Pregnancy in a Chinese woman with nonclassical 11β-hydroxylase deficiency caused by novel compound heterozygous mutations: a case report, literature review and functional validation

doi:10.21203/rs.3.rs-5267458/v1

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Pregnancy in a Chinese woman with nonclassical 11β-hydroxylase deficiency caused by novel compound heterozygous mutations: a case report, literature review and functional validation

https://doi.org/10.21203/rs.3.rs-5267458/v1

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Background

Congenital adrenocortical hyperplasia caused by 11β-hydroxylase deficiency (11β-OHD) due to CYP11B1 mutations in 46,XX patients is typically characterized by hyporeninemic hypokalemia hypertension, virilization, precocious pseudopuberty, accelerated skeletal maturation and short stature. Impaired fertility has been reported in the virilizing 11β-OHD form unless properly treated.

Case presentation:

A 35-year-old female patient with nonclassical 11β-OHD due to novel compound heterozygous mutations (V316M; C262_F264del) in CYP11B1 suffered from menstrual irregularities, infertility, hirsutism and low-renin hypertension with typical hormone profiles including an elevated 11-deoxycorticosterone and testosterone. Her reduced fertility recovered after the initiation of corticosteroid therapy, and conception was later successfully achieved by in vitro fertilization and frozen-thawed embryo transfer. Functional characterization of CYP11B1 V316M and C262_F264del mutations in human adrenocortical cells confirmed 7%-16% of residual enzyme activity (V316M: 11.5% ± 2.4%; C262_F264del: 7.8% ± 2.9%; V316M; C262_F264del: 16.5% ± 0.6%).

Conclusions

We reported a successful pregnancy in a female patient with nonclassical 11β-OHD due to compound heterozygosity of novel CYP11B1 mutations by in vitro fertilization. The close coordination of care by a multidisciplinary medical team is beneficial for patients with congenital adrenocortical hyperplasia to achieve an accurate diagnosis, proper fertility management and uneventful pregnancy.

11β-Hydroxylase deficiency

CYP11B1

P450 oxidoreductase deficiency

POR

Congenital adrenal hyperplasia

Congenital adrenal hyperplasia (CAH) comprises a set of autosomal recessive disorders [1, 2], with the most common form being steroid 21-hydroxylase deficiency that covers around 90–95% of CAH cases [3, 4]. 11β-hydroxylase deficiency (11β-OHD) caused by biallelic mutations of cytochrome P450 family 11 subfamily B member 1 (CYP11B1) gene ranks the second most common type of CAH which accounts for 0.2–8% of cases [5]. Rarer forms of CAH include steroid P450 oxidoreductase deficiency caused by mutations in POR gene encoding the enzyme P450 oxidoreductase [6]. The occurrence of 11β-OHD in the general population is approximately 1 in 100000–200000, with a higher prevalence in the Israeli population of Jewish descent in the Middle East and North Africa impacting 1:5000–7000 live births [7]. The mutations in CYP11B1 lead to a decrease in the conversion of 11-deoxycorticosterone (DOC) to corticosterone and 11-deoxycortisol to cortisol, further resulting in the accumulation of steroid precursors [8]. Consequently, individuals with classical 11β-OHD exhibit elevated serum levels of DOC, 17-hydroxyprogesterone and androgens, leading to hypertension with reduced renin levels, hypokalemia, and genital ambiguity [9]. The milder nonclassical form of 11β-OHD is characterized by mild virilization, irregular menstruation, hirsutism and subfertility, with hypertension being uncommon [10]. ClinVar Database (https://www.ncbi.nlm.nih.gov/clinvar/) has recorded over 200 variants of CYP11B1 to date including splicing, missense/nonsense, deletions, insertions and complex rearrangements [11]. The impact of these mutations on CYP11B1 enzyme activity has been mainly explored by the prediction based on three-dimensional protein structure and functional characterization by in vitro study.

Here, we report a Chinese woman with nonclassical 11β-OHD caused by a compound heterozygosity of a novel C262_F264del mutation and a known V316M mutation in CYP11B1. A heterozygous POR G537S mutation was also detected in this woman whose husband coincidently harbored a heterozygous POR M184T mutation. The patient successfully achieved conception by proper fertility therapy under cooperative surveillance by a multidisciplinary team.

