SRY、MIS、T在男性假两性畸形诊治中的作用及雄激素受体基因突变的检测
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摘要
研究背景:
两性畸形是泌尿生殖系统少见病,近年来随着临床诊断技术的不断进步,人们就诊意识的增强,两性畸形患者的就诊及确诊率不断提高,两性畸形逐渐被人们所重视。尽管如此,两性畸形因其病因复杂,分类混乱,给临床诊治带来了较大的困难。尤以男性假两性畸形的临床诊治是泌尿外科医生较为棘手的问题。
男性假两性畸形根据病因大体可分为:1、促性腺激素性性机能减退;2、睾酮合成障碍;3、雄激素受体不敏感综合症;4、5-a还原酶缺乏;5、苗勒氏管永存综合症;6、性腺发育不良;7、46XY女性化综合症等,如果再细分则种类更多。由于对该疾病的认识有限,临床上明确诊断有一定困难,诊断的不明确也导致了治疗的盲目性。目前认为,早期明确诊断,早期综合治疗对于部分类型的男性假两性畸形患者会有更好的治疗效果。它不仅能减轻患者的经济负担及手术创伤带来的痛苦,更重要的是能最大程度的避免患者的心理畸形。
男性生殖系统及第二性征的发育比较复杂。人类原始未分化性腺是具有双潜能的性腺,SRY基因是男性Y染色体短臂上的性别决定基因,其表达诱导原始未分化性腺向睾丸发育,是男性性别发育的始动因素。研究显示性别的决定并非由SRY基因单一因素所决定,其对于睾丸的绝对意义受到了质疑,通过对SRY基因的检测,探讨其在临床诊断中的作用。睾丸的发育除受到众多上游因素影响外,还受到睾丸自身分泌的各种因子的多重作用。睾丸的两种主要细胞Leydig细胞、Sertoli细胞分别分泌睾酮(T testosterone)和苗勒氏管抑制因子(MIS)。睾酮基本能反应睾丸的功能状态,但它不能完全诱导个体的男性化进程,不能保证男性生殖道及第二性征的完全发育。最近苗勒氏管抑制因子(MIS)的生理作用越来越受到重视,它的主要作用是抑制副中肾管发育为输卵管,子宫和阴道上部,若MIS功能异常也将导致两性畸形的产生。我们拟通过通过检测SRY基因对睾丸的敏感性, MIS、T在男性假两性畸形血清中的表达,探讨它们在男性假两性畸形诊断中的作用及相关性,为临床男性假两性畸形的明确诊断提供更多的依据。
雄激素不敏感综合症(AIS)是男性假两性畸形中较为常见的一种类型,受体的缺陷程度不同使临床表现差异很大,分为完全性雄激素不敏感综合症(CAIS)和不完全性雄激素不敏感综合症(IAIS)。AIS属于X连锁隐性遗传病,是位于X染色体上决定雄激素受体的基因发生突变,引起雄激素靶细胞膜上的雄激素受体缺陷,造成对雄激素不敏感。对AIS病因的研究已取得一定的进展,发现了一些可能的致病突变,但其确切的发病机制仍不十分清楚,我们拟对1个患完全性雄激素不敏感综合症的小家系进行雄激素受体基因的检测,明确其可能存在的致病突变基因,在分子水平上对其诊断提供有价值的资料。
目的:
明确SRY基因、MIS、T三项指标在男性假两性畸形诊断中的作用及其相关性,为临床明确诊断提供依据。对1个完全性雄激素不敏感综合症的小家系进行雄激素受体基因的检测,明确其可能存在的致病突变基因。
方法:
收集男性假两性畸形及无生殖系统病变患者清晨空腹静脉血,分置两管。管1:促凝:离心后取上清(血清)置于EP管中,-20度保存待测MIS及T。管2:EDTA抗凝:提取基因组DNA。
1.测试受试者染色体核型,提取受试者DNA,应用PCR技术对所有标本SRY基因进行检测。
2.对两组标本采用双抗体夹心酶联免疫吸附试验( ELISA)检测T及MIS值,对所得结果进行统计学分析,探讨SRY基因、T及MIS在男性假两性畸形诊断中的意义及相关性。
3.对患完全性雄激素不敏感综合症的两同胞兄弟提取DNA,采用基因测序技术分析雄激素受体基因,并进行比对分析。
结果:
1.患病组MIS水平较对照组显著增高,差异性显著(P<0.05),有统计学意义。
2.患病组T水平虽较对照组高,但无显著性差异(P>0.05),无统计学意义。
3.患病组中SRY ( + )6例, SRY ( - ) 1例;对照组中7例SRY皆( + )。所有受试者皆有睾丸。SRY基因对于诊断睾丸存在状况的敏感性为92.8%(13/14)。
4.检测到患完全性雄激素不敏感综合症的两同胞兄弟AR基因外显子8第2615位的碱基发生G→C置换,导致了所编码的氨基酸发生错义突变由精氨酸R突变为苏氨酸T(Arg872Thr)。
结论:
1.MIS在男性假两性畸形的诊断中有较重要意义,当患者的MIS水平高时,多为男性假两性畸形;而T虽在其诊断中意义不大,但对于其分型有意义,同时还可作为评估患者治疗效果的检测指标。
2.在男性假两性畸形的诊断中SRY基因对于睾丸存在与否的敏感性为92.8%,不能作为判断睾丸的存在与否唯一指标,其与MIS相结合则可提高诊断的准确率。
3.我们发现了一个新的点突变:雄激素受体(AR)基因外显子8第2615位的碱基发生G→C置换,导致了所编码的氨基酸发生错义突变由精氨酸R突变为苏氨酸T(Arg872Thr)。这一突变可能是导致完全性雄激素不敏感综合症的一个致病因素。
Background:
Hermaphroditism is a rare form of urogenital diseases. In recent years, with the improvement of clinical diagnosis and the enhancement of people's awareness of visits, the number of patients and accuracy rate of diagnosis gradually rise. Therefore, hermaphroditism is taken more and more seriously. Nevertheless, because of complex pathogenesis of hermaphroditism, the classification is confused. There has been more difficulty in clinical diagnosis, especially in male pseudohermaphroditism diagnosis.
