Abstract
Background
Differences/disorders of sex development (DSD) encompass a wide range of conditions. Their clinical spectrum and etiological diagnosis have not been reported in Moroccan patients.
Aims
The study aims to highlight the clinical spectrum, etiological diagnosis, and management of patients with DSD.
Subjects and methods
This is a retrospective study of all patients diagnosed with DSD under the age of 18 years, who were referred to the Pediatric Endocrinology Department and the Medical Genetics Laboratory at HASSAN II University Hospital of Fez between June 2018 and June 2023.
Results
Out of 57 patients, 54.4% (n = 31) were diagnosed with 46,XX DSD, the most common type, while 45.6% (n = 26) had 46,XY DSD. Patients with 46,XX DSD presented earlier than those with 46,XY DSD, at a median age of 0.08 years and 0.96 years, respectively. The most commonly reported complaint was atypical genitalia. At the first presentation, the sex of rearing was already assigned to 26 males and 27 females. All patients with 46,XX DSD were diagnosed with congenital adrenal hyperplasia (CAH) at a median age of diagnosis of 0.92 years. Of these, 11 patients were raised as males. Disorders of androgen action or synthesis were more common in XY patients (69.2%). The consanguinity rate was 46.5%, and there were 19 cases with a positive family history, with 10 siblings having died.
Conclusion
DSD are not rare in Morocco. Overall, CAH remains the most frequent DSD etiology. Molecular genetic analyses are needed to determine the accurate etiological distribution of DSD, especially in XY patients.
Introduction
Differences (or disorders) of sex development (DSD) are defined as congenital conditions in which inconsistencies occur in chromosomal, gonadal, and anatomical (genital) sex development (1). DSD exhibits intricate pathophysiology and remarkable heterogeneity, including diverse phenotypes that impact both the endocrine and reproductive systems (2, 3, 4). This diversity presents a significant challenge for public health, spanning clinical diagnosis, genetic etiology, patient management, and long-term outcomes (5).
These disorders can be detected prenatally during routine obstetrician-gynecologist consultations through ultrasound or often become evident at birth, such as atypical genitalia, bilateral cryptorchidism, perineal hypospadias, bifid scrotum, clitoromegaly, posterior labial fusion, or palpable gonads in a child with a female appearance (3). Others may go unnoticed during childhood and only become apparent in adolescence, such as patients with primary amenorrhea, delayed puberty, infertility, or mismatched sexual characteristics with their assigned sex (3, 4). Once the disorder is recognized, it is important to determine a sex assignment as quickly as possible to prevent any psychological and social trauma. These individuals and their families must be managed by a multidisciplinary team that will decide, based on various considerations, which tests to perform, what diagnosis to establish, and, consequently, which therapeutic approaches to follow. This includes making surgical decisions and determining the appropriate gender.
Data on the incidence and prevalence of DSD are limited (6). However, this incidence is estimated to be about 1:4500 to 1:5000 for newborns with overt atypical genitalia (7, 8). This arises in 1:300 newborns when considering all genital variations, including undescended testes and hypospadias (9). Worldwide, congenital adrenal hyperplasia (CAH) due to 21-hydroxylase (21OH) deficiency is the most common cause of 46,XX DSD, with an estimated incidence of 1 in 14,000–15,000. This varies among regions due to ethnic diversity (10). In Morocco, there are no national guidelines for diagnosing and managing DSD. Nevertheless, suspected cases in newborns, children, or adolescents are referred to a referral hospital where a multidisciplinary team, including pediatric and adolescent endocrinologists, urologists, psychiatrists, gynecologists, and geneticists, is involved. Furthermore, there is no data on the frequency of etiological and clinical characteristics of patients with DSD among the Moroccan population. Thus, our study aimed to assess the clinical spectrum, etiological diagnosis, and management of Moroccan patients with DSD.
Subjects and methods
We conducted a retrospective analysis of all patients under the age of 18 years with suspected DSD. These patients were referred to the Pediatric Endocrinology Department and the Medical Genetics Laboratory at HASSAN II University Hospital of Fez between June 2018 and June 2023. Ethical approval was obtained from the Ethics Committee of the Faculty of Medicine of Rabat, Morocco (CERB 14-24). Written informed consent was obtained from all parents or legal guardians, either during follow-up at the pediatric endocrinology department or during karyotype analysis at the medical genetics laboratory. All parents or legal guardians agreed to take part in this study.
