands revealed two of them to be of maternal origin and the other two to be of paternal origin.

CONCLUSION

The two cell lineages composing the true hermaphrodite are heterogeneous because those originated from the fertilization of two genetically different maternal haploid cells by two different spermatozoa.

Male pseudohermaphroditism with 5-alpha-reductase deficiency: report of two new familial cases. The importance of early diagnosis

We report two new familial cases of male pseudohermaphroditism due to 5-alpha-reductase deficiency, from the south of Spain. They were born with ambiguous genitalia and were reared as females. At the time of puberty, both brothers virilized partially and underwent a change of gender role from female to male with a stormy psychic readjustment period. We stress the value of the prolonged chorionic gonadotropin test for an early diagnosis.

Anti-müllerian hormone in children with androgen insensitivity

Anti-Müllerian hormone (AMH), also called Müllerian inhibiting substance or factor, is secreted in high amounts by the immature Sertoli cell; it is negatively regulated by testosterone at puberty. In the present study, we measured serum AMH in 20 patients with defects of androgen synthesis or action: 9 with complete androgen insensitivity syndrome, 9 with a partial form, 1 patient with 3 beta-hydroxysteroid dehydrogenase deficiency, and 1 with Leydig cell agenesis. AMH was also determined in 15 control patients with idiopathic male pseudohermaphroditism. The serum AMH concentration was elevated in all testosterone-insensitive or -deficient patients compared with control levels during the first year of life. From 1 yr of age to the onset of puberty, serum AMH levels in patients with androgen insensitivity returned to normal values, but after pubertal development began, AMH levels again rose to extremely high levels in the complete androgen insensitivity syndrome. These results suggest that AMH is negatively regulated by testosterone not only at puberty, but also during the postnatal period. An elevation of serum AMH appears to be an interesting marker of androgen resistance or defect of androgen production in sexually ambiguous male infants.

[Antimullerian hormone in clinical human applications]

Anti-Müllerian hormone (AMH) is synthesized by immature Sertoli cells and by postnatal granulosa cells. Assay of serum AMH is useful in clinical situations to search for the presence of testicular tissue or to assess its functional value before puberty. At the time of puberty, serum levels of AMH decrease dramatically, a negative correlation has been demonstrated between AMH and testosterone serum levels. AMH assay is also useful in a rare form of male pseudohermaphroditism, characterized by the persistence of uterus and tubes in an otherwise normally virilized patient. AMH levels are undetectable or severely decreased in the case of a mutation of the AMH gene itself. In contrast, the concentration of serum AMH is normal if the syndrome is due to an insensitivity of AMH target organs.

Clinical and anatomical spectrum in XX sex reversed patients. Relationship to the presence of Y specific DNA-sequences

OBJECTIVE

Testicular differentiation can occur in the absence of the Y chromosome giving XX sex-reversed males. Although Y chromosomal sequences can be detected in the majority of male subjects with a 46,XX karyotype, several studies have shown that approximately 10% of patients lack Y material including the SRY gene. The aim of this study was to see if the classification of XX sex-reversed individuals into three groups, Y-DNA-positive phenotypically normal XX males, Y-DNA-negative XX males with genital ambiguities and Y-DNA-negative true hermaphrodites can be applied to our cases.

DESIGN

Endocrinological and genetic studies were conducted in 20 XX sex-reversed patients.

PATIENTS

Twenty patients with various phenotypes were studied. They were between 20 days and 35 years old. Ten presented ambiguous external genitalia (Prader's stages II to IV). After laparotomy or gonadal biopsy, the diagnosis was 46,XX true hermaphroditism in five, and XX male in 15.

MEASUREMENTS

Blood samples were obtained from all patients for hormonal and molecular studies. Basal levels of testosterone, oestradiol and pituitary gonadotrophins were measured by RIA. In addition, two stimulation tests were performed: gonadotrophin stimulation with GnRH and testicular stimulation with hCG. Several Y-specific DNA sequences of the short arm of the Y chromosome were analysed by Southern blot and polymerase chain reaction methods.

RESULTS

In this study, three categories of XX sex-reversed individuals were observed: phenotypically normal males with or without gynaecomastia, males with genital ambiguities, and true hermaphrodites. Endocrinological data were similar in XX males and in true hermaphrodites. Testosterone levels exhibited normal (n = 9) or decreased (n = 11) values. The hCG response was low. FSH and LH were elevated in 13 patients. Molecular analysis in ten patients showed varying amounts of Y material including the Y boundary and SRY. Ten patients with various phenotypes lacked Y chromosomal DNA. There was no relation between Leydig cell function (as indicated by testosterone levels before or after hCG stimulation) and the presence of Y chromosome material.

CONCLUSION

Although the presence of Y-specific DNA generally results in a more masculinized phenotype, exceptions do occur. In the Y-DNA-negative group, complete or incomplete masculinization in the absence of SRY suggests a mutation of one or more downstream non-Y, testis-determining genes.

Evaluation of SHBG test for disclosure of insensitivity to androgens

A laboratory test enabling to reveal and confirm the suspicion on the insensitivity to androgens was evaluated. The test consisted of determination of the decline in plasma level of sex hormone binding globulin (SHBG) on the 7th day after administration of a single dose of testosterone preparation (Testoviron Depot 100, Schering, 2 mg/kg body weight). The upper limit of percentual SHBG decline, below which the patients can be considered normal responders (i.e. subjects without insensitivity to androgens), obtained from the follow up of the time course of SHBG changes after Testoviron application to 6 healthy men, was established as 83.6%. The level of percentual SHBG decline, above which the patients were considered non-responders with impaired peripheral sensitivity to androgens was assessed from the imprecision of immunoradiometric determination of SHBG and amounted 91.9%. The test was used and evaluated in 26 patients with 46 XY karyotype, representing various cases of intersex, gonadal dysgenesis and male hypogonadism, out of which four subjects with clinically confirmed impaired peripheral sensitivity to androgens were discovered. The test however, appeared not to be reliable in cases of very low basal SHBG levels, i.e. below 15 nmol/l.