The patient and her family gave written informed consent for the use of clinical data and biomaterials in accordance with the guidelines of the ethics committee of The First Affiliated Hospital With Nanjing Medical University.

Clinical characteristics and hormonal profiles

The 35-year-old female (karyotype: 46, XX) patient of nonconsanguineous origin was referred to endocrinologists (M.S. and Z.W.) due to infertility for 8 years and hypertension for 20 years. Table 1 summarized the hormone profiles of the patient. The patient was born at term after a normal pregnancy and delivery with normal female external genitalia. The patient reported an early growth cessation, menstruated irregularly (ranging from 10 to 70 days), and had a history of a natural miscarriage and a vulvar adhesion detachment surgery due to trauma. On physical examination, she presented with signs of virilization, including a deep voice, skin hyperpigmentation, facial hirsutism and breast underdevelopment. A relatively short stature of 157 centimeters and overweight (body mass index 25.15 kg/m²) were also observed. Her blood pressure was high-normal (121/80 mmHg at admission) under the treatment of nifedipine (5 mg/d). The pelvic ultrasound revealed a normal uterus. There were bilateral adrenal adenomas (right: 10 mm × 10 mm; left: 32 mm × 19 mm) on computed tomography imaging. The patient displayed an elevated testosterone (5.56 nmol/L), dehydroepiandrosterone (24.6 µmol/L), 17-hydroxyprogesterone (5.31 ng/mL), and a significantly increased concentration of DOC (11392.3 pg/mL). The aldosterone concentration was below the detection limit (< 20 pg/mL) with a low level of renin (0.05 ng/mL/h). Serum sodium and potassium levels were within the reference range. Decreased adrenal reserve was detected by the adrenocorticotropic hormone stimulation test (baseline cortisol was 177.8 nmol/L, and 30 min after adrenocorticotropic hormone stimulation, it increased to 189.9 nmol/L; after 60 min, it elevated further to 192.7 nmol/L). In contrast, adrenocorticotropic hormone stimulated a significant increase of 17-hydroxyprogesterone (baseline 17-hydroxyprogesterone was 3.43 ng/mL, which increased to 23.69 ng/mL at 30 min and to 28.9 ng/mL at 60 min). In addition, the patient showed a pituitary microadenoma with an approximately 2-fold increase of prolactin (1077.34 mIU/L). The other adrenal, gonadal and pituitary hormones were within the reference ranges except for a slight decrease of estradiol (70.61 pmol/L). The patient was suspected of CAH specifically 11β-OHD based on the clinical manifestations, imaging and laboratory tests.

Table 1

Summary of hormonal profiles of the patient.
Parameter	Baseline	1 months after treatment	Reference range
Aldosterone (pg/mL)	< 20	NA	32–395
Renin (ng/mL/h)	0.05	NA	0.93–6.5
Serum K⁺ (mmol/L)	4.09	4.66	3.5–5.5
Serum Na⁺ (mmol/L)	138.6	137.1	137–147
ACTH 0:00 am (pg/mL)	40.23	NA	7.2–63.3
Cortisol 0:00 am (nmol/L)	184.2	NA	170–440
ACTH 8:00 am (pg/mL)	48.2	123.3	7.2–63.3
Cortisol 8:00 am (nmol/L)	205.7	251.2	170–440
ACTH 4:00 pm (pg/mL)	30.62	NA	7.2–63.3
Cortisol 4:00 pm (nmol/L)	108.9	NA	170–440
Testosterone (nmol/L)	5.56	1.99	0.35–2.6
Progesterone (nmol/L)	2	2.03	0.64–3.81 (follicular phase)
17-hydroxyprogesterone (ng/mL)	5.31	NA	0.07–1.53
DOC (pg/mL)	11392.3	NA	≤ 180 (follicular phase)
Estradiol (pmol/L)	70.61	4412	99.1-447.7 (follicular phase)
DHEA (µmol/L)	24.6	3.5	0.2–10.6
Prolactin (mIU/L)	1077.34	179.15	70.8-566.4 (follicular phase)
ACTH, adrenocorticotropic hormone; DHEA, dehydroepiandrosterone; DOC, 11-deoxycorticosterone; Na⁺, sodium; NA, not available; K⁺, potassium.