Detailed clinical data were obtained from the patient’s medical records, including age, sex of rearing at the first presentation, reason for initial admission, family history, consanguinity, confirmed etiological diagnosis, presence/absence of Müllerian structures, gonads (by ultrasound and MRI investigations), hypertension, and laboratory findings.
The external genitalia score (EGS) was used to describe the external genitalia in our patients. The EGS includes an evaluation of the presence and location of gonads, the degree of labioscrotal fusion, the size of the genital tubercle, and the position of the urethral meatus (11). The EGS uses a gradual scale from female to male (range 0–12) and was calculated retrospectively from the described clinical features. Patients were categorized as having a suspected DSD if they had overt atypical genitalia or features including isolated perineal hypospadias, isolated micropenis, isolated clitoromegaly, any form of familial hypospadias, isolated bilateral undescended testes, or an EGS of less than 10.5 (11). Additionally, patients with a discrepancy between their genital appearance and karyotype, often identified during investigations for delayed puberty or primary amenorrhea, were included (12). Final gender, treatment type at diagnosis, and age at the first surgical intervention were recorded.
Luteinizing hormone (LH), follicle-stimulating hormone (FSH), anti-Müllerian hormone (AMH), and cortisol levels were assessed by chemiluminescence immunoassay (Cobas® e411 by Roche). Testosterone and 17-hydroxypregnenolone were measured by enzyme-linked fluorescent assay (VIDAS® by BioMérieux) and liquid chromatography-tandem mass spectrometry, respectively. Other adrenal steroids and dihydrotestosterone (DHT) were evaluated by RIA in different European laboratories. A uterus or ovaries are considered small if their length or volume is below the normal values described previously (13). In diffuse hyperplasia, the limbs of the adrenal glands are >5 cm in length and >10 mm in thickness (14).
The appropriate diagnosis was determined through a combination of a medical history review of the physical examination, karyotype evaluation, hormonal levels, serum electrolytes, and radiological findings. We categorized our patients into two primary groups based on their karyotypes: those with 46,XY DSD and those with 46,XX DSD.
In the 46,XX DSD group, the diagnosis of the salt-wasting (SW) form of 21OH deficiency was based on the findings of SW syndrome (abnormal serum electrolytes), atypical genitalia, and a basal 17-hydroxyprogesterone (17OHP) level above 10 ng/mL (15). In the absence of SW syndrome, the simple virilizing (SV) form was considered. Atypical genitalia, elevated 17OHP, and 11-deoxycorticosterone (DOC) levels with hypertension were suggestive of 11β-hydroxylase (11β-OH) deficiency. Atypical genitalia (in both XX and XY patients) with or without salt wasting and a high 17hydroxy-pregnenolone to 17OHP ratio were accepted for 3β-hydroxysteroid dehydrogenase (3β-HSD) deficiency.
In the 46,XY DSD group, prepubertal patients underwent the human chorionic gonadotrophin (hCG) stimulation test. This involved a subcutaneous injection of rhCG (Ovitrelle® 250 μg). The levels of testosterone, DHT, and Δ4-androstenedione (Δ4A) were measured at baseline and 72 h post-injection. A two-fold or more increase in testosterone level indicated functional testicular tissue (16). In patients with normal testosterone and DHT responses to the stimulation test, absence of Müllerian structures, and elevated levels of LH, FSH, and AMH, the diagnosis of androgen insensitivity syndrome (AIS) was suspected. Those with normal female external genitalia appearance were classified as complete AIS (CAIS), while those with genital variations and who showed some phallic growth in response to testosterone therapy might have partial AIS (PAIS) (4). Additionally, a testosterone to DHT ratio greater than 30 and a reduced testosterone to Δ4A ratio (less than 0.8) were suggestive of 5α-reductase deficiency (5-αRD) and 17β-hydroxysteroid dehydrogenase (17β-HSD) deficiency, respectively (17). Gonadal regression syndrome was diagnosed in a patient who showed no testosterone response to the hCG stimulation test and had bilateral anorchia detected by imaging and laparoscopic exploration. In patients exhibiting undermasculinization, underdeveloped or cryptorchid gonads, low baseline levels of AMH and testosterone, normal to elevated levels of LH, and elevated FSH, partial gonadal dysgenesis (PGD) was suspected (4).
