A novel morphological approach to gonads in disorders of sex development

BDE-209 toxicity: From spermiogenesis to sexual maturity in F1 male mice

Most studies of enviromental toxic chemicals focused on the meiosis stage during spermatogenesis, however, the research on the spermiogenesis damage phenotype of BDE-209 is limited. This study aimed to evaluate the processes by which BDE-209 regulates the formation of acrosomes and mitochondrial sheath (MS), key structures during spermiogenesis and fertilization. ICR mice were divided into control, low, medium, and high-dose BDE-209 groups and treated for 42 days. A comprehensive method combining ultrastructural analysis, transcriptomics, molecular biology, and fertility experiments was adopted. In mice exposed to BDE-209, testicular dysplasia, altered sex hormone concentrations, decreased semen quality, and head and tail deformities occurred. Chromatin condensation failure was present in BDE-209-exposed spermatozoa with decreased mRNA and protein levels of PRM1 and TNP1. BDE-209 disrupts the acrosome biogenesis process by disrupting the Golgi structure and the apical ectoplasmic specialization (ES) structure. BDE-209 exposure caused multiple damage to the MS and down-regulated the mRNA levels of Akap3, Akap4, Cfap44, Ccdc40, Dhah1, etc. These injuries resulted in subfertility in BDE-209 male mice, and the male offspring also exhibited gonadal dysplasia, sex hormonal changes, and decreased semen quality. Conclusively, BDE-209 exposure induced spermiogenesis defects and subfertility. F0 and F1 males showed a similar injury phenotype. This study advanced the understanding of the damage phenotype of spermiogenesis and complemented the reproductive toxicity of F1 male mice. These findings might be important for the study of related molecular mechanisms and the mitigation of BDE-209 exposure on offspring development.

Ultrasonography for disorders of sex development in pediatrics

Objective

This study aimed to evaluate the clinical value of ultrasonography in the management of disorders of sex development (DSDs).

Methods

Ultrasonographic appearance and clinical data of 82 cases with DSD were reviewed retrospectively.

Results

In total, there were 54 cases with the male phenotype and 28 cases with the female phenotype. All 12 cases with ovotesticular DSD were confirmed by surgery or pathological examination. Furthermore, 2 of 12 cases with ovotesticular DSD were misdiagnosed by ultrasonography.

Conclusions

Ultrasonography can not only evaluate the internal sex organs in pediatric patients, but also estimate the type, location, size, and morphology of the gonads, which provides important imaging evidence for clinical diagnosis and treatment.

Ovarian Dynamics and Pathological Conditions in Camelids

Domestic camelids comprise Dromedary, Bactrian (old-world camelids, OWC), alpaca, and Lama (new-world camelids, NWC). They possess unique reproductive physiology distinct from other livestock. A key feature is being induced ovulators, triggered by beta nerve growth factor (βNGF) present in the seminal plasma. Proper ovarian function is crucial for reproductive management and biotechnologies. In the absence of ovulation, camelids display overlapping follicular waves, with puberty and sexual receptivity influenced by factors like weight and age. Follicular growth patterns vary among these species and are better monitored via transrectal ultrasonography. Physiological variations in ovarian dynamics and hormonal activity differ among members of the Camelidae. Understanding these differences is essential for production and conservation efforts, particularly in wild species. Ovarian disorders, including failure to ovulate or respond to therapy, frequently cause subfertility or infertility in affected females. Superstimulatory and synchronisation protocols that rely on exogenous progestin, eCG, and FSH supplementation have been developed to address some causes of irregular ovarian dynamics. This paper reviews the current knowledge on follicular wave dynamics, their manipulation, and the common ovarian disorders affecting reproduction in camelids.

Phenotypic variability and management of patients with mosaic monosomy X and Y chromosome material: a case series

BACKGROUND

we aim to discuss the origin and the differences of the phenotypic features and the management care of rare form of disorder of sex development due to Mosaic monosomy X and Y chromosome materiel.

