In Children with 46, XY DSD; HCG Testing Is Not Always the Best Answer for Testicular Function Assessment

In Children with 46, XY DSD; HCG Testing Is Not Always the Best Answer for Testicular Function Assessment | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article In Children with 46, XY DSD; HCG Testing Is Not Always the Best Answer for Testicular Function Assessment Shaymaa Raafat, Doaa Khater This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-743544/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Hormonal levels are the hallmark for the assessment of testicular function in XY DSD (Disorders of sex development). Traditionally, it has relied on testosterone level increment after hCG (human chorionic gonadotropin) stimulation testing. More recently role of Sertoli cell hormones is more emphasized. Objectives: Evaluating the role of serum anti-mullerian hormone and inhibin B on function of the pre-pubertal testis without the need for hCG stimulation test. Method: The study was conducted in the Endocrinology Clinic in Alexandria University Children's Hospital. All patients who present with XY DSD were tested for testosterone (T), dihydrotestosterone (DHT), Follicle stimulating hormone (FSH), luteinizing hormone (LH), anti-mullerian hormone (AMH), inhibin B. All cases had hCG stimulation test. Results: The hCG stimulation test was done for 32 cases. There was significant positive correlation between serum testosterone levels before and after hCG stimulation test (p <0.001). Similarly, significant correlation was identified between basal AMH and testosterone increment after hCG stimulation (p <0.001) and between basal levels of AMH and inhibin ( MC p= 0.025). Conclusion: Single measurement of basal AMH and/or inhibin B can detect the presence and function of testes by a reliable non-invasive way. Basal AMH assessment is an important tool to distinguish between cryptorchidism and anorchia. hCG test is needed in the work-up of patients with inconclusive results. Pediatrics Testosterone Anti-mullerian hormone inhibin B testis Figures Figure 1 Figure 2 Summary What is known - Hormonal levels are the hallmark for the assessment of testicular function in XY DSD -Traditionally, it has relied on testosterone level increment after hCG (human chorionic gonadotropin) stimulation testing What is new - Sertoli cell hormones are more appreciated. - Basal AMH and/or inhibin B can detect the presence and function of testes by a reliable non-invasive way Introduction The classification of 46, XY DSD includes defects in testicular development, testosterone biosynthetic defects or its action defect. [1-4] Traditionally, the standard endocrinological evaluation of 46, XY DSD cases is based on measurement of testosterone, dihydrotestosterone and androstenedione and their ratios either in mini-puberty or after human chorionic gonadotropin (hCG) stimulation which reflects the activity of the testicular Leydig cells. Although it leads to etiological diagnosis of XY DSD cases such as testosterone biosynthetic defects, 5-alpha reductase deficiency or abnormal androgen receptor activity, however, it is cumbersome and needs multiple sampling.[5] More recently, there has been growing evidence of the value of Sertoli cell function assessment as it secretes hormones like anti-mullerian hormone (AMH) and inhibin B. Mullerian ducts have completely disappeared in the male 10 weeks after conception, but testes continue to churn out high amounts of AMH throughout childhood, when basal testosterone and gonadotropin levels have little clinical use. This makes AMH an appealing biomarker for pediatric endocrinologists, not to mention that prior gonadotropin stimulation is not required.[6] Moreover, it can be used in the evaluation of boys with non-palpable gonads. [7] Inhibin B is another useful marker of normal testicular tissue; therefore, basal inhibin B measurement can be used as a reliable tool to assess both the existence and function of the testes and spermatogenesis afterwards. [8-10] However, the value of AMH and inhibin B in evaluating cases with XY DSD has been challenged. [2,11] We report our experience of the role of serum AMH and inhibin B in assessing the function of the pre-pubertal testis without the need for hCG stimulation test. Methods All cases of 46, XY DSD who were referred to Endocrinology Clinic in Alexandria University Children's Hospital, Egypt for evaluation of atypical genitalia during the period from 1/1/2017-31/12/2019 were included in the study. After informed consent and explanation of the study objectives, peripheral blood was collected for karyotyping, basal serum testosterone (T), dihydrotestosterone (DHT), follicle stimulating hormone (FSH), luteinizing hormone (LH), antimullarian hormone (AMH) and inhibin B.[12]All patients had a Human Chorionic Gonadotropin stimulation test using human chorionic gonadotropin (1500 IU/day) intra-muscular injections for three consecutive days. Venous samples were taken before the test and 24 hours after the third injection, then T/DHT ratio was calculated. We considered functioning testicular tissue when testosterone increment was more than twice the baseline value or absolute testosterone concentration above the upper limit of normal pre-pubertal range. [1,13] Patients with T/ DHT ratio >25 were diagnosed as 5 alpha reductase deficiency and below this value were diagnosed as androgen insensitivity syndrome.[14] Infants in the period of mini-puberty, testosterone and dihydrotestosterone were measured without stimulation and the T/ DHT ratio was calculated. The results of serum hormones were compared with normal reference ranges according to age.[15] Data were analyzed using IBM SPSS software package version 20.0 . (Armonk, NY: IBM Corp). [16] The research has been complied with all the relevant national regulations, institutional policies and in accordance the tenets of the Helsinki Declaration, and has been approved by the Ethics Committee of the College of Medicine, Alexandria University. Written informed consents were obtained from all patients’ legal guardians Results Forty cases were identified with XY DSD. Their age of presentation ranged between zero day to 13 years with a mean of 2.75 ± 3.45 Basal levels of FSH were within normal reference range for age and sex in 35 cases (87.5%) and higher than reference range in 5. Serum LH levels were within reference range for age in all cases. Basal AMH levels were within normal reference range for age in 29 cases (72.5%), 9 cases had low level of AMH and only 2 had high basal AMH. For basal inhibin B, 16 cases (40%) had normal serum level for age, 15 cases had high levels (37.5%), and 9 cases showed low level (22.5%). (Fig. 1) The hCG stimulation test was done for 32 cases (8 cases were in mini-puberty period that does not need hCG testing). The relationship between serum testosterone level before and after hCG stimulation test is shown in table 1. After hCG stimulation test, adequate testosterone response (increment) was observed in 26 cases (81.2%). While, the remaining 6 cases had inadequate response. The testosterone/ DHT ratio was calculated in each case. That ratio was exceeding 25 in 14 cases who were diagnosed as 5 alpha reductase deficiency. Furthermore, such ratio couldn’t be assessed in one case. Table 2 shows the correlation between basal inhibin B, AMH, FSH and testosterone response after hCG stimulation test. Similarly, there was a significant correlation between basal AMH and testosterone increment after hCG stimulation i.e. delta change of serum testosterone (p < 0.001). (Fig. 2). A positive correlation was found between basal level of AMH and inhibin ( MC p= 0.003). (Table 3) Discussion In the current study, both AMH and inhibin B levels were generally lower than normal reference ranges for age in cases with primary gonadal failure, and they were normal in partial androgen insensitivity syndrome (PAIS), and 5α-reductase deficiency. AMH was higher than reference ranges in 2 cases with androgen insensitivity syndrome while, Inhibin B was higher in 15 cases. Despite these variations, the results showed a positive correlation between mean basal levels of AMH and inhibin B which suggest a discriminatory value of the determination of AMH and inhibin B levels in the diagnosis of XY DSD cases. Several previous reports [ 1 , 2 , 10 , 17 ] have shown that AMH and inhibin B are low in dysgenetic testes, undetectable in patients with anorchia and normal or high in other causes of XY DSD (androgen biosynthesis or action defect, AIS, 5α-reductase deficiency and Leydig cell hypoplasia). A study in Denmark showed that the median serum levels of inhibin B hormone in patients with vanishing testes was markedly lower than those in cases of bilateral cryptorchidism. [ 18 ] A significant correlation between AMH and inhibin B was demonstrated in older patients 1-13year-old in former studies, however, they were not correlated for 0.5-1year-old patients with XY DSD [ 2 , 19 , 20 ] Our study found a strong correlation between basal AMH, inhibin B, and FSH levels and hCG induced testosterone increment (p < 0.001). It worth mentioning that the need for hCG stimulation test in the work-up is controversial. Adding to that, there is an extensive range of regimens for hCG stimulation test performance and the definition of an adequate testosterone response to hCG stimulation is also unclear and may depend on the regimen and the age of the child. [ 15 ] Our data showed that a low AMH correlates well with a low hCG-stimulated level in most of the cases, however a normal AMH might not predict a normal HCG-stimulated testosterone value as in the cases with LCH. Similar findings were reported by Ahmed SF et al [ 1 ] while other investigators found that assessment of serum AMH confirms the testicular function without the need for hCG stimulation tests. [ 17 ] In our study, 32 cases -beyond the period of mini-puberty- had hCG stimulation test. Post stimulation testosterone level showed increment after stimulation in most of them (81.2%). There was a positive relation between serum testosterone level before and after hCG stimulation test indicating an adequate leydig cell function. Patients who did not show adequate post stimulation increment of testosterone (Leydig cell dysfunction) were 2 cases with studied testicular regression syndrome (TRS), 2 with gonadal dysgenesis, 1 with Leydig cell hypoplasia and 1 with 5 alpha reductase deficiency. Post stimulation inadequate testosterone response with lower level of AMH and inhibin B in the case with 5 alpha reductase deficiency is attributed to associated cryptorchidism. The studied testicular regression syndrome (TRS) cases had very low basal levels of AMH and inhibin B. Stoppa-Vaucher S et al [ 21 ] concluded that undetectable AMH level and the absence of Müllerian structures on pelvic ultrasound strongly suggests a diagnosis of bilateral anorchia as early as 3 days of age. Weintraub A et al [ 22 ] reported that assessment of AMH can distinguish between cryptorchidism and anorchia. We can conclude that a single measurement of basal AMH and/or inhibin B is highly confirmative of the presence and function of testes. Therefore, basal AMH and inhibin B might substitute the need for Serum FSH levels, were within normal reference ranges for age in all cases except 3 cases with TRS and 2patients with gonadal dysgensis. These cases had high FSH levels with low AMH and inhibin B levels. Assessment of basal FSH levels in patients with XY DSD might elucidate their etiology. High FSH with a low AMH and inhibin B can discriminate cases of defective testicular development from other causes of XY DSD. Moreover, the inverse relationship between circulating FSH and inhibin B levels observed in the current study adds to the current evidence that pre-pubertal Sertoli cells in humans can inhibit FSH release. [ 18 , 23 , 24 ] On the contrary, basal LH levels were within the normal reference ranges in all cases. Cases with primary gonadal failure showed normal LH levels despite high serum FSH levels. Previous report of 395 cases of under-masculinized 46XY males suggests that FSH is a more useful indicator of testicular dysfunction in the pre-pubertal age group being an indirect measure of Sertoli cell function. The limitations of this study include a single center experience and a small number of patients. In conclusion, our study confirmed that a single measurement of basal AMH and/or inhibin B can detect the presence and function of testes. Basal AMH assessment is an important tool to distinguish between cryptorchidism and anorchia. Basal FSH level is an indirect indicator of the Sertoli cell function. Future prospective studies on larger number of patients may decide on the real need for hCG testing in the work-up of these patients. Abbreviations AMH: Antimullerian hormone DHT: dihydrotestosterone DSD: Disorders of sex development FSH: Follicle stimulating hormone hCG: human chorionic gonadotropin T: testosterone LH: luteinizing hormone LCH: Leydig cell hypoplasia PAIS: partial androgen insensitivity syndrome TRS: testicular regression syndrome Declarations - Conflicts of interest statement: The Authors declare no conflict of interest. - Funding sources: No funding was received for this work from any source -Code availability: N/A. All data generated or analysed during this study are included in this article. Further enquiries can be directed to the corresponding author. -Author’s contributions: - All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission of the final version of the manuscript. -Study conception and design: Shaymaa Raafat -Data collection, analysis and interpretation of results, draft manuscript preparation: Shaimaa Raafat, Doaa Khater -Statement of Ethics: The study was performed in accordance with the principles of the Declaration of Helsinki and was approved by the Ethics Committee of the College of Medicine, Alexandria University. (IRB MED# 24/2018). -Consent to participate: Written informed consent was obtained from the parents/ legal guardian of participant prior to the study -Consent for publication: All authors approve the publication References Ahmed SF, Achermann JC, Arlt W, Balen A, Conway G, Edwards Z, et al. Society for Endocrinology UK guidance on the initial evaluation of an infant or an adolescent with a suspected disorder of sex development (Revised 2015). Clin Endocrinol (Oxf). 2016 May; 84(5):771-88. Hafez M, El Dayem SM, El Mougy F, Atef A, Kandil M, Galal A, Al Hamid AA. The role of anti-Mullerian and inhibin B hormones in the evaluation of 46, XY disorders of sex development. J Pediatr Endocrinol Metab. 2014; 27(9-10):891-9. Donohoue PA. 46, XY DSD. In: Behrman RE, Kliegman RM, Stanton BF, Schor NF, St. Game III JW, eds. Nelson Textbook of Pediatrics. 20 th Philadelphia: Saunders, 2016; 2751-9. Erdogan S, Kara C, Ucakturk A, Aydin M. Etiological classification and clinical assessment of children and adolescents with disorders of sex development. J Clin Res Pediatr Endocrinol . 2011; 3(2):77-83. Lee PA, Nordenstrom A, Houk CP, Ahmed SF , Auchus R , Baratz A , et al. global disorders of sex development update since 2006: Perceptions, approach and care. Horm Res Paediatr. 2016; 85(3):158-80. Josso N, Rey RA. What Does AMH Tell Us in Pediatric Disorders of Sex Development? Front Endocrinol (Lausanne). 2020; 11:619. Baetens D, Mladenov W, Menten B, Menten B , Desloovere A , Iotova V , et al. Extensive clinical, hormonal and genetic screening in a large consecutive series of 46, XY neonates and infants with atypical sexual development. Orphanet J Rare Dis. 2014; 9(1):209-21. Iliadou PK, Tsametis C, Kaprara A, Papadimas I, Goulis DG. The Sertoli cell: Novel clinical potentiality. Hormones (Athens). 2015; 14(4):505-14. Moradi M, Alemi M, Moradi A, Izadi B, Parhodah F, Torkaman AF. Does inhibin B help us to confidently refuse diagnostic testicular biopsy in azoospermia? Iran J Reprod Med. 2012; 10(3):243-8. Grinspon RP, Loreti N, Braslavsky D, Bedecarrás P , Ambao V , Gottlieb S , et al. Sertoli cell markers in the diagnosis of paediatric male hypogonadism. J Pediatr Endocrinol Metab. 2012; 25(1-2):3-11. Hughes IA, Nihoul-Fekete C, Thomas B, Cohen-Kettenis PT. Consequences of the ESPE/LWPES guidelines for diagnosis and treatment of disorders of sex development. Best Pract Res Clin Endocrinol Metab . 2007; 21(3):351-65. Chen WANG, Jie WU, Chen ZONG, Jie XU, Huang-Xian JU. Chemiluminescent immunoassay and its applications. Chin J Anal Chem. 2012; 40(1):3-10. Ng KL, Ahmed SF, Hughes IA. Pituitary-gonadal axis in male undermasculinisation. Arch Dis Child. 2000;82(1):54-8. Phelan N, Williams EL, Cardamone S, Lee M , Creighton SM , Rumsby G , Conway GS . Screening for mutations in 17 β-hydroxysteroid dehydrogenase and androgen receptor in women presenting with partially virilised 46, XY disorders of sex development. Eur J Endocrinol. 2015; 172(6):745-51. Andersson AM, Toppari J, Haavisto AM, Petersen JH, Simell T, Simell O, et al. Longitudinal reproductive hormone profiles in infants: peak of inhibin B levels in infant boys exceeds levels in adult men. J Clin Endocrinol Metab 1998 Feb;83(2):675-81. Kirkpatrick LA, Feeney BC. A simple guide to IBM SPSS statistics for version 20.0. Student ed. Belmont, Calif.: Wadsworth, Cengage Learning; 2013. Grinspon RP, Rey RA. New perspectives in the diagnosis of pediatric male hypogonadism: the importance of AMH as a Sertoli cell marker. Arq Bras Endocrinol Metabol 2011;55:512–9 Thorup J, Petersen BL, Kvist K, Cortes D. Bilateral vanished testes diagnosed with a single blood sample showing very high gonadotropins (follicle-stimulating hormone and luteinizing hormone) and very low inhibin B. Scand J Urol Nephrol 2011;45:425–31. Cortes D, Clasen-Linde E, Hutson JM, Li R, Thorup J. The Sertoli cell hormones inhibin-B and anti Müllerian hormone have different patterns of secretion in prepubertal cryptorchid boys. J Pediatr Surg 2016;51(3):475-80. Kubini K, Zachmann M, Albers N, Hiort O, Bettendorf M, Wölfle J, et al. Basal inhibin B and the testosterone response to human chorionic gonadotropin correlate in prepubertal boys. J Clin Endocrinol Metab 2000;85(1):134-8. Stoppa-Vaucher S, Djemli A, Van Vliet G. Undetectable AMH at 3 days of age: a clue to bilateral anorchia. Clin Biochem 2010;43(16-17):1373-4. Weintraub A, Eldar-Geva T. Anti-Mullerian Hormone (AMH) Determinations in the Pediatric and Adolescent Endocrine Practice. Pediatr Endocrinol Rev 2017;14(4):364-370. Juniarto AZ, van der Zwan YG, Santosa A, Ariani MD, Eggers S, Hersmus R, et al. Hormonal evaluation in relation to phenotype and genotype in 286 patients with a disorder of sex development from Indonesia. Clin Endocrinol (Oxf) 2016; 85(2):247-57. Raivio T, Dunkel L. Inverse relationship between serum inhibin B and FSH levels in prepubertal boys with cryptorchidism. Pediatr Res 1999;46(5):496-500. Tables Table (1) Comparison between serum testosterone level before and after hCG stimulation (n=32) Testosterone level (ng/ml) Before After Delta testosterone # Min. – Max. 0.01–3.30 0.05–9.72 0.0–7.78 Mean ± SD. 0.50 ± 0.82 4.03 ± 2.28 3.72 ± 1.97 Median 0.10 4.93 2.77 P < 0.001 * #: delta (after – before) p: p value for Wilcoxon signed ranks test for comparing between before and after stimulation. *: Statistically significant at p ≤ 0.05 SD = standard deviation hCG = human chorionic gonadotropin Table (2) Relation between testosterone response after hCG stimulation with basal FSH, inhibin B and AMH (n = 32) Response of testosterone Test of sig. P No Response (n = 6) Response (n = 26) No. % No. % FSH Low 0 0.0 0 0.0 χ 2 = 16.246 * FE p= 0.005 * Normal 2 33.3 26 100.0 High 4 66.7 0 0.0 Inhibin B Low 5 83.3 4 15.4 χ 2 = 6.789 * MC p= 0.003 * Normal 1 16.7 11 42.3 High 0 0.0 11 42.3 AMH Low 6 100.0 3 11.6 χ 2 = 13.812 * MC p= 0.001 * Normal 0 0.0 22 84.6 High 0 0.0 1 3.8 χ 2 , p: χ 2 and p values for Chi square test MC: Monte Carlo for Chi square test FE: Fisher Exact for Chi square test *: Statistically significant at p ≤ 0.05 FSH = Follicle stimulating hormone LH = luteinizing hormone AMH = anti-mullerian hormone Table (3) Relation between serum levels of Inhibin B and AMH Inhibin B Test of sig. P AMH Low (n= 9) Normal (n= 16) High (n= 15) No. % No. % No. % Low 6 66.7 2 12.5 1 7.1 χ 2 = 12.180 * MC p= 0.003 * Normal 3 33.3 14 87.5 12 78.6 High 0 0.0 0 0.0 2 14.3 Min. – Max. 0.01 – 163.1 17.73 - 171.10 30.70 - 333.0 H= 6.886 0.074 Mean ± SD. 60.33 ± 51.61 90.65 ± 62.18 145.04 ± 98.96 Median 48.20 76.80 122.0 Sig. between stages p 1 =0.312, p 2 =0.003 * p 3 =0.170 r s (p) 0.513 * (0.004 * ) χ AMH = anti-mullerian hormone 2 , p: χ 2 and p values for Chi square test MC: Monte Carlo for Chi square test H,p: H and p values for Kruskal Wallis test , Significance between groups was done using Mann Whitney test r s : Spearman coefficient *: Statistically significant at p ≤ 0.05 Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-743544","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":42071545,"identity":"489b419f-4093-4ca6-9a12-f16252d5191e","order_by":0,"name":"Shaymaa Raafat","email":"","orcid":"","institution":"Alexandria University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Shaymaa","middleName":"","lastName":"Raafat","suffix":""},{"id":42071546,"identity":"23442d7e-c953-4676-89a4-cae9921a8f65","order_by":1,"name":"Doaa Khater","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA20lEQVRIiWNgGAWjYDCCAwgm4wMULjFamA1I1sImQZQWvhvJDz/z1NTZ87P3Hqvmqbkjx8/A/PDRDTxaJG+kGUvzHDucOLPnXNptnmPPjCUb2IyNc/BoMbiRYCDNw3YgweBGjtltHrbDiRsO8LBJ49eS/vk3z786e/v7b8yKef4RpSXHTJq3jZlxgwSPGTNvGxFaJM+8KbOc23c4ccaZHGNJIMNYspmAX/iOp2++8eYbMMTazxh+ePPtsBw/e/PDx/i0gAATDwqDmYByEGD8gc4YBaNgFIyCUYAMALRUUDn7uIIqAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0002-3377-8949","institution":"Alexandria University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Doaa","middleName":"","lastName":"Khater","suffix":""}],"badges":[],"createdAt":"2021-07-22 15:25:37","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-743544/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-743544/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":11929295,"identity":"882fa2e4-e30d-4ff9-b0a0-d73702cb5c2b","added_by":"auto","created_at":"2021-07-29 16:57:20","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":34703,"visible":true,"origin":"","legend":"Distribution of the studied cases according to basal FSH, LH, AMH and inhibin B levels for age (n =40)\nFSH= Follicle stimulating hormone\nLH= Luteinizing hormone\nAMH= Anti-mullerian hormone","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-743544/v1/ff32cd3dc9ad99bb8ba2f426.jpg"},{"id":11929093,"identity":"01b4418b-058a-4699-b341-ac7a2b83236f","added_by":"auto","created_at":"2021-07-29 16:54:20","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":46764,"visible":true,"origin":"","legend":"Correlation between Delta change of testosterone and serum AMH.\nAMH= Anti-mullerian hormone","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-743544/v1/a4b011ec5a5a858e9580d823.jpg"},{"id":13706180,"identity":"4f94fb97-aea2-4a96-b9cf-916e3e7e6665","added_by":"auto","created_at":"2021-09-17 13:56:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":332151,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-743544/v1/b0687a4a-773b-41e3-891d-abb4d2a9a427.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eIn Children with 46, XY DSD; HCG Testing Is Not Always the Best Answer for Testicular Function Assessment\u003c/p\u003e","fulltext":[{"header":"Summary","content":"\u003cp\u003e\u003cstrong\u003eWhat is known\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e- Hormonal levels are the hallmark for the assessment of testicular function in XY DSD\u003c/p\u003e\n\u003cp\u003e-Traditionally, it has relied on testosterone level increment after hCG (human chorionic gonadotropin) stimulation testing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWhat is new\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e- Sertoli cell hormones are more appreciated.\u003c/p\u003e\n\u003cp\u003e- Basal AMH and/or inhibin B can detect the presence and function of testes by a reliable non-invasive way\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eThe classification of 46, XY DSD includes defects in testicular development, testosterone biosynthetic defects or its action defect. [1-4]\u003c/p\u003e\n\u003cp\u003eTraditionally, the standard endocrinological evaluation of 46, XY DSD cases is based on measurement of testosterone, dihydrotestosterone and androstenedione and their ratios either in mini-puberty or after human chorionic gonadotropin (hCG) stimulation which reflects the activity of the testicular Leydig cells. Although it leads to etiological diagnosis of XY DSD cases such as testosterone biosynthetic defects, 5-alpha reductase deficiency or abnormal androgen receptor activity, however, it is cumbersome and needs multiple sampling.[5] More recently, there has been growing evidence of the value of Sertoli cell function assessment as it secretes hormones like anti-mullerian hormone (AMH) and inhibin B. Mullerian ducts have completely disappeared in the male 10 weeks after conception, but testes continue to churn out high amounts of AMH throughout childhood, when basal testosterone and gonadotropin levels have little clinical use. This makes AMH an appealing biomarker for pediatric endocrinologists, not to mention that prior gonadotropin stimulation is not required.[6]\u003c/p\u003e\n\u003cp\u003eMoreover, it can be used in the evaluation of boys with non-palpable gonads. [7] Inhibin B is another useful marker of normal testicular tissue; therefore, basal inhibin B measurement can be used as a reliable tool to assess both the existence and function of the testes and spermatogenesis afterwards. [8-10]\u003c/p\u003e\n\u003cp\u003eHowever, the value of AMH and inhibin B in evaluating cases with XY DSD has been challenged. [2,11] We report our experience of the role of serum AMH and inhibin B in assessing the function of the pre-pubertal testis without the need for hCG stimulation test.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eAll cases of 46, XY DSD who were referred to Endocrinology Clinic in Alexandria University Children's Hospital, Egypt for evaluation of atypical genitalia during the period from 1/1/2017-31/12/2019 were included in the study. After informed consent and explanation of the study objectives, peripheral blood was collected for karyotyping, basal serum testosterone (T), dihydrotestosterone (DHT), follicle stimulating hormone (FSH), luteinizing hormone (LH), antimullarian hormone (AMH) and inhibin B.[12]All patients had a Human Chorionic Gonadotropin stimulation test using human chorionic gonadotropin (1500 IU/day) intra-muscular injections for three consecutive days. Venous samples were taken before the test and 24 hours after the third injection, then T/DHT ratio was calculated. We considered functioning testicular tissue when testosterone increment was more than twice the baseline value or absolute testosterone concentration above the upper limit of normal pre-pubertal range. [1,13] Patients with T/ DHT ratio \u0026gt;25 were diagnosed as 5 alpha reductase deficiency and below this value were diagnosed as androgen insensitivity syndrome.[14] Infants in the period of mini-puberty, testosterone and dihydrotestosterone were measured without stimulation and the T/ DHT ratio was calculated. The results of serum hormones were compared with normal reference ranges according to age.[15]\u003c/p\u003e\n\u003cp\u003eData were analyzed using IBM SPSS software package version 20.0\u003cem\u003e. \u003c/em\u003e(Armonk, NY: IBM Corp). [16] The research has been complied with all the relevant national regulations, institutional policies and in accordance the tenets of the Helsinki Declaration, and has been approved by the Ethics Committee of the College of Medicine, Alexandria University. Written informed consents were obtained from all patients\u0026rsquo; legal guardians\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eForty cases were identified with XY DSD. Their age of presentation ranged between zero day to 13 years with a mean of 2.75\u0026thinsp;\u0026plusmn;\u0026thinsp;3.45\u003c/p\u003e \u003cp\u003eBasal levels of FSH were within normal reference range for age and sex in 35 cases (87.5%) and higher than reference range in 5. Serum LH levels were within reference range for age in all cases. Basal AMH levels were within normal reference range for age in 29 cases (72.5%), 9 cases had low level of AMH and only 2 had high basal AMH. For basal inhibin B, 16 cases (40%) had normal serum level for age, 15 cases had high levels (37.5%), and 9 cases showed low level (22.5%). (Fig.\u0026nbsp;1)\u003c/p\u003e \u003cp\u003eThe hCG stimulation test was done for 32 cases (8 cases were in mini-puberty period that does not need hCG testing). The relationship between serum testosterone level before and after hCG stimulation test is shown in table 1.\u003c/p\u003e \u003cp\u003eAfter hCG stimulation test, adequate testosterone response (increment) was observed in 26 cases (81.2%). While, the remaining 6 cases had inadequate response. The testosterone/ DHT ratio was calculated in each case. That ratio was exceeding 25 in 14 cases who were diagnosed as 5 alpha reductase deficiency. Furthermore, such ratio couldn\u0026rsquo;t be assessed in one case.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;2 shows the correlation between basal inhibin B, AMH, FSH and testosterone response after hCG stimulation test.\u003c/p\u003e \u003cp\u003eSimilarly, there was a significant correlation between basal AMH and testosterone increment after hCG stimulation i.e. delta change of serum testosterone (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). (Fig.\u0026nbsp;2).\u003c/p\u003e \u003cp\u003eA positive correlation was found between basal level of AMH and inhibin (\u003csup\u003eMC\u003c/sup\u003ep= 0.003). (Table\u0026nbsp;3)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn the current study, both AMH and inhibin B levels were generally lower than normal reference ranges for age in cases with primary gonadal failure, and they were normal in partial androgen insensitivity syndrome (PAIS), and 5α-reductase deficiency. AMH was higher than reference ranges in 2 cases with androgen insensitivity syndrome while, Inhibin B was higher in 15 cases. Despite these variations, the results showed a positive correlation between mean basal levels of AMH and inhibin B which suggest a discriminatory value of the determination of AMH and inhibin B levels in the diagnosis of XY DSD cases.\u003c/p\u003e \u003cp\u003eSeveral previous reports [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] have shown that AMH and inhibin B are low in dysgenetic testes, undetectable in patients with anorchia and normal or high in other causes of XY DSD (androgen biosynthesis or action defect, AIS, 5α-reductase deficiency and Leydig cell hypoplasia). A study in Denmark showed that the median serum levels of inhibin B hormone in patients with vanishing testes was markedly lower than those in cases of bilateral cryptorchidism. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eA significant correlation between AMH and inhibin B was demonstrated in older patients 1-13year-old in former studies, however, they were not correlated for 0.5-1year-old patients with XY DSD [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eOur study found a strong correlation between basal AMH, inhibin B, and FSH levels and hCG induced testosterone increment (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eIt worth mentioning that the need for hCG stimulation test in the work-up is controversial. Adding to that, there is an extensive range of regimens for hCG stimulation test performance and the definition of an adequate testosterone response to hCG stimulation is also unclear and may depend on the regimen and the age of the child. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] Our data showed that a low AMH correlates well with a low hCG-stimulated level in most of the cases, however a normal AMH might not predict a normal HCG-stimulated testosterone value as in the cases with LCH. Similar findings were reported by Ahmed SF et al [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] while other investigators found that assessment of serum AMH confirms the testicular function without the need for hCG stimulation tests. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] In our study, 32 cases -beyond the period of mini-puberty- had hCG stimulation test. Post stimulation testosterone level showed increment after stimulation in most of them (81.2%). There was a positive relation between serum testosterone level before and after hCG stimulation test indicating an adequate leydig cell function. Patients who did not show adequate post stimulation increment of testosterone (Leydig cell dysfunction) were 2 cases with studied testicular regression syndrome (TRS), 2 with gonadal dysgenesis, 1 with Leydig cell hypoplasia and 1 with 5 alpha reductase deficiency. Post stimulation inadequate testosterone response with lower level of AMH and inhibin B in the case with 5 alpha reductase deficiency is attributed to associated cryptorchidism.\u003c/p\u003e \u003cp\u003eThe studied testicular regression syndrome (TRS) cases had very low basal levels of AMH and inhibin B. Stoppa-Vaucher S et al [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] concluded that undetectable AMH level and the absence of M\u0026uuml;llerian structures on pelvic ultrasound strongly suggests a diagnosis of bilateral anorchia as early as 3 days of age. Weintraub A et al [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] reported that assessment of AMH can distinguish between cryptorchidism and anorchia. We can conclude that a single measurement of basal AMH and/or inhibin B is highly confirmative of the presence and function of testes. Therefore, basal AMH and inhibin B might substitute the need for\u003c/p\u003e \u003cp\u003eSerum FSH levels, were within normal reference ranges for age in all cases except 3 cases with TRS and 2patients with gonadal dysgensis. These cases had high FSH levels with low AMH and inhibin B levels. Assessment of basal FSH levels in patients with XY DSD might elucidate their etiology. High FSH with a low AMH and inhibin B can discriminate cases of defective testicular development from other causes of XY DSD. Moreover, the inverse relationship between circulating FSH and inhibin B levels observed in the current study adds to the current evidence that pre-pubertal Sertoli cells in humans can inhibit FSH release. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eOn the contrary, basal LH levels were within the normal reference ranges in all cases. Cases with primary gonadal failure showed normal LH levels despite high serum FSH levels. Previous report of 395 cases of under-masculinized 46XY males suggests that FSH is a more useful indicator of testicular dysfunction in the pre-pubertal age group being an indirect measure of Sertoli cell function.\u003c/p\u003e \u003cp\u003eThe limitations of this study include a single center experience and a small number of patients.\u003c/p\u003e \u003cp\u003eIn conclusion, our study confirmed that a single measurement of basal AMH and/or inhibin B can detect the presence and function of testes. Basal AMH assessment is an important tool to distinguish between cryptorchidism and anorchia. Basal FSH level is an indirect indicator of the Sertoli cell function. Future prospective studies on larger number of patients may decide on the real need for hCG testing in the work-up of these patients.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAMH: Antimullerian hormone\u003c/p\u003e\n\u003cp\u003eDHT: dihydrotestosterone\u003c/p\u003e\n\u003cp\u003eDSD: Disorders of sex development\u003c/p\u003e\n\u003cp\u003eFSH: Follicle stimulating hormone\u003c/p\u003e\n\u003cp\u003ehCG: human chorionic gonadotropin\u003c/p\u003e\n\u003cp\u003eT: testosterone\u003c/p\u003e\n\u003cp\u003eLH: luteinizing hormone\u003c/p\u003e\n\u003cp\u003eLCH:\u0026nbsp;Leydig cell hypoplasia\u003c/p\u003e\n\u003cp\u003ePAIS: partial androgen insensitivity syndrome\u003c/p\u003e\n\u003cp\u003eTRS: testicular regression syndrome\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e-\u003cstrong\u003eConflicts of interest statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Authors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003e-\u003cstrong\u003eFunding sources:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for this work from any source\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e-Code availability:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eN/A.\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this article. Further enquiries can be directed to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e-Author\u0026rsquo;s contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e- All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission of the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e-Study conception and design: Shaymaa Raafat\u003c/p\u003e\n\u003cp\u003e-Data collection, analysis and interpretation of results, draft manuscript preparation: Shaimaa Raafat, Doaa Khater\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e-Statement of Ethics:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was performed in accordance with the principles of the Declaration of Helsinki and was approved by the Ethics Committee of the College of Medicine, Alexandria University. (IRB MED# 24/2018).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e-Consent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the parents/ legal guardian of participant prior to the study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e-Consent for publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors approve the publication\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAhmed SF, Achermann JC, Arlt W, Balen A, Conway G, Edwards Z, et al. Society for Endocrinology UK guidance on the initial evaluation of an infant or an adolescent with a suspected disorder of sex development (Revised 2015). Clin Endocrinol (Oxf). 2016 May; 84(5):771-88.\u003c/li\u003e\n \u003cli\u003eHafez M, El Dayem SM, El Mougy F, Atef A, Kandil M, Galal A, Al Hamid AA. The role of anti-Mullerian and inhibin B hormones in the evaluation of 46, XY disorders of sex development. 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J Pediatr Endocrinol Metab. 2012; 25(1-2):3-11.\u003c/li\u003e\n \u003cli\u003eHughes IA, Nihoul-Fekete C, Thomas B, Cohen-Kettenis PT. Consequences of the ESPE/LWPES guidelines for diagnosis and treatment of disorders of sex development. \u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Consequences+of+the+ESPE%2FLWPES\"\u003eBest Pract Res Clin Endocrinol Metab\u003c/a\u003e. 2007; 21(3):351-65.\u003c/li\u003e\n \u003cli\u003eChen WANG, Jie WU, Chen ZONG, Jie XU, Huang-Xian JU. Chemiluminescent immunoassay and its applications. Chin J Anal Chem. 2012; 40(1):3-10.\u003c/li\u003e\n \u003cli\u003eNg KL, Ahmed SF, Hughes IA. Pituitary-gonadal axis in male undermasculinisation. Arch Dis Child. 2000;82(1):54-8.\u003c/li\u003e\n \u003cli\u003ePhelan N, Williams EL, Cardamone S, \u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Lee%20M%5BAuthor%5D\u0026cauthor=true\u0026cauthor_uid=25740850\"\u003eLee M\u003c/a\u003e, \u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Creighton%20SM%5BAuthor%5D\u0026cauthor=true\u0026cauthor_uid=25740850\"\u003eCreighton SM\u003c/a\u003e, \u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Rumsby%20G%5BAuthor%5D\u0026cauthor=true\u0026cauthor_uid=25740850\"\u003eRumsby G\u003c/a\u003e, \u003ca href=\"https://www.ncbi.nlm.nih.gov/pubmed/?term=Conway%20GS%5BAuthor%5D\u0026cauthor=true\u0026cauthor_uid=25740850\"\u003eConway GS\u003c/a\u003e. Screening for mutations in 17 \u0026beta;-hydroxysteroid dehydrogenase and androgen receptor in women presenting with partially virilised 46, XY disorders of sex development. Eur J Endocrinol. 2015; 172(6):745-51.\u003c/li\u003e\n \u003cli\u003eAndersson AM, Toppari J, Haavisto AM, Petersen JH, Simell T, Simell O, et al. Longitudinal reproductive hormone profiles in infants: peak of inhibin B levels in infant boys exceeds levels in adult men. J Clin Endocrinol Metab 1998 Feb;83(2):675-81.\u003c/li\u003e\n \u003cli\u003eKirkpatrick LA, Feeney BC. A simple guide to IBM SPSS statistics for version 20.0. Student ed. Belmont, Calif.: Wadsworth, Cengage Learning; 2013.\u003c/li\u003e\n \u003cli\u003eGrinspon RP, Rey RA. New perspectives in the diagnosis of pediatric male hypogonadism: the importance of AMH as a Sertoli cell marker. Arq Bras Endocrinol Metabol 2011;55:512\u0026ndash;9\u003c/li\u003e\n \u003cli\u003eThorup J, Petersen BL, Kvist K, Cortes D. Bilateral vanished testes diagnosed with a single blood sample showing very high gonadotropins (follicle-stimulating hormone and luteinizing hormone) and very low inhibin B. Scand J Urol Nephrol 2011;45:425\u0026ndash;31.\u003c/li\u003e\n \u003cli\u003eCortes D, Clasen-Linde E, Hutson JM, Li R, Thorup J. The Sertoli cell hormones inhibin-B and anti M\u0026uuml;llerian hormone have different patterns of secretion in prepubertal cryptorchid boys. J Pediatr Surg 2016;51(3):475-80.\u003c/li\u003e\n \u003cli\u003eKubini K, Zachmann M, Albers N, Hiort O, Bettendorf M, W\u0026ouml;lfle J, et al. Basal inhibin B and the testosterone response to human chorionic gonadotropin correlate in prepubertal boys. J Clin Endocrinol Metab 2000;85(1):134-8.\u003c/li\u003e\n \u003cli\u003eStoppa-Vaucher S, Djemli A, Van Vliet G. Undetectable AMH at 3 days of age: a clue to bilateral anorchia. Clin Biochem 2010;43(16-17):1373-4.\u003c/li\u003e\n \u003cli\u003eWeintraub A, Eldar-Geva T. Anti-Mullerian Hormone (AMH) Determinations in the Pediatric and Adolescent Endocrine Practice. Pediatr Endocrinol Rev 2017;14(4):364-370.\u003c/li\u003e\n \u003cli\u003eJuniarto AZ, van der Zwan YG, Santosa A, Ariani MD, Eggers S, Hersmus R, et al. Hormonal evaluation in relation to phenotype and genotype in 286 patients with a disorder of sex development from Indonesia. Clin Endocrinol (Oxf) 2016; 85(2):247-57.\u003c/li\u003e\n \u003cli\u003eRaivio T, Dunkel L. Inverse relationship between serum inhibin B and FSH levels in prepubertal boys with cryptorchidism. Pediatr Res 1999;46(5):496-500.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cdiv class=\"gridtable\"\u003e\n \u003ctable border=\"1\" id=\"Taba\"\u003e\n \u003ccaption\u003e\n \u003cp\u003eTable (1)\u003c/p\u003e\n \u003cp\u003eComparison between serum testosterone level before and after hCG stimulation (n=32)\u003c/p\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eTestosterone level (ng/ml)\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eBefore\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eAfter\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eDelta testosterone \u003csup\u003e#\u003c/sup\u003e\u003c/div\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMin. \u0026ndash; Max.\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.01\u0026ndash;3.30\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.05\u0026ndash;9.72\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.0\u0026ndash;7.78\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD.\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.50\u0026thinsp;\u0026plusmn;\u0026thinsp;0.82\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4.03\u0026thinsp;\u0026plusmn;\u0026thinsp;2.28\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3.72\u0026thinsp;\u0026plusmn;\u0026thinsp;1.97\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMedian\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.10\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4.93\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2.77\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eP\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003e*\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e#: delta (after \u0026ndash; before)\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003ep: p value for Wilcoxon signed ranks test for comparing between before and after stimulation.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e*: Statistically significant at p\u0026thinsp;\u0026le;\u0026thinsp;0.05\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eSD\u0026thinsp;=\u0026thinsp;standard deviation\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003ehCG\u0026thinsp;=\u0026thinsp;human chorionic gonadotropin\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable border=\"1\" id=\"Tabb\"\u003e\n \u003ccaption\u003e\n \u003cp\u003eTable (2)\u003c/p\u003e\n \u003cp\u003eRelation between testosterone response after hCG stimulation with basal FSH, inhibin B and AMH (n = 32)\u003c/p\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"4\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eResponse of testosterone\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eTest of sig.\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eP\u003c/div\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eNo Response\u003c/span\u003e\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003e(n\u0026thinsp;=\u0026thinsp;6)\u003c/span\u003e\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eResponse\u003c/span\u003e\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003e(n\u0026thinsp;=\u0026thinsp;26)\u003c/span\u003e\u003c/div\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eNo.\u003c/span\u003e\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003e%\u003c/span\u003e\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eNo.\u003c/span\u003e\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003e%\u003c/span\u003e\u003c/div\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eFSH\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eLow\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.0\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.0\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;16.246\u003csup\u003e*\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003csup\u003eFE\u003c/sup\u003ep= 0.005\u003csup\u003e*\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eNormal\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e33.3\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e26\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e100.0\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eHigh\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e66.7\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.0\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eInhibin B\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eLow\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e5\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e83.3\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e15.4\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;6.789\u003csup\u003e*\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003csup\u003eMC\u003c/sup\u003ep= 0.003\u003csup\u003e*\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eNormal\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e16.7\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e11\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e42.3\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eHigh\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.0\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e11\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e42.3\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\"\u003eAMH\u003c/span\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eLow\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e6\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e100.0\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e11.6\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;13.812\u003csup\u003e*\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003csup\u003eMC\u003c/sup\u003ep= 0.001\u003csup\u003e*\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eNormal\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.0\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e22\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e84.6\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eHigh\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e0.0\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e3.8\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e, p: \u0026chi;\u003csup\u003e2\u003c/sup\u003e and p values for \u003cspan class=\"Bold\"\u003eChi square test\u003c/span\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003eMC: \u003cspan class=\"Bold\"\u003eMonte Carlo\u003c/span\u003e for Chi square test\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003eFE: \u003cspan class=\"Bold\"\u003eFisher Exact\u003c/span\u003e for Chi square test\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e*: Statistically significant at p\u0026thinsp;\u0026le;\u0026thinsp;0.05\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003eFSH\u0026thinsp;=\u0026thinsp;Follicle stimulating hormone\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003eLH\u0026thinsp;=\u0026thinsp;luteinizing hormone\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003eAMH\u0026thinsp;=\u0026thinsp;anti-mullerian hormone\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" width=\"0\"\u003e\n \u003ccaption\u003e\n \u003cp\u003eTable (3)\u003c/p\u003e\n \u003cp\u003eRelation between serum levels of Inhibin B and AMH\u003c/p\u003e\n \u003c/caption\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"151\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"6\" width=\"295\"\u003e\n \u003cp\u003e\u003cstrong\u003eInhibin B\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" width=\"79\"\u003e\n \u003cp\u003e\u003cstrong\u003eTest of sig.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" width=\"84\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"151\"\u003e\n \u003cp\u003e\u003cstrong\u003eAMH\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"98\"\u003e\n \u003cp\u003e\u003cstrong\u003eLow\u003cbr\u003e\u0026nbsp;(n= 9)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"98\"\u003e\n \u003cp\u003e\u003cstrong\u003eNormal\u003cbr\u003e\u0026nbsp;(n= 16)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"98\"\u003e\n \u003cp\u003e\u003cstrong\u003eHigh\u003cbr\u003e\u0026nbsp;(n= 15)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"151\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"151\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49\"\u003e\n \u003cp\u003e66.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49\"\u003e\n \u003cp\u003e12.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49\"\u003e\n \u003cp\u003e7.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" width=\"79\"\u003e\n \u003cp\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e= 12.180\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" width=\"84\"\u003e\n \u003cp\u003e\u003csup\u003eMC\u003c/sup\u003ep= 0.003\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"151\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49\"\u003e\n \u003cp\u003e33.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49\"\u003e\n \u003cp\u003e87.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49\"\u003e\n \u003cp\u003e78.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"151\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49\"\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"49\"\u003e\n \u003cp\u003e14.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"151\"\u003e\n \u003cp\u003eMin. \u0026ndash; Max.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"98\"\u003e\n \u003cp\u003e0.01 \u0026ndash; 163.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"98\"\u003e\n \u003cp\u003e17.73 - 171.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"98\"\u003e\n \u003cp\u003e30.70 - 333.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" width=\"79\"\u003e\n \u003cp\u003eH= 6.886\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" width=\"84\"\u003e\n \u003cp\u003e0.074\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"151\"\u003e\n \u003cp\u003eMean \u0026plusmn; SD.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"98\"\u003e\n \u003cp\u003e60.33 \u0026plusmn; 51.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"98\"\u003e\n \u003cp\u003e90.65 \u0026plusmn; 62.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"98\"\u003e\n \u003cp\u003e145.04 \u0026plusmn; 98.96\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"151\"\u003e\n \u003cp\u003eMedian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"98\"\u003e\n \u003cp\u003e48.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"98\"\u003e\n \u003cp\u003e76.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"98\"\u003e\n \u003cp\u003e122.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"151\"\u003e\n \u003cp\u003e\u003cstrong\u003eSig. between stages\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"6\" width=\"295\"\u003e\n \u003cp\u003ep\u003csub\u003e1\u003c/sub\u003e=0.312, p\u003csub\u003e2\u003c/sub\u003e=0.003\u003csup\u003e*\u003c/sup\u003e p\u003csub\u003e3\u003c/sub\u003e=0.170\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"84\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"151\"\u003e\n \u003cp\u003e\u003cstrong\u003er\u003csub\u003es\u003c/sub\u003e(p)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"6\" width=\"295\"\u003e\n \u003cp\u003e0.513\u003csup\u003e*\u003c/sup\u003e(0.004\u003csup\u003e*\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"79\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"84\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\"\u003e\u0026chi; AMH\u0026thinsp;=\u0026thinsp;anti-mullerian hormone\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\"\u003e\u003csup\u003e2\u003c/sup\u003e, p: \u0026chi;\u003csup\u003e2\u003c/sup\u003e and p values for \u003cspan class=\"Bold\"\u003eChi square test\u003c/span\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\"\u003eMC: \u003cspan class=\"Bold\"\u003eMonte Carlo\u003c/span\u003e for Chi square test\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\"\u003eH,p: H and p values for \u003cspan class=\"Bold\"\u003eKruskal Wallis test\u003c/span\u003e, Significance between groups was done using \u003cspan class=\"Bold\"\u003eMann Whitney test\u003c/span\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\"\u003er\u003csub\u003es\u003c/sub\u003e: Spearman coefficient\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\"\u003e*: Statistically significant at p\u0026thinsp;\u0026le;\u0026thinsp;0.05\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Testosterone, Anti-mullerian hormone, inhibin B, testis","lastPublishedDoi":"10.21203/rs.3.rs-743544/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-743544/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eHormonal levels are the hallmark for the assessment of testicular function in XY DSD (Disorders of sex development). Traditionally, it has relied on testosterone level increment after hCG (human chorionic gonadotropin) stimulation testing. More recently role of Sertoli cell hormones is more emphasized.\u003c/p\u003e\u003cp\u003eObjectives: Evaluating the role of serum anti-mullerian hormone and inhibin B on function of the pre-pubertal testis without the need for hCG stimulation test.\u003c/p\u003e\u003cp\u003eMethod: The study was conducted in the Endocrinology Clinic in Alexandria University Children's Hospital. All patients who present with XY DSD were tested for testosterone (T), dihydrotestosterone (DHT), Follicle stimulating hormone (FSH), luteinizing hormone (LH), anti-mullerian hormone (AMH), inhibin B. \u0026nbsp;All cases had hCG stimulation test.\u003c/p\u003e\u003cp\u003eResults: The hCG stimulation test was done for 32 cases. There was significant positive correlation between serum testosterone levels before and after hCG stimulation test (p \u0026lt;0.001). Similarly, significant correlation was identified between basal AMH and testosterone increment after hCG stimulation (p \u0026lt;0.001) and between basal levels of AMH and inhibin (\u003csup\u003eMC\u003c/sup\u003ep= 0.025).\u003c/p\u003e\u003cp\u003eConclusion: Single measurement of basal AMH and/or inhibin B can detect the presence and function of testes by a reliable non-invasive way. Basal AMH assessment is an important tool to distinguish between cryptorchidism and anorchia. hCG test is needed in the work-up of patients with inconclusive results.\u003c/p\u003e","manuscriptTitle":"In Children with 46, XY DSD; HCG Testing Is Not Always the Best Answer for Testicular Function Assessment","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-07-29 16:54:19","doi":"10.21203/rs.3.rs-743544/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f29457e3-3f19-43a2-a4ac-5388c9bef796","owner":[],"postedDate":"July 29th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":6074662,"name":"Pediatrics"}],"tags":[],"updatedAt":"2021-08-27T18:22:42+00:00","versionOfRecord":[],"versionCreatedAt":"2021-07-29 16:54:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-743544","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-743544","identity":"rs-743544","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}