Genetic testing (using next-generation sequencing) identified a homozygous missense mutation (NM_000941: c.1370G>A (p.R457H) in exon 12 of the POR gene) in one patient with Cytochrome P450 oxidoreductase (POR) deficiency. Testing for the CYP21A2 gene using Sanger sequencing and multiplex ligation-dependent probe amplification was negative in two patients. Similarly, Sanger sequencing for the AR and SRD5A2 genes was negative in three patients. All genetic tests were conducted in independent laboratories, not in our center’s laboratory. Financial constraints prevented genetic analysis in the remaining patients.
Statistical analysis
The results were presented differently depending on the nature of the data. For non-parametric data, the results were expressed as median (range) values and were analyzed using the Mann–Whitney U test. On the other hand, for parametric data that exhibited normal distribution confirmed by the Shapiro–Wilk test, the data were presented as mean ± s.d. and analyzed using Student’s t-test. Categorical variables were compared between the two groups using the chi-square test. Statistical significance was set at a P-value <0.05. The data were analyzed using SPSS software (Statistical Package for the Social Sciences, version 23; SPSS Inc.).
Results
During the evaluation period, 57 patients were diagnosed with DSD due to a range of underlying etiologies. Of these, 54.4% (n = 31) were diagnosed with 46,XX DSD, while 45.6% (n = 26) were diagnosed with 46,XY DSD.
Age, sex, and complaints at first presentation
At presentation, the overall median age was 0.17 (0.01–18) years. Notably, patients in the 46,XX DSD group tended to present earlier, at a median age of 0.08 (0.01–15) years, compared to those in the 46,XY DSD group, who had a median age of 0.96 (0.01–18) years (P = 0.023, P < 0.05) (Table 1). With regard to the sex of rearing at the first presentation, 45.6% (n = 26) of patients were already assigned as male and 47.4% (n = 27) as female. Four patients were not assigned a social sex at their first admission. Within the 46,XX DSD subset, notably, 11 patients (35.48%) out of 31 cases were raised as male, while 20 patients (64.52%) were raised as female. Seven cases (26.92%) were assigned females in the 46,XY DSD group.
Distribution of age, sex at first presentation, consanguinity, and family history of patients with DSD.
| 46,XX DSD n (%) | 46,XY DSD n (%) | Total DSD n (%) | |
|---|---|---|---|
| 31 (54.4) | 26 (45.6) | 57 (100) | |
| Age median (range) year | 0.08 (0.01–15) | 0.96 (0.01–18) | 0.17 (0.01–18) |
| Sex at first presentation | |||
| Male | 11 (35.48) | 15 (57.7) | 26 (45.6) |
| Female | 20 (64.52) | 7 (26.92) | 27 (47.4) |
| Not assigned | 0 | 4 (15.38) | 4 (7) |
| Parental consanguinity | 11/20 (55) | 9/23 (39.1) | 20/43 (46.5) |
| Positive family history | 15 cases | 4 cases | 19 cases |
The primary reason for hospital admission in both the 46,XX DSD and 46,XY DSD groups was atypical genitalia, accounting for 58% (n = 18) and 42.3% (n = 11) of cases, respectively. This condition constituted 50.8% of all admission complaints, followed by SW or adrenal crisis, representing 21% (n = 12) of cases (Fig. 1).
Distribution of patient’s study by the primary reason for admission. AC/SW, adrenal crisis/salt wasting; IWG, insufficient weight gain.
Citation: Endocrine Connections 13, 10; 10.1530/EC-24-0236
Consanguinity and family history
A history of parental consanguinity was reported in 20 cases (46.5%) out of 43 families. The proportion of reported parental consanguinity was 55% among patients with 46,XX DSD and 39.1% in the 46,XY DSD group; however, this difference was not statistically significant (P = 0.29, P > 0.05). The status of parental consanguinity was not available in eight cases. Remarkably, a positive family history of similar conditions was reported in 33.3% (19/57) of cases involving 13 families (Table 1). Interestingly, it was noted that ten children died due to various causes within these families; six due to dehydration and SW (age range: 1 day to 3 months), one due to unexplained discontinuation of hydrocortisone treatment (age of 7 years), and in three cases, the cause was not reported (age range: 1 month to 11 years).