Reduced inhibin and elevated gonadotropin levels in early pubertal boys with testicular defects

In the prepubertal quiescent period, the control of gonadotropin secretion is assumed to be mediated by neuroendocrine inhibitory mechanisms, whereas little or no effect is thought to be mediated by the gonad. However, in pubertal-aged children with primary gonadal failure, gonadotropins increase to supranormal levels, suggesting that gonadal factors become more important in the control of gonadotropin secretion at that age. These gonadal factors have been poorly characterized so far. To clarify the relationship of inhibin and testosterone to the control of gonadotropin secretion during sexual maturation, we examined serum inhibin, testosterone, LH, and FSH concentrations in 10 boys with testicular defects and in nine healthy boys, in prepuberty and in early puberty. Serum was obtained at 15-min intervals for at least 6 h during the night. Prepubertal-aged boys with testicular defects had only slightly higher FSH levels than healthy boys, and their LH and inhibin levels were no different. In contrast, pubertal-aged boys with testicular defects had higher LH and FSH levels and lower inhibin levels than healthy boys. In prepubertal-aged boys, no correlation was found between individual mean inhibin level and mean FSH or LH level. In contrast, in pubertal-aged boys, an inverse nonlinear relationship between mean inhibin level and mean FSH and LH level was seen. The inverse value for inhibin correlated with FSH (r = 0.74, p < 0.01) and with LH (r = 0.81, p < 0.01). In conclusion, our results suggest that inhibin is a factor involved in the control of gonadotropin secretion in boys, at least in the pubertal period.

Müllerian inhibiting substance in the diagnosis and management of intersex and gonadal abnormalities

Müllerian inhibiting substance (MIS), a gonadal hormone important in sexual differentiation, is high (10 to 70 ng/mL) in human male serum postnatally for several years before declining during the peripubertal period, but is undetectable in female serum until the onset of puberty. The sexually dimorphic secretion of MIS suggested possibilities for its use in several clinical settings. Thirty-one patients with intersex and gonadal anomalies from 17 institutions were therefore evaluated between 1989 and 1992 with an MIS enzyme-linked immunosorbent assay (ELISA). Serum MIS levels correlated with the presence of testicular tissue in two patients with suspected anorchia, five patients with male pseudohermaphroditism, and eight other intersex patients with undescended testes, dysgenetic gonads, or ovotestes. In these latter patients, serial MIS values were also helpful to confirm complete removal of gonadal tissue postoperatively. MIS may be a more sensitive marker for the presence of testicular tissue than serum testosterone levels, both before and after the neonatal androgen surge, and, consequently, may obviate the need for human chorionic gonadotropin stimulation in the evaluation of certain intersex disorders. In values were useful in differentiating the underlying etiology of the disorder. Four patients with undetectable levels have presumptive MIS gene mutations, while 7 others with MIS values of 2 to 45 ng/mL may have bioinactive hormone of MIS receptor defects. Finally, two young girls with ovarian granulosa cell tumors had elevated MIS values that fell from 18 to 2 ng/mL and from 6.5 to 1 ng/mL during postoperative follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)

17 alpha-Hydroxylase deficiency with persistence of müllerian ducts in a genotypic male and paradoxical aldosterone secretion

We report a case of congenital adrenal hyperplasia due to 17 alpha-hydroxylase deficiency in a Chinese genotypic male patient. Despite the male genotype, normal female external genitalia were present and with the introduction of cyclical oestrogen therapy withdrawal bleeding occurred, confirming the presence of functional endometrial tissue. We believe this to be the first report of persistent Mullerian duct structures in a genotypic male with 17 alpha-hydroxylase deficiency. It could be explained by either impaired secretion or impaired action of anti-Mullerian hormone. Further, contrary to the usual finding of suppressed aldosterone secretion, this patient had measurable levels of plasma aldosterone.

The persistent müllerian duct syndrome: a rare cause of cryptorchidism

The persistent Müllerian duct syndrome is characterized by the retention of Müllerian derivatives in patients otherwise normally virilized. Clinically, the persistence of uterus and tubes leads either to cryptorchidism or inguinal hernia, depending on whether or not the Müllerian derivatives can be mobilized during testicular descent. The condition is usually discovered at surgery, however preoperative sonography could allow the diagnosis to be made preoperatively. The molecular basis of the persistent Müllerian duct syndrome is heterogeneous, and is reflected by wide variations in the serum concentration of anti-Müllerian hormone. Some cases are apparently due to end-organ resistance, and are associated with normal serum levels of the hormone. Others, characterized by absent or low hormone concentrations, can be explained by mutations of the gene coding for anti-Müllerian hormone, which are distributed along the whole length of the coding region.

Steroid 17β-hydroxysteroid dehydrogenase deficiency in man: an inherited form of male pseudohermaphroditism

Sixty-eight males with testicular 17β-hydroxysteroid dehydrogenase deficiency (17β-HSD) were identified among a highly inbred Arab population in Israel, and 45 studied over the last 15 years. The founders of this defect originated in the mountainous region of present Lebanon and Syria, but most of the families now live in Jerusalem, Hebron, the Tel-Aviv area, and in particular Gaza, where the frequency of affected males is estimated at 1 in 100 to 150. Affected individuals (46,XY) are born with ambiguity of the genitalia and reared as females until puberty. Thereafter marked virilization occurs, leading in many cases to the spontaneous adoption of a male gender role. Adults develop a male habitus with abundant body hair and beard, and the phallus and testes enlarge to adult proportions. Gender reassignment was possible only when enough erectile tissue was present at birth and developed into a normal size penis with systemic testosterone. male genitoplasty was performed in 15 children and 8 post-pubertal patients, and female genitoplasty in 2 children and 4 post-pubertal patients. In adults the defect is characterized by markedly increased concentrations of 4-androstendione (4-A) with borderline low to normal testosterone (T) levels, and a high 4-A/T ratio. Dihydrotestosterone (DHT) concentrations were either moderately decreased, normal, or high, and dehydroepiandrosterone levels were high. The estrogen pathway was also impaired, even though both estrone and estradiol-17β levels were elevated. Children had low basal levels of all androgens, but the defect could be demonstrated after prolonged stimulation with human chorionic gonadotropin. LH and FSH levels were very high after puberty, and normal in childhood. However, an over-response to gonadotropin-releasing hormone was found at all ages. Studies in testicular tissue revealed various abnormalities in steroid metabolism. Tissue from pre-pubertal patients metabolized progesterone (P) only to 4-A, while tissue from post-pubertal patients metabolized P to 16α- and 16β-hydroxyprogesterone (5.4- to 10.3-fold greater production), 17α-hydroxyprogesterone (5.4- to 8-fold smaller production), 4-A and T. 4-A was also metabolized to T, indicating that 17β-HSD was no longer deficient. Flow studies with equimolar concentrations of [¹⁴C]P and [³H]pregnenolone showed that the 5-ene pathway was the preferential one for androgen biosynthesis. Both in vivo and in vitro studies indicate that the severity of testicular 17β-HSD deficiency changes with age. Whereas the enzyme activity is absent in childhood, there is a progressive restoration after puberty. Androgen production increases progressively to normal so that T and DHT concentrations are sufficiently high to gradually induce somatic and genital virilization, thus enabling an adequate male gender function.

