## 4 Discussion
However, this percentage was higher than that observed in other studies on DSD patients (around 30%) [27; 28; 29; 30; 31; 32]. This higher percentage may have been due to the fact that the patients tested by sequencing comprised those with a severe DSD phenotype [28]. A similar percentage of diagnosis was found for both 46,XY and 46,XX patients. The genes that presented pathogenic or likely pathogenic variants or VUS were _RSPO1_, _FGFR1_, _WTL_, _CHD7_, _AR_, _NIPBL_, _AMHR2_, _AR_, _EMX2_, _CYP17A1_, _NR0B1_, _GNRHR_, _GATA4_, and _ATM_ genes. As in other studies, the frequency of _AR_ gene mutations was higher than that of other genes [28; 33; 34; 35]. The variant described in the _GATA4_ gene, c.698C>A (p.Thr233 Lys), fell within the N-terminal zinc finger region, one that was recently proved by [PERSON] to have a pathogenic effect in 46,XY DSD, unlike variants in other regions of this gene, which usually have a benign contribution [36]. Another pathogenic variant identified in the present study was in the _NIPBL_ gene; this variant is associated with Cornelia [PERSON] syndrome. The genetic diagnosis for this patient was due to genital abnormalities seen and less to the dysmorphic and neuropsychiatric signs classically associated with this syndrome. A limitation of the present study was the impossibility of evaluating the parents to establish the de novo or inherited characteristics of the unknown variants, as well as the inability to perform functional studies for these variants. However, an important contribution of this study was that it was the first in the authors' country to perform a well-defined algorithm for genetic testing in DSD. In conclusion, an evaluation following a genetic testing algorithm including karyotype and _SRY_ gene testing, _CYP21A2_ analysis, chromosomal analysis by microarray, and next-generation sequencing provided a diagnosis for 87 patients with a spectrum of diagnostic yield between 15 and 50%, depending on the technique. Additionally, new genetic variants not previously described in DSD patients were observed. Conceptualization, D.M., C.A. and S.B. ; methodology, D.M., C.A., S.B., P.G.-S., R.A.P., I.M.P., V.C., C.G., L.B. and G.Z. ; software, D.M. ; validation, D.M., C.A., S.B., P.G.-S., R.A.P., I.M.P., V.C., C.G., L.B. and G.Z. ; formal analysis, D.M., C.A. and S.B. ; investigation, D.M., C.A., S.B., P.G.-S., R.A.P., I.M.P., V.C., C.G., L.B. and G.Z. ; resources, D.M. ; data curation, D.M. ; writing--original draft preparation, D.M., C.A. and S.B. ; writing--review and editing, D.M., C.A. and S.B. ; visualization, D.M., C.A., S.B., P.G.-S., R.A.P., I.M.P., V.C., C.G., L.B. and G.Z. ; supervision, D.M., C.A. and S.B. ; project administration. All authors have read and agreed to the published version of the manuscript. This research received no external funding. The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of \"[PERSON]\" University of Medicine and Pharmacy, Cluj-Napoca, Romania (389/4.10.2019). Informed Consent Statement: Informed consent was obtained from all subjects involved in the study. The data presented in this study are available on request from the corresponding author. The authors declare no conflict of interest.