46,XX DSD group
Out of 31 patients diagnosed with 46,XX DSD, 74.19% (23 patients) were found to have 21OH deficiency, 9.7% (3 patients) had 11β-OH deficiency, 6.4% (2 patients) had 3β-HSD deficiency, and one patient was diagnosed with POR deficiency. Two patients (6.45%) did not receive a definitive diagnosis. The etiologies and clinical characteristics are summarized in Table 2.
Etiologies and clinical characteristics of patients with 46,XX DSD.
| 46,XX DSD | n (%) | Median (range) age at diagnosis, year | Clinical characteristics |
|---|---|---|---|
| 31 (100) | 0.92 (0.01–16) | ||
| SV form of 21OH deficiency | 12 (38.71) | 1.5 (0.17–14) | Atypical genitalia, isolated clitoromegaly, hypoglycemia, hyperpigmentation, hirsutism, acne |
| SW form of 21OH deficiency | 11 (35.48) | 0.17 (0.01–2) | Atypical genitalia, SW, isolated clitoromegaly, hyperpigmentation |
| 11β-OH deficiency | 3 (9.68) | 4 (0.33–15) | Isolated clitoromegaly, hypertension, hirsutism, acne |
| 3β-HSD deficiency | 2 (6.45) | 2.5 (1–4) | Atypical genitalia, adrenal crisis |
| POR deficiency | 1 (3.23) | 16 | Atypical genitalia |
| Unknown etiologies | 2 (6.45) | – | Atypical genitalia |
HSD, hydroxysteroid dehydrogenase; OH, hydroxylase; SV, simple virilization; SW, salt wasting.
Among 23 patients with 21OH deficiency, 12 (35.48%) had the SV form, and 11 (38.71%) had the SW form. Most of these patients were identified during the neonatal period or within the first few years of life. However, a notable exception concerns two patients, one reared as male and the other as female, who were presented at a very late age of 7 and 14 years, respectively. Both were diagnosed with the SV form, initially presenting due to atypical genitalia and primary amenorrhea, respectively. The clinical data showed that 11 patients (11/23) were encountering significant symptoms, including dehydration, vomiting, diarrhea, and SW/adrenal crisis, which led to multiple hospitalizations. Physical examination showed varying degrees of atypical genitalia with a median EGS value of 6 (range: 1–8.5). Radiological investigation revealed that three patients with the SV form had a hypoplastic uterus, along with an ovarian cyst in two of them. One patient with the SW form had a small uterus (<1.2 cm in length) and small ovaries (<0.4 mL in volume). Adrenal hyperplasia was detected in two patients (enlarged by 5 mm). All patients diagnosed with 21OH deficiency showed significantly elevated basal levels of 17OHP ranging between 85 and 1500 (ng/mL) (<2.5).
Three females from two unrelated families, diagnosed with 11β-OH deficiency, presented with clitoromegaly either at birth or during their first year of life, except for one female who developed hypertension at the age of 15 and exhibited a masculine morphotype along with symptoms of acne and hirsutism. Biochemically, elevated levels of DOC > 3751 (pg/mL) (<300) and reduced cortisol concentrations <3.22 (µg/dL) (5.98–18.25) were found in these patients. Moreover, two of the unrelated females displayed both hypertension and decreased levels of blood potassium.
A 1.5-month-old and 1.5-year-old female were presented due to an adrenal crisis. They had atypical genitalia (both had an EGS of 5). The suspicion arose that the diagnosis might be CAH due to 3β-HSD deficiency, primarily because of the elevated ratios of 17OH-pregnenolone 8.2 (ng/mL) (0.1–2.4) and 3.67 (ng/mL) to 17OHP 2 (ng/mL) and 0.1 (ng/mL), respectively. 21OH deficiency was excluded due to negative genetic testing of the CYP21A2 gene.
A 15-year-old patient reared as male was admitted for an evaluation of atypical genitalia (EGS of 6.5). Additionally, the patient had reached Tanner stage V in breast development. Ultrasound and MRI scans revealed the presence of a small-sized uterus, a vaginal cavity, and bilateral ovarian cysts. Biochemical results for his age had shown that he had hypokalemia, normal levels of testosterone 0.33 (ng/mL) (0.1–0.75), and cortisol 10.4 (µg/dL) (5.98–18.25). Plasma DHEAS level was also normal at 97.6 (µg/dL) (8.6–250). The patient was genetically confirmed to have POR deficiency. Following discussions with both the parents and the patient, a decision was made not to pursue a sex change to female as psychological evaluations affirmed the patient’s current male gender orientation. As a result, the patient underwent a hysterectomy, bilateral salpingo-oophorectomy, and bilateral mastectomy at the age of 16 and subsequently initiated testosterone replacement therapy.
46,XY DSD group
In this study, 26 patients were identified with the 46,XY karyotype. Of these, 69.2% (n = 18) were suspected of having disorders related to androgen action or synthesis, while 7.7% (n = 2) were diagnosed with disorders of gonadal development. In six patients (23.1%), a definitive diagnosis could not be established, and they remain under investigation (Table 3).
Etiologies and clinical characteristics of patients with 46,XY DSD.
| 46,XY DSD | n (%) | Median (range) age at diagnosis, year | Clinical characteristics |
|---|---|---|---|
| 26 (100) | 5 (0.17–18.5) | ||
| Disorders in androgen action or synthesis(n = 18) | |||
| CAIS | 4 (15.4) | 16.75 (9–18.5) | Female genitalia, primary amenorrhea |
| PAIS | 2 (7.7) | 1.95 (1.4–2.5) | Atypical genitalia |
| 3β-HSD deficiency | 5 (19.2) | 2 (0.2–5) | Atypical genitalia, adrenal crisis, hypoglycemia, salt wasting |
| 17β-HSD deficiency | 2 (7.7) | 3.25 (1.5–5) | Atypical genitalia |
| 5-α reductase deficiency | 1 (3.8) | 3 | Atypical genitalia |
| Not classified | 4 (15.4) | – | Atypical genetalia |
| Disorders of gonadal development (n = 2) | |||
| Gonadal regression syndrome | 1 (3.8) | 7 | Isolated micropenis |
| Partial gonadal dysgenesis | 1 (3.8) | 3 | Atypical genitalia |
| Unknown etiologies | 6 (23.1) | – | Posterior hypospadias, atypical genitalia |
CAIS, complete androgen insensitivity syndrome; HSD, hydroxysteroid dehydrogenase; PAIS, partial androgen insensitivity syndrome.
Among patients with suspected disorders in androgen action or synthesis, CAIS was presumed in four patients at a median age of 16.75 (range: 9–18.5) years. These cases typically present late, usually during adolescence, due to primary amenorrhea. However, one case initially presented with abdominal pain at 6 years of age, which later imaging identified as inguinal testes. The EGS ranged from 0 to 1 in these cases, indicating the presence of abdominal or inguinal testicles with a normal female external genitalia appearance. Notably, in six patients, hormonal measurements suggested PAIS due to elevated basal testosterone levels, with a mean of 1.4 ± 1.9 (ng/mL) (0.05–6.2), as well as elevated LH and AMH levels. This could not be genetically confirmed. However, two of these patients showed good phallic growth in response to testosterone therapy, making the diagnosis of PAIS more likely. The remaining four patients were considered as having disorders of androgen action or synthesis that could not be specifically classified.
In one patient with an EGS of 9, the testosterone and DHT levels, and the testosterone/DHT ratio were 1.78 (ng/mL), 0.05 (ng/mL), and 35, respectively, suggesting a potential 5-αRD. A negative genetic analysis of the androgen receptor (AR) gene ruled out the possibility of PAIS.
Additionally, genetic testing ruled out the possibility of PAIS and 5-αRD in two patients, aged 1.5 years and 5 years, who were evaluated for atypical genitalia and exhibited an EGS of 6.5 and 9, respectively. Both had low testosterone but normal LH levels. The elevated serum Δ4A level and a reduced ratio of testosterone to Δ4A (<0.8) indicated a potential 17β-HSD deficiency. Notably, 19.2% (five cases) of patients were suspected to have a 3β-HSD deficiency; among them, two infants presented with adrenal crises during the neonatal period. The remaining three patients, aged 2 months, 7 months, and 2 years, were referred for medical evaluation due to insufficient weight gain, SW, and atypical genitalia, respectively. On examination, the EGS was between 5.5 and 10.5. Laboratory tests showed low cortisol levels ranging from 0.5 to 4.14 (µg/dL) (5.98–18.25), along with elevated 17OH-pregnenolone to 17OHP ratios. Hyperkalemia was present in all cases, and one patient had hypoglycemia. No Müllerian structures were detected in any patients with disorders in androgen action or synthesis.