METHODS

We report our experience with patients harboring mosaic monosomy X and Y chromosome material diagnosed by blood cells karyotypes and cared for in our department from 2005 to 2022.

RESULTS

We have included five infants in our study. The current average age was 8 years. In four cases, the diagnosis was still after born and it was at the age of 15 years in one case. Physical examination revealed a variable degree of virilization, ranging from a normal male phallus with unilateral ectopic gonad to ambiguous with a genital tubercle and bilateral not palpable gonads in four cases and normal female external genitalia in patient 5. Karyotype found 45, X/46, XY mosaicism in patient 1 and 2 and 45, X/46, X, der (Y) mosaicism in patient 3, 4 and 5. Three cases were assigned to male gender and two cases were assigned to female. After radiologic and histologic exploration, four patients had been explored by laparoscopy to perform gonadectomy in two cases and Mullerian derivative resection in the other. Urethroplasty was done in two cases of posterior hypospadias. Gender identity was concordant with the sex of assignment at birth in only 3 cases.

CONCLUSION

Because of the phenotypic heterogeneity of this sexual disorders and the variability of its management care, then the decision should rely on a multidisciplinary team approach.

"Waking up" the sleeping metaphor of normality in connection to intersex or DSD: a scoping review of medical literature

The aim of the study is to encourage a critical debate on the use of normality in the medical literature on DSD or intersex. For this purpose, a scoping review was conducted to identify and map the various ways in which "normal" is used in the medical literature on DSD between 2016 and 2020. We identified 75 studies, many of which were case studies highlighting rare cases of DSD, others, mainly retrospective observational studies, focused on improving diagnosis or treatment. The most common use of the adjective normal was in association with phenotypic sex. Overall, appearance was the most commonly cited criteria to evaluate the normality of sex organs. More than 1/3 of the studies included also medical photographs of sex organs. This persistent use of normality in reference to phenotypic sex is worrisome given the long-term medicalization of intersex bodies in the name of a "normal" appearance or leading a "normal" life. Healthcare professionals should be more careful about the ethical implications of using photographs in publications given that many intersex persons describe their experience with medical photography as dehumanizing.

Early Bilateral Gonadoblastoma in a Patient with Mixed Gonadal Dysgenesis (Karyotype 45,X/46,XY): Case Report and Review of Literature

Background

Mixed gonadal dysgenesis is a rare congenital and challenging condition, characterized mainly by 45,X/46,XY karyotype mosaicism, asymmetrical gonadal development and various internal and external genital anatomy. Because of frequent disorder of genital development and a higher risk of germ cell neoplasia, management of these patients is complex and requires multidisciplinary approach.

Case

We present a 45,X/46,XY mixed gonadal dysgenesis patient diagnosed with gonadoblastoma in both gonads after bilateral gonadectomy at 1 year of age.

Conclusions

Because of high risk for malignant transformation, gonadectomy of a streak-like gonad and biopsy with orchidopexy or gonadectomy of a dysgenetic testicle is recommended at an early age.

Mild androgen insensitivity syndrome: the current landscape

OBJECTIVE

Mild Androgen Insensitivity (MAIS) belongs to the Androgen Insensitivity Syndrome (AIS) spectrum, an X-linked genetic disease that is the most common cause of differences in sex development (DSD). Unfortunately, AIS studies mainly focus on the partial and the complete phenotype, and the mild phenotype (MAIS) has been barely reported. Our purpose is to explore the MAIS facets, clinical features, and molecular aspects.

METHODS

We collected all reported MAIS cases in the medical literature and presented them based on the phenotype and the molecular diagnosis.

RESULTS

We identified 49 different AR mutations in 69 individuals in the literature. We compared the AR mutations presented in MAIS individuals with AR mutations previously reported in other AIS phenotypes (CAIS and PAIS) regarding the type, location, genotype-phenotype correlation, and functional studies.