True hermaphrodites: an experimental model in the mouse

When the Y chromosome from the Mus musculus domesticus mouse strain is placed onto the C57BL/6J mouse background ovarian and testicular components develop in half of the XY progeny (B6.YDOM), providing an excellent model of true hermaphroditism. We examined the correlation between gonadal sex and development of the internal genital tract in the B6.YDOM mouse at puberty. Of 55 mice examined 20 had bilateral testes, 33 were true hermaphrodites and 2 had mixed gonadal dysgenesis. In all mice with bilateral testes male accessory sexual organs developed bilaterally. In the true hermaphrodites testes were found on either side but preferentially on the left side. When a male feature was present on the ipsilateral side of the ovary, the seminal vesicle was more frequently found than prostate or vas. Testicular mass was significantly different between the true hermaphrodites with and those without bilateral seminal vesicles. Similar difference was found in those with and without bilateral prostates. The serum testosterone level was not significantly different between these groups. We conclude that the testicular mass is a better discriminant than serum testosterone for the presence or absence of seminal vesicles and prostates at puberty.

[Clinical, cytogenetic, endocrinological and histological studies in true hermaphrodites]

The clinical, cytogenetic, endocrinological and histologic features of nine mexican patients with true hermaphroditism are reported. Ages at admission ranged from 10 months to 27 years; in seven cases a male sex of rearing was documented, being 46,XX (n = 6) the most frequent karyotype. Basal levels of gonadotrophins, gonadal steroids, and the testosterone response to exogenous HCG varied depending upon age as well as with type and functional status of the gonadal tissue. However, ovarian tissue always preserved its function better than the testicular tissue did. In one of the patients who presented cyclic hematuria, spontaneous ovulation was documented by serum progesterone monitoring (progesterone = 4.3-11.0 ng/mL during luteal phase). Ovo-testis was the most common gonad present; in four cases bilateral ovo-testes were found. Internal genitalia varied depending on the existing gonad, although in all cases a uterus was found. These findings are in accordance with previous reports of individuals bearing true hermaphroditism in other populations.

Male pseudohermaphroditism due to Leydig cell agenesia and absence of testicular LH receptors

OBJECTIVE

The aim of our study was to establish the definitive diagnosis in an adult patient with male pseudohermaphroditism in whom testicular feminization syndrome had been suspected at the age of 8, based on genetic, clinical and pathological studies.

DESIGN

Hypothalamo-hypophysio-testicular function was assessed in vivo. Androgen mechanism of action and testicular gonadotrophin binding were studied in vitro.

PATIENT

At the age of 33 the phenotype was almost completely feminine except for slight clitoral enlargement and posterior labial fusion. Internal genital duct derivatives were masculine except for a short vagina. Both testes were cryptorchid.

MEASUREMENTS

LH and FSH were determined pre- and post-gonadectomy. Progesterone, 17-OH-progesterone, androstenedione, dehydroepiandrosterone testosterone (T) and oestradiol were determined basally in peripheral and spermatic blood post-hCG stimulation, and in peripheral blood after orchidectomy. Dihydrotestosterone (DHT) receptors and 5 alpha-reductase activity were determined in genital skin fibroblasts. Receptors for LH and FSH were determined in membrane preparations from both testes.

RESULTS

LH was high (31 IU/l) and FSH (8 IU/ml) normal. T or steroid precursors were detected basally or after hCG stimulation in peripheral blood showing absence of testicular production. Spermatic venous blood steroid concentrations were consistent with slight T production, in accordance with testis histology which showed few Leydig-like cells among fibroblasts in the interstitial space. DHT specific binding capacity and affinity and 5 alpha-reductase activity were normal in genital skin fibroblasts. Gonadotrophin binding studies in testicular membranes confirmed the absence of LH specific binding, whereas FSH binding was higher than normal when expressed per mg of protein (27.0 vs 9.4 +/- 0.6 fmol/mg protein in controls), and lower than normal in both testes since patient's testicular weights were abnormally low.

CONCLUSIONS

The patient was considered to have an almost complete form of Leydig cell agenesia/hypoplasia in which absence of specific LH binding correlated with total absence of differentiated Leydig cells and insensitivity of undifferentiated interstitial cells to LH stimulation.

A cluster of male pseudohermaphrodites with 5 alpha-reductase deficiency in Papua New Guinea

We report a cluster of male pseudohermaphrodites from the Simbari Anga linguistic group in the Eastern Highlands of Papua New Guinea. These subjects are born with a rudimentary clitoral-like penis and pseudovaginal perineoscrotal hypospadias. At puberty, the penis enlarges with concurrent growth of pubic and axillary hair and significant muscular development. There is significant facial hair, but it is less than that of their normal male siblings or other male relatives. Plasma collected from four adult subjects revealed elevated plasma testosterone levels, low to low normal dihydrotestosterone levels, and elevated testosterone/dihydrotestosterone ratios. All subjects had high urinary aetiocholanolone/androsterone ratios, and C19 and C21 5 beta/5 alpha metabolite ratios. Decreased 5 alpha-reductase activity was demonstrated in fibroblasts cultured from genital skin. The data indicate a phenotypic and biochemical profile similar to patients studied in the Dominican Republic, except for a greater abundance of facial and body hair. The phenotypic variability, as pertains to facial and body hair, may be related to differences in familial expression, as well as the degree of enzyme deficiency. Infants, thought to be females at birth, were reared as girls until puberty in a society practising one of the strictest gender segregations known. At puberty, these 'girls' were discovered to be boys, and a switch of gender roles was instituted. Recently, however, some Muniri, Dunkwi and northern Simbari hamlets recognize these individuals as male in infancy and rear them as boys, calling them 'kwalatmala' to distinguish them from normal males, accepting them as an intersex destined to occupy male adult roles.