At ages 3 and 7, the diagnosis of PGD and gonadal regression syndrome was retained in two male patients, respectively. Clinically, the case with PGD had micropenis with posterior hypospadias. Ultrasound examinations revealed underdeveloped bilateral gonads located in the inguinal canal, with no Müllerian structures. A very low testosterone < 0.05 (ng/mL) (<0.2) and AMH <0.09 (ng/mL) (1.43–11.6) levels supported the diagnosis of PGD. The lack of testosterone response to the hCG stimulation test and the absence of gonads through ultrasound and laparoscopic exploration confirmed the diagnosis of gonadal regression syndrome for the second patient. Treatment with testosterone was started for these patients.
Medical, surgical treatments, and gender (re)assignment
At diagnosis, all patients with CAH were initiated on glucocorticoid therapy, specifically hydrocortisone, and salt supplementation (sodium chloride) was added to patients with the SW form of CAH. On the other hand, females with CAIS started estrogen therapy post-gonadectomy. Testosterone replacement therapy was initiated according to the final gender (re)assignment; this treatment was started in three patients with karyotype 46,XX who kept the male orientation and refused to transition to female. However, in the other two patients who kept the male orientation, no information about testosterone replacement therapy was recorded.
In the 46,XY karyotype, four patients initiated testosterone replacement therapy to address testosterone deficiency and to promote penile growth. A total of 34 patients underwent at least one surgical intervention. The median age at the first surgical procedure was 4 (range: 2–16) years and 5.5 (range:1.5–18.5) years in the 46,XX DSD group and 46,XY DSD group, respectively. However, 13 patients under the age of 2 years have not yet received or planned any surgical intervention and are still under follow-up.
Gender (re)assignment procedures were carried out in ten cases, resulting in 25 males (44.6%) and 31 females (55.4%) in the study group. Regrettably, one patient passed away before a sex assignment could be made. Gender dysphoria was not observed in any case that underwent or refused gender reassignment.
Discussion
In this 5-year study, we highlight the spectrum and clinical characteristics of 57 patients diagnosed with 46,XX DSD and 46,XY DSD at a tertiary center. To our knowledge, this constitutes the first patient series on DSD originating from Morocco. Overall, our findings reveal that CAH was the most common cause of DSD in our patient series. Furthermore, the age of presentation can vary widely, from the neonatal stage to late adolescence. We also observed that the clinical symptoms of DSD were wide ranging, including severe degrees of atypical genitalia, clitoromegaly, amenorrhea, hypospadias, micropenis, and delayed puberty.
Many studies have shown a higher prevalence rate of 46,XY DSD compared to 46,XX DSD (18, 19, 20, 21, 22, 23). On the other hand, our study revealed a higher proportion of 46,XX DSD cases (54.4%) than 46,XY DSD cases (45.6%). This finding aligns with data from a Sudanese case series, in which 60.5% of patients were genetically female (46,XX) and 39.5% had a 46,XY karyotype (24). Likewise, a 20-year study from Thailand also reported a predominance of 46,XX DSD cases at 63.6% as compared to 26.4% with 46,XY DSD (25). In our study, the median age at presentation across all patients was 0.17 years (2 months). Notably, this was significantly lower in the 46,XX DSD group (0.08 years) compared to the 46,XY DSD group (0.96 years). This could be due to the elevated occurrence of CAH in the 46,XX DSD group, a condition known for its severe symptoms such as SW and adrenal crisis, as well as atypical genitalia often manifesting from the neonatal period. This finding is consistent with other studies (19, 24, 25). Moreover, the delayed presentation for some cases, particularly in 46,XY patients, could be attributed to the fact that these conditions are often not noticed at birth, especially in cases of CAIS with a female phenotypic appearance or in undervirilized males with no positive family history. This can also be attributed to social and cultural factors, where expectations regarding gender-related matters can influence when parents or individuals feel obliged to consult a doctor (19).