Molecular genetic analysis

In order to confirm the diagnosis of CAH, a panel of candidate genes related to adrenal hyperplasia (n = 276, listed in Table 2) by targeted exome next-generation sequencing was performed. Genomic DNA was extracted from the peripheral blood leukocytes using the QIAamp DNA Mini Kit (Qiagen). The extracted DNA was segmented and amplified by PCR. The amplification product was purified twice with magnetic beads (Beckman) and captured by a customized panel probe (Illumina). The exon, intron-exon boundaries, and the 5’ and 3′ flanking regions of the panel genes were sequenced by NextSeq500 sequencer (Illumina). Raw data was aligned to the reference human genome hg19/ GRCh38 using the Burrows-Wheeler Aligner, and annotated using the method reported by Zhang [12]. All variants were classified according to the American College of Medical Genetics and Genomics (ACMG) 2015 classification [13]: pathogenic, likely pathogenic, uncertain significance, likely benign and benign. Sanger sequencing (Biosune) was performed in suspected variations. The sequencing results were analyzed using DNASTAR software (Madison).

Table 2

The panel of candidate genes related to adrenal hyperplasia.
A2ML1	AAAS	AARS2	ABCD1	AIP	AIRE	AKRIC2	AKR1C4
AMH	AMHR2	ANOS1	APC	AQP2	AR	ARL6	ARMC5
ARNT2	ARX	ATRX	AURKC	AVP	AVPR2	BBS1	BBS10
BBS12	BBS2	BBS4	BBS5	BBS7	BBS9	BMP15	BMP4
BMPRIB	BRAF	BSND	BTK	CASR	CATSPER1	CBX2	CCDC28B
CD96	CDKNIB	CDKNIC	CDON	CEP19	CEP290	CFTR	CHD7
CHEK2	CHRM3	CLCNKA	CLCNKB	CLPP	CYB5A	CYP11A1	CYP11B1
CYP11B2	CYP17A1	CYP19A1	CYP21A2	DAZL	DCAF17	DHCR7	DHH
DIAPH2	DISP1	DMRT1	DPY19L2	DUSP6	ERCC6	ERCC8	ESR1
FEZF1	FGD1	FGF17	FGF8	FGFR1	FGFR2	FIGLA	FLRT3
FMR1	FOXL2	FSHB	FSHR	GATA4	GDNF	GH1	GH2
GHR	GHRH	GHRHR	GHSR	GK	GK2	GLCCI1	GLI2
GLI3	GNAI2	GNAS	GNRH1	GOPC	GPR101	GNRHR	H19
H6PD	HARS2	HCCS	HDAC8	HESX1	HFE	HFM1	HGF
HOXA13	HS6ST1	HSD11B1	HSD11B2	HSD17B3	HSD17B4	HSD3B2	IARS2
ICK	IGSF1	IL17RD	INSL3	INSR	IRF6	KCNJ1	KCNJ5
KCNQ1OT1	KDM6A	KIF1B	KISSI	KISSIR	KLHL10	KMT2D	KRAS
LARS2	LEPR	LHB	LHCGR	LHX3	LHX4	LZTFL1	MAMLD1
MAP2K1	MAP2K2	MAP3K1	MAX	MC2R	MCM4	MCM9	MED12
MENI	MID1	MKKS	MKRN3	MKS1	MRAP	MYH8	NAA10
NANOS1	NF1	NFKB2	NNT	NOBOX	NROB1	NR3C1	NR5A1
NRAS	NSDHL	NSMF	ORC1	OTX2	PAX6	PCNT	PCSK1
PDE11A	PDE8B	PEX1	PEX10	PEX12	PEX13	PEX14	PEX19
PEX2	PEX26	PEX3	PEX5	PEX6	PHF6	PLAU	POF1B
POLR3A	POLR3B	POMC	POR	POU1F1	PRKACA	PRKAR1A	PRKCA
PROK2	PROKR2	PROP1	PSMC3IP	PTCH1	PTPN11	RAB23	RAB3GAP2
RAFl	RASA2	RBM28	REN	RET	RIPK4	RIT1	RNF216
ROR2	RSPO1	RXFP2	RXRA	RXRB	SDCCAG8	SDHB	SDHC
SDHD	SEMA3A	SEMA3E	SHH	SHOC2	SIX3	SLC12A1	SLC26A8
SOS1	SOX10	SOX2	SOX3	SOX9	SPATA16	SPRY4	SRD5A2
SRY	STAG3	STAR	STAT5B	SYCP3	TAC3	TACR3	TAF4B
TBX19	TGIF1	THRA	THRB	TMEM127	TMEM67	TP53	TRH
TRHR	TRIM3	TSPYL1	TTC8	TWNK	TXNRD2	USP9Y	UTY
VHL	WDPCP	WDR11	WNK1	WNK4	WNT3	WNT3	WNT5A
WT1	ZFPM2	ZIC2	ZMYND15