Incidence of intratubular germ cell neoplasia in androgen insensitivity syndrome

Gonadal histology was investigated by means of conventional microscopy in 6 patients with complete androgen insensitivity syndrome, in 11 with incomplete androgen insensitivity syndrome, and in 3 with 5 alpha-reductase syndrome. Twelve subjects were prepubertal and 8 pubertal. In all patients gonadal tissue was removed as a prophylactic measure and no patients gave rise to any clinical suspicion of a tumour. Eight patients with incomplete androgen insensitivity syndrome, 5 of whom (62.5%) were prepubertal, showed intratubular germ cell neoplasia and in 6 of them it was bilateral. Histochemical and immunohistochemical analysis showed considerable agreement between atypical morphological aspects and positive response to Schiff's periodic acid and to staining with the anti-placenta alkaline phosphatase antibody. Our patients were characterized by one of the highest reported incidences of intratubular germ cell neoplasia, particularly at prepubertal age. These findings would seem to indicate that a rethink is needed concerning the general opinion that patients with androgen intensivity syndrome have practically no risk of developing malignancy, and that orchidectomy is not advisable before puberty is completed.

A case of male pseudohermaphroditism due to 17 alpha-hydroxylase deficiency and hormonal profiles in the nuclear family

A genetic male with 17 alpha-hydroxylase deficiency is described. The patient, raised as a female, was seen at 17 yr of age for impuberism. She presented all the features of the classical severe form of the disease: complete female phenotype; hypertension; hypokalemia; elevated levels of plasma progesterone, 11-deoxycorticosterone, corticosterone (B), and ACTH; and suppression of renin and aldosterone production. Levels of 17-hydroxyprogesterone, 17-hydroxypregnenolone, and all androgens were barely detectable. Hormone steroid patterns were determined in basal conditions and after acute ACTH stimulation in the parents and the two unaffected brothers in order to identify the heterozygotes. Subtle abnormalities in B and aldosterone secretion were observed in the male members of the family. On the basis of an increased ratio of B to aldosterone the two brothers were assumed to be heterozygotes. The mother had normal basal and stimulated levels of B, deoxycorticosterone, and aldosterone. In the parents and two brothers the progesterone responses to ACTH were exaggerated. The most striking finding in the father and both brothers was the observation of increased basal plasma 17-hydroxyprogesterone, unresponsive to ACTH stimulation, suggesting a partial Leydig cell 17,20-lyase deficiency in the male heterozygotes of this family. This study shows that a short ACTH test can help to identify the heterozygotes in affected families, but the abnormalities found are more heterogeneous than previously suggested.

Female pseudohermaphroditism due to a maternal adrenocortical tumor

A 15-yr-old, apparently male, patient presented with a 2-yr history of gynecomastia and poor genital development. A normally formed, but small, penis with a phallic urethra was present, and testes were impalpable. The karyotype was 46,XX, and at laparotomy a uterus, Fallopian tubes, and ovaries were found, but there was no testicular tissue. The mother had had regular periods ever since menarche at 14 yr. She had complained of hirsutism since the birth of the child, and on examination 15 yr later had marked clitoromegaly. Serum androgens were elevated: testosterone, 4.5 nmol/L (normal, 0.5-3); dehydroepiandrosterone sulfate, 18 mumol/L (normal, 3-12); and androstenedione, 35 nmol/L (normal, 3-8). All failed to suppress with dexamethasone. Abdominal computed tomographic scan revealed a 9 X 6-cm mass in the position of the left adrenal gland. This was removed at laparotomy and found to be an adrenocortical tumor. Postoperatively, the androgens returned to normal. Virilization of a female fetus due to androgens secreted by a maternal adrenal tumor has only been described three times previously, and the presentation has never been delayed so long.

C19 and C21 5 beta/5 alpha metabolite ratios in subjects treated with the 5 alpha-reductase inhibitor finasteride: comparison of male pseudohermaphrodites with inherited 5 alpha-reductase deficiency

Male subjects administered the 5 alpha-reductase inhibitor finasteride were studied to determine its effect on C19 and C21 5 alpha-metabolism. Plasma testosterone (T) and 5 alpha-dihydrotestosterone (DHT) were measured and T/DHT ratios determined at doses of 0.2-80 mg. Urinary etiocholanolone (5 beta)/androsterone (5 alpha) ratios and 5 beta/5 alpha metabolite ratios of cortisol, 11 beta-hydroxyandrostenedione, and corticosterone were also measured. The steroid profile was compared to male pseudohermaphrodites with inherited 5 alpha-reductase deficiency who have a global defect in C19 and C21 5 alpha-metabolism. The mean plasma DHT levels were decreased at all doses, resulting in elevated T/DHT ratios. The mean urinary etiocholanolone/androsterone, 11 beta-hydroxyetiocholanolone/11 beta-hydroxyandrosterone, tetrahydrocortisol/allotetrahydrocortisol, and tetrahydrocorticosterone/allotetrahydrocorticosterone ratios were elevated compared to pretreatment levels and placebo control values. The mean ratios appeared to be dose dependent for plasma T/DHT, urinary etiocholanolone/androsterone tetrahydrocorticosterone/allotetrahydrocorticosterone ratios. The mean 11 beta-hydroxyetiocholanolone-hydroxyandrosterone ratio was maximally elevated at the lowest doses. The results indicate that finasteride has a broad steroid spectrum inhibiting C19 and C21 5 alpha-steroid metabolism and affecting hepatic and peripheral 5 alpha-metabolism. These results suggest that a single gene codes for a single 5 alpha-reductase enzyme with affinity for multiple steroid substrates. The steroid profile is strikingly similar to that of male pseudohermaphrodites with inherited 5 alpha-reductase deficiency.

[Diagnosis of ambiguous genitalia]

Diagnosis in patients with ambiguous genitalia is based on various investigations. Simple genital examination is not sufficient to attribute sex. Scarce androgenization in a male patient or marked androgenization in a female may both lead to the same stages of genital ambiguity according to Prader. It is important to get information about genital ambiguity in the family, drug consumption during gestation and signs of virilization in pregnant mothers. External genital findings must be integrated by visualization of urogenital sinus by X-rays, ultrasounds and endoscopy. Furthermore, hormonal evaluations on plasma and 24 hours urines allow diagnosis of some disorders of adrenal and gonadal steroidogenesis. To define genetic sex, chromosomal examination is required to integrate X chromatine investigation and fluorescent staining of Y chromosome. Evaluation of psychosexuality in patients who have already got gender identity is mandatory.

