Male Infertility: Causes and Management at a Tertiary Care Center in India.

Background Infertility and problems of impaired fecundity have been a concern through the ages and are also considerable clinical problems today, affecting many couples worldwide. Most infertility cases are primarily attributed to male factors, which play a significant role. Additionally, a substantial number of these patients exhibit suboptimal sperm parameters. The study is mainly designed for individual intervention and outcome. We aim to evaluate the demographics, etiology, utilization of treatments, and outcomes of males undergoing infertility treatment. Methodology We retrospectively enrolled infertile couples from January 2021 to March 2023, covering the past two years. All patients were evaluated and investigated per the study protocol to identify the cause of infertility. Results Two thousand three hundred forty-eight males were enrolled in the study, of whom 1,484 (63%) were found to have a standard semen analysis. A total of 868 (37%) had abnormal semen parameters. Two hundred and seventy-two (12%) patients completed the evaluation. All parameters, except for hypospermia, displayed lower percentages of motility compared to normozospermia. All semen parameters, except for hypospermia, showed a significantly lower normal morphology in comparison to normozospermia. This reduction increased by 10% for each year of age increment. Conclusions The study concluded by following a protocol for evaluating male patients. If an abnormal sperm parameter is identified before considering intracytoplasmic sperm injection (ICSI), it is recommended to conduct at least karyotyping and microdeletion analysis on the Y-chromosome's q arm.

Characteristics and Management of Children With Suspected COVID-19 Admitted to Hospitals in India: Implications for Future Care.

INTRODUCTION: There is a growing focus on researching the management of children with COVID-19 admitted to hospital, especially among developing countries with new variants alongside concerns with the overuse of antibiotics. Patient care can be improved with guidelines, but concerns with the continued imprudent prescribing of antimicrobials, including antibiotics, antivirals, and antimalarials. OBJECTIVE: Consequently, a need to document the current management of children with COVID-19 across India. Key outcome measures included the percentage of prescribed antimicrobials, adherence to current guidelines, and mortality. METHODOLOGY: A point prevalence study using specially developed report forms among 30 hospitals in India. RESULTS: The majority of admitted children were aged between 11 and 18 years (70%) and boys (65.8%). Reasons for admission included respiratory distress, breathing difficulties, and prolonged fever. 75.3% were prescribed antibiotics typically empirically (68.3% overall), with most on the Watch list (76.7%). There were no differences in antibiotic prescribing whether hospitals followed guidelines or not. There was also appreciable prescribing of antimalarials (21.4% of children), antivirals (15.2%), and antiparasitic medicines (27.2%) despite limited evidence. The majority of children (92.2%) made a full recovery. CONCLUSION: It was encouraging to see low hospitalization rates. However, concerns about high empiric use of antibiotics and high use of antimalarials, antivirals, and antiparasitic medicines exist. These can be addressed by instigating appropriate stewardship programs.

A Prospective Case-control Trial to Evaluate and Compare the Efficacy and Safety of Atosiban versus Placebo in In vitro Fertilization-embryo Transfer Program.

BACKGROUND: Recent developments in assisted reproductive technology focus on potential advances to improve its success rate. Atosiban, a combined oxytocin/vasopressin V1a receptor antagonist, is a novel class of drug involved in basic priming of the uterus for successful implantation during embryo transfer (ET). OBJECTIVES: The objective of this study is to evaluate the efficacy of atosiban (study group) in ET patients in comparison to placebo (control group) regarding implantation rate (IR), clinical pregnancy rate (CPR), and ongoing pregnancy rate and to assess the safety profile of atosiban. MATERIALS AND METHODS: A total of 320 women undergoing in vitro fertilization-ET at a tertiary care hospital were enrolled in the study. In the study group, atosiban was given as initial intravenous (IV) bolus injection 0.9 ml (6.75 mg), 30 min before ET followed by continuous IV infusion of atosiban. In the control group, placebo (normal saline) was infused at the same rate and dose. Pregnancy was confirmed 14 days after ET by ß-human chronic gonadotropin level. IR and CPR were determined by doing transvaginal sonography 3 weeks and 6 weeks postET, respectively. RESULTS: In women with atosiban treatment, the positive pregnancy rate and CPRs were 41.25% and 36.25%, respectively. The IR per embryo transferred was 17.5%. No major side effects of atosiban were noted among enlisted patients. The miscarriage rate and ectopic pregnancy rate were low (12.12% and 4.54%, respectively). Forty-two women had singleton gestation, while twin and triplet pregnancies were encountered in 13 and 3 women, respectively. No congenital anomalies were observed during an antenatal scan at 18-20 weeks in ongoing pregnancies. The positive pregnancy rate, the CPR, and the IR in the control group was 35%, 30%, and 16.5%, respectively, which was significantly lower than the atosiban group. CONCLUSION: Atosiban reduces uterine contractions and increases endomyometrial perfusion, both of which have potential benefits regarding improved IRs, CPR, and ongoing pregnancy rates. Atosiban has a good embryonic safety profile.