Male pseudohermaphroditism can be largely divided into different types according to etiology: 1、gonadotropin sexual function decline; 2、testosterone synthesis defect; 3、androgen receptor insensitivity syndrome; 4、5-a reductase deficiency; 5、Mullerian Duct Syndrome forever; 6、gonadal dysgenesis; 7、46XY feminization syndrome, etc. If further subdivided, there can be more types. Because of limited understanding of this disease, there are difficulties in diagnose, which leads to the blindness of treatment. Currently, some people argue that early diagnosis and comprehensive treatment are useful for treatment of some types of male pseudohermaphroditism. It not only reduces the financial burden of patients due to pain and trauma of surgery, but more importantly, protects patients against psychological influence to the greatest degree.
The auxetic process of male reproductive system and the development of secondary sexual characteristics are considerably complex. Undifferentiated gonad in human is bipotential. SRY is a sex-determining gene in short arm of Y chromosome which induces bipotential gonads to testis. It is also the initiating factor in male development. Studies have shown that sex is not completely determined by the SRY gene whose absolute significance of testicular is questioned. Examining SRY gene could contribute to clarify the effect on clinical diagnosis. The development of testis is not only associated with upstream factors but also multiple roles of cytokines secreted by testis. Leydig and Sertoli cell of testis produces two hormones respectively, Müllerian-inhibiting substance (MIS) and testosterone. Testosterone can basically represent the function of testis, but it can not induce the development of masculinity, the male reproductive tract, secondary sexual characteristics. The physiological effects of MIS have been paid more attention. The main effect of MIS is to suppress mullerian duct developing to oviduct, uterus and supravaginal portion. So the dysfunction of MIS will lead to the hermaphroditism. We planed to examine the testis sensitivity of SRY gene, the expression of MIS, T in serum of male hermaphroditism in order to disclose the effect on the diagnosis of male hermaphroditism. The genes of MIS, SRY,T play important role on sex determine, so we detected the expression of MIS, T, SRY gene in the patients who have been diagnosised as male pseudohermaphroditism and explored their roles in disease diagnosis.
Androgen insensitivity syndrome (AIS) which is the more common type of male pseudohermaphroditism, is divided into complete androgen insensitivity syndrome(CAIS) and incomplete androgen insensitivity syndrome (IAIS). AIS,the X-linked recessive genetic disease, is the mutation of androgen receptor gene in the X chromosome and the defect of androgen receptor of the cell membrane , resulting in androgen insensitivity. The study on etiology of AIS has been made great progress, and the possible pathogenic mutations have been reported, however, the exact mechanism of AIS is not clear. We examined the expression of androgen receptor in patients from small family constellation and tested the possible mutant gene to provide valuable evidences at the molecular level for the disease diagnosis.
Objectives:
To clarify the effect of three indicators (MIS, T, SRY) in the diagnosis of male pseudohermaphroditism and the relation between them for clinical treatment for providing more evidence to diagnosize male pseudohermaphroditism.,and to find the possible pathogenic mutant genes by examining the expression of androgen receptor in patients from small family constellation.
Methods:
Collect the fasting blood of patients (male pseudohermaphroditism) and normal people (non genital disease). After centrifugation, the supernatant (serum) is respectively placed into EP tube for testing MIS, T and the EDTA anticoagulant tube for genomic DNA.
1. Extract DNA samples for testing karyotype and use PCR for testing SRY gene.
2. Detection of expression of T and MIS by double antibody sandwich enzyme-linked immunosorbent assay (ELISA) and analysis the results, discussion for the meaning and relation between SRY, T, MIS and the diagnosis of male pseudohermaphroditism.