Incomplete virilization and subclinical mineralocorticoid excess in a boy with partial 17,20-desmolase/17 alpha-hydroxylase deficiency

A 17-year-old boy is described with impaired virilization and subclinical mineralocorticoid excess owing to combined 17,20-desmolase/17 alpha-hydroxylase deficiency. His basal plasma progesterone was 20.9 nmol/l (reference value 0.50-1.88), 17-hydroxyprogesterone 21.3 nmol/l (reference value 3.05-4.84), testosterone 6.85 nmol/l (reference value 14.1-22.0), and his excretion of tetrahydro-11-deoxycorticosterone 11.8 mumol/24 h (reference value 1.0-1.5). The differential effects of this combined enzyme deficiency on adrenal and testicular function were studied by ACTH stimulation, dexamethasone suppression, hCG stimulation, and suppression treatment with testosterone.

Effect of gonadectomy on growth hormone, IGF-I and sex steroids in children with complete and incomplete androgen insensitivity

IGF-I, testosterone and estradiol levels were evaluated in 8 girls with androgen insensitivity immediately before and from 1 to 3 months after bilateral gonadectomy. In 6 patients GH secretion was evaluated before and after gonadectomy by means of an arginine test and in 3 a sleep test was also performed. Mean IGF-I level before surgery was significantly higher than that of normal controls (2850 +/- 1230 vs 1680 +/- 1040 U/l, p less than 0.025). After gonadectomy a significant decrease was evident for testosterone, estradiol and IGF-I levels. A positive correlation between IGF-I and estradiol levels was present before surgery (p less than 0.005). The presence of a correlation with estradiol, but not with testosterone, and the knowledge that this syndrome is due to an insensitivity to androgens, but not to estradiol, support the hypothesis that the estradiol level is the major determinant for the control of IGF-I values in these patients. After gonadectomy, a substantial decrease of the 12-h nocturnal GH secretion was evident. Comparison of the nocturnal GH levels before surgery of the 3 patients with those of normal subjects of the same age showed hormonal values higher than 1 SD over the mean values of control subjects. Even if the number of patients studied is too small to draw any definitive conclusion, these data may suggest that sex hormones play a role in the control of IGF-I levels, a function which seems to be mediated through GH secretion.

Luteinizing hormone response to an oestradiol challenge in 5 intersex pigs possessing ovotestes

After challenge with oestradiol benzoate, the mean maximum LH concentration in 5 XX intersex pigs possessing ovarian and testicular tissue, or only testicular tissue, was 2.10 (+/- 0.41) ng/ml compared with 8.9 ng/ml in mature domestic gilts. These results indicate that exposure of the pig brain to testosterone before Day 30 of gestation is important, or that early testicular secretions other than testosterone are involved in the determination of brain gender. The observation that some intersex pigs show normal oestrous cycles implies that the response to these prenatal factors is primarily quantitative rather than qualitative.

Decreased 3 alpha-androstanediol glucuronide levels in plasma and random urines in male pseudohermaphroditism caused by 5 alpha-reductase deficiency

Concentrations of 3 alpha-diol glucuronide (3 alpha-diol G) in plasma and/or random urine samples were determined in seven subjects with familial male pseudohermaphroditism (FMP) due to 5 alpha-reductase deficiency (5 alpha-RD). All subjects were natives of an isolated Turkish village with a high incidence of consanguineous marriage. A specific and sensitive antibody to 3 alpha-diol was used for radioimmunoassay of 3 alpha-diol G after hydrolysis and chromatographic purification. The mean plasma 3 alpha-diol G in three subjects (31 ng/dL) was much lower than the normal male concentration (516 +/- 50) (+/- SE) and was even lower than normal female values (119 +/- 10.9 ng/dL). In five subjects, mean urinary 3 alpha-diol G in random urine samples was 7.6 (range 2.1 to 12.7) ng/mg creatinine. This was considerably decreased compared with the mean adult male concentration of 65.4 +/- 9.4 and even lower than normal age-matched nonhirsute female values (19.6 +/- 2.1 ng/mg Cr). To validate the use of 3 alpha-diol G/creatinine ratios in random urine samples, correlations of three consecutive eight-hour samples with 24-hour values were determined in 8 male and 3 female age-matched controls. There was an excellent correlation (r = .95) and the linear regression line (y = 0.51x + 2.58) indicates that the 24-hour excretion of 3 alpha-diol G in microgram/24 h is approximately twice the random urinary concentration in ng/mg Cr.(ABSTRACT TRUNCATED AT 250 WORDS)

Modulation of luteinizing hormone secretion by estrogens in patients with Reifenstein's syndrome

The role of estrogens on gonadotropin secretion was assessed in two siblings with incomplete virilization syndrome type I due to partial androgen insensitivity (Reinfenstein's syndrome). Serum levels of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) were measured before and after 100 micrograms LH-releasing hormone (RH) intravenous (IV) stimulation, as well as during long-term clomiphene citrate (CC) administration. Serum testosterone (T) and estrogens were determined before and during daily administration of human chronic gonadotropin (hCG) and also during the CC treatment. Basal levels of LH were elevated in both patients: 12.5 +/- 1.1 mIU in patient A and 19.8 +/- 1.8 mIU/ml in patient B. Conversely, FSH levels were within normal limits. Administration of LH-RH in both subjects induced a rise in LH levels, while FSH concentration showed no increase. The CC administration resulted in a significant (P less than 0.005) increment in serum LH levels without changes in FSH concentration. An important increase of serum T and estradiol (E2) levels was noted during CC administration; thus, in patient A those levels augmented from 20 to 48 ng/ml for T and from 78 to 220 pg/ml for E2; and patient B showed an increment from 20 to 35 ng/ml for T, and from 55 to 180 pg/ml for E2. The daily administration of hCG was followed by an increment in both T and E2 levels, which was of lesser degree for estrone concentration. These results suggest that endogenous estrogens, particularly E2, modulate LH secretion in patients with partial androgen insensitivity; however, it appears that estrogens had no physiologic effect on FSH secretion.