Iron Deficiency Anemia with Menorrhagia: Ferric Carboxymaltose a Safer Alternative to Blood Transfusion.

BACKGROUND: Menstrual disorder accounts for 5%-10% of the women presenting with iron deficiency anemia (IDA) in the perimenopausal age group. Heavy menstrual bleeding in this age group leads to severe anemia and frequently requires blood transfusion which has its own adverse effects. We today have ferric carboxymaltose (FCM) as a safer alternative to blood transfusion. OBJECTIVE: The objective of the study is to evaluate the safety and efficacy of FCM in treating anemia in patients of menorrhagia. Thus avoiding blood transfusion. MATERIALS AND METHODS: It was an open, single arm observational study including 90 women of age more than 30 years with definitive diagnosis of menorrhagia with IDA and hemoglobin (Hb) levels between 4 gm% and 11 gm%. Intravenous FCM (500-1500 mg) was administered, and the improvement in blood indices was assessed after 3 weeks of total dose infusion. Menorrhagia was controlled by medical treatment till Hb improvement was achieved and definitive surgical intervention was done. RESULT: Most of the women were in the age group of 40-50 years. Blood indices measured pre-FCM and 3 weeks post-FCM showed a mean increase in Hb from 8.33 ± 1.10 to 10.89 ± 1.02 with a statistically significant P < 0.01. There was a statistically significant rise of packed cell volume, serum ferritin, and serum iron in the post-FCM blood levels after 3 weeks. No serious life-threatening adverse events were observed after FCM administration. CONCLUSION: Intravenous FCM is an effective and a safe treatment option for IDA with a single administration of high dose without serious adverse effects obviating the need for blood transfusion before surgery.

Safety and Efficacy of Intravenous Ferric Carboxy Maltose in Iron Deficiency Anaemia During Post-partum Period.

BACKGROUND: Iron deficiency is the commonest treatable cause of postpartum anaemia. Parenteral iron therapy results in faster and higher replenishment of iron stores and correction of haemoglobin levels with better compliance. Ferric Carboxy Maltose is an effective and a safe option which can be administered intravenously in single total correction dose without any serious adverse effects.The study was done to evaluate the efficacy and safety of Ferric Carboxy Maltose in the treatment of iron deficiency anaemia in post-natal patients. METHODS: It was an open, single arm study including 615 women with diagnosis of Iron deficiency anaemia and haemoglobin (Hb) levels between 4gm% and 11gm% from January 2013 to December 2016. Intravenous Ferric Carboxy Maltose(500-1500mg) was administered and the improvement in haemoglobin levels and iron stores were assessed after three weeks of total dose infusion. RESULTS: Out of the 615 women, 595 women were included in the analysis. Most of the women were in the age group of 27-30 years. Most of the women had mild anaemia as per World Health Organisation guidelines. Mean hemoglobin levels significantly increased over a period of three weeks after Ferric Carboxy Maltose administration. Other parameters like total iron binding capacity, Ferritin and Iron also had a significant improvement after Ferric Carboxy Maltose administration. No serious adverse events were observed after Ferric Carboxy Maltose. CONCLUSIONS: Intravenous Ferric Carboxy Maltose was an effective and a safe treatment option for iron deficiency anaemia and has an advantage of single administration of high doses without serious adverse effects.

Treatment Outcome of Ovulation-inducing Agents in Patients with Anovulatory Infertility: A Prospective, Observational Study.

