46,XX/SRY-negative true hermaphrodite

Objective: To describe genetic evaluation and response to surgery and letrozole therapy of a 46, XX/SRY-negative true hermaphrodite. Design: Case report. Setting: University Medical Center. Patient(s): Nineteen-year-old male with penile hypospadias, micropenis, and crytorchidism at the time of birth. Intervention(s): Unilateral gonadectomy, and contralateral conservative gonadal surgery, followed by therapy with letrozole. Main Outcome Measure(s): Histopathologic, genetic and hormonal studies. Result(s): Genetic analysis showed that the subject was 46, XX/SRY-negative. Gonadectomy of the left gonad was performed at 16 years. The gonad resected was an ovotestes. The patient's estradiol was high (492 +/- 25 pmol/L), whereas the testosterone was low (4.2 +/- 0.5 nmol/L). Nineteen months later, conservative gonadal surgery of the contralateral gonad was performed to resect ovarian tissue, and treatment with letrozole was started. During letrozole treatment, testosterone was significantly increased (8 +/- 0.7 nmol/L), but estradiol was not changed (323 +/- 118 pmol/L). After letrozole withdrawal, testosterone did not decreased significantly (6.9 +/- 0.4 nmol/L), estradiol showed an oscillating pattern and a gonadal ultrasound showed an ovoid structure, which appeared to correspond to a follicle. At that time, estradiol was elevated (393 pmol/L). Conclusion(s): We present the case of a 46, XX/SRY-negative phenotypic male with bilateral ovotestes. Conservative gonadal surgery should be performed only when all ovarian tissue can be resected. Our results suggest that letrozole is not an adequate treatment for 46, XX true hermaphrodite males with ovotestes. (Fertil Steril (R) 2010; 94: 2330. e13-e16. (C) 2010 by American Society for Reproductive Medicine.)