Sex hormone-binding globulin response to the anabolic steroid stanozolol: evidence for its suitability as a biological androgen sensitivity test

Both the androgen-induced decline in serum sex hormone-binding globulin (SHBG) levels during puberty and the anabolic effect of exogenous testosterone are absent in patients with androgen insensitivity (testicular feminization). To determine whether the androgen-induced decline in serum SHBG could be used as a test of androgen sensitivity, we studied the effect of the anabolic-androgenic steroid stanozolol (17 beta-hydroxy-17 alpha-methyl-5 alpha-androstano-[3,2-c]pyrazol) on serum SHBG in 25 control subjects, 3 patients with complete androgen insensitivity, and 4 patients with partial androgen insensitivity. Stanozolol was administered orally for 3 days (0.2 mg/kg.day); blood samples were taken before and 5, 6, 7, and 8 days after the beginning of the test for measurements of serum SHBG. The lowest value (i.e. the peak response) in each subject was used as the measure of the response to stanozolol. In the control subjects the mean nadir serum SHBG level was 51.6 +/- 5.9% (+/- SD) of the initial value (P less than 0.001). In the 4 patients with partial androgen insensitivity the nadir serum SHBG ranged from 73-89%, and in the 3 patients with complete androgen insensitivity it ranged from 93-97% of the initial value. Thus, the decrease in serum SHBG after short term administration of stanozolol reflects androgen responsiveness and, thus, may be used to differentiate patients with androgen insensitivity syndromes from those with other causes of male pseudohermaphroditism.

Decrease of serum sex hormone-binding globulin as a marker of androgen sensitivity. Correlation with clinical response

An evaluation of the usefulness of determining the decrease in serum sex hormone-binding globulin after exogenous testosterone was studied in 55 prepubertal patients with ambiguous external genitalia or micropenis. The biochemical response (androgen sensitivity test) was compared with the clinical response as judged by signs of androgen stimulation of external genitalia. Patients were divided in two groups according to age. Group I, 11 patients younger than 3 months and Group II, 44 patients older than 3 months. Only in 54% of Group I was there a correlation between the androgen sensitivity test and the clinical response to androgens in either a positive (4 patients) or negative sense (2 patients). On the other hand, the androgen sensitivity test and the clinical response to androgens correlated in 91% of the patients of Group II in either a positive (35 patients) or negative sense (5 patients). Two of the 4 patients with lacking correlation had a negative androgen sensitivity test and micropenis secondary to pituitary deficiency. It is concluded that in prepubertal patients older than 3 months with abnormalities of sex differentiation, the androgen sensitivity test and the clinical response to androgens are useful for evaluating androgen sensitivity. The clinical response to androgens is useful in early life when a positive response is found.

Familial male pseudohermaphroditism and testicular descent in the racoon dog (Nyctereutes)

Sexual differentiation was investigated in familial male pseudohermaphroditism in Nyctereutes procyonoides (Canidae). In intersex males, development of external genital organs and prostate glandular tissue was severely disturbed; Wolffian (mesonephric) duct derivatives developed prepubertally but were absent in some adults. Müllerian (paramesonephric) duct regression was complete. Testicular descent was undisturbed. Male/female sex differences in plasma testosterone, 5 alpha-dihydrotestosterone, and luteinizing hormone concentrations were present. Intersex plasma hormone concentrations were within the normal male range. The concentration of androgen receptors in pubic skin was similar in male, female, and intersex animals and no significant differences in affinity for the ligand were detected. It was concluded that in intersex animals androgen-dependent virilisation was deficient despite the presence of androgens and androgen receptors and that this condition had not affected gubernaculum development and testicular descent.

Inherited impairment of nuclear androgen uptake as a cause of familial androgen insensitivity

The endocrine and biochemical characteristics of four related 46,XY pseudohermaphrodite patients with the Reifenstein Syndrome are presented. All of them (6 and 9 years old, first generation, and 9 and 12 months old, second generation) exhibited ambiguity of external genitalia and a family pedigree characteristic of an X-linked pattern of inheritance. Serum basal levels of LH, FSH, testosterone (T), androstenedione and 5 alpha-dihydrotestosterone (DHT) were within normal limits. Administration of hCG induced a normal response in terms of serum T in three of the patients, with a concomitant increase in serum DHT. However, an abnormally elevated T: DHT ratio was found in two of these subjects on the day of maximal T response (T: DHT ratio, 24 and 27; normal range, 4-21). Genital skin-derived fibroblasts from all patients were studied for [3H]DHT uptake in a whole-cell monolayer assay. Three of the mutant strains exhibited values of [3H]DHT uptake at 37 degrees C within the lower limits of normality (39.4-47.05 fmol/mg protein/h; normal strains, 36-101 fmol/mg protein/h), whereas fibroblasts from the remaining patient presented a slightly decreased uptake (31.66 fmol/mg protein); when studied at 42 degrees C, all mutant strains behaved as the normal controls. The existence of a specific 4.6 S cytosol androgen receptor was clearly seen in the two mutant strains when analysed by sucrose gradient centrifugation. Nevertheless, in one of the mutant strains, a significantly low maximal nuclear [3H]DHT uptake was detected (173.6 fmol/mg DNA; control strain, 301.6 fmol/mg DNA). The overall data were interpreted as demonstrating the existence of an impaired uptake of the androgen-receptor complex at the nuclear levels as the cause of the incomplete phenotypic expression of androgen action in this family. In this setting, the presence of low peripheral 5 alpha-reductase activity may be considered as a secondary manifestation of the androgen insensitivity.

Social and hormonal influences on behavior of adult male, female, and pseudohermaphroditic rhesus monkeys

We previously demonstrated that in a simple pair test situation the expression of adult male sexual behavior by rhesus monkeys depends on both prenatal (organizational) and adult (activational) androgen exposure. In the present study we used a more complex social situation (trio tests) to evaluate the behavior of males, females, and female pseudohermaphrodites. In these trio tests, the experimental subjects were tested with two estrogenized stimulus females simultaneously. Sex differences in behavior were made apparent by this complex testing situation that could not have emerged in the pair test. Gonadectomized males and female pseudohermaphrodites, but not ovariectomized females that were concurrently receiving TP, exhibited increased male sexual behavior in trio tests compared to pair tests. In trio tests, the males and pseudohermaphrodites showed evidence of partner preference by interacting almost exclusively with one of the two stimulus females. These "preferred females" in turn were responsible for the majority of the proceptive behavior exhibited in these tests. Ovariectomized females rarely displayed male sexual behavior in either test situation. These results further support the hypothesis that prenatal androgen exposure predisposes monkeys to exhibit masculine behavior traits when they reach adulthood and are exposed to the activational influences of androgens.