The targeted exome next-generation sequencing confirmed that the patient carried a compound heterozygous mutation in CYP11B1 (NM_000497): c.946G > A (p.V316M) and c.784_792del (p.C262_F264del). Sanger sequencing analysis of CYP11B1 exon 4 and 5 in the patient’s parents revealed the paternal origin of the mutation c.946G > A (p.V316M) and the maternal origin of the mutation c.784_792del (p.C262_F264del) (Fig. 1A and 1B). The CYP11B1 V316M has been previously reported in a patient with 11β-OHD without functional validation [14], while CYP11B1 C262_F264del was a novel mutant to the best of our knowledge. Unexpectedly, the patient also carried a heterozygous POR (NM_001395413) c.1609G > A (p.G537S) mutation that has been reported in a patient with cytochrome P450 oxidoreductase deficiency but was classified as uncertain significance according to ACMG [15]. Her additional heterozygous POR mutation was unlikely to be responsible for the cause of CAH due to its autosomal recessive transmission trait.

According to the ACMG classification, both CYP11B1 variants (V316M and C262_F264del) were classified as uncertain significance. We further performed homology alignment and pathogenicity-prediction algorithms to understand if the detected CYP11B1 mutations can cause changes in enzyme structure. Homology alignments indicated that CYP11B1 V316 and C262_F264 residues were highly conserved among different species (Fig. 1C). Pathogenicity-prediction algorithms by SIFT (http://sift.jcvi.org/) and PolyPhen-2 (http://genetics.bwh.harvard.edu/pph2) both predicted a pathogenic effect of the CYP11B1 V316M mutation. The impact of CYP11B1 C262_F264del mutation using the same pathogenicity-prediction algorithms was unknown, while this non-frameshift mutation was very likely to cause functional change due to the deletion of an amino acid and the shortening of the protein.

Fertility treatment

After 11β-OHD diagnosis was confirmed, the patient was prescribed hydrocortisone (20–30 mg/d) and labetalol (100 mg/d), as well as hormone replacement therapy composed of estradiol and progesterone. Bromocriptine (2.5 mg/d) was also given due to the high level of prolactin. At one month after the treatment, the patient’s testosterone, dehydroepiandrosterone and prolactin fell to normal ranges (1.99 nmol/L, 3.5 µmol/L, and 179.15 mIU/L, respectively) (Table 1). Blood pressure was controlled under 140/90 mmHg.

Before in vitro fertilization management, the patient was referred to preconception genetic counseling (W.W.) that recommended a genetic analysis on her husband. It showed that her husband unexpectedly harbored a previously reported heterozygous POR c.551T > C (p.M184T) mutation [16] that was classified as uncertain significance according to ACMG. Considering the couple both presented with a heterozygous POR mutation with uncertain pathogenic effect, preimplantation genetic testing was not suggested and a regular in vitro fertilization was performed (W.W.). Gonadotropin-releasing hormone antagonist protocol was used for ovarian stimulation. A total of 11 oocytes were retrieved. After fertilization and culture, we obtained 4 blastocyst stage (D5) embryos. All embryos were frozen because of the high risk of ovarian hyperstimulation syndrome. The patient underwent hormone replacement therapy for frozen-thawed embryo. Clinical pregnancy was diagnosed 14 days after embryo transfer with positive human chorionic gonadotropin level and confirmed 3 weeks later by transvaginal ultrasonography. She received routine follow-up management in Department of Obstetrics and Department of Obstetrics Endocrinology after pregnancy. Hydrocortisone was maintained during the whole treatment phase.