Regarding the main reason for admission, half (29/57, 50.8%) of the patients were referred due to atypical genitalia as the most common reason, followed by symptoms of SW and adrenal crisis (12/57, 21%). In fact, atypical genitalia is the most common reason for consultation, regardless of the classification of DSD in most studies (17, 25, 26). However, only 18 patients (31.6%) with atypical genitalia were detected at birth in our setting, and most of them with a 46,XX karyotype. This current situation is still not optimal, as not all occurrences of atypical genitalia are identified accurately and immediately at the time of birth. In addition, this lack of identification can be attributed to the absence of established national guidelines for diagnosing and managing DSD.
In different studies, the sex assigned to patients at the time of presentation tends to vary; some studies report a female predominance (7, 17, 27), while others indicate a male predominance (27, 29). Nonetheless, in our patient series, the representation of both sexes is nearly equal, with 27 females and 26 males. However, four patients (7%) were not assigned a social sex at their first presentation. Those without sex assignments were born with severe atypical genitalia, and all of them had a 46,XY karyotype. These findings appear to be consistent with those from Germany and Kenya, which have rates of 3.8% (three cases) and 5.6% (three cases), respectively (7, 29). However, this rate is higher in the cohorts from Turkey and Brazil (17, 25, 26).
Interestingly, more than one-third of CAH patients in the 46,XX DSD group (11/29, 37.9%) were raised as males, while the remaining (18/29, 62.1%) were raised as females. We observed that the decision regarding sex assignment in these patients was generally made by the parents right after the child’s birth, typically based on the presence of a genital tubercle and its length despite its atypical appearance, or the medical staff’s decision. We assessed the impact of genital tubercle length on the assignment of male sex in these cases (cases of 46,XX DSD). Our findings revealed that the length of the genital tubercle was notably greater in those assigned males as opposed to females, with statistical significance (P < 0.01). The median EGS was 7 (range: 6–8.5) in these cases. This may explain why parents chose the male sex. However, the mean genital tubercle length in our study was 3 ± 0.75 cm, which is lower than the 6.0 ± 2.34 cm reported in the cohort by Gürbüz et al. (26), where male sex assignment was recommended. In this study, we observed that the timing and choice of sex of rearing in newborns, despite the level of genital variations, were influenced by several factors. These factors included delayed diagnosis, administrative complications related to insurance organizations (which require the assignment of a patient’s sex), cultural factors, and the families’ desire for a male child, especially in a society with a strong preference for males. Following further consultations, five patients underwent sex reassignment to females, while five remained as males. Among the latter, three declined to undergo a sex change, as psychological evaluations concurred with their existing male orientation. This condition arises from exposure to elevated levels of androgens either during prenatal development or after birth, leading to the masculinization of gender-related behaviors (30).
In line with expectations, the rate of parental consanguinity in DSD patients was significantly elevated at 46.5%, compared to 23.4% in our general population (P = 0.029) (31). This rate rose to 55% in the 46,XX group. This could explain the high occurrence of conditions with autosomal recessive inheritance in our setting, particularly in CAH cases. This finding implies that individuals in our community may carry a single copy of genetic variants associated with autosomal recessive conditions (such as CAH), contributing to an increased risk of these conditions manifesting in offspring when paired with a carrier partner, which is also supported by the high rate of similar cases (33.3%) and high mortality rates among family members. Similar to findings from other studies, especially those carried out in Arab countries, this study presents one of the most elevated rates of consanguinity observed in a single study (18, 23, 31).
All etiologies identified in the 46,XX DSD group were due to CAH (29/31, 93.55%). Similar to the literature, reporting a frequency of 1:15,000 live births, CAH due to 21OH deficiency is the most common cause of 46,XX DSD in our series, representing 79.31% (23/29), followed by 11β-hydroxylase deficiency with 10.34% (3/29) and 3β-HSD deficiency with 6.9% (2/29) (7, 18, 23, 26, 32, 33). However, in a cohort from South Africa, ovotesticular DSD was diagnosed in 61%, followed by CAH in 24% of patients with 46,XX DSD (20). The median age at diagnosis is approximately 0.92 years, dropping to less than 2 months in cases with the SW form of CAH. This lag in diagnosis can be ascribed to the lack of an established neonatal CAH screening program. Conversely, in countries with CAH neonatal screening, the diagnosis age is lower, generally under 1 month or even less than 3 weeks (34, 35). We hope that the implementation of a national neonatal CAH screening program in our country will help to prevent late diagnosis of CAH, thereby enabling earlier identification of atypical genitalia and aiding in the determination of the most appropriate sex of rearing.