CONCLUSION

This review provides a landscape of the mild phenotype of AIS. Most MAIS patients present with male infertility. Therefore, AR gene sequencing should be considered during male infertility investigation, even in males with typically male external genitalia. In addition, MAIS can be part of other medical conditions, such as X-linked spinal and bulbar muscular atrophy (Kennedy's disease).

Clinical and Histological Features of Ovarian Hypoplasia/Dysgenesis in Alpacas

Alpacas have a high incidence of congenital reproductive tract abnormalities, including ovarian hypoplasia/dysgenesis. Diagnosis of this condition is often challenging. The present study describes the clinical, ultrasonographic, and histologic features of ovarian hypoplasia/dysgenesis syndrome in 5 female alpacas. Additionally, serum AMH levels were compared between female alpacas diagnosed with ovarian hypoplasia/dysgenesis and a group of reproductively sound females (n = 11). The syndrome was suspected based on the presence of an infantile uterus and lack of ovaries by ultrasonography and laparoscopy. All females had normal female karyotype (n = 74 XX), but one presented a minute chromosome. The ovaries from these cases showed 3 main histological classifications: hypoplasia (n = 2), dysgenesis (n = 2), and dysplasia (n = 1). Serum AMH levels in affected females were significantly lower (P < 0.05) than those of reproductively sound control females. In conclusion, Serum AMH level may be helpful in the rapid diagnosis of ovarian hypoplasia/dysgenesis syndrome in alpacas. Furthermore, this syndrome in alpacas presents a variety of histological features. Different mechanisms may be involved in the derangement of ovarian differentiation. Further studies are needed to elucidate the causes of the syndrome.

Two Sisters with Kallmann Syndrome, Gonadal Dysgenesis, and Multiple Neuromuscular and Endocrine Disorders: Report of Two Cases with Description of an Unusual Association

Kallmann syndrome (KS) is an uncommon genetic disorder characterized by isolated congenital hypogonadotropic hypogonadism (CHH) and anosmia/hyposmia. KS originates from abnormal embryonic migration of olfactory axons and gonadotropin-releasing hormone (GnRH)-synthesizing neurons. It can be challenging to diagnose due to its heterogeneous clinical presentation and genes implied. Herein, we report a rare phenotype of KS in two sisters accompanied by a variety of nonreproductive disorders such as hypoparathyroidism, hypercortisolism, atrophy of the cerebellum, intellectual disability, and remarkably, ovarian dysgenesis. Additionally, both subjects present muscle weakness, exercise intolerance, marked hypotonia and seizures, being suspected, although not fully confirmed, mitochondrial encephalomyopathy. These cases illustrate the heterogeneous clinical presentation and the diagnostic difficulties often found in patients suffering from this condition. These clinical features have never been described before as associated with KS; therefore, we decided to report this novel KS phenotype.

Disorders of Sex Development: Classification, Review, and Impact on Fertility

In this review, the elements included in both sex determination and sex differentiation are briefly analyzed, exposing the pathophysiological and clinical classification of disorders or anomalies of sex development. Anomalies in sex determination without sex ambiguity include gonadal dysgenesis, polysomies, male XX, and Klinefelter syndrome (dysgenesis and polysomies with a female phenotype; and sex reversal and Klinefelter with a male phenotype). Other infertility situations could also be included here as minor degrees of dysgenesis. Anomalies in sex determination with sex ambiguity should (usually) include testicular dysgenesis and ovotesticular disorders. Among the anomalies in sex differentiation, we include: (1) males with androgen deficiency (MAD) that correspond to those individuals whose karyotype and gonads are male (XY and testes), but the phenotype can be female due to different hormonal abnormalities. (2) females with androgen excess (FAE); these patients have ovaries and a 46,XX karyotype, but present varying degrees of external genital virilization as a result of an enzyme abnormality that affects adrenal steroid biosynthesis and leads to congenital adrenal hyperplasia; less frequently, this can be caused by iatrogenia or tumors. (3) Kallman syndrome. All of these anomalies are reviewed and analyzed herein, as well as related fertility problems.