Unilateral true hermaphrodite with 46,XX/46,XY dispermic chimerism

A 13 year old female presented with ambiguous external genitalia, right inguinal ovotestis, left ovary, apparently normal Mullerian system, and absent Wolffian system. Cultured lymphocytes showed a 46,XX/46,XY karyotype. Histopathology of the gonads confirmed true hermaphroditism. The presence of two genetically different erythrocyte populations was observed. The findings suggested that the patient is a true hermaphrodite dispermic chimera.

Failure of the müllerian regression factor in two patients with complete androgen insensitivity syndrome

The present paper describes the histological and endocrinologic features of 2 subjects with 46,XY karyotype affected by complete androgen insensitivity syndrome (AIS) with müllerian structures. Both patients had fallopian tubes, but only one had also uterus and presented a seminoma. Serum levels of luteinizing hormone, testosterone and estradiol were high or in the upper part of normal limits, whereas levels of follicle-stimulating hormone were normal. The association between AIS and the presence of müllerian structures observed in these 2 patients might be explained by an impaired synthesis of müllerian regression factor or by a failure in its mechanism of action.

[True hermaphroditism in a child with a chimeric XX/XY chromosome, a double erythrocyte population and an unusual Lewis (a+ b+) phenotype]

A 2 years-old Korean girl is seen because of ambiguous external genitalia. Surgical exploration shows the right gonad to be an ovary and the left one to be an ovotestis, thus demonstrating a true hermaphroditism. Cytogenetic studies of peripheral lymphocytes reveal a mixture of 46,XX and 46,XY cells, with a predominant XX cell line. The patient's red cells are composed of two distinct populations differing in three genetically independent blood group systems. The ratios of the two cell lines in various tissues, especially among the cells secreting Lewis antigens, appear to be very different and suggest several hypothesis to explain the highly unusual red cell Lewis phenotype Le (a+ b+). We conclude to a dispermic chimera, however the adopted status of this child prevents any identification of the maternal or paternal contributions. Because of the physical aspect it was decided to remove the ovotestis, to repair the external genitalia and to bring up this child as a female.

A phenotypic male with true hermaphroditism and a 46,XX/46,XY/47,XXY karyotype

A phenotypic boy presenting with gynaecomastia showed a mixed karyotype of 46,XX/46,XY/47,XXY. The left gonad was normally descended into the scrotum, but proved to be an ovary without any testicular structures. After left gonadectomy, plasma androgen and estrogen levels showed that the right gonad only contained testicular tissue. Seven patients with this form of triple mosaicism have been described but the clinical features are strikingly different among the described cases.

H-Y intermediate phenotype in male pseudohermaphroditism

A child with ambiguous genitalia was born after an uncomplicated pregnancy. Laparotomy revealed intraabdominal hypoplastic testes containing normal appearing Leydig cells; germ cells were present in the left gonad, not in the right. The karyotype was 46,XY in blood leukocytes and in fibroblasts cultured from the gonads; there was no evidence of mosaicism. Endocrinologic study revealed no disorder of steroidogenesis. Androgen receptors were not studied. Serologic evaluation of blood leukocytes revealed the presence of H-Y antigen, but there are reasons to believe that less H-Y antigen was present in the cells of the patient than was present in corresponding cells from normal males. Gonadectomy and clitoral recession were performed at 3 weeks of age, and the patient was reared as a girl. We speculate that reduced expression of H-Y may have induced aberrant development of the gonads.

Intersexuality in five pigs, with particular reference to oestrous cycles, the ovotestis, steroid hormone secretion and potential fertility

Reproductive tissues, steroid hormone secretion, and sexual behaviour have been examined in five gilts, in each of which the right gonad was an ovotestis. Although from different females, these animals were sired by the same boar and each possessed an XX sex chromosome constitution as determined by karyotype analysis of blood cells. Despite variable amounts of testicular tissue in the ovotestis and unilateral development of a prominent epididymis, four of the animals had oestrous cycles of normal duration (20-22 days) and extended periods of standing oestrus (3-6 days). The fifth animal did not have detectable oestrous cycles but was extremely aggressive in the presence of a mature boar. Two of the gilts were mated, and there were small numbers of embryos in each uterine horn 23 and 26 days later. Removal of the ovary did not prompt compensatory hypertrophy in the ovarian portion of the ovotestis, nor did injection of pregnant mare serum gonadotrophin stimulate detectable follicular growth in ovarian tissue adjoining testicular tissue. Concerning the aetiology of this intersex condition, the unilateral appearance of an ovotestis precludes any simple involvement of a translocated portion of the Y chromosome or systemic effects of unusual titres of the putative H-Y antigen. However, bearing in mind a predisposition to gonadal asymmetry in eutherian mammals, a case is advanced for apposition or incorporation of adrenocortical tissue in the right embryonic ovary. The resultant virilization of neighbouring reproductive tissues would stem from adrenocortical androgen synthesis.

Urinary steroid metabolites in subjects with male pseudohermaphroditism due to 5 alpha-reductase deficiency

To investigate the enzymatic basis for abnormal steroid metabolism in subjects with male pseudohermaphroditism due to 5 alpha-reductase deficiency, the ring A reduced urinary 5 beta and 5 alpha metabolites of testosterone, androstenedione, 11 beta-hydroxyandrostenedione, cortisol and corticosterone were measured by gas chromatography. Assays of the four pairs of urinary 5 beta and 5 alpha steroid metabolites revealed decreased conversion of the parent steroids to 5 alpha-reduced urinary metabolites, with increased 5 beta to 5 alpha urinary steroid metabolite ratios. These studies establish that increased urinary 5 beta/5 alpha ratios are distinctive for this disorder, and represent the most reliable method for confirming the diagnosis of primary inherited 5 alpha-reductase deficiency. These data also suggest that the conversion on the many delta 4-3 ketosteroids to 5 alpha-reduced steroids may be due to a single enzyme with broad specificity, or multiple enzyme reductases with a common regulator.