OBJECTIVE: To compare different treatment regimens on pregnancy rate and outcome in patients with anovulatory infertility. PATIENTS AND METHODS: A prospective observational study was conducted on patients with infertility due to anovulation. Patients treated with clomiphene citrate (CC) 50/100 mg/day from 2nd to 6th day of menstrual cycle (MC) (n = 38), short gonadotropin-releasing hormone (GnRH) agonist regimen (leuprolide [0.5 mg subcutaneous] + recombinant follicle-stimulating hormone [rFSH] [225 IU intramuscular [IM] from 2nd to 10th day of MC [n = 32]), long GnRH agonist regimen (leuprolide from 21st day followed by leuprolide + rFSH from 2nd to 10th day of MC [n = 19]), and antagonist regimen (human menopausal gonadotropin [hMG] [150 IU IM] from 2nd day followed by hMG + cetrorelix from 7th to 10th day of MC) (n = 6) were recruited and followed up for follicular size, endometrial thickness, and pregnancy test. Data were analyzed using appropriate statistical test andP < 0.05 was considered statistically significant. RESULTS: A significant increase in follicular diameter and endometrial thickness was observed in patients treated with gonadotropin regimens as compared to CC alone (P < 0.0001). The highest number of positive pregnancy test with ultrasonographic evidence of gestational sac was observed with leuprolide + rFSH (long regimen) (10/19, 52.6%) followed by leuprolide + rFSH (short regimen) (13/32, 40.6%) while least in antagonist regimen (2/6, 33.3%) and CC (1/38, 2.63%). All regimens were well tolerated. CONCLUSION: Treatment outcome was better with long agonist regimen.

Pregnancy Outcome in Patients with Solitary Kidney.

BACKGROUND: Solitary kidney may be congenital or as a result of nephrectomy. There is a lot of literature available on quality of life in these patients, but there is limited data on pregnancy outcome. OBJECTIVES: To study pregnancy outcome in patients with solitary kidney either congenital or due to nephrectomy. MATERIALS AND METHODS: Study Design This is a retrospective observational study conducted at tertiary health center in Ahmedabad, from 2011 to 2014. Sample Size There were 164 patients of solitary kidney, out of which two patients had congenital solitary kidney and the remaining had solitary kidney due to nephrectomy. Among 164 patients, 96 (58.53 %) patients had completed family, 37 (22.56 %) patients did not try for pregnancy, 15 (9.14 %) patients have conceived, 12 (7.3 %) were lost to follow up and 4 (2.43 %) patients were infertile. Method Patients in reproductive age group (20-40 years), with solitary kidney either congenital or due to nephrectomy, were included. Maternal and fetal outcome was studied, and patients were followed up till 2 years postpartum. Exclusion Criteria Patients with solitary kidney due to post-renal transplant were excluded. RESULTS: There were 15 (9.14 %) patients who had conceived, out of which 11 (73.33) patients delivered and 4 (26.67 %) patients had spontaneous abortion. Two patients developed gestational hypertension and one had preeclampsia. On follow-up, all babies were normal and none of them had delayed developmental milestones. CONCLUSION: Preconceptional counseling should be done in these patients regarding risk of developing preeclampsia during pregnancy and preterm delivery. These patients can have good pregnancy outcome with close monitoring during antenatal period.

A Case of Primary Amenorrhea with Swyer Syndrome.

Swyer syndrome with complete gonadal dysgenesis is associated with an absence of testicular differentiation in a phenotypic female with a 46, XY karyotype. A 14-year-old unmarried girl was referred with complaints of primary amenorrhea and nondevelopment of breast. Her built was normal. Examination of her secondary sexual characteristics revealed no breast development, absent axillary hairs, and sparse pubic hairs. External genitalia was of female type. Karyotype showed genotype of 46, XY. Magnetic resonance imaging revealed hypoplastic uterus with absent fallopian tubes and ovaries. A diagnosis of Swyer syndrome was made. Laparoscopy showed infantile uterus, normal fallopian tubes, and streak gonads. Laparoscopic removal of streak gonads was done as there is a risk of gonadoblastoma in such cases. The patient was started on hormonal replacement therapy. Swyer syndrome results mainly due to mutation in certain genes such as SRY gene, which leads to failure of development of testis.

Successful Pregnancy Outcome in a Patient with Solitary Kidney Affected by Angiomyolipoma: A Rare Case.

Renal angiomyolipoma is a rare benign tumour and its occurrence during pregnancy is even rare. It is usually diagnosed incidentally. It can increase in size during pregnancy and can present acutely as rupture with retroperitoneal haemorrhage, mechanism of which is still unclear. We present a case of successful pregnancy outcome in a patient with congenital solitary kidney affected by angiomyolipoma, diagnosed incidentally at 19 years of age. The patient had conceived twice. Her antenatal and post partum period was uneventful both the times.

