First-trimester determination of fetal gender by ultrasound: measurement of the ano-genital distance

Association between maternal androgen levels and early fetal sex differentiation: Anogenital distance and genital tubercle length in the first trimester

PURPOSE

To evaluate the use of anogenital distance (AGD) and genital tubercle length (GTL) between 11 and 13 + 6 weeks of gestation for fetal sex determination and to assess the impact of maternal androgen levels on these measurements.

METHODS

A cross-sectional study was conducted from February to June 2017 with patients undergoing first trimester Down syndrome screening. Inclusion criteria were: (1) female age 18-49, (2) gestational age between 11 and 13 + 6 weeks, (3) optimal visualization of AGD and GTL, and (4) nonsmoking status. Maternal androgen levels (total testosterone, free testosterone, androstenedione, and dehydroepiandrostenedione) were measured simultaneously with ultrasound.

RESULTS

AGD was significantly higher in male fetuses compared to females. With a cutoff of 5.0 mm, fetal sex was identified in 82 % of female fetuses and 70 % of male fetuses after the 12th week. Linear regression analysis showed that only AGD was a significant predictor of fetal sex (β: 0.54, p < 0.001). In the 12-12 + 6 week group, a positive correlation between AGD and maternal androstenedione was found in female fetuses (r: 0.23, p = 0.038). In contrast, negative correlations were observed between AGD and both androstenedione (r: -0.475, p < 0.001) and total testosterone (r: -0.282, p = 0.026) in male fetuses.

CONCLUSION

AGD and GTL measurements show sexual dimorphism in the first trimester, with AGD correlating positively with maternal androstenedione in females and negatively in males. These findings suggest that AGD and GTL are reliable, non-invasive methods for early fetal sex determination.

Effectiveness of prenatal ultrasound in fetal sex identification: a systematic review and meta-analysis

This systematic review and meta-analysis aimed to assess the accuracy and success rate of ultrasound in determining fetal sex. A search was conducted on Medline, Cochrane Library, and EMBASE databases, and the reference lists of selected studies were also reviewed. Meta-analyses were performed using Revman 5.4.1 and Meta-DiSc 2.0. Twenty-eight studies met the criteria for inclusion in the systematic review. Nine studies reported the accuracy rate of first-trimester fetal sex identification, with a mean accuracy of 85% and a median of 87%. Six studies provided accuracy rates for second and third-trimester identifications, with mean and median rates of 92% and 99%, respectively. A pooled sensitivity and specificity analysis shows that the sensitivity increased from 69% at 11 weeks to 89% at 12 weeks to 96% at 13 weeks. Forest plots on the success rates indicated no significant statistical differences between first-trimester ultrasound sex determination and actual birth sex, with p values of 0.06 for males and 0.08 for females. Similarly, second and third-trimester forest plots showed p values of 0.70 for males and 0.14 for females. In conclusion, ultrasound accuracy for fetal sex determination rises from 87% in first to 99% in second trimesters. The success rate shows no significant difference for either trimester. However, male sex is more easily detected in the second and third trimesters, while female sex is more easily detected in the first trimester. The sensitivity of fetal sex detection in the first trimester increases with gestational age. These findings suggest that prenatal ultrasound sex determination can be useful in managing sex-related pregnancy complications.

Longitudinal Evaluation of Fetal and Infant AGD in Healthy Children: Association With Penile Size, Testosterone, and DHT

CONTEXT

The anogenital distance (AGD) is considered a postnatal readout of early fetal androgen action. Little is known of prenatal AGD and how it correlates with AGD postnatally.

OBJECTIVE

We present longitudinal measurements of fetal and infant AGD. We evaluate the impact of testosterone and dihydrotestosterone at minipuberty on AGD and penile size.

METHODS

We performed secondary analyses of an observational, prospective pregnancy and birth cohort, COPANA (2020-2022), at Copenhagen University Hospital-Rigshospitalet, enrolling 685 healthy, singleton pregnant women, of whom 657 attended third trimester ultrasound and 589 infants completed follow-up. Fetal AGD was measured at third semester ultrasound (gestational week 29-34), and infant AGD, penile width, stretched penile length, and circulating testosterone and dihydrotestosterone (LC-MS/MS) were assessed at the minipuberty clinical examination (approximately 3.5 months postpartum).

RESULTS

AGD was available in 650/657 fetuses (310 boys) and 588/589 infants (287 boys). Boys had longer fetal and infant AGD than girls; fetal AGDas: mean (SD) 21.4 mm (±3.5), fetal AGDaf: 12.8 mm (±2.3), P < .001, infant AGDas: 32.0 mm (±5.6) and infant AGDaf: 15.8 (±3.3), P < .001. Fetal AGD correlated with infant AGD in boys and girls (Spearman r = .275, P < .001 and r = .189, P = .001 respectively), but not with circulating testosterone or dihydrotestosterone at minipuberty. Penile size correlated positively with circulating androgen levels at minipuberty: stretched penile length vs testosterone: r = .235, P < .001.