3. Application of gene sequencing technique on DNA extracted from two patients suffering from complete androgen insensitivity syndrome, to find the possible gene mutation.
Results:
1. The level of MIS in patient group is significantly increase, compared to control group (p<0.05).
2. The level of T in patient group is higer than that in contron group, but there is not significant difference (p>0.05).
3. In patient group, five subjectes were postive, two subjectes were negative. In control group, seven cases were postive. All subjects have testes. The sensitivity for the diagnosis of testis was 92.8% (13/14).
4. AR gene existing in a missense mutation exon 8 (from Arg to Glu) has been identified in patients with complete androgen insensitivity syndrome.
Conclusions:
1. MIS plays an important role in the diagnosis of male pseudohermaphroditism. Patients with high levels of MIS may suffer from male pseudohermaphroditism. Although the expression of T in the diagnosis has little significance, it is useful for typing and evaluating on the effect of treatment.
2. SRY gene can not be considered as the only indicator evaluating the function and status of testis.
3. There is basic radical permutation (from G to C) at 2615 in exon 8, resulting in the missense mutation from Arginine to Threonine.
两性畸形是泌尿生殖系统少见病,近年来随着临床诊断技术的不断进步,人们就诊意识的增强,两性畸形患者的就诊及确诊率不断提高,两性畸形逐渐被人们所重视。尽管如此,两性畸形因其病因复杂,分类混乱,给临床诊治带来了较大的困难。尤以男性假两性畸形的临床诊治是泌尿外科医生较为棘手的问题。
男性假两性畸形根据病因大体可分为:1、促性腺激素性性机能减退;2、睾酮合成障碍;3、雄激素受体不敏感综合症;4、5-a还原酶缺乏;5、苗勒氏管永存综合症;6、性腺发育不良;7、46XY女性化综合症等,如果再细分则种类更多。由于对该疾病的认识有限,临床上明确诊断有一定困难,诊断的不明确也导致了治疗的盲目性。目前认为,早期明确诊断,早期综合治疗对于部分类型的男性假两性畸形患者会有更好的治疗效果。它不仅能减轻患者的经济负担及手术创伤带来的痛苦,更重要的是能最大程度的避免患者的心理畸形。
男性生殖系统及第二性征的发育比较复杂。人类原始未分化性腺是具有双潜能的性腺,SRY基因是男性Y染色体短臂上的性别决定基因,其表达诱导原始未分化性腺向睾丸发育,是男性性别发育的始动因素。研究显示性别的决定并非由SRY基因单一因素所决定,其对于睾丸的绝对意义受到了质疑,通过对SRY基因的检测,探讨其在临床诊断中的作用。睾丸的发育除受到众多上游因素影响外,还受到睾丸自身分泌的各种因子的多重作用。睾丸的两种主要细胞Leydig细胞、Sertoli细胞分别分泌睾酮(T testosterone)和苗勒氏管抑制因子(MIS)。睾酮基本能反应睾丸的功能状态,但它不能完全诱导个体的男性化进程,不能保证男性生殖道及第二性征的完全发育。最近苗勒氏管抑制因子(MIS)的生理作用越来越受到重视,它的主要作用是抑制副中肾管发育为输卵管,子宫和阴道上部,若MIS功能异常也将导致两性畸形的产生。我们拟通过通过检测SRY基因对睾丸的敏感性, MIS、T在男性假两性畸形血清中的表达,探讨它们在男性假两性畸形诊断中的作用及相关性,为临床男性假两性畸形的明确诊断提供更多的依据。
雄激素不敏感综合症(AIS)是男性假两性畸形中较为常见的一种类型,受体的缺陷程度不同使临床表现差异很大,分为完全性雄激素不敏感综合症(CAIS)和不完全性雄激素不敏感综合症(IAIS)。AIS属于X连锁隐性遗传病,是位于X染色体上决定雄激素受体的基因发生突变,引起雄激素靶细胞膜上的雄激素受体缺陷,造成对雄激素不敏感。对AIS病因的研究已取得一定的进展,发现了一些可能的致病突变,但其确切的发病机制仍不十分清楚,我们拟对1个患完全性雄激素不敏感综合症的小家系进行雄激素受体基因的检测,明确其可能存在的致病突变基因,在分子水平上对其诊断提供有价值的资料。
目的:
明确SRY基因、MIS、T三项指标在男性假两性畸形诊断中的作用及其相关性,为临床明确诊断提供依据。对1个完全性雄激素不敏感综合症的小家系进行雄激素受体基因的检测,明确其可能存在的致病突变基因。
方法:
收集男性假两性畸形及无生殖系统病变患者清晨空腹静脉血,分置两管。管1:促凝:离心后取上清(血清)置于EP管中,-20度保存待测MIS及T。管2:EDTA抗凝:提取基因组DNA。
1.测试受试者染色体核型,提取受试者DNA,应用PCR技术对所有标本SRY基因进行检测。
2.对两组标本采用双抗体夹心酶联免疫吸附试验( ELISA)检测T及MIS值,对所得结果进行统计学分析,探讨SRY基因、T及MIS在男性假两性畸形诊断中的意义及相关性。
3.对患完全性雄激素不敏感综合症的两同胞兄弟提取DNA,采用基因测序技术分析雄激素受体基因,并进行比对分析。
结果:
1.患病组MIS水平较对照组显著增高,差异性显著(P<0.05),有统计学意义。
2.患病组T水平虽较对照组高,但无显著性差异(P>0.05),无统计学意义。
3.患病组中SRY ( + )6例, SRY ( - ) 1例;对照组中7例SRY皆( + )。所有受试者皆有睾丸。SRY基因对于诊断睾丸存在状况的敏感性为92.8%(13/14)。
4.检测到患完全性雄激素不敏感综合症的两同胞兄弟AR基因外显子8第2615位的碱基发生G→C置换,导致了所编码的氨基酸发生错义突变由精氨酸R突变为苏氨酸T(Arg872Thr)。
结论:
1.MIS在男性假两性畸形的诊断中有较重要意义,当患者的MIS水平高时,多为男性假两性畸形;而T虽在其诊断中意义不大,但对于其分型有意义,同时还可作为评估患者治疗效果的检测指标。
2.在男性假两性畸形的诊断中SRY基因对于睾丸存在与否的敏感性为92.8%,不能作为判断睾丸的存在与否唯一指标,其与MIS相结合则可提高诊断的准确率。
3.我们发现了一个新的点突变:雄激素受体(AR)基因外显子8第2615位的碱基发生G→C置换,导致了所编码的氨基酸发生错义突变由精氨酸R突变为苏氨酸T(Arg872Thr)。这一突变可能是导致完全性雄激素不敏感综合症的一个致病因素。
Background:
Hermaphroditism is a rare form of urogenital diseases. In recent years, with the improvement of clinical diagnosis and the enhancement of people's awareness of visits, the number of patients and accuracy rate of diagnosis gradually rise. Therefore, hermaphroditism is taken more and more seriously. Nevertheless, because of complex pathogenesis of hermaphroditism, the classification is confused. There has been more difficulty in clinical diagnosis, especially in male pseudohermaphroditism diagnosis.
Male pseudohermaphroditism can be largely divided into different types according to etiology: 1、gonadotropin sexual function decline; 2、testosterone synthesis defect; 3、androgen receptor insensitivity syndrome; 4、5-a reductase deficiency; 5、Mullerian Duct Syndrome forever; 6、gonadal dysgenesis; 7、46XY feminization syndrome, etc. If further subdivided, there can be more types. Because of limited understanding of this disease, there are difficulties in diagnose, which leads to the blindness of treatment. Currently, some people argue that early diagnosis and comprehensive treatment are useful for treatment of some types of male pseudohermaphroditism. It not only reduces the financial burden of patients due to pain and trauma of surgery, but more importantly, protects patients against psychological influence to the greatest degree.
The auxetic process of male reproductive system and the development of secondary sexual characteristics are considerably complex. Undifferentiated gonad in human is bipotential. SRY is a sex-determining gene in short arm of Y chromosome which induces bipotential gonads to testis. It is also the initiating factor in male development. Studies have shown that sex is not completely determined by the SRY gene whose absolute significance of testicular is questioned. Examining SRY gene could contribute to clarify the effect on clinical diagnosis. The development of testis is not only associated with upstream factors but also multiple roles of cytokines secreted by testis. Leydig and Sertoli cell of testis produces two hormones respectively, Müllerian-inhibiting substance (MIS) and testosterone. Testosterone can basically represent the function of testis, but it can not induce the development of masculinity, the male reproductive tract, secondary sexual characteristics. The physiological effects of MIS have been paid more attention. The main effect of MIS is to suppress mullerian duct developing to oviduct, uterus and supravaginal portion. So the dysfunction of MIS will lead to the hermaphroditism. We planed to examine the testis sensitivity of SRY gene, the expression of MIS, T in serum of male hermaphroditism in order to disclose the effect on the diagnosis of male hermaphroditism. The genes of MIS, SRY,T play important role on sex determine, so we detected the expression of MIS, T, SRY gene in the patients who have been diagnosised as male pseudohermaphroditism and explored their roles in disease diagnosis.
Androgen insensitivity syndrome (AIS) which is the more common type of male pseudohermaphroditism, is divided into complete androgen insensitivity syndrome(CAIS) and incomplete androgen insensitivity syndrome (IAIS). AIS,the X-linked recessive genetic disease, is the mutation of androgen receptor gene in the X chromosome and the defect of androgen receptor of the cell membrane , resulting in androgen insensitivity. The study on etiology of AIS has been made great progress, and the possible pathogenic mutations have been reported, however, the exact mechanism of AIS is not clear. We examined the expression of androgen receptor in patients from small family constellation and tested the possible mutant gene to provide valuable evidences at the molecular level for the disease diagnosis.
Objectives:
To clarify the effect of three indicators (MIS, T, SRY) in the diagnosis of male pseudohermaphroditism and the relation between them for clinical treatment for providing more evidence to diagnosize male pseudohermaphroditism.,and to find the possible pathogenic mutant genes by examining the expression of androgen receptor in patients from small family constellation.
Methods:
Collect the fasting blood of patients (male pseudohermaphroditism) and normal people (non genital disease). After centrifugation, the supernatant (serum) is respectively placed into EP tube for testing MIS, T and the EDTA anticoagulant tube for genomic DNA.
1. Extract DNA samples for testing karyotype and use PCR for testing SRY gene.
2. Detection of expression of T and MIS by double antibody sandwich enzyme-linked immunosorbent assay (ELISA) and analysis the results, discussion for the meaning and relation between SRY, T, MIS and the diagnosis of male pseudohermaphroditism.
3. Application of gene sequencing technique on DNA extracted from two patients suffering from complete androgen insensitivity syndrome, to find the possible gene mutation.
Results:
1. The level of MIS in patient group is significantly increase, compared to control group (p<0.05).
2. The level of T in patient group is higer than that in contron group, but there is not significant difference (p>0.05).
3. In patient group, five subjectes were postive, two subjectes were negative. In control group, seven cases were postive. All subjects have testes. The sensitivity for the diagnosis of testis was 92.8% (13/14).
4. AR gene existing in a missense mutation exon 8 (from Arg to Glu) has been identified in patients with complete androgen insensitivity syndrome.
Conclusions:
1. MIS plays an important role in the diagnosis of male pseudohermaphroditism. Patients with high levels of MIS may suffer from male pseudohermaphroditism. Although the expression of T in the diagnosis has little significance, it is useful for typing and evaluating on the effect of treatment.
2. SRY gene can not be considered as the only indicator evaluating the function and status of testis.
3. There is basic radical permutation (from G to C) at 2615 in exon 8, resulting in the missense mutation from Arginine to Threonine.
引文
1.陈华、李世荣、覃霞等两性畸形的临床研究进展中国美容整形外科杂志.2007 ,18 (4): 301-304.
2. Melo KF, Mendonca BB , Billerbeck AE , et al.Clinical , hormonal , behavioral , and genetic characteristics of androgen insensitivity syndrome in a Brazilian cohort : five novel mutations in the androgen receptor gene [J] . J Clin EndocrinolMetab. 2003 ,88 :3241 - 3250.
3. Farkas A, Chertin B, Hadas- Halpren I. 1 - Stagefeminizing genitoplasty : 8 years of experience with 49 cases[J] . J Urol. 2001 ,165 :2341– 2346.
4. Lee MM ,Donahoe PK. Mullerian inhibiting substance : a gonadal hormone with multiple functions. Endoc Rev . 1993 , 14 :152-164.
5. Josso N. Padiatric applications of antiMullerian hormone researeh. Horm Res . 1995 ,43 :243-248.
6. Sinclair AH , Berta P , Palmer MS , et al . A gene from the human sex determining region encodes a protein with homology to a conserved DNA-binding motif [J] . Nature . 1990 , 346 :240-244.
7. Behringer RR ,Finegold MJ ,Cate RL. Mulerianinhibiting substance function duringmammalian sexual development . Cell .1994 ,79 :415-418.
8. Mishina Y. The in vivo function of Mullerianinhibiting substance dur-ing mammalian sexual development . In : Matzuk MM , et al. (eds)Transgenics in Endocrinology. Totowa , New Jersey : Humana PressInc. 2001 ,41-59.
9. Teixeira J , Maheswaran S , Donahoe KP. Müllerian Inhibiting Substance :An Instructive Developmental Hormone with Diagnostic and Possible Therapeutic Applications[J] . Endocrineeviews . 2001,22: 657– 674.
10. Teixeira J , Fynn - Thompson E , Payne HA , et al . Mullerrian– Inhibiting Substance Regulates Androgen Synthesis at the Transcriptional Level [J] . Endocrinology. 1999,140: 4732– 4738.
11.徐伟珏,许恩,严肃等血清苗勒氏抑制物质值的测定与小儿泌尿生殖器畸形的关系中国医师杂志. 2003增刊1-3.
12. Josso N, LegeaiL, ForestMG, et al. An enzyme linked immunoassay for antimullerian hormone: Anew tool for the evaluation of testicularfunction in infants and children. J Cli EndocrinolMetab. 1990,70:23-27.
13. Hudson PL, Dougas I, Donahoe PK, et al. An immunoassay to detecthuman mullerian inhibiting substance in males and females duringnormal development. J Clin Endocrinol Metab.1990,70: 16-22.
14. Rey R, Mebarki F, Forest MG, et al. Anti-mullerian hormone inchildren with androgen insensitivity. J Clin Endocrinol Metab.1994,79: 960-964.
15. Sinclair AH, Berta P, Palmar MS, et al. A gene from the human sex- determioing region encodes a protein with homology to a conserve dDNA binding molif [J].Nature.1990,346:240.
16. Page DC, Mosher R , Simpson EM , et al. The sex determining region of the human Y chromosome [J]. Cell.1987,51:1094.
17. Wallrath D, Foote S, Hilton A, et al. The human Y Chromosome : ainterval map based on natureally occurring deletion [J]. Science .1992 , 258 :52-54.
18. Koopman P, Munsterberg A, Capel B, et al. Expression of a candidate sex determining gene during mouse testis differentiation[J] . Nature .1990, 348 :450.
19. Margarit E, Coll MD, Oliva R, et al . SRYgene transferred to the long arm of the X chromosome in a Y- positive XX true hermaphrodite. AmJ MedGenet .2000, 90:25– 28.
20.张忠恕性别畸形生殖与避孕. 1997,17:311-314.
21.刘鸿嬉,常晓兰,蔡琼等. SRY基因检测在性分化发育异常诊断中的应用[J].中国优生与遗传杂志. 2003,11:37-39.
22.刘维瑜,金春莲.人类性别决定相关基因的研究进展[J].国外医学遗传学分册, 2005, 28 : 262 - 264.
23. Bangsboll S, Qvist I, LebechPE, et al. Testicular feminization syndrome and associated gonadaltumors in Denmark[J]. Acta obstet Gynecol Scand, 1992, 71 : 63-66.
24.崔毓桂雄激素受体的结构和功能国外医学计划生育分册, 1994, 13∶201-203
25.方圻主编现代内科学(下卷) 1第1版1北京∶人民军医出版社, 1995,2443-2453.
26. W ilson JD. Syndromes of androgen resistance.Biol Reprod, 1992, 46 :168-170.
27.迟铖,母义明.雄激素不敏感综合征中国实用内科杂志2006, 26:1574-1577.
28.卢建,王进,陈光椿.五个完全性雄激素不敏感综合征家系雄激素受体基因突变的研究中华医学杂志1999, 79:444-445.
29. Maclean HE , Chu S , Warne GL , et al. Related individuals with different androgentherapy. J Clin Invest , 1991 , 87 : 1413-1421.
30.申漫里男性假两性畸形的分子遗传学研究进展中华小儿外科杂志2000, 21: 57-59.
31. Luisi BF, Xu WX, Otwinowski Z, et al.Crystallographic analysis of the interaction of the glucocorticoid receptor with DNA. Nature ,1991 , 352 :497-505.
32.杨兵,曾令奇,孙则禹等,男性假两性体的病因诊断,南京军医学院学报2003,25:267-270.
33. Sultan C,Lumbroso S, Paris F, et al. Disorders of androgen action. Semin RepordMed. 2002, 20: 217-228.
34. Thomas F. Kolon, MD. Disorders of sexual development copyright. Sexual Dev elopement 2008, 2:172-180.
35. Radpour R, Falah M, Aslani A, et al. Identification of a Critical Novel Mutation in the Exon 1 of Androgen Receptor Gene in TwoBrothers with Complete Androgen Insensitivity Syndrome. J Androl. 2009,30:230-232.
1.黄澄如实用小儿泌尿外科学北京人民卫生出版社2006:415-440
2.申漫里男性假两性畸形的分子遗传学研究进展中华小儿外科杂志2000 :21(1)57-59
3. Josso N, LegeaiL, ForestMG, et al. An enzyme linked immunoassay for anti2mullerian hormone: Anew tool for the evaluation of testicularfunction in infants and children. J Cli EndocrinolMetab, 1990, 70:23-27.
4.罗维思女性假两性畸形4例病因及临床分析广东医学2006,27(8):1233-1235
5.刘学军孙广慈赫伟等真两性畸形诊断治疗的探讨中华整形烧伤外科杂志1999 ,15 (2): 129-131
6.刘国昌温英泉袁继炎等苗勒管抑制物质在儿童外生殖器畸形诊断中的价值中华小儿外科杂志2006 27(8):410-413
7.林巧稚主编.妇科肿瘤[M]1北京:北京人民卫生出版社,1984.235～237
8.刘鸿禧常晓兰蔡琮SRY基因检测在性分化异常诊断中的应用中国优生与遗传杂志2003 ,11(1): 37-39
9.李钢,何学酉,王晓刚,等.男性假两性畸形的诊断与治疗初探(附47例报告) [J ].中国男科学杂志, 2006 ,20(5) :26 - 30.
10. Costa EM,Mendonca BB,Inacio M,et al.Management of an bigouous genitalia in pseudohermaphrodites:new perpectives on vaginal dilation[J].Fertil Steril,1997, 69:229～232.
11.俞天麟.肾上腺性征异常症[A].见:吴阶平.泌尿外科学[M].济南:山东科技出版社,1993.993～1002.
12. White PC.Steroid 11β-hydroxyase deficiency and related disorders[J].Am J Clin Endocrinol Metab,1994,23:325～326.
13. Thomas F. Kolon, MD Disorders of Sexual Development Copyright . Sexual Dev elopement 2008;2:172-180
14.杨兵,曾令奇,孙则禹等,男性假两性体的病因诊断,南京军医学院学报2003,25(4):267-270.
15. Sultan C,Lumbroso S, Paris F, et al. Disorders of androgen action. Semin RepordMed, 2002, 20 (3) : 217-228
16.刘学军孙广慈赫伟等,真两性畸形诊断治疗的探讨中华整形烧伤外科杂志1999 ,15 (2):129-132
17. Denes FT, Mendonca BB, Arap S. Laparoscop ic management of intersexual states. Urol Clin North Am, 2001, 28: 31-42
18.王小林张文周学锋腹腔镜在儿童真两性畸形诊疗中的应用中国微创外科杂志2008,8(2):162-163
19. Hrabovszky Z, Hutson JM. Androgen imp rinting of the brain in animal models and humanswith intersex disorders: review and recommendations. J Urol, 2002, 168: 2142-2148
2. Melo KF, Mendonca BB , Billerbeck AE , et al.Clinical , hormonal , behavioral , and genetic characteristics of androgen insensitivity syndrome in a Brazilian cohort : five novel mutations in the androgen receptor gene [J] . J Clin EndocrinolMetab. 2003 ,88 :3241 - 3250.
3. Farkas A, Chertin B, Hadas- Halpren I. 1 - Stagefeminizing genitoplasty : 8 years of experience with 49 cases[J] . J Urol. 2001 ,165 :2341– 2346.
4. Lee MM ,Donahoe PK. Mullerian inhibiting substance : a gonadal hormone with multiple functions. Endoc Rev . 1993 , 14 :152-164.
5. Josso N. Padiatric applications of antiMullerian hormone researeh. Horm Res . 1995 ,43 :243-248.
6. Sinclair AH , Berta P , Palmer MS , et al . A gene from the human sex determining region encodes a protein with homology to a conserved DNA-binding motif [J] . Nature . 1990 , 346 :240-244.
7. Behringer RR ,Finegold MJ ,Cate RL. Mulerianinhibiting substance function duringmammalian sexual development . Cell .1994 ,79 :415-418.
8. Mishina Y. The in vivo function of Mullerianinhibiting substance dur-ing mammalian sexual development . In : Matzuk MM , et al. (eds)Transgenics in Endocrinology. Totowa , New Jersey : Humana PressInc. 2001 ,41-59.
9. Teixeira J , Maheswaran S , Donahoe KP. Müllerian Inhibiting Substance :An Instructive Developmental Hormone with Diagnostic and Possible Therapeutic Applications[J] . Endocrineeviews . 2001,22: 657– 674.
10. Teixeira J , Fynn - Thompson E , Payne HA , et al . Mullerrian– Inhibiting Substance Regulates Androgen Synthesis at the Transcriptional Level [J] . Endocrinology. 1999,140: 4732– 4738.
11.徐伟珏,许恩,严肃等血清苗勒氏抑制物质值的测定与小儿泌尿生殖器畸形的关系中国医师杂志. 2003增刊1-3.
12. Josso N, LegeaiL, ForestMG, et al. An enzyme linked immunoassay for antimullerian hormone: Anew tool for the evaluation of testicularfunction in infants and children. J Cli EndocrinolMetab. 1990,70:23-27.
13. Hudson PL, Dougas I, Donahoe PK, et al. An immunoassay to detecthuman mullerian inhibiting substance in males and females duringnormal development. J Clin Endocrinol Metab.1990,70: 16-22.
14. Rey R, Mebarki F, Forest MG, et al. Anti-mullerian hormone inchildren with androgen insensitivity. J Clin Endocrinol Metab.1994,79: 960-964.
15. Sinclair AH, Berta P, Palmar MS, et al. A gene from the human sex- determioing region encodes a protein with homology to a conserve dDNA binding molif [J].Nature.1990,346:240.
16. Page DC, Mosher R , Simpson EM , et al. The sex determining region of the human Y chromosome [J]. Cell.1987,51:1094.
17. Wallrath D, Foote S, Hilton A, et al. The human Y Chromosome : ainterval map based on natureally occurring deletion [J]. Science .1992 , 258 :52-54.
18. Koopman P, Munsterberg A, Capel B, et al. Expression of a candidate sex determining gene during mouse testis differentiation[J] . Nature .1990, 348 :450.
19. Margarit E, Coll MD, Oliva R, et al . SRYgene transferred to the long arm of the X chromosome in a Y- positive XX true hermaphrodite. AmJ MedGenet .2000, 90:25– 28.
20.张忠恕性别畸形生殖与避孕. 1997,17:311-314.
21.刘鸿嬉,常晓兰,蔡琼等. SRY基因检测在性分化发育异常诊断中的应用[J].中国优生与遗传杂志. 2003,11:37-39.
22.刘维瑜,金春莲.人类性别决定相关基因的研究进展[J].国外医学遗传学分册, 2005, 28 : 262 - 264.
23. Bangsboll S, Qvist I, LebechPE, et al. Testicular feminization syndrome and associated gonadaltumors in Denmark[J]. Acta obstet Gynecol Scand, 1992, 71 : 63-66.
24.崔毓桂雄激素受体的结构和功能国外医学计划生育分册, 1994, 13∶201-203
25.方圻主编现代内科学(下卷) 1第1版1北京∶人民军医出版社, 1995,2443-2453.
26. W ilson JD. Syndromes of androgen resistance.Biol Reprod, 1992, 46 :168-170.
27.迟铖,母义明.雄激素不敏感综合征中国实用内科杂志2006, 26:1574-1577.
28.卢建,王进,陈光椿.五个完全性雄激素不敏感综合征家系雄激素受体基因突变的研究中华医学杂志1999, 79:444-445.
29. Maclean HE , Chu S , Warne GL , et al. Related individuals with different androgentherapy. J Clin Invest , 1991 , 87 : 1413-1421.
30.申漫里男性假两性畸形的分子遗传学研究进展中华小儿外科杂志2000, 21: 57-59.
31. Luisi BF, Xu WX, Otwinowski Z, et al.Crystallographic analysis of the interaction of the glucocorticoid receptor with DNA. Nature ,1991 , 352 :497-505.
32.杨兵,曾令奇,孙则禹等,男性假两性体的病因诊断,南京军医学院学报2003,25:267-270.
33. Sultan C,Lumbroso S, Paris F, et al. Disorders of androgen action. Semin RepordMed. 2002, 20: 217-228.
34. Thomas F. Kolon, MD. Disorders of sexual development copyright. Sexual Dev elopement 2008, 2:172-180.
35. Radpour R, Falah M, Aslani A, et al. Identification of a Critical Novel Mutation in the Exon 1 of Androgen Receptor Gene in TwoBrothers with Complete Androgen Insensitivity Syndrome. J Androl. 2009,30:230-232.
1.黄澄如实用小儿泌尿外科学北京人民卫生出版社2006:415-440
2.申漫里男性假两性畸形的分子遗传学研究进展中华小儿外科杂志2000 :21(1)57-59
3. Josso N, LegeaiL, ForestMG, et al. An enzyme linked immunoassay for anti2mullerian hormone: Anew tool for the evaluation of testicularfunction in infants and children. J Cli EndocrinolMetab, 1990, 70:23-27.
4.罗维思女性假两性畸形4例病因及临床分析广东医学2006,27(8):1233-1235
5.刘学军孙广慈赫伟等真两性畸形诊断治疗的探讨中华整形烧伤外科杂志1999 ,15 (2): 129-131
6.刘国昌温英泉袁继炎等苗勒管抑制物质在儿童外生殖器畸形诊断中的价值中华小儿外科杂志2006 27(8):410-413
7.林巧稚主编.妇科肿瘤[M]1北京:北京人民卫生出版社,1984.235～237
8.刘鸿禧常晓兰蔡琮SRY基因检测在性分化异常诊断中的应用中国优生与遗传杂志2003 ,11(1): 37-39
9.李钢,何学酉,王晓刚,等.男性假两性畸形的诊断与治疗初探(附47例报告) [J ].中国男科学杂志, 2006 ,20(5) :26 - 30.
10. Costa EM,Mendonca BB,Inacio M,et al.Management of an bigouous genitalia in pseudohermaphrodites:new perpectives on vaginal dilation[J].Fertil Steril,1997, 69:229～232.
11.俞天麟.肾上腺性征异常症[A].见:吴阶平.泌尿外科学[M].济南:山东科技出版社,1993.993～1002.
12. White PC.Steroid 11β-hydroxyase deficiency and related disorders[J].Am J Clin Endocrinol Metab,1994,23:325～326.
13. Thomas F. Kolon, MD Disorders of Sexual Development Copyright . Sexual Dev elopement 2008;2:172-180
14.杨兵,曾令奇,孙则禹等,男性假两性体的病因诊断,南京军医学院学报2003,25(4):267-270.
15. Sultan C,Lumbroso S, Paris F, et al. Disorders of androgen action. Semin RepordMed, 2002, 20 (3) : 217-228
16.刘学军孙广慈赫伟等,真两性畸形诊断治疗的探讨中华整形烧伤外科杂志1999 ,15 (2):129-132
17. Denes FT, Mendonca BB, Arap S. Laparoscop ic management of intersexual states. Urol Clin North Am, 2001, 28: 31-42
18.王小林张文周学锋腹腔镜在儿童真两性畸形诊疗中的应用中国微创外科杂志2008,8(2):162-163
19. Hrabovszky Z, Hutson JM. Androgen imp rinting of the brain in animal models and humanswith intersex disorders: review and recommendations. J Urol, 2002, 168: 2142-2148