An Overview on Fertility Outcome in Renal Transplant Recipients.

BACKGROUND: The number of patients undergoing renal transplant are increasing with time. Most of these patients fall in the reproductive age group, who are going to conceive sooner or later. But there are few recipients who either are infertile before transplant or became infertile due to underlying renal pathology responsible for transplantation. OBJECTIVE: To study fertility outcome in female renal transplant recipients. STUDY DESIGN: This is a retrospective study conducted at tertiary health center in Ahmedabad, from 2004 to 2014. INCLUSION CRITERIA: Renal transplant recipients in the reproductive age group (20-40 years of age) were followed up in gynecology outdoor patient department. SAMPLE SIZE: There were 211 female renal transplant recipients, out of which 113 (53.5 %) patients had complete family, 3 (1.41 %) patients were infertile, 16 (7.58 %) patients have conceived, 33 (15.63 %) patients were lost to follow-up and remaining 46 (21.8 %) did not try for pregnancy. EXCLUSION CRITERIA: Unmarried patients, divorced and widow patients were excluded. RESULTS: Out of 19 patients, 16 patients conceived and 3 were infertile. The main cause of infertility in these patients was ovarian factor in 2 patients and tubal factor in 1 patient. Among 16 patients, 8 patients had missed abortion, 2 patients had preterm deliveries and 6 patients had term deliveries. CONCLUSION: Peritransplant and preconceptional counseling plays an important role for renal transplant recipients to help them understand the effect of renal pathology and transplantation on their fertility. They can have good fertility and pregnancy outcome with optimum functioning graft.

Effects of Granulocyte Colony-Stimulating Factor (GCSF) on Persistent Thin Endometrium in Frozen Embryo Transfer (FET) Cycles.

OBJECTIVE: To predict the effectiveness of granulocyte colony-stimulating factor (GCSF) in the treatment of persistent thin endometrium resistant to other treatments in frozen embryo transfer (FET) cycles. STUDY DESIGN: This is a hospital-based prospective study. PATIENTS: Thirty-five women with persistent thin endometrium (<7 mm) resistant to standard treatments were involved in this study. INTERVENTIONS: Intrauterine infusion of GCSF (300 mcg/1 ml) was done in patients with thin endometrium on day 14 of FET cycles, and their endometrial thicknesses were measured after 48 h of infusion. MAIN OUTCOME MEASURES: The primary outcome was an increase in endometrial thickness and the secondary outcome measures were chemical and clinical pregnancies. RESULTS: The endometrial thickness increased from 5.86 ± 0.58 to 6.58 ± 0.84 mm after GCSF infusion. In 19 of the 35 participants (54.28 %) endometrial thickness increased to ≥7 mm and they subsequently underwent embryo transfer. Of these, 3 (15.78 %) patients had chemical pregnancy, but there was no clinical pregnancy. In 16 participants, embryo transfer was canceled in view of insufficient endometrial thickness (<7 mm). CONCLUSION: GCSF caused a small increase in endometrial thickness in women with persistent thin endometrium, but there was no improvement in their pregnancy rates.

Endometrial and Subendometrial Vascularity by Three-Dimensional (3D) Power Doppler and Its Correlation with Pregnancy Outcome in Frozen Embryo Transfer (FET) Cycles.

PURPOSE OF THE STUDY: To study the role of endometrial and subendometrial blood flow measured by 3D power Doppler as predictors of pregnancy in frozen embryo transfer (FET) cycles. METHODS: A hospital-based prospective study of two hundred and twenty-one (221) women undergoing FET cycles with a triple-line endometrium ≥7 mm on day 14 endometrial and subendometrial blood flow was assessed using 3D power Doppler, and various indices endometrial volume, subendometrial volume and their vascularisation index (VI), flow index (FI) and vascularisation flow index (VFI) were obtained and compared between the pregnant and the non-pregnant group. Primary outcome was clinical pregnancy. RESULTS: Out of 221 women, 97(43.89 %) became pregnant, while 124 (56.10 %) failed to become pregnant. The endometrial volume was comparable between the two groups. Endometrial VI, FI and VFI were significantly higher in the pregnant as compared to the non-pregnant group. There was a significant difference in subendometrial VI and VFI between the two groups, but FI was similar. CONCLUSIONS: Endometrial and subendometrial vascularity by 3D power Doppler can be a useful parameter in predicting pregnancy in FET cycles.