CONCLUSION

AGD is sexually dimorphic already in the third trimester. Fetal and infant AGD correlate. AGD is associated with body size but not circulating androgen levels at minipuberty. These findings suggest that fetal and infant AGD reflect androgen action during early fetal development.

The Predictive Accuracy of Anogenital Distance and Genital Tubercle Angle for First-Trimester Fetal Sex Determination

BACKGROUND

Early identification of fetal gender is crucial for managing gender-linked genetic disorders. This study aimed to evaluate the predictive performance of anogenital distance (AGD) and genital tubercle angle (GTA) for fetal sex determination during the first trimester.

METHODS

A multicenter retrospective cohort study was conducted on 312 fetal cases between 11 and 13 + 6 weeks of gestation from two tertiary hospitals. AGD and GTA measurements were taken from midsagittal plane images using ultrasound, with intra- and inter-reader reproducibility assessed. Binomial logistic regression and ROC curve analysis were employed to determine the diagnostic performance and optimal cutoff points.

RESULTS

AGD had a mean of 7.16 mm in male fetuses and 4.42 mm in female fetuses, with a sensitivity of 88.8%, specificity of 94.4%, and an area under the ROC curve (AUC) of 0.931 (95% CI: 0.899-0.962) using 5.74 mm as a cutoff point. For GTA, the mean was 35.90 degrees in males and 21.57 degrees in females, with a sensitivity of 92%, specificity of 84.7%, and an AUC of 0.932 (95% CI: 0.904-0.961) using 28.32 degrees as a cutoff point. The reproducibility results were excellent for AGD (intra-operator ICC = 0.938, inter-operator ICC = 0.871) and moderate for GTA (intra-operator ICC = 0.895, inter-operator ICC = 0.695).

CONCLUSIONS

The findings suggest that AGD and GTA are reliable markers for early fetal sex determination, with AGD showing higher reproducibility. The findings highlight the feasibility and accuracy of these non-invasive sonographic markers and their potential usefulness in guiding timely interventions and enhancing the management of gender-linked genetic conditions.

First trimester identification of fetal sex by ultrasound

PURPOSE

The hypothesis was fetal sex determination by ultrasound at 11-14 weeks' gestation has sufficient accuracy to be clinically relevant.

METHODS

Fetal sex assessment by transabdominal ultrasound was performed in 567 fetuses at 11-14 weeks' gestation (CRL: 45-84 mm). A mid-sagittal view of the genital region was obtained. The angle of the genital tubercle to a horizontal line through the lumbosacral skin surface was measured. The fetus was assigned male sex if the angle was > 30°, and female sex if the genital tubercle was parallel or convergent (< 10°). At an intermediate angle of 10-30°, the sex was not assigned. The results were divided into three categories based on gestational age: 11 + 2 to 12 + 1, 12 + 2 to 13 + 1, and 13 + 2 to 14 + 1 weeks' gestation. To establish its accuracy, the first trimester fetal sex determination was compared to fetal sex determined on a mid-second trimester ultrasound.

RESULTS

Sex assignment was successful in 534/683 (78%) of the cases. The overall accuracy of fetal sex assignment across all gestational ages studied was 94.4%. It was 88.3%, 94.7%, and 98.6% at 11 + 2 to 12 + 1, 12 + 2 to 13 + 1, and 13 + 2 to 14 + 1 weeks' gestation, respectively.

CONCLUSION

Prenatal sex assignment at the time of first trimester ultrasound screening has a high accuracy rate. The accuracy improved with increasing gestational age, which suggests that if clinically important decisions, such as chorionic villus sampling, are to be made based on fetal sex, they should be delayed until the latter part of the first trimester.

Imaging in fetal genital anomalies

Genital anomalies are a heterogeneous group of congenital pathologies that have become increasingly relevant since the Chicago Consensus of 2005. Their postnatal diagnosis has developed significantly in the last two decades, while prenatal diagnosis seems to be underdeveloped, with few protocols available, fragmented scientific literature, and low diagnostic rates. This review aims to examine the current status of this subspecialty from the perspective of prenatal imaging. Indications for the evaluation of fetal genitalia can be divided into medical and non-medical reasons. Medical reasons include sex-linked disorders, detection of other anomalies, relevant family history, or multiple pregnancy. Non-medical reasons include parental request for sex disclosure. Disclosure of fetal sex may be associated with ethical, legal, and medical issues. The main imaging technology used is 2D ultrasound, although there are other complementary techniques such as 3D, MRI, or Color Doppler. Regarding working methodology, several authors have drawn attention to the lack of standardized protocols and guidelines. Most guidelines tend to limit their recommendations to study indications and ethical issues. Technical proposals, measurements, or working methods have not yet been standardized. Fetal sex determination is usually divided into early and late gestation. Early gestation is based on the sagittal sign. Late gestation is based on direct visualization. There are several measurements to describe male and female genitalia, such as penile length, bilabial diameter, or scrotal diameter. Prenatal diagnosis of genital pathologies presents some particularities such as the wide spectrum of phenotypes, the high frequency of associated deformities, or the time of diagnosis. Some of the most frequent pathologies are ambiguous genitalia, fetal sex discordance, hypospadias, micropenis, clitoromegaly, ovarian cysts, hydro(metro)colpos, and cloacal anomalies. Higher-quality studies and direction from scientific societies through the implementation of clinical guidelines are needed.

Clinical spectrum of female genital malformations in prenatal diagnosis

Introduction

Fetal genital malformations represent a rare and heterogeneous group of congenital malformations of the disorders of sexual development (DSD) spectrum.

Methods

A thorough literature review on the main topics in the prenatal approach towards DSD was conducted.

Results

First, a thorough overview on prenatal characteristics of the most common fetal genital malformations of ovaries, uterus and external genitalia, and second, a standardized approach for differential diagnosis in the presence of direct and indirect prenatal signs of DSDs.

Conclusions

This review is mainly directed towards the aspects of female genital malformations with  aspects of male DSD explained as well to aid in the prenatal differential diagnosis.

Androgens and the masculinization programming window: human-rodent differences

Human male reproductive disorders are common and may have a fetal origin - the testicular dysgenesis syndrome (TDS) hypothesis. In rats, experimentally induced TDS disorders result from disruption of fetal androgen production/action specifically in the masculinization programming window (MPW). MPW androgen action also programs longer anogenital distance (AGD) in male versus female rats; shorter male AGD is correlated with risk and severity of induced TDS disorders. AGD thus provides a lifelong, calibrated readout of MPW androgen exposure and predicts likelihood of reproductive dysfunction. Pregnant rat exposure to environmental chemicals, notably certain phthalates (e.g. diethyl hexl phthalate, DEHP; dibutyl phthalate, DBP), pesticides or paracetamol, can reduce fetal testis testosterone and AGD and induce TDS disorders, provided exposure includes the MPW. In humans, AGD is longer in males than females and the presumptive MPW is 8-14 weeks' gestation. Some, but not all, epidemiological studies of maternal DEHP (or pesticides) exposure reported shorter AGD in sons, but this occurred at DEHP exposure levels several thousand-fold lower than are effective in rats. In fetal human testis culture/xenografts, DEHP/DBP do not reduce testosterone production, whereas therapeutic paracetamol exposure does. In humans, androgen production in the MPW is controlled differently (human chorionic gonadotrophin-driven) than in rats (paracrine controlled), and other organs (placenta, liver, adrenals) contribute to MPW androgens, essential for normal masculinization, via the 'backdoor pathway'. Consequently, early placental dysfunction, which is affected by maternal lifestyle and diet, and maternal painkiller use, may be more important than environmental chemical exposures in the origin of TDS in humans.

Fetal anogenital distance using ultrasound

OBJECTIVE

This study measured anogenital distance (AGD) during late second/early third trimester of pregnancy to confirm previous findings that AGD can be measured noninvasively in the fetus using ultrasound and further showed differences in reference ranges between populations.

METHOD

Two hundred ten singleton pregnancies were recruited at the Rosie Hospital, Cambridge, UK. A 2D ultrasound was performed between 26 and 30 weeks of pregnancy. AGD was measured from the centre of the anus to the base of the scrotum in males and to the posterior convergence of the fourchette in females.

RESULTS

A significant difference in AGD between males and females (P < .0001) was found, replicating previous results with a significant correlation between estimated fetal weight (EFW) and AGD in males only (P = .006). A comparison of AGD using reference data from an Israeli sample (n = 118) and our UK sample (n = 208) showed a significant difference (P < .0001) in both males and females, after controlling for gestational age (GA).

CONCLUSION

Our results confirm that AGD measurement in utero using ultrasound is feasible. In addition, there are strong sex differences, consistent with previous suggestions that AGD is influenced by prenatal androgen exposure. AGD lengths differ between the UK and Israel; therefore, population-specific normative values may be required for accurate clinical assessments.

First trimester determination of fetal gender by ultrasonographic measurement of anogenital distance: A cross-sectional study

Background

In some patients with a family history of the gender-linked disease, determination of the fetal gender in the first trimester of pregnancy is of importance. In X-linked recessive inherited diseases, only the male embryos are involved, while in some conditions, such as congenital adrenal hyperplasia, female embryos are affected; hence early determination of fetal gender is important.

Objective

The aim of the current study was to predict the gender of the fetus based on the accurate measurement of the fetal anogenital distance (AGD) by ultrasound in the first trimester.

Materials and Methods

To determine the AGD and crown-rump length in this cross-sectional study, 316 women with singleton pregnancies were exposed to ultrasonography. The results were then compared with definitive gender of the embryos after birth.

Results

The best cut-off for 11 wk to 11 wk, 6 days of pregnancy was 4.5 mm, for 12 wk to 12 wk, 6 days was 4.9 mm, and for 13 wk to 13 wk, 6 days was 4.8 mm.

Conclusion

AGD is helpful as an ultrasonographic marker that can determine fetal gender in the first trimester, especially after 12 wks.

Anogenital Distance and Perineal Measurements of the Pelvic Organ Prolapse (POP) Quantification System

Anogenital distance (AGD) is a sexually dimorphic attribute, twice longer in males than in females, and a marker of intrauterine hormonal environment. Interest in AGD measurements is increasing due to mounting evidence on their potential clinical implications. A parallel set of perineal measurements, the Pelvic Organ Prolapse Quantification System (POP-Q), include similar, but not exactly the same, landmarks: the perineal body (PB) and the genital hiatus (GH) lengths. However, clinical reproducibility of both perineal measurements and their usefulness to describe perineal anthropometry needs to be elucidated. To our knowledge, there is no publication in video format showing the methodology of these measurements. The main objective of this work is to show how to properly perform perineal anthropometry, including measurements of the AGD in its two variants [anoclitoral (AGDAC) and anofourchette (AGDAF)], genital hiatus (GH) and perineal body (PB). Moreover, we explored if there were differences in these measurements in women with and without Pelvic Organ Prolapse (POP). We research whether the anthropometric characteristics of the perineum, such as AGD (which is determined prenatally), may be altered in these women and be an independent etiological factor for pelvic floor dysfunction. We show two different ways of measuring perineal lengths, as they might be quite comparable. Our suggestion is that unifying perineal measurements could be useful for clinical and biomedical investigation. More studies are needed in order to compare GH and PB measurements and its AGD counterparts to analyze which procedures are more reproducible with less intra and interobserver variability.

Accuracy of fetal sex determination in the first trimester of pregnancy using 3D virtual reality ultrasound

PURPOSE

Early detection of fetal sex is becoming more popular. The aim of this study was to evaluate the accuracy of fetal sex determination in the first trimester, using 3D virtual reality.

METHODS

Three-dimensional (3D) US volumes were obtained in 112 pregnancies between 9 and 13 weeks of gestational age. They were offline projected as a hologram in the BARCO I-Space and subsequently the genital tubercle angle was measured. Separately, the 3D US aspect of the genitalia was examined for having a male or female appearance.

RESULTS

Although a significant difference in genital tubercle angles was found between male and female fetuses, it did not result in a reliable prediction of fetal gender. Correct sex prediction based on first trimester genital appearance was at best 56%.

CONCLUSION

Our results indicate that accurate determination of the fetal sex in the first trimester of pregnancy is not possible, even using an advanced 3D US technique.

An appropriate way to predict fetal gender at first trimester: anogenital distance

BACKGROUND

Using anogenital distance to determine fetal sex is a new method. There is only one study in the literature. We predict that it will pass through the literature as a new method that can be used in determining fetal sex especially in first trimester.

INTRODUCTION

Determination of fetal gender before birth has been a matter of curiosity for both the family and the clinician. In the presence of gender-linked genetic disease, it becomes an obligation instead of an interest. The aim of this study was to determine the fetal gender accurately at first trimester with anogenital distance (AGD) and to investigate the correlations of nuchal translucency (NT), fetal heart rate (FHR), and crown-rump length (CRL) with AGD.

MATERIALS AND METHODS

In this prospective cross-sectional study, AGD measurement was performed in 111 patients with singleton pregnancy from 11 to 13 weeks and 6 days (CRL 45-84 mm). Measurements of AGD ≥4.8 mm were identified for males, and AGD <4.8 mm for females.

RESULTS

Genders were demonstrated accurately for males as 76.7% and for females as 97.1%. The mean value of AGD was 3.6 mm for females and 5.1 mm for males. There were no relations between fetal gender and FHR and also NT.

CONCLUSIONS

Gender can be detected with great accuracy in gestations between 11 to 13 weeks and 6 days by using AGD. CRL and gestational week (GW) were determined as nonsignificant predictors of fetal gender by AGD measurement. In order to obtain more accurate results with AGD, consideration of further studies with larger series in different races is recommended.