Is ideal for patients presenting with ambiguous genitalia, patients suspected to have a disorder of sexual development and patients suspected to have congenital adrenal hyperplasia (CAH).
The Blueprint Genetics Abnormal Genitalia/ Disorders of Sex Development Panel (test code EN0201):
Read about our accreditations, certifications and CE-marked IVD medical devices here.
Refer to the most current version of ICD-10-CM manual for a complete list of ICD-10 codes.
- Blood (min. 1ml) in an EDTA tube
- Extracted DNA, min. 2 μg in TE buffer or equivalent
- Saliva (Please see Sample Requirements for accepted saliva kits)
Label the sample tube with your patient’s name, date of birth and the date of sample collection.
We do not accept DNA samples isolated from formalin-fixed paraffin-embedded (FFPE) tissue. In addition, if the patient is affected with a hematological malignancy, DNA extracted from a non-hematological source (e.g. skin fibroblasts) is strongly recommended.
Please note that, in rare cases, mitochondrial genome (mtDNA) variants may not be detectable in blood or saliva in which case DNA extracted from post-mitotic tissue such as skeletal muscle may be a better option.
Read more about our sample requirements here.
Disorders of sex development (DSD) are a group of congenital conditions characterized by problems in the course of gender patterning, gonadal and sex development. It has been estimated that 1% – 2% of live births have some aspect of DSD. Approximately 5% of infants with DSD have ambiguous genitalia and indeterminate sex at birth. However, the vast majority of these patients do not require corrective surgery. Patients with 46,XY DSD have often impaired androgen synthesis or action and may have normal female external genitalia, while patients with 46,XX DSD conditions have often androgen excess. In 46,XX females, congenital adrenal hyperplasia (CAH) caused by 21-hydroxylase deficiency (21-OHD) is the most common cause of DSD. The estimated prevalence of CAH is 1:10,000 and 90%-95% of cases are due to mutations in CYP21A2. The severity of the condition often depends on the residual enzyme activity subdiving CYP21A2 mutations in severe (classic phenotype, enzyme activity 0%-10%) and mild (non-classic, enzyme activity 20%-50%). Androgen insensitivity syndrome (AIS), caused by mutations in AR, is characterized by feminization of external genitalia and atypical sexual development in 46,XY individuals. The condition may be complete, partial or mild, depending on the level of androgen insensitivity. Mutations in the AR gene explain up to 95% of cases with complete androgen insensitivity, while the proportions are lower for the partial and mild subtypes. The combined prevalence of various AIS subtypes is estimated to be 5:100,000.
Genes in the Abnormal Genitalia/ Disorders of Sex Development Panel and their clinical significance
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|AMH||Persistent Mullerian duct syndrome||AR||5||56|
|AMHR2||Persistent Mullerian duct syndrome||AR||6||37|
|AR||Androgen insensitivity, Hypospadias 1, X-linked||XL||147||612|
|ARX#||Lissencephaly, Epileptic encephalopathy, Corpus callosum, agenesis of, with abnormal genitalia, Partington syndrome, Proud syndrome, Hydranencephaly with abnormal genitalia, Intellectual developmental disorder||XL||66||93|
|ATRX||Carpenter-Waziri syndrome, Alpha-thalassemia/mental retardation syndrome, Holmes-Gang syndrome, Juberg-Marsidi syndrome, Smith-Fineman-Myers syndrome, Mental retardation-hypotonic facies syndrome||XL||65||165|
|BCOR||Microphthalmia, syndromic, Oculofaciocardiodental syndrome||XL||40||53|
|CDKN1C||Beckwith-Wiedemann syndrome, IMAGE syndrome||AD||35||81|
|CHD7||Isolated gonadotropin-releasing hormone deficiency, CHARGE syndrome||AD||276||860|
|CYB5A||46, XY disorder of sex development, Methemoglobinemia, type IV||AR||3||5|
|CYP11A1||Adrenal insufficiency, congenital, with 46,XY sex reversal, partial or complete||AD/AR||14||28|
|CYP11B1*||Adrenal hyperplasia, congenital, due to 11-beta-hydroxylase deficiency, Glucocorticoid-remediable aldosteronism||AD/AR||55||147|
|CYP17A1||Adrenal hyperplasia, congenital, due to 17-alpha-hydroxylase deficiency||AR||35||126|
|CYP19A1||Aromatase deficiency, Aromatase excess syndrome||AR||17||52|
|CYP21A2*||Adrenal hyperplasia, congenital, due to 21-hydroxylase deficiency, Hyperandrogenism, nonclassic , due to 21-hydroxylase deficiency||AR||48||296|
|DHH||46,XY partial gonadal dysgenesis, with minifascicular neuropathy, 46,XY sex reversal 7||AD/AR||5||18|
|DYNC2H1||Short -rib thoracic dysplasia with or without polydactyly type 1, Short -rib thoracic dysplasia with or without polydactyly type 3, Asphyxiating thoracic dysplasia (ATD; Jeune), SRPS type 2 (Majewski)||AR/Digenic||148||205|
|ERCC3||Xeroderma pigmentosum, Trichothiodystrophy, photosensitive||AR||10||19|
|FEZF1||Hypogonadotropic hypogonadism 22 with or without anosmia, Kallmann syndrome||AR||2||3|
|FGF17||Hypogonadotropic hypogonadism 20, with or without anosmia||AD/Multigenic||2||5|
|FGFR1||Pfeiffer syndrome, Trigonocephaly, Hypogonadotropic hypogonadism, Osteoglophonic Dwarfism - Craniostenosis, Hartsfield syndrome||AD/Digenic/Multigenic||72||257|
|FIG4||Amyotrophic lateral sclerosis, Polymicrogyria, bilateral occipital, Yunis-Varon syndrome, Charcot-Marie-Tooth disease||AD/AR||34||69|
|FSHB||Hypogonadotropic hypogonadism 24 without anosmia||AR||5||8|
|GATA4*||Tetralogy of Fallot, Atrioventricular septal defect, Testicular anomalies with or without congenital heart disease, Ventricular septal defect, Atrial septal defect||AD||37||140|
|GNRH1||Hypogonadotropic hypogonadism 12 with or without anosmia||AR||1||10|
|HS6ST1*||Hypogonadotropic hypogonadism 15, with or without anosmia, Kallmann syndrome||AD||7|
|HSD17B3||Neurodevelopmental disorder with hypotonia, neonatal respiratory insufficiency, and thermodysregulation||AR||24||63|
|HSD3B2||3-beta-hydroxysteroid dehydrogenase, II deficiency||AR||11||63|
|IRF6||Orofacial cleft, Popliteal pterygium syndrome, van der Woude syndrome||AD||45||338|
|KISS1||Hypogonadotropic hypogonadism 13 with or without anosmia, Central precocious puberty||AR||1||10|
|KISS1R||Precocious puberty, central 1||AD/AR||7||36|
|LEPR#||Leptin receptor deficiency||AR||4||30|
|LHB*||Hypogonadotropic hypogonadism 23 with or without anosmia||AR||6||8|
|LHCGR||Precocious puberty, male, Leydig cell hypoplasia, Luteinizing hormone resistance, female||AR||34||76|
|MAMLD1||Hypospadias 2, X-linked||XL||5||20|
|MAP3K1||46,XY sex reversal 6||AD||9||27|
|MKRN3||Central precocious puberty||AD||6||32|
|MKS1||Bardet-Biedl syndrome, Meckel syndrome||AR||50||52|
|NR0B1||Adrenal hypoplasia, congenital, 46,XY sex reversal||XL||73||252|
|NR5A1||Adrenocortical insufficiency, Premature ovarian failure, 46,XY sex reversal||AD||28||183|
|NSMF||Hypogonadotropic hypogonadism 9 with or without anosmia||AD||8|
|POR||Disordered steroidogenesis due to cytochrome p450 oxidoreductase deficiency, Antley-Bixler syndrome||AR||14||70|
|PROK2||Hypogonadism, hypogonadotropic, Kallmann syndrome||AR||7||20|
|PROP1||Pituitary hormone deficiency, combined||AR||33||37|
|RNF216*||Cerebellar ataxia and hypogonadotropic hypogonadism (Gordon Holmes syndrome)||AR||10||14|
|RSPO1||Palmoplantar hyperkeratosis with squamous cell carcinoma of skin and 46,XX sex reversal||AR||3||5|
|SAMD9||Mirage syndrome, Tumoral calcinosis, normophosphatemic||AD/AR||10||27|
|SGPL1||Nephrotic syndrome 14||AR||8||17|
|SOX10||Peripheral demyelinating neuropathy, central dysmyelination, Waardenburg syndrome, and Hirschsprung disease, Kallmann syndrome||AD||56||148|
|SOX9||Campomelic dysplasia, 46,XY sex reversal, Brachydactyly with anonychia (Cooks syndrome)||AD||47||144|
|SRD5A2||Steroid 5-alpha-reductase 2 deficiency||AR||45||119|
|SRY||46,XX disorder of sex development, 46,XY disorder of sex development||YL||29||109|
|STAR||Lipoid adrenal hyperplasia||AD/AR||34||83|
|TOE1||Pontocerebellar hypoplasia type 7||11||12|
|TSPYL1||Sudden infant death with dysgenesis of the testes syndrome, 46, XY disorder of sex development||AR||1||8|
|WDR11||Hypogonadotropic hypogonadism, Kallmann syndrome||AD||3||17|
|WT1||Denys-Drash syndrome, Frasier syndrome, Wilms tumor, Nephrotic syndrome, type 4||AD||42||183|
|ZFPM2||46,XY sex reversal, Diaphragmatic hernia 3, Tetralogy of Fallot||AD/AR||9||50|
The gene has suboptimal coverage (means <90% of the gene’s target nucleotides are covered at >20x with mapping quality score (MQ>20) reads), and/or the gene has exons listed under Test limitations section that are not included in the panel as they are not sufficiently covered with high quality sequence reads.
Some, or all, of the gene is duplicated in the genome. Read more.
The sensitivity to detect variants may be limited in genes marked with an asterisk (*) or number sign (#). Due to possible limitations these genes may not be available as single gene tests.
Gene refers to the HGNC approved gene symbol; Inheritance refers to inheritance patterns such as autosomal dominant (AD), autosomal recessive (AR), mitochondrial (mi), X-linked (XL), X-linked dominant (XLD) and X-linked recessive (XLR); ClinVar refers to the number of variants in the gene classified as pathogenic or likely pathogenic in this database (ClinVar); HGMD refers to the number of variants with possible disease association in the gene listed in Human Gene Mutation Database (HGMD). The list of associated, gene specific phenotypes are generated from CGD or Mitomap databases.
Non-coding variants covered by Abnormal Genitalia/ Disorders of Sex Development Panel
To view complete table content, scroll horizontally.
|Gene||Genomic location HG19||HGVS||RefSeq||RS-number|
Test Strength and Limitations
The strengths of this test include:
- CAP accredited laboratory
- CLIA-certified personnel performing clinical testing in a CLIA-certified laboratory
- Powerful sequencing technologies, advanced target enrichment methods and precision bioinformatics pipelines ensure superior analytical performance
- Careful construction of clinically effective and scientifically justified gene panels
- Some of the panels include the whole mitochondrial genome (please see the Panel Content section)
- Our Nucleus online portal providing transparent and easy access to quality and performance data at the patient level
- Our publicly available analytic validation demonstrating complete details of test performance
- ~2,000 non-coding disease causing variants in our clinical grade NGS assay for panels (please see ‘Non-coding disease causing variants covered by this panel’ in the Panel Content section)
- Our rigorous variant classification scheme
- Our systematic clinical interpretation workflow using proprietary software enabling accurate and traceable processing of NGS data
- Our comprehensive clinical statements
A significant proportion of pathogenic CYP21A2 variants are secondary to gene conversions. We have been able to detect some gene conversions and some copy number variants in patients referred to clinical testing; however, we have not performed an analytic validation of these variant types and our detection capabilities are likely limited.
Genes with suboptimal coverage in our assay are marked with number sign (#) and genes with partial, or whole gene, segmental duplications in the human genome are marked with an asterisk (*) if they overlap with the UCSC pseudogene regions. Gene is considered to have suboptimal coverage when >90% of the gene’s target nucleotides are not covered at >20x with mapping quality score (MQ>20) reads. The technology may have limited sensitivity to detect variants in genes marked with these symbols (please see the Panel content table above).
This test does not detect the following:
- Complex inversions
- Gene conversions
- Balanced translocations
- Some of the panels include the whole mitochondrial genome but not all (please see the Panel Content section)
- Repeat expansion disorders unless specifically mentioned
- Non-coding variants deeper than ±20 base pairs from exon-intron boundary unless otherwise indicated (please see above Panel Content / non-coding variants covered by the panel).
This test may not reliably detect the following:
- Low level mosaicism in nuclear genes (variant with a minor allele fraction of 14.6% is detected with 90% probability)
- Stretches of mononucleotide repeats
- Low level heteroplasmy in mtDNA (>90% are detected at 5% level)
- Indels larger than 50bp
- Single exon deletions or duplications
- Variants within pseudogene regions/duplicated segments
- Some disease causing variants present in mtDNA are not detectable from blood, thus post-mitotic tissue such as skeletal muscle may be required for establishing molecular diagnosis.
The sensitivity of this test may be reduced if DNA is extracted by a laboratory other than Blueprint Genetics.
For additional information, please refer to the Test performance section and see our Analytic Validation.
The genes on the panel have been carefully selected based on scientific literature, mutation databases and our experience.
Our panels are sectioned from our high-quality, clinical grade NGS assay. Please see our sequencing and detection performance table for details regarding our ability to detect different types of alterations (Table).
Assays have been validated for various sample types including EDTA-blood, isolated DNA (excluding from formalin fixed paraffin embedded tissue), saliva and dry blood spots (filter cards). These sample types were selected in order to maximize the likelihood for high-quality DNA yield. The diagnostic yield varies depending on the assay used, referring healthcare professional, hospital and country. Plus analysis increases the likelihood of finding a genetic diagnosis for your patient, as large deletions and duplications cannot be detected using sequence analysis alone. Blueprint Genetics’ Plus Analysis is a combination of both sequencing and deletion/duplication (copy number variant (CNV)) analysis.
The performance metrics listed below are from an initial validation performed at our main laboratory in Finland. The performance metrics of our laboratory in Marlborough, MA, are equivalent.
Performance of Blueprint Genetics high-quality, clinical grade NGS sequencing assay for panels.
|Sensitivity % (TP/(TP+FN)||Specificity %|
|Single nucleotide variants||99.89% (99,153/99,266)||>99.9999%|
|Insertions, deletions and indels by sequence analysis|
|1-10 bps||99.2% (7,745/7,806)||>99.9999%|
|11-50 bps||99.13% (2,524/2,546)||>99.9999%|
|Copy number variants (exon level dels/dups)|
|1 exon level deletion (heterozygous)||100% (20/20)||NA|
|1 exon level deletion (homozygous)||100% (5/5)||NA|
|1 exon level deletion (het or homo)||100% (25/25)||NA|
|2-7 exon level deletion (het or homo)||100% (44/44)||NA|
|1-9 exon level duplication (het or homo)||75% (6/8)||NA|
|Simulated CNV detection|
|5 exons level deletion/duplication||98.7%||100.00%|
|Microdeletion/-duplication sdrs (large CNVs, n=37))|
|Size range (0.1-47 Mb)||100% (25/25)|
|The performance presented above reached by Blueprint Genetics high-quality, clinical grade NGS sequencing assay with the following coverage metrics|
|Mean sequencing depth||143X|
|Nucleotides with >20x sequencing coverage (%)||99.86%|
Performance of Blueprint Genetics Mitochondrial Sequencing Assay.
|Sensitivity %||Specificity %|
|ANALYTIC VALIDATION (NA samples; n=4)|
|Single nucleotide variants|
|Heteroplasmic (45-100%)||100.0% (50/50)||100.0%|
|Heteroplasmic (35-45%)||100.0% (87/87)||100.0%|
|Heteroplasmic (25-35%)||100.0% (73/73)||100.0%|
|Heteroplasmic (15-25%)||100.0% (77/77)||100.0%|
|Heteroplasmic (10-15%)||100.0% (74/74)||100.0%|
|Heteroplasmic (5-10%)||100.0% (3/3)||100.0%|
|Heteroplasmic (<5%)||50.0% (2/4)||100.0%|
|CLINICAL VALIDATION (n=76 samples)|
|Single nucleotide variants n=2026 SNVs|
|Heteroplasmic (45-100%)||100.0% (1940/1940)||100.0%|
|Heteroplasmic (35-45%)||100.0% (4/4)||100.0%|
|Heteroplasmic (25-35%)||100.0% (3/3)||100.0%|
|Heteroplasmic (15-25%)||100.0% (3/3)||100.0%|
|Heteroplasmic (10-15%)||100.0% (9/9)||100.0%|
|Heteroplasmic (5-10%)||92.3% (12/13)||99.98%|
|Heteroplasmic (<5%)||88.9% (48/54)||99.93%|
|Insertions and deletions by sequence analysis n=40 indels|
|Heteroplasmic (45-100%) 1-10bp||100.0% (32/32)||100.0%|
|Heteroplasmic (5-45%) 1-10bp||100.0% (3/3)||100.0%|
|Heteroplasmic (<5%) 1-10bp||100.0% (5/5)||99,997%|
|SIMULATION DATA /(mitomap mutations)|
|Insertions, and deletions 1-24 bps by sequence analysis; n=17|
|Homoplasmic (100%) 1-24bp||100.0% (17/17)||99.98%|
|Heteroplasmic (50%)||100.0% (17/17)||99.99%|
|Heteroplasmic (25%)||100.0% (17/17)||100.0%|
|Heteroplasmic (20%)||100.0% (17/17)||100.0%|
|Heteroplasmic (15%)||100.0% (17/17)||100.0%|
|Heteroplasmic (10%)||94.1% (16/17)||100.0%|
|Heteroplasmic (5%)||94.1% (16/17)||100.0%|
|Copy number variants (separate artifical mutations; n=1500)|
|Homoplasmic (100%) 500 bp, 1kb, 5 kb||100.0%||100.0%|
|Heteroplasmic (50%) 500 bp, 1kb, 5 kb||100.0%||100.0%|
|Heteroplasmic (30%) 500 bp, 1kb, 5 kb||100.0%||100.0%|
|Heteroplasmic (20%) 500 bp, 1kb, 5 kb||99.7%||100.0%|
|Heteroplasmic (10%) 500 bp, 1kb, 5 kb||99.0%||100.0%|
|The performance presented above reached by following coverage metrics at assay level (n=66)|
|Mean of medians||Median of medians|
|Mean sequencing depth MQ0 (clinical)||18224X||17366X|
|Nucleotides with >1000x MQ0 sequencing coverage (%) (clinical)||100%|
|rho zero cell line (=no mtDNA), mean sequencing depth||12X|
The target region for each gene includes coding exons and ±20 base pairs from the exon-intron boundary. In addition, the panel includes non-coding and regulatory variants if listed above (Non-coding variants covered by the panel). Some regions of the gene(s) may be removed from the panel if specifically mentioned in the ‘Test limitations” section above. If the test includes the mitochondrial genome the target region gene list contains the mitochondrial genes. The sequencing data generated in our laboratory is analyzed with our proprietary data analysis and annotation pipeline, integrating state-of-the art algorithms and industry-standard software solutions. Incorporation of rigorous quality control steps throughout the workflow of the pipeline ensures the consistency, validity and accuracy of results. Our pipeline is streamlined to maximize sensitivity without sacrificing specificity. We have incorporated a number of reference population databases and mutation databases including, but not limited, to 1000 Genomes Project, gnomAD, ClinVar and HGMD into our clinical interpretation software to make the process effective and efficient. For missense variants, in silico variant prediction tools such as SIFT, PolyPhen,MutationTaster are used to assist with variant classification. Through our online ordering and statement reporting system, Nucleus, ordering providers have access to the details of the analysis, including patient specific sequencing metrics, a gene level coverage plot and a list of regions with suboptimal coverage (<20X for nuclear genes and <1000X for mtDNA) if applicable. This reflects our mission to build fully transparent diagnostics where ordering providers can easily visualize the crucial details of the analysis process.
We provide customers with the most comprehensive clinical report available on the market. Clinical interpretation requires a fundamental understanding of clinical genetics and genetic principles. At Blueprint Genetics, our PhD molecular geneticists, medical geneticists, and clinical consultants prepare the clinical statement together by evaluating the identified variants in the context of the phenotypic information provided in the requisition form. Our goal is to provide clinically meaningful statements that are understandable for all medical professionals regardless of whether they have formal training in genetics.
Variant classification is the cornerstone of clinical interpretation and resulting patient management decisions. Our classifications follow the ACMG guideline 2015.
The final step in the analysis is orthogonal confirmation. Sequence and copy number variants classified as pathogenic, likely pathogenic, and variants of uncertain significance (VUS) are confirmed using bi-directional Sanger sequencing or by orthogonal methods such as qPCR/ddPCR when they do not meet our stringent NGS quality metrics for a true positive call.
Our clinical statement includes tables for sequencing and copy number variants that include basic variant information (genomic coordinates, HGVS nomenclature, zygosity, allele frequencies, in silico predictions, OMIM phenotypes, and classification of the variant). In addition, the statement includes detailed descriptions of the variant, gene, and phenotype(s) including the role of the specific gene in human disease, the mutation profile, information about the gene’s variation in population cohorts, and detailed information about related phenotypes. We also provide links to the references, abstracts, and variant databases used to help ordering providers further evaluate the reported findings if desired. The conclusion summarizes all of the existing information and provides our rationale for the classification of the variant.
Identification of pathogenic or likely pathogenic variants in dominant disorders or their combinations in different alleles in recessive disorders are considered molecular confirmation of the clinical diagnosis. In these cases, family member testing can be used for risk stratification. We do not recommend using variants of uncertain significance (VUS) for family member risk stratification or patient management. Genetic counseling is recommended.
Our interpretation team analyzes millions of variants from thousands of individuals with rare diseases. Our internal database and our understanding of variants and related phenotypes increases with every case analyzed. Our laboratory is therefore well-positioned to re-classify previously reported variants as new information becomes available. If a variant previously reported by Blueprint Genetics is re-classified, our laboratory will issue a follow-up statement to the original ordering healthcare provider at no additional cost, according to our latest follow-up reporting policy.
- AIS - DSD Support Group
- AIS-DSD Support Group
- Accord Alliance
- Androgen Insensitivity SyndromeSupport Group
- Androgen Insensitivity Syndrome Support Group
- CAH support group
- CARES Foundation
- Congenital Adrenal Hyperplasia Education and Support Group
- Congenital Adrenal Hyperplasia education and support group
- GARD - Persistent Mullerian Duct Syndrome
- GeneReviews - 46,XY Disorder of Sex Development
- GeneReviews - Androgen Insensitivity Syndrome
- GeneReviews - Congenital Adrenal Hyperplasia
- Intersex Society of North America
- NORD - Androgen Insensitivity Syndrome
- NORD - Congenital Adrenal Hyperplasia
- NORD - Persistent Mullerian duct syndrome
- National Adrenal Diseases Foundation