A transvaginal removal and repair of vesicovaginal fistula due to mesh erosion.

Vesicovaginal fistula (VVF) is a devastating social problem. It can either result from obstetric trauma or following gynecological surgeries, malignancy, or radiation. We present a case of a 70-year-old woman who had a VVF following mesh augmentation surgery for anterior compartment prolapse. She required a transvaginal removal of the eroded mesh followed by a transvaginal repair of VVF using a Martius flap, 6 weeks later. Transvaginal removal of mesh is technically feasible and a good approach. Timing and route of surgery should be individualized.

Unusual presentation of twisted ovarian cyst.

Ovarian torsion (also termed as adnexal torsion) refers to partial or complete rotation of the ovary and a portion of fallopian tube along its supplying vascular pedicle. It occurs commonly in reproductive age group; more on the right side (60%) and often presents with acute lower abdominal pain lasting for few hours and up to 24 h, accounting for 2.7% of acute gynecological conditions. It is one of the devastating conditions, hampering blood supply of ovary which may lead to total necrosis of ovarian tissue and complications, if not diagnosed and managed in time. Hence, we present a case on a twisted ovarian cyst in postmenopausal woman with unusual symptomatology leading to delayed diagnosis and loss of an ovary.

Prevalence of female sexual dysfunction among Indian fertile females.

BACKGROUND: Female sexual dysfunction (FSD) is described as difficulty experienced by a female during any stage of a normal sexual activity including physical pleasure, desire, arousal, or orgasm. There are various factors responsible for FSD including psychological status of a person, gynecological or medical problems, long use of certain drugs, and social beliefs. OBJECTIVES: To study the prevalence and various factors associated with FSD. MATERIALS AND METHODS: Study Design - This study design was a cross-sectional observational study conducted at Tertiary Care Centre, in Ahmedabad from June 2015 to March 2016. Sample Size - One hundred and fifty-three fertile females in reproductive age group (20-47 years) were included in the study. Written and informed consent was obtained from all the females. Methods - FSD was assessed with a detailed 19-item female sexual function index questionnaire. All six domains of sexual dysfunction, i.e., desire, arousal, lubrication, orgasm, satisfaction, and pain were studied. Various associated factors such as gynecological or psychological problems were also studied. Exclusion - Infertile patients were excluded from the study. RESULTS: The prevalence of FSD was 55.55% among 153 fertile females. FSD was more prevalent in the age group of 26-30 years and with duration of marriage >16 years. FSD was also more common in females with middle education and those belonging to upper middle socioeconomic status. Psychological stress was significantly associated with FSD. CONCLUSION: It is right of every female to lead healthy sexual life as it is key to happiness in marriage. Females with FSD can be managed with proper counseling and treating the underlying etiology.

Female sexual dysfunction in patients with endometriosis: Indian scenario.

BACKGROUND: Female sexual dysfunction (FSD) in Indian women is often overlooked due to cultural beliefs and considered as social taboos. Sexuality is an important and integral part of life. There are many causes of sexual dysfunction, but the prevalence of FSD in endometriotic patients is still underdiagnosed. MATERIALS AND METHODS: Study design - Cross-sectional observational study conducted at tertiary care center, from June 2015 to March 2016. Sample size - Fifty-one patients in reproductive age group (18-47 years) who were diagnosed with endometriosis on diagnostic laparoscopy were included. Methods - FSD was assessed with a detailed 19-item female sexual function index questionnaire. All six domains of sexual dysfunction, i.e., desire, arousal, lubrication, orgasm, satisfaction, and pain were studied. Exclusion - Patients with other gynecological, medical or surgical history were excluded. RESULTS: Out of 51 patients with endometriosis, 47.06% of patients had sexual dysfunction. With the increase in staging of endometriosis, sexual dysfunction prevalence is also rising. FSD was 100% in patients with severe endometriosis as compared to 33.33% in minimal endometriosis. CONCLUSION: Every individual deserves good sexual life. The sexual dysfunction associated with endometriosis should also be taken into consideration while managing these patients.

Uterine conserving surgery in a case of cervicovaginal agenesis with unicornuate uterus.

The presence of cervicovaginal agenesis with unicornuate uterus is a very rare mullerian anomaly. Its true incidence is still unknown. The presence of functioning unicornuate uterus poses a great challenge for a gynecologist because a successful repair could restore normal menses and may preserve a patient's fertility. Hence, we report a case of 16-year-old unmarried female who presented with chief complaints of primary amenorrhea with cyclical lower abdominal pain. On clinical and radiological evaluation, she was diagnosed with complete cervicovaginal agenesis with right unicornuate uterus (hematometra and hematosalpinx). She underwent vaginoplasty (McIndoes method) along with uterovaginal anastomosis by neocervix formation, in order to preserve her uterus. On follow-up, her vagina was completely healed, and she was menstruating normally.

Successful Term Pregnancy in a Second Trimester Female with Urosepsis: A Case Report.

Urolithiasis means calculus in urinary system. It is a rare condition in pregnancy which can have devastating results for the mother in the form of pyonephrosis and septicaemia and to the foetus in the form of IUGR and prematurity. This is a rare case report of a 27-year old female patient who presented with perinephric abscess and hydronephrosis at 22 weeks of pregnancy. With proper evaluation and management, pregnancy continued till term with good perinatal outcome.

Prevalence; Characteristics and Management of Endometriosis Amongst Infertile Women: A One Year Retrospective Study.

BACKGROUND: Endometriosis appears to affect every aspect of a women's reproductive system resulting in infertility and spontaneous pregnancy loss. This study aims to find out the prevalence & clinical characteristics of endometriosis amongst infertile women. SETTINGS AND DESIGN: A Hospital based retrospective study over a period of one year. MATERIALS AND METHODS: It is a retrospective study conducted in the gynaecology department in Institute of Kidney Diseases & Research Centre; Ahmedabad from April 2012 to March 2013 amongst women with a primary complaint of infertility (Primary/Secondary).A total of 372 patients underwent diagnostic hysterolaparoscopy and of these 180 patients who had laparoscopic evidence of endometriosis was included in the study. All of these patients and their findings were analysed with respect to the clinical signs and symptoms. The outcome after appropriate management was analysed in subsequent follow up. STATISTICAL ANALYSIS: All collected data was entered into the SPSS version 20. Categorical data are expressed in frequency or percentage. Chi-Square test and Fisher-Exact test has been performed to carry out p-value for categorical data. P-value <0.05 shows statistically significant difference. RESULTS: The frequency of endometriosis among women with infertility subjected to diagnostic hysterolaparoscopy was found to be 48.38%. Statistical significant association with severity of disease was associated with symptoms like dysmenorrhea, chronic pelvic pain, restricted uterine mobility and adnexal tenderness. (p <0.01) Ultrasound finding of endometrioma with ground glas appearance also had statistical significant association with staging of disease (p <0.01). CONCLUSION: Endometriosis amongst infertile women is increasingly being detected due to greater use of laparoscopy in evaluation of infertility.Though most signs do not correlate with severity of disease however the presence of restricted uterine mobility, adnexal tenderness & chronic pelvic pain should always raise the suspicion of endometriosis. Laparoscopy remains the gold standard for diagnosing and staging endometriosis.

Nonclassic congenital adrenal hyperplasia misdiagnosed as Turner syndrome.

We present a patient with nonclassic congenital adrenal hyperplasia (NCAH) misdiagnosed as mosaic Turner syndrome. She presented with complaints of primary infertility. Short stature, the presence of facial hair and hoarse voice was also noted. She had primary amenorrhea and was advised for karyotype at 16 years of age, which was reported as 45, X[20]/46, XX[80], stating her as a case of mosaic Turner syndrome. Clitoroplasty was done at 21 years of age for clitoromegaly, which was noticed during puberty. The diagnosis of mosaic Turner could not explain the virilization. Therefore, we repeated the karyotype, which revealed 46, XX in more than 100 metaphases and was sufficient to exclude mosaicism. Furthermore, the endocrinological evaluation revealed high testosterone level with a normal 17 alpha-hydroxyprogesterone (17-OHP). The presence of pubertal onset virilization with a karyotype of 46, XX and raised testosterone level with normal 17-OHP level, raised the suspicion of NCAH for which adrenocorticotropic hormone stimulation test was done which confirmed the diagnosis of NCAH.