eMedicine Specialties > Obstetrics and Gynecology > Reproductive Endocrinology and Infertility

Ovotestis: Follow-up

Author: Molina B Dayal, MD, MPH, Associate Professor, Medical Director of Egg Donation Program, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Medical Faculty Associates, George Washington University School of Medicine
Coauthor(s): Candice B O'Hern, MD, Resident Physician, Department of Obstetrics and Gynecology, George Washington University Hospital
Contributor Information and Disclosures

Updated: Dec 1, 2009

Follow-up

Complications

  • Traditionally, complications from the surgical treatment of patients with disorders of sexual development were related to stenosis after vaginal reconstruction procedures and urinary tract problems associated with correction of severe hypospadias.
  • Today, patients are diagnosed and operated on earlier and tend to have fewer complications.
  • Gender assignment should be made prior to age 18 months, when children develop gender identity, so as to minimize psychosocial trauma.

Prognosis

  • Aside from the physical and emotional consequences associated with genital ambiguity, patients with ovotesticular disorder of sexual development usually do not possess other developmental malformations.
  • These individuals generally are of average intelligence and have a normal life expectancy.
  • Fertility potential does exist in people with ovotesticular disorder of sexual development who are given a female sexual assignment. Ovulation can occur, and several pregnancies have been reported in this group. To date, all documented offspring have been male. One report describes a 46,XX/46,XY infertile chimeric male who fathered a child with sperm obtained from his testicular tissue through intracytoplasmic sperm injection.7,8
  • People with ovotesticular disorder of sexual development who are given a male sex assignment rarely reproduce. Spermatogenesis has been reported in only 12% of these cases, and tubular atrophy with hypoplastic testicular tissue is the norm. There are only 3 reported cases of males with OT-DSD fathering children.
  • Patients should be counseled that infertility is common despite excision of discordant tissue and genital reconstruction.
  • Many patients with ovotesticular disorder of sexual development are sexually active with a small portion being sexually dissatisfied. Those raised as males may complain of an inability to have and/or maintain erections, while females may complain of vaginal stenosis, recurrent cystitis, and hot flushes.

Patient Education

  • Once the diagnosis of genital ambiguity is made, ongoing psychological support for the patient, parents, and other family members is critical.
  • Psychological counseling is perhaps even more important for patients with a diagnosis delayed until puberty or adult life.

Miscellaneous

Medicolegal Pitfalls

  • Although gender assignment in the newborn period should be based on the individual's potential for normal sexual function and the potential for future reproductive function, most cases of ovotesticular disorder of sexual development are diagnosed during the adolescent period, so gender usually is not reassigned. Rather, surgery is performed to conform to the patient's preestablished gender. Identity and self esteem issues in this age group make psychological support of utmost importance.
  • Genital ambiguity in the newborn period should be viewed as a medical emergency until salt wasting adrenogenital syndrome (ie, CAH) and pituitary insufficiency have been ruled out. Supportive management must be provided for suspected salt-wasting forms of CAH and pituitary insufficiency until these potentially life-threatening conditions have been ruled out.

Special Concerns

  • Because most cases of ovotesticular disorder of sexual development are diagnosed during adolescence, gender usually is not reassigned. Rather, surgery is performed to conform to the patient's preestablished gender.
  • Identity and self-esteem issues in this age group make psychological support of utmost importance.
 


More on Ovotestis

Overview: Ovotestis
Differential Diagnoses & Workup: Ovotestis
Treatment & Medication: Ovotestis
Follow-up: Ovotestis
Multimedia: Ovotestis
References
Further Reading
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References

  1. Kasami M, Yoshida M, Isogaki J, et al. Bilateral breast tumors, malignant phyllodes tumor and invasive lobular carcinoma in a 46,XX/46,XY mosaic female with family history of breast cancer. Pathol Int. Feb-Mar 1997;47(2-3):147-54. [Medline].

  2. Chaudhury P, Majmudar B, Moller KA. Invasive squamous cell carcinoma of the vagina in the setting of true hermaphroditism. Gynecol Oncol. Jan 2006;100(1):210-2. [Medline].

  3. Ouhilal S, Turco J, Nangia A, et al. True hermaphroditism presenting as bilateral gynecomastia in an adolescent phenotypic male. Fertil Steril. Apr 2005;83(4):1041. [Medline].

  4. Sanlaville D, Vialard F, Thepot F, et al. Functional disomy of Xp including duplication of DAX1 gene with sex reversal due to t(X;Y)(p21.2;p11.3). Am J Med Genet A. Jul 30 2004;128(3):325-30. [Medline].

  5. Chen CP, Chern SR, Sheu JC, et al. Prenatal diagnosis, sonographic findings and molecular genetic analysis of a 46,XX/46,XY true hermaphrodite chimera. Prenat Diagn. Jun 2005;25(6):502-6. [Medline].

  6. Verkauskas G, Jaubert F, Lortat-Jacob S, Malan V, Thibaud E, Nihoul-Fékété C. The long-term followup of 33 cases of true hermaphroditism: a 40-year experience with conservative gonadal surgery. J Urol. Feb 2007;177(2):726-31; discussion 731. [Medline].

  7. Sugawara N, Tokunaga Y, Maeda M, et al. A successful pregnancy outcome using frozen testicular sperm from a chimeric infertile male with a 46, XX/46, XY karyotype: case report. Hum Reprod. Jan 2005;20(1):147-8. [Medline].

  8. Schultz BA, Roberts S, Rodgers A, Ataya K. Pregnancy in true hermaphrodites and all male offspring to date. Obstet Gynecol. Feb 2009;113(2 Pt 2):534-6. [Medline].

  9. Abbas NE, Toublanc JE, Boucekkine C, et al. A possible common origin of "Y-negative" human XX males and XX true hermaphrodites. Hum Genet. Mar 1990;84(4):356-60. [Medline].

  10. Ablett MJ, Masters J, Elliott ST. Case report: A rapidly expanding testicular mass due to a ruptured ovarian follicle. Br J Radiol. Apr 1996;69(820):366-7. [Medline].

  11. al Jurayyan NA, Patel PJ, al Herbish AS, et al. Ambiguous genitalia: comparative role of pelvic ultrasonography and genitography. Ann Trop Paediatr. Sep 1995;15(3):203-7. [Medline].

  12. Almaguer MC, Saenger P, Linder BL. Phallic growth after hCG. A clinical index of androgen responsiveness. Clin Pediatr (Phila). Jun 1993;32(6):329-33. [Medline].

  13. Bercovici JP, Nahoul K, Maudelonde T, et al. Plasma androgens during the luteal phase in a case of true hermaphroditism with bilateral ovotestis. J Steroid Biochem. May 1985;22(5):631-4. [Medline].

  14. Bergmann M, Schleicher G, Bocker R, Nieschlag E. True hermaphroditism with bilateral ovotestis: a case report. Int J Androl. Apr 1989;12(2):139-47. [Medline].

  15. Berkovitz GD, Fechner PY, Marcantonio SM, et al. The role of the sex determining region of the X chromosome (SRY) in the etiology of 46XX true hermaphroditism. Hum Genet. 1992;88:411.

  16. Berkovitz GD, Fechner PY, Zacur HW, et al. Clinical and pathologic spectrum of 46,XY gonadal dysgenesis: its relevance to the understanding of sex differentiation. Medicine (Baltimore). Nov 1991;70(6):375-83. [Medline].

  17. Bernard-Gallon DJ, Dechelotte P, Vissac C, et al. BRCA1 and BRCA2 protein expressions in an ovotestis of a 46, XX true hermaphrodite. Breast Cancer Res. 2001;3(1):61-5. [Medline].

  18. Burgner DP, Kinmond S, Wallace AM, et al. Male pseudohermaphroditism secondary to panhypopituitarism. Arch Dis Child. - Kinmond S;75(2):153-5. [Medline].

  19. Damario MA, Rock JA. Diagnostic Approach to Ambiguous Genitalia. In: Adashi EY, Rock JA, Rosenwaks Z, eds. Reproductive Endocrinology, Surgery, and Technology. Philadelphia, Pa: Lippincott Williams & Wilkins; 1996:890-914.

  20. Damiani D, Fellous M, McElreavey K, et al. True hermaphroditism: clinical aspects and molecular studies in 16 cases. Eur J Endocrinol. Feb 1997;136(2):201-4. [Medline].

  21. Decker JP, Lerner HJ, Schwartz I. Breast carcinoma in a 46, XX true hermaphrodite. Cancer. Apr 1 1982;49(7):1481-4. [Medline].

  22. Diamond M, Sigmundson HK. Management of intersexuality. Guidelines for dealing with persons with ambiguous genitalia. Arch Pediatr Adolesc Med. Oct 1997;151(10):1046-50. [Medline].

  23. Eberenz W, Rosenberg HK, Moshang T, et al. True hermaphroditism: sonographic demonstration of ovotestes. Radiology. May 1991;179(2):429-31. [Medline].

  24. Farag TI, Al-Awadi SA, Tippett P, et al. Al-Awadi SA. J Med Genet. Dec 1987;24(12):784-6. [Medline].

  25. Fechner PY. The role of SRY in mammalian sex determination. Acta Paediatr Jpn. Aug 1996;38(4):380-9. [Medline].

  26. Giltay JC, Brunt T, Beemer FA, et al. Polymorphic detection of a parthenogenetic maternal and double paternal contribution to a 46,XX/46,XY hermaphrodite. Am J Hum Genet. Apr 1998;62(4):937-40. [Medline].

  27. Guaschino S, Stola E, Spinillo A, et al. True hermaphroditism: diagnosis and surgical treatment. Clin Exp Obstet Gynecol. 1988;15(3):74-9. [Medline].

  28. Hadjiathanasiou CG, Brauner R, Lortat-Jacob S, et al. True hermaphroditism: genetic variants and clinical management. J Pediatr. Nov 1994;125(5 Pt 1):738-44. [Medline].

  29. Harbison MD, Magid ML, Josso N, et al. Anti-Mullerian hormone in three intersex conditions. Ann Genet. 1991;34(3-4):226-32. [Medline].

  30. Hasty LA, Rock JA. True hermaphroditism. In: Adashi EY, Rock JA, Rosenwaks Z, eds. Reproductive Endocrinology, Surgery, and Technology. Philadelphia, Pa: Lippincott Williams & Wilkins; 1996:978-988.

  31. Hayashi T, Kageyama Y, Ishizaka K, et al. True hermaphroditism associated with microphthalmia. Eur J Endocrinol. Jan 1999;140(1):62-5. [Medline].

  32. Heyns CF, de Kock ML, Deale CJ. A true hermaphrodite with some unusual features. Urology. Mar 1990;35(3):247-9. [Medline].

  33. Inoue H, Nomura M, Yanase T, et al. A rare case of 46,XX true hermaphroditism with hidden mosaicism with sex-determining region Y chromosome-bearing cells in the gonads. Intern Med. May 1998;37(5):467-71. [Medline].

  34. Iyer AK, McCabe ER. Molecular mechanisms of DAX1 action. Mol Genet Metab. Sep-Oct 2004;83(1-2):60-73. [Medline].

  35. Jakubowski L, Jeziorowska A, Constantinou M, et al. Xp;Yp translocation inherited from the father in an SRY, RBM, and TSPY positive true hermaphrodite with oligozoospermia. J Med Genet. Oct 2000;37(10):E28. [Medline].

  36. Jarrah N, El-Shanti H, Khier A, et al. Familial disorder of sex determination in seven individuals from three related sibships. Eur J Pediatr. Dec 2000;159(12):912-8. [Medline].

  37. Jimenez AL, Kofman-Alfaro S, Berumen J, et al. Partially deleted SRY gene confined to testicular tissue in a 46,XX true hermaphrodite without SRY in leukocytic DNA. Am J Med Genet. Aug 28 2000;93(5):417-20. [Medline].

  38. Kojima Y, Hayashi Y, Asai N, et al. Detection of the sex-determining region of the Y chromosome in 46,XX true hermaphroditism. Urol Int. Aug 1998;60(4):235-8. [Medline].

  39. Koopman P. The molecular biology of SRY and its role in sex determination in mammals. Reprod Fertil Dev. 1995;7(4):713-22. [Medline].

  40. Krob G, Braun A, Kuhnle U. True hermaphroditism: geographical distribution, clinical findings, chromosomes and gonadal histology. Eur J Pediatr. Jan 1994;153(1):2-10. [Medline].

  41. Krstic Z, Perovic S, Radmanovic S, et al. Surgical treatment of intersex disorders. J Pediatr Surg. Sep 1995;30(9):1273-81. [Medline].

  42. Kucheria K, Mohapatra I, Taneja N, et al. Genetic heterogeneity in true hermaphrodites. A report of two cases. J Reprod Med. Jul 1994;39(7):550-2. [Medline].

  43. Kutteh WH, Santos-Ramos R, Ermel LD. Accuracy of ultrasonic detection of the uterus in normal newborn infants: implications for infants with ambiguous genitalia. Ultrasound Obstet Gynecol. Feb 1995;5(2):109-13. [Medline].

  44. Letterie GS, Page DC. Dysgerminoma and gonadal dysgenesis in a 46,XX female with no evidence of Y chromosomal DNA. Gynecol Oncol. Jun 1995;57(3):423-5. [Medline].

  45. Lim DJ, Mullins DL, Stevens PS. Crossed ectopia of ovotestis in a case of true hermaphroditism. J Pediatr Surg. Oct 1996;31(10):1440-2. [Medline].

  46. Lobaccaro JM, Lumbroso S, Belon C, et al. [Genes of the Y chromosome and Turner syndrome]. Ann Endocrinol (Paris). 1994;54(5):323-9. [Medline].

  47. Lobe TE, Woodall DL, Richards GE, et al. The complications of surgery for intersex: changing patterns over two decades. J Pediatr Surg. Jul 1987;22(7):651-2. [Medline].

  48. Luks FI, Hansbrough F, Klotz DH Jr, et al. Early gender assignment in true hermaphroditism. J Pediatr Surg. Dec 1988;23(12):1122-6. [Medline].

  49. Maciel-Guerra AT, de Mello MP, Coeli FB, Ribeiro ML, Miranda ML, Marques-de-Faria AP, et al. XX Maleness and XX true hermaphroditism in SRY-negative monozygotic twins: additional evidence for a common origin. J Clin Endocrinol Metab. Feb 2008;93(2):339-43. [Medline].

  50. MacLean HE, Warne GL, Zajac JD. Intersex disorders: shedding light on male sexual differentiation beyond SRY. Clin Endocrinol (Oxf). Jan 1997;46(1):101-8. [Medline].

  51. Malavaud B, Mazerolles C, Bieth E, et al. Pure seminoma in a male phenotype 46,XX true hermaphrodite. J Urol. Jul 2000;164(1):125-6. [Medline].

  52. Margarit E, Coll MD, Oliva R, et al. SRY gene transferred to the long arm of the X chromosome in a Y-positive XX true hermaphrodite. Am J Med Genet. Jan 3 2000;90(1):25-8. [Medline].

  53. McGillivray BC. The newborn with ambiguous genitalia. Semin Perinatol. Dec 1992;16(6):365-8. [Medline].

  54. Minowada S, Hara M, Shinohara M, et al. Investigation of genetic markers in a true hermaphrodite with chi 46,XX/46,XY. Hum Genet. 1982;60(4):376-8. [Medline].

  55. Morohashi K. The ontogenesis of the steroidogenic tissues. Genes Cells. Feb 1997;2(2):95-106. [Medline].

  56. Mulhall JP, Reijo R, Alagappan R, et al. Azoospermic men with deletion of the DAZ gene cluster are capable of completing spermatogenesis: fertilization, normal embryonic development and pregnancy occur when retrieved testicular spermatozoa are used for intracytoplasmic sperm injection. Hum Reprod. Mar 1997;12(3):503-8. [Medline].

  57. Nihoul-Fékété C, Thibaud E, Lortat-Jacob S, Josso N. Long-term surgical results and patient satisfaction with male pseudohermaphroditism or true hermaphroditism: a cohort of 63 patients. J Urol. May 2006;175(5):1878-84. [Medline].

  58. Page J. The newborn with ambiguous genitalia. Neonatal Netw. Aug 1994;13(5):15-21. [Medline].

  59. Quigley MM, Vaughn TC, Hammond CB, Haney AF. Production of testosterone and estrogen in vitro by gonadal tissue from a 46,XY true hermaphrodite with gonadal failure and gonadoblastoma. Obstet Gynecol. Aug 1981;58(2):253-9. [Medline].

  60. Ramkissoon Y, Goodfellow P. Early steps in mammalian sex determination. Curr Opin Genet Dev. Jun 1996;6(3):316-21. [Medline].

  61. Reijo R, Alagappan RK, Patrizio P, Page DC. Severe oligozoospermia resulting from deletions of azoospermia factor gene on Y chromosome. Lancet. May 11 1996;347(9011):1290-3. [Medline].

  62. Roth LM, Cleary RE, Hokum WL. Ultrastructure of an ovotestis in a case of true hermaphroditism. Obstet Gynecol. Nov 1976;48(5):619-24. [Medline].

  63. Schiebel K, Winkelmann M, Mertz A, et al. Abnormal XY interchange between a novel isolated protein kinase gene, PRKY, and its homologue, PRKX, accounts for one third of all (Y+)XX males and (Y-)XY females. Hum Mol Genet. Oct 1997;6(11):1985-9. [Medline].

  64. Schwartz S, Depinet TW, Leana-Cox J, et al. Sex chromosome markers: characterization using fluorescence in situ hybridization and review of the literature. Am J Med Genet. Jul 11 1997;71(1):1-7. [Medline].

  65. Secaf E, Hricak H, Gooding CA, Ho VW, Gorczyca DP, Ringertz H, et al. Role of MRI in the evaluation of ambiguous genitalia. Pediatr Radiol. 1994;24(4):231-5. [Medline].

  66. Sloan MS, Rosenberg SM, Brown JA. Primary amenorrhea and virilization in a true hermaphrodite with a rare dicentric Y chromosome. Obstet Gynecol. Sep 1984;64(3 Suppl):64S-67S. [Medline].

  67. Sugimoto S, Igarashi T, Tada M, et al. [Two cases of true hermaphrodite: the usefulness of laparoscopic gonadectomy in childhood. A case report]. Nippon Hinyokika Gakkai Zasshi. Dec 1998;89(12):971-4. [Medline].

  68. Talerman A, Verp MS, Senekjian E, et al. True hermaphrodite with bilateral ovotestes, bilateral gonadoblastomas and dysgerminomas, 46,XX/46,XY karyotype, and a successful pregnancy. Cancer. Dec 15 1990;66(12):2668-72. [Medline].

  69. Tanaka Y, Fujiwara K, Yamauchi H, et al. Pregnancy in a woman with a Y chromosome after removal of an ovarian dysgerminoma. Gynecol Oncol. Dec 2000;79(3):519-21. [Medline].

  70. Teele RL, Share JC. Ultrasonography of the female pelvis in childhood and adolescence. Radiol Clin North Am. Jul 1992;30(4):743-58. [Medline].

  71. Toublanc JE, Boucekkine C, Abbas N, et al. Hormonal and molecular genetic findings in 46,XX subjects with sexual ambiguity and testicular differentiation. Eur J Pediatr. 1993;152 Suppl 2:S70-5. [Medline].

  72. Tsuchiya K, Reijo R, Page DC, Disteche CM. Gonadoblastoma: molecular definition of the susceptibility region on the Y chromosome. Am J Hum Genet. Dec 1995;57(6):1400-7. [Medline].

  73. van Niekerk WA, Retief AE. The gonads of human true hermaphrodites. Hum Genet. 1981;58(1):117-22. [Medline].

  74. Verp MS, Harrison HH, Ober C, et al. Chimerism as the etiology of a 46,XX/46,XY fertile true hermaphrodite. Fertil Steril. Feb 1992;57(2):346-9. [Medline].

  75. Viger RS, Silversides DW, Tremblay JJ. New insights into the regulation of mammalian sex determination and male sex differentiation. Vitam Horm. 2005;70:387-413. [Medline].

  76. Vojnovic M, Martinov-Cvejin M, Grujic V. [Biosocial aspects of physician-patient communication in general medicine]. Med Pregl. Sep-Oct 1997;50(9-10):395-8. [Medline].

  77. Walker AM, Walker JL, Adams S, et al. True hermaphroditism. J Paediatr Child Health. Feb 2000;36(1):69-73. [Medline].

  78. Wiersma R. True hermaphroditism in southern Africa: the clinical picture. Pediatr Surg Int. May 2004;20(5):363-8. [Medline].

  79. Williams C, Hughes IA. Unusual dual genital duct remnants in true hermaphroditism. J Med Genet. Mar 1988;25(3):206-8. [Medline].

  80. Wright NP, Wales JK. An unusal case of hermaphroditism--a 46,XX/69,XXY chimera. J Pediatr Endocrinol Metab. Jun 2004;17(6):905-8. [Medline].

  81. Yu Q, Huang S, Ye L, et al. The role of sexual related Y gene detection in the diagnosis of patients with gonadal dysgenesis. Chin Med J (Engl). Feb 2001;114(2):128-31. [Medline].

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Keywords

hermaphrodite, intersex, true hermaphroditism, ambiguous genitalia, ovary, testis, ovotestes, testicular tissue, ovarian tissue, ovotesticular disorder, ovotesticular disorder of sexual development, disorder of sexual development

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Contributor Information and Disclosures

Author

Molina B Dayal, MD, MPH, Associate Professor, Medical Director of Egg Donation Program, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Medical Faculty Associates, George Washington University School of Medicine
Molina B Dayal, MD, MPH is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine, and Society for Reproductive Endocrinology and Infertility
Disclosure: Nothing to disclose.

Coauthor(s)

Candice B O'Hern, MD, Resident Physician, Department of Obstetrics and Gynecology, George Washington University Hospital
Candice B O'Hern, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Gerard S Letterie, DO, Associate Clinical Professor, Medical Director of In-vitro Fertilization Lab, Department of Obstetrics and Gynecology, Virginia Mason Medical Center, University of Washington
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

A David Barnes, MD, PhD, MPH, FACOG, Consulting Staff, Department of Obstetrics and Gynecology, Mammoth Hospital (Mammoth Lakes, California), Pioneer Valley Hospital (Salt Lake City, Utah), Warren General Hospital (Warren, Pennsylvania), and Mountain West Hospital (Tooele, Utah)
A David Barnes, MD, PhD, MPH, FACOG is a member of the following medical societies: American College of Forensic Examiners, American College of Obstetricians and Gynecologists, American Medical Association, Association of Military Surgeons of the US, and Utah Medical Association
Disclosure: Nothing to disclose.

CME Editor

Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Hancock Medical Center
Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians
Disclosure: Nothing to disclose.

Chief Editor

Bryan D Cowan, MD, Professor and Chairman, Department of Obstetrics and Gynecology, University of Mississippi College of Medicine; Consulting Staff, Department of Obstetrics and Gynecology, Veterans Affairs Medical Center; Medical Director, Wiser Hospital for Women, University of Mississippi Medical Center
Bryan D Cowan, MD is a member of the following medical societies: American Association of Gynecologic Laparoscopists, American College of Obstetricians and Gynecologists, American Gynecological and Obstetrical Society, American Medical Association, American Society for Reproductive Medicine, Association of Professors of Gynecology and Obstetrics, Central Association of Obstetricians and Gynecologists, Endocrine Society, Sigma Xi, Society for Assisted Reproductive Technologies, Society for Gynecologic Investigation, Society for the Study of Reproduction, and Society of Laparoendoscopic Surgeons
Disclosure: Wyeth None Speaking and teaching

 
 
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