In the 46,XY DSD group, the most presumed cause was related to disorders of androgen action or synthesis, accounting for 69.2% (18 cases). Within this group, a disorder of androgen action (AIS) was suspected in 23.1% (six cases). This finding is congruent with multiple studies conducted in different countries (7, 17, 20, 21, 23, 36). Moreover, defects in androgen synthesis are another common cause of 46,XY DSD, especially 5-αRD. It is worth noting that in a recent cohort from Turkey, 5-αRD was identified as the most common cause of 46,XY DSD, followed by CAIS and PAIS (26). In our 46,XY group, only one patient was presumed to have 5-αRD. Additionally, 17β-HSD and 3β-HSD deficiencies can be seen in many patients with 46,XY androgen synthesis defects (19, 24). In our cohort, five patients were suspected to have 3β-HSD deficiency, and two male patients displaying a reduced ratio of testosterone to Δ4A were presumed to have 17β-HSD deficiency. Furthermore, genetic analysis of the HSD17B3 and HSD3B2 genes is needed for a conclusive diagnosis. In the cohort from North India, 26 out of 102 patients with 46,XY DSD were diagnosed with 17β-HSD deficiency, and the majority were being raised as males, albeit with varying degrees of genital variations (21). Additionally, in line with our findings, some studies report the occurrence of 3β-HSD deficiency in their cohorts, with a variable number of affected patients in their studies (7, 23, 24, 36).
We observed a lower incidence of gonadal regression syndrome (one case), which concurs with most published series (23, 24). This contrasts with Erdoğan et al.’s (18) findings, where gonadal regression syndrome was more frequent in their cohort. On the other hand, PGD is more common in patients with 45,X/46,XY karyotype than 46,XY karyotype, including females with a Turner syndrome phenotype, undervirilized males, or normal phenotypic males (38). This may explain the low rate in our cohort, in which chromosomal DSD were excluded.
The age at diagnosis in the 46,XY DSD group varies widely from one etiology to another, ranging from 0.17 to 18.5 years, with a median age of 5 years. However, this age at diagnosis was typically delayed in CAIS cases until puberty, with a median age of 16.7 years. Similar to the findings from India, a median age at diagnosis of 18 years was observed in the CAIS patients (21). This is higher than that in the study carried out in Brazil and Thailand, with 9.4 years and 3.3 years, respectively (24, 26). In the study from Denmark, which evaluated only women with 46,XY karyotypes, the median age at diagnosis was found to be 7.5 years in AIS and 17 years in gonadal dysgenesis (39).
The present study has some limitations. The limited number of patients, as it is from a single center, and the retrospective nature of this study represent major limitations for the clinical applicability of our findings. The etiological diagnosis and classification of patients in our cohort may change, particularly for XY DSD patients, as genetic studies become more accessible in the future.
Conclusion
In this pioneering study spanning 5 years, we present a comprehensive analysis of patients diagnosed with DSD in Morocco. This study represents the first patient series of its kind in the country. Overall, CAH is the most common cause. CAH was the sole diagnosis in the 46,XX DSD group, while disorders related to androgen action or synthesis were the most presumed diagnoses in the 46,XY DSD group. However, further molecular genetic analyses are needed for accurate diagnosis, especially in XY patients. The elevated rate of consanguinity observed in our study may account for the predominance of CAH cases. Careful sex assignment and psychosocial support are recommended. Healthcare system improvements, including standardized guidelines, a national DSD registry, and a neonatal CAH screening program, are pivotal. Further follow-up investigations are necessary to assess the long-term outcomes.
Declaration of interest
The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the study reported.
Funding
This work did not receive any specific grant from any funding agency in the public, commercial, or not-for-profit sector.
Data availability statement
The data used to support the findings of this study are available from the corresponding author upon request.
Author contribution statement
HB, SA, and LB designed and supervised the study. MA and AA contributed to the collection and/or assembly of data and the clinical characterization of the patients. MH and SA collected and analyzed the data, interpreted the data, and wrote the article. HB, SA, IO and LB performed a critical review of the manuscript. All authors approved the version to be published.
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