Functional validation

We further performed functional validation of the detected CYP11B1 mutations. A detailed description of materials and methods is available in the Data Supplement. The cDNA encoding human wild-type CYP11B1 or CYP11B1 mutants (V316M, C262_F264del and V316M; C262_F264del) was prepared by CloneEZ Seamless cloning in the pcDNA3.1+-3*Flag plasmid (Public Protein/Plasmid Library). Human adrenocortical cell (HAC15, ATCC CRL-3301, RRID:CVCL_S898) transfection was performed as previously described [17]. HAC15 cells were cultured with starvation medium (DMEM [Dulbecco's Modified Eagle's Medium]-F12 [1:1] supplemented with 0.1% calf serum) at 72 hours after transfection for another 24 hours. Cells and supernatant were then harvested for transcriptional analysis and steroid measurement, respectively. Steroid DOC and corticosterone were measured by liquid chromatography with tandem mass spectrometry. The CYP11B1 activity of the mutants was expressed as a percentage of substrate conversion in nanogram per deciliter of fold change of gene expression, defining CYP11B1 wild-type activity as 100%.

Transient transfection induced a high expression of CYP11B1 in HAC15 cells expressing wild-type CYP11B1 (570-fold change), CYP11B1 V316M (916-fold change), CYP11B1 C262_F264del (261-fold change) or CYP11B1 V316M; C262_F264del (676-fold change) compared with cells transfected with empty vector (Fig. 2A). All mutations caused a residual activity of 7%-16% of CYP11B1 wild-type activity (V316M: 11.5% ± 2.4% (mean ± SD); C262_F264del: 7.8% ± 2.9%; V316M; C262_F264del: 16.5% ± 0.6%), quantified by measuring the conversion of DOC to corticosterone (Fig. 2B).

Literature search

We searched the PubMed database using terms for medical subject headings and/or text words associated with 11β-OHD and pregnancy. A summary of patients with genetically confirmed 11β-OHD with successful pregnancy was shown in Table 3 [14, 18–22]. It appeared that the 11β-OHD case we presented here was the first to achieve successful conception by in vitro fertilization and frozen-thawed embryo transfer.

Table 3

Summary of pregnant cases in 46,XX female with genetically confirmed 11β-OHD.
Number of cases	Country	Mutation	Clinical manifestation	Fertility therapy	Fertility outcome	Reference
1	Australia	DS + 2; p. G444D	Ambiguous genitalia, hypertensive, insulin resistance	Dexamethasone 0.75 to 2 mg/day, clomiphene 50 mg from day 5 to 10 of each menstrual cycle	Gestational hypertension with normal outcome	Simm PJ et al [18]
2	German	Homo p. P159L	Premature pubarche; regular periods	Prednisolone (unknown dose)	4 uncomplicated pregnancies with normal outcomes	Parajes S et al [19]
3	Italy	p. R143W; p. A306V	Facial acne	Prednisolone (unknown dose)	1 uncomplicated pregnancy with normal outcome	Menabo S et al [20]
4	South East Asian origin	Homo p. R143W	Secondary amenorrhoea, hirsutism	Prednisolone, cyproterone acetate (unknown dose)	4 uncomplicated pregnancies with normal outcomes and 1 miscarriage	Mooij CF et al [21]
5	Bulgaria	p. V316M; p. D480Tfs*2	Normal female external genitalia, primary infertility, hirsutism, severe hypertension	Dexamethasone (unknown dose)	1 uncomplicated pregnancy with normal outcome	Zacharieva S et al [14]
6	Brasilia	Homo c.799G > A	Precocious pubarche, genital ambiguity, hypertension	NA	3 uncomplicated pregnancies with normal outcomes	Valadares LP et al [22]
Homo, homozygous; NA, not available.