Somatomedin response to testosterone stimulation in children with male pseudohermaphroditism, cryptorchidism, anorchia, or micropenis

Somatomedin-C (Sm-C) levels increase during puberty. To determine if testosterone could play a role in the pubertal Sm-C increase, 17 boys with low levels of endogenous testosterone (80 ng/dl) were studied before and 7 days after im testosterone treatment. The serum testosterone levels achieved were comparable to those found during normal puberty in most instances. After parenteral testosterone administration, serum somatomedin activity (bioassay) increased in 9 patients (from 10-56% above basal levels) and decreased in 3 (from 3.2-20.3% below basal levels); overall, there was a significant 19.2% increase (P less than 0.02). Testosterone per se did not induce an increase in bioassayable Sm, since its addition to serum failed to cause increments in activity. After im testosterone treatment, serum Sm-C levels (determined by RIA) increased in every patient studied. The mean percent increase above basal levels was 108% (range, 14-202%; n = 10; P less than 0.001). Mean serum GH increased significantly (P less than 0.05) from 4.9 ng/ml before exogenous testosterone to 12.0 ng/ml afterward. The data show that parenteral testosterone administration can increase serum Sm activity and Sm-C, probably through increased pituitary GH secretion, and this response occurs in boys ranging in age from 0.24-14.57 yr.

Plasma androgens during the luteal phase in a case of true hermaphroditism with bilateral ovotestis

A true hermaphrodite with a bilateral ovotestis and a 46 XX karyotype was studied. This 14-year old subject developed ambiguous puberty with bilateral gynecomastia and stage IV public hair. Relatively high level of testosterone (T) (2.80 ng/ml), was found. The 5 alpha-reductase activity for T in the pubic skin was similar to that observed in normal adult males. A hemorrhagic corpus luteum in the left ovotestis was observed at laparotomy. The luteal phase immediately after dexamethasone administration (1 mg/day for 7 days) was characterized by a significant decrease of plasma androgens, T and androstenedione (A). The constantly low level of T (0.30 ng/ml) during the luteal phase in this subject did not appear to be due to the previously administered dexamethasone. This decrease of T production in the luteal phase might be secondary either to the increase of the estradiol-17 beta (E2) secreted by the corpus luteum or to the decrease of LH levels. Both mechanisms might act concomitantly.

Pituitary and gonadal function in pubertal and adult male rabbits with pseudohermaphroditism secondary to immunization of mothers against testosterone

Pituitary and testicular function was studied in pubertal and adult rabbits with pseudohermaphroditism secondary to immunization of mothers against testosterone. Circulating testosterone, LH and FSH levels showed a developmental pattern during sexual maturation, similar to that observed in controls. Plasma FSH levels were elevated in male pseudohermaphrodites despite normal plasma testosterone concentrations. Fighting, male sexual behaviour and coitus occurred normally as in controls. The testicular response to endogenous elevated LH levels and the pituitary LH and FSH responses to LRH injection and to castration were similar in affected males and in controls. These observations suggest that inhibition of the central effects of androgens during the embryonic and perinatal period has little or no effect on the differentiation and maturation of the hypothalamo-pituitary-testicular axis in rabbit.

Morphological and hormonal features of an ovine and a caprine intersex

A caprine and an ovine intersex were examined to compare their morphological and hormonal features in light of their cytogenetic make-up. Both animals, registered as females at birth, developed male-like appearance and behaviour as they approached the age of sexual maturity. Plasma testosterone concentrations in the intersexes were similar to those in adult males of the respective species. Cytogenetic analyses showed male and female cells in the blood while cultures of solid tissue contained only female cells suggesting that both were blood chimeras similar to the bovine freemartins.

[Morphologic and hormonal correlates of true hermaphroditism in the rabbit]

A macro-microscopical and histological investigation of the urogenital system organs of a rabbit-hermophrodite has been performed with an aim to compare the content of sex steroids in the peripheral and in the gonadal blood estimated by means of radioimmunological methods. Certain anomalies have been found out in the development of external and internal sex organs, kidneys and urinary bladder. Testosterone and estradiol concentration in blood flowing from the ovotestis is decreased, as it is in the periphral blood. The rabbit urogenital system organs have been studied from the 12th day of the intrauterine development up to the 10th day of the postnatal life. The results of the investigation performed make it possible to consider that the developmental anomalies in the rabbit-hermophrodite have, evidently, appeared between the 20th--25th days of its intrauterine development as a result of certain disbalance of sex steroids.

Serum lactic dehydrogenase: a tumor marker of ovarian dysgerminoma in a female pseudohermaphrodite

A case of a female pseudohermaphrodite who presented with a large ovarian dysgerminoma is reported. Preoperatively, markedly elevated levels of serum lactic dehydrogenase (LDH) were noted. After complete excision of the tumor, serum levels of LDH returned to normal levels. Only five other cases of dysgerminoma with elevated serum LDH have been reported. In each case, as in the present one, LDH levels were significantly higher than in any other ovarian tumor. LDH can be considered as an enzymatic tumor marker of ovarian dysgerminoma, for diagnosis, prognosis, and surveillance.

Leydig cell hypoplasia causing male pseudohermaphroditism: diagnosis 13 years after prepubertal castration

An 11-yr-old patient with male pseudohermaphroditism who was castrated at nine days of age and raised thereafter as a female was evaluated to determine the cause of abnormal sexual differentiation. Stimulation with ACTH for 8 h revealed no abnormality in the biosynthesis of cortisol or adrenal androgens. The administration of fluoxymesterone (10 mg, orally, daily) for 5 weeks at age 13 yr led to significant decrements in serum levels of sex steroid-binding globulin and T4-binding globulin to a degree similar to that found in 2 normal men, but no change in the basally elevated levels of FSH and LH. LH bioactivity was normal in the rat Leydig cell bioassay. Skin fibroblasts cultured from a labial skin biopsy revealed normal 5 alpha-reductase activity and normal androgen receptors. Reexamination of the original testis specimens by light microscopy failed to reveal Leydig cells. Furthermore, when immunoperoxidase staining for testosterone was performed on the tissue sections, only 30-35 positive cells/10 high power fields were seen. In contrast, examination of testis sections from 4 male infants who died of other causes revealed 94-836 cells/10 high power fields that stained positively for testosterone. Although hCG stimulation testing to confirm Leydig cell hypoplasia could not be done in this patient because of previous castration, this patient demonstrates that the diagnosis can be made without it by the use of immunohistochemical stains and in vivo and in vitro tests to exclude other disorders of androgen biosynthesis or androgen action.