SALSA MLPA probemix P185-C2 Intersex Lot C2-1015: As compared to the previous version C1 (lot C1-0611), the lengths of four probes have been adjusted.

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1 mix P185-C2 Intersex Lot C2-1015: As compared to the previous version C1 (lot C1-0611), the lengths of four s have been adjusted. The sex-determining region on chromosome Y (SRY) is the most important sex-determining region in humans. As a transcriptional activator, the SRY protein s main function is to initiate male sex determination by regulating a genetic switch in male development. In addition to SRY, the dosage-sensitive sex reversal (DSS) gene, NR0B1 (also known as DAX1) has also been found to influence sex-determination. Duplication of the NR0B1 gene region, resulting in two active copies of DAX1 can override the testis-determining signal, resulting in the development of ovaries and an XY female. In testicular Sertoli and Leydig cells, DAX1 can be up-regulated by WNT4. The SOX9 gene functions as a critical Sertoli cell differentiation factor. SOX9 deletions, as well as chromosomal rearrangements such as deletions, in an enhancer containing region far upstream of SOX9 can lead to campomelic dysplasia with or without XY sex reversal (Leipoldt et al, 2007; Katoh-Fukui et al, 2015). The NR5A1 gene encodes the orphan nuclear receptor steroidogenic factor-1 which plays a key role in regulating adrenal and gonadal development, steroidogenesis and reproduction. Haploinsufficiency of NR5A1 has been described in several 46, XY individuals with mild gonadal dysgenesis and impaired androgenization, but normal adrenal function, suggesting that dosage-sensitive or domain-specific effects of SF1 action are important in human testicular development and function. The P185-C2 mix contains s for the following genes: NR0B1 (DAX1) and CXorf21 on Xp21.2, SOX9 on 17q24.3, SRY and ZFY on Yp11.3, WNT4 on 1p36.12 and NR5A1 on 9q33. Furthermore, s specific for the X and Y-chromosomes are included. In addition, 9 reference s are included in this mix, detecting several different autosomal chromosomal locations. This SALSA mix is designed to detect deletions/duplications of one or more sequences in the aforementioned genes in a DNA sample. Heterozygous deletions of autosomal recognition sequences should give a 35-50% reduced relative peak height of the amplification product of that. Deletions of a s recognition sequence on the X-chromosome will lead to a complete absence of the corresponding amplification product in males, whereas female heterozygotes are recognisable by a 35-50% reduction in relative peak height. Note that a mutation or polymorphism in the sequence detected by a can also cause a reduction in relative peak height, even when not located exactly on the ligation site! In addition, some signals are more sensitive to sample purity and small changes in experimental conditions. Therefore, deletions and duplications detected by MLPA should always be confirmed by other methods. Not all deletions and duplications detected by MLPA will be pathogenic; users should always verify the latest scientific literature when interpreting their findings. We have no information on what percentage of defects in these genes is caused by deletions/duplications of complete exons. Finally, note that most defects in these genes are expected to be small (point) mutations, most of which will not be detected by this SALSA test. SALSA mixes and reagents are sold by for research purposes and to demonstrate the possibilities of the MLPA technique. They are not CE/FDA certified for use in diagnostic procedures. Purchase of the SALSA test mixes and reagents includes a limited license to use these products for research purposes. The use of this SALSA mix and reagents requires a thermocycler with heated lid and sequence type electrophoresis equipment. Different fluorescent PCR primers are available. The MLPA technique has been first described in Nucleic Acid Research 30, e57 (2002). Related SALSA mixes P050 CAH: Genes included CYP21A2, CYP21A1P, and TNXB. P334 Gonadal: Genes included DMRT1, CYP17A1, SRD5A2 and HSD17B3. More information Website : info@mlpa.com (information & technical questions); order@mlpa.com (for orders) Mail : bv; Willem Schoutenstraat 1, 1057 DL Amsterdam, the Netherlands SALSA P185 Intersex mix Page 1 of 7

2 References Barbaro M. et al., Isolated 46,XY gonadal dysgenesis in two sisters caused by a Xp21.2 interstitial duplication containing the DAX1 gene. J Clin Endocrinol metab 92: Bardoni B et al., A dosage sensitive locus at chromosome Xp21 is involved in male to female sex reversal. Nature Genetics 7:497. Benko S et al., Disruption of a long distance regulatory region upstream of SOX9 in isolated disorders of sex development. J Med Genet. 48: Katoh-Fukui Y et al., Testicular dysgenesis/regression without campomelic dysplasia in patients carrying missense mutations and upstream deletion of SOX9. Mol Genet Genomic Med 3: Kim GJ et al., Copy number variation of two separate regulatory regions upstream of SOX9 causes isolated 46,XY or 46,XX disorder of sex development. J Med Genet. 52: Kon M and Fukami M, Submicroscopic copy-number variations associated with 46,XY disorders of sex development. Molecular and Cellular Pediatrics 2:7. Leipoldt M et al., Two novel translocation breakpoints upstream of SOX9 define borders of the proximal and distal cluster region in campomelic dysplasia. Clin Genet 71: Data analysis The P185-C2 Intersex mix contains 44 MLPA s with amplification products between 130 and 494 nt. In addition, it contains 10 control fragments generating an amplification product smaller than 120 nt: four DNA Quantity fragments (Q-fragments) at nt, three DNA denaturation control fragments (D-fragments) at nt, one X-fragment at 100 nt and two Y-fragment at 105 nt and 118 nt. More information on how to interpret observations on these control fragments can be found in the MLPA protocol. The 105, 118, 214, 241 and 351 nt Y chromosome specific s will only generate a signal on male DNA samples. Data generated by this mix can be intra-sample normalised by dividing the peak height of each amplification product by the total peak height of only the reference s in the mix (block normalisation). Secondly, inter-sample normalisation can be achieved by dividing the intra-normalised ratio in a sample by the average intra-normalised ratio of all reference samples. Please note that this type of normalisation assumