Diagnostic approach in 46, XY DSD: an endocrine society of bengal (ESB) consensus statement
Authors: Baidya Arjun , Basu Asish Kumar , Bhattacharjee Rana , Biswas Dibakar , Biswas Kaushik , Chakraborty Partha Pratim , Chatterjee Purushottam , Chowdhury Subhankar , Dasgupta Ranen , Ghosh Amritava , Ghosh Sujoy , Giri Debasis , Goswami Soumik , Maisnam Indira , Maiti Animesh , Mondal Sunetra , Mukhopadhyay Pradip , Mukhopadhyay Sarmishtha , Mukhopadhyay Satinath , Pal Salil Kumar , Pandit Kaushik , Ray Sayantan , Chowdhury Bibek Roy , Raychaudhuri Moutusi , Raychaudhuri Pradip , Roy Ajitesh , Sahana Pranab Kumar , Sanyal Debmalya , Sanyal Trinanjan , Saraogi Ravi Kant , Sarkar Dasarathi , Sengupta Nilanjan , Singh Awadhesh Kumar , Sinha Anirban 
Published: November 2022

Abstract

Objectives
46, XY difference/disorder of sex development (DSD) is a relatively uncommon group of heterogeneous disorders with varying degree of underandrogenization of male genitalia. Such patients should be approached systematically to reach an aetiological diagnosis. However, we lack, at present, a clinical practice guideline on diagnostic approach in 46, XY DSD from this part of the globe. Moreover, debate persists regarding the timing and cut-offs of different hormonal tests, performed in these cases. The consensus committee consisting of 34 highly experienced endocrinologists with interest and experience in managing DSD discussed and drafted a consensus statement on the diagnostic approach to 46, XY DSD focussing on relevant history, clinical examination, biochemical evaluation, imaging and genetic analysis.

Content
The consensus was guided by systematic reviews of existing literature followed by discussion. An initial draft was prepared and distributed among the members. The members provided their scientific inputs, and all the relevant suggestions were incorporated. The final draft was approved by the committee members.

Summary
The diagnostic approach in 46, XY DSD should be multidisciplinary although coordinated by an experienced endocrinologist. We recommend formal Karyotyping, even if Y chromosome material has been detected by other methods. Meticulous history taking and thorough head-to-toe examination should initially be performed with focus on external genitalia, including location of gonads. Decision regarding hormonal and other biochemical investigations should be made according to the age and interpreted according to age-appropriate norms Although LC-MS/MS is the preferred mode of steroid hormone measurements, immunoassays, which are widely available and less expensive, are acceptable alternatives. All patients with 46, XY DSD should undergo abdominopelvic ultrasonography by a trained radiologist. MRI of the abdomen and/or laparoscopy may be used to demonstrate the Mullerian structure and/or to localize the gonads. Genetic studies, which include copy number variation (CNV) or molecular testing of a candidate gene or next generation sequencing then should be ordered in a stepwise manner depending on the clinical, biochemical, hormonal, and radiological findings.

Outlook
The members of the committee believe that patients with 46, XY DSD need to be approached systematically. The proposed diagnostic algorithm, provided in the consensus statement, is cost effective and when supplemented with appropriate genetic studies, may help to reach an aetiological diagnosis in majority of such cases.