Management of 46,XY Differences/Disorders of Sex Development (DSD) Throughout Life

Differences/disorders of sex development (DSD) are a heterogeneous group of congenital conditions that result in discordance between an individual's sex chromosomes, gonads, and/or anatomic sex. Advances in the clinical care of patients and families affected by 46,XY DSD have been achieved since publication of the original Consensus meeting in 2006. The aims of this paper are to review what is known about morbidity and mortality, diagnostic tools and timing, sex of rearing, endocrine and surgical treatment, fertility and sexual function, and quality of life in people with 46,XY DSD. The role for interdisciplinary health care teams, importance of establishing a molecular diagnosis, and need for research collaborations using patient registries to better understand long-term outcomes of specific medical and surgical interventions are acknowledged and accepted. Topics that require further study include prevalence and incidence, understanding morbidity and mortality as these relate to specific etiologies underlying 46,XY DSD, appropriate and optimal options for genitoplasty, long-term quality of life, sexual function, involvement with intimate partners, and optimizing fertility potential.

Disorders of sex development: Genetic characterization of a patient cohort

Disorders of sex development (DSDs) are congenital conditions in which the external appearance of the individual does not coincide with the chromosomal constitution or the gonadal sex. In other words, there is an ambiguous or intermediate condition between the male and female phenotypes of the anatomical sex. These atypical conditions are manifested in several ways, ranging from genital ambiguity to phenotypes that are so attenuated that they can go unnoticed or appear normal. Currently, there is a lack of understanding of the factors responsible for these outcomes; however, they are likely to be conditioned by genetic, hormonal and environmental factors during prenatal and postnatal development. The present study determined the genetic etiology of DSDs in Colombian patients by conventional cytogenetic analysis, FISH and MLPA (for SF1, DAX1, SOX9, SRY and WNT4). A cohort of 43 patients with clinical phenotypes of sex development disorder was used in the present study. Using this multistep experimental approach, a diagnostic percentage of 25.58% was obtained: 17 patients (39.53%) were classified as having gonadal development disorders, the majority of which were ovotesticular disorders with numerical and/or structural alterations of the sex chromosomes, 9 patients (20.93%) were classified as having testicular DSD with a 46,XY karyotype, and 3 patients (6.98%) as having ovarian DSD with a 46,XX karyotype. The remaining 14 patients (32.56%) were classified as 'other' since they could not be grouped into a specific class of gonadal development, corresponding to hypospadias and multiple congenital anomalies. These findings highlight the importance of histological and cytogenetic studies in a gonadal biopsy. In 11/43 cases, the multistep experimental protocol presented in the present study yielded etiological or histological findings that could be used to define the medical management of patients with DSDs. In conclusion, for the etiological diagnosis of DSDs, a broad‑spectrum approach that includes endocrinological tests, conventional karyotyping, molecular karyotyping by FISH and, molecular tests is required, in addition to gonadal tissue analyses, to identify genetic alterations.

[Atypical genital development and tumor risk]

Atypical genital development (AGD), also called disorders of sex development are a set of miscellaneous pathologies who have in common a morphological and/or functional abnormality of the internal and/or external genital organs. The Chicago classification identifies 3 major groups based on karyotype, hormone balance and genetic studies. Some AGD predispose to the occurrence of tumors, mainly malignant germ cell tumors. The tumor risk depends on many factors: the type of AGD, the position of the gonad, the age of the patient, the phenotype, the function of the gonad and the presence of germ cells in the gonad. AGD with the highest tumor risk are those with gonadal dysgenesis, implying an incomplete differentiation of the bipotential gonad (dysplasia). Monitoring of patients with AGD and indication of prophylactic gonadectomies should be individualized according to tumor risk.