Our study reported compound heterozygous CYP11B1 mutations (c.946G > A [p.V316M]; c.784_792del [p.C262_F264del]) in a Chinese female patient presenting with menstrual irregularities, infertility, hirsutism and low-renin hypertension due to 11β-OHD. The compound heterozygous CYP11B1 mutation was confirmed to cause a deficiency in 11β-OHD activity, thereby resulting in a typical change of hormone profile including an elevated DOC, 17-hydroxyprogesterone and testosterone, and a suppressed renin and aldosterone level. The reduced fertility of this patient likely caused by disrupted hormone production recovered after the initiation of an adequate corticosteroid therapy, and conception was later successfully achieved.

11β-OHD can be classified as classical and nonclassical phenotypes according to the degree of clinical severity and percentage loss of CYP11B1 activity [10]. Classical 11β-OHD is characterized by hyporeninemic hypokalemia hypertension, virilization, precocious pseudopuberty, accelerated skeletal maturation and short stature. In contrast, the less frequent nonclassical 11β-OHD is characterized by normal external genitalia at birth, precocious pseudopuberty, hirsutism, menstrual irregularities, and rarely observed arterial hypertension [23]. The patient we reported here was diagnosed with nonclassical 11β-OHD based on clinical manifestations. The hormone profile further supported this diagnosis, as the baseline adrenocorticotropic hormone and cortisol levels have been reported to be normal or near-normal in nonclassical 11β-OHD which were unlikely observed in the classical form [23]. A high concordance of clinical and hormone profiles of 11β-OHD has been reported, thereby leading to a recommendation for the use of 11-deoxycortisol/ cortisol ratio for the differentiation of classical and nonclassical 11β-OHD [23]. The levels of 11-deoxycortisol/ cortisol ratio > 2.2, < 1.5 and < 0.1 have shown 100% of specificity in the differentiation of classical, nonclassical 11β-OHD and control groups in a previous study [23]. However, the measurement of 11-deoxycortisol was not available in our clinical center. The measurement of 11-deoxycortisol, DOC, 17-hydroxyprogesterone, and androstenedione taken as a supplement in regular clinical routines would improve the diagnostic and differentiation accuracy of 11β-OHD [23].

11β-OHD caused by biallelic mutations of CYP11B1 occurs in ~ 1:100000 to 1:200000 live births in general nonconsanguineous populations, and shows ethnic and geographical predominance in the Middle East and North Africa where consanguinity is common resulting in identical mutations [24]. It has been reported that there are more homozygous CYP11B1 mutations than compound heterozygous mutations in 11β-OHD [24]. Despite a nonconsanguineous origin, the patient was diagnosed with 11β-OHD due to compound heterozygous CYP11B1 mutations derived from a paternal origin of the mutation V316M and a maternal origin of the mutation C262_F264del. The missense mutation V316M has been previously reported in a Bulgarian woman who harbored compound heterozygous CYP11B1 mutations (V316M; D480Tfs*2) and presented with a similar phenotype to the current patient including normal female external genitalia, primary infertility, hirsutism and severe hypertension [14]. We confirmed that this mutation classified as uncertain significance by ACMG was pathogenic because it induced an 88% loss in enzyme activity in functional analysis. In addition, we reported a novel non-frameshift C262_F264del mutation. Functional characterization showed that C262_F264del mutation can cause a 92% decrease in CYP11B1 enzyme activity. The compound heterozygosity of V316M and C262_F264del resulted in 16% of residual enzyme activity that further supported the diagnosis of nonclassical 11β-OHD, because previous reports showed that a residual CYP11B1 activity of 10–25% was associated with the clinical phenotype of nonclassical 11β-OHD [10, 21]. Over 200 variants of CYP11B1 have been recorded in ClinVar Database (https://www.ncbi.nlm.nih.gov/clinvar/) to date, while the majority are classified as variants of uncertain significance by ACMG guideline, leading to a challenging interpretation [11]. In silico analysis of the changes in CYP11B1 structure induced by mutations is predictive but not confirmatory due to the unsatisfactory genotype-structure-phenotype concordance [24] and highly variable phenotypes especially in nonclassical 11β-OHD [10]. Functional validation by in vitro study followed by detection of steroid profile using liquid chromatography with tandem mass spectrometry is of significance as there is a concordance of clinical and hormone profiles that can reflect the severity of the impairment degree of enzyme activity [23].

Hormonal factors contribute to reduced fertility in patients with 11β-OHD in which adrenal androgens and progesterone play an essential role [25]. Excess adrenal androgens suppress follicular development, compromise ovulation, cause endometrial molecular alterations and disrupt embryo implantation [26, 27]. Progesterone disrupts gonadotropin-releasing hormone pulse frequency and interferes with female cycle [28]. Slight glucocorticoid overtreatment is therefore necessary to achieve pregnancy. Hydrocortisone is the glucocorticoid of choice during pregnancy because it is efficiently metabolized by placental 11β-hydroxysteroid dehydrogenase type 2 and is thus safe for the fetus [29, 30]. Based on the summary of previously reported cases and our experience with this patient who used oral hydrocortisone (20–30 mg/d for one month) before pregnancy, women with genetically confirmed 11β-OHD can achieve conception when properly treated with oral medications [6, 31]. Our study was the first to report the successful conception in a female patient with 11β-OHD by in vitro fertilization. In vitro fertilization can be used to segment ovarian stimulation and embryo transfer to avoid the negative effect of high progesterone and low estrogen on endometrial receptivity by freezing available embryos [32], which can increase the success rate of pregnancy in CAH women [33].

Preconception genetic counseling is mandatory for patients with 21-hydroxylase deficiency to evaluate the risk of having a child affected with the same disease, as it follows an autosomal recessive trait with an estimate of carriers about 1 in 50 to 1 in 60 [25]. Despite a much lower prevalence of 11β-OHD and P450 oxidoreductase deficiency, genetic counseling is significant, as shown in our case that genetic counseling assisted the identification of heterozygous POR mutations in the patient and her husband. To decrease the risk of passing CAH onto the carrier’s offspring, preimplantation genetic testing before in vitro fertilization can be performed if the diseasing-causing mutation is pathogenic. The fetus can also be tested for karyotype and gene mutation via chorionic villus sampling, amniocentesis, or cell-free fetal DNA testing in the prenatal phase [6].

In conclusion, we reported a successful pregnancy in a nonclassical 11β-OHD patient who had reduced fertility and compound heterozygosity of novel CYP11B1 mutations after in vitro fertilization and frozen-thawed embryo transfer. Cooperative management by a multidisciplinary team including endocrinologists, reproductive specialists, geneticists, and obstetricians is beneficial for women with 11β-OHD to achieve an accurate diagnosis, proper fertility management and uneventful pregnancy.

11β-OHD

11β-hydroxylase deficiency

ACMG

American College of Medical Genetics and Genomics

CAH

congenital adrenal hyperplasia

CYP11B1

cytochrome P450 family 11 subfamily B member 1

DOC

11-deoxycorticosterone

POR

P450 oxidoreductase

Ethics approval and consent to participate

The study was approved by The First Affiliated Hospital With Nanjing Medical University, Nanjing, China, and was conducted in accordance with the local legislation and institutional requirements.

Consent for publication

The patient and her family gave written informed consent for the use of clinical data and biomaterials in accordance with the local ethics committee.

Availability of data and materials

The raw data will be made available on reasonable request by the corresponding authors.

Competing interests

The authors declare that the study was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Funding

The author(s) declare that financial support was received for the research, authorship, and/or publication of this article. This work was supported by the Key Project supported by Medical Science and Technology Development Foundation, Jiangsu Committee of Health [grant number K2023046], and China Postdoctoral Science Foundation [grant number 2022TQ0132].

Authors’ contributions

Y.Y. performed experiments, analyzed and interpreted the experimental data, and drafted the manuscript. M.G. collected patient data, and performed experiments and sequence alignment. M.S. supervised the study, visited the patient and revised the manuscript. W.W and Z.W. visited the patient and revised the manuscript. All authors read and approved the final manuscript.

Acknowledgements

No applicable.

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No competing interests reported.

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Pregnancy in a Chinese woman with nonclassical 11β-hydroxylase deficiency caused by novel compound heterozygous mutations: a case report, literature review and functional validation

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Abstract

Background

Case presentation:

Conclusions

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Background

Case presentation

Clinical characteristics and hormonal profiles

Molecular genetic analysis

Fertility treatment

Functional validation

Literature search

Discussion and conclusions

Abbreviations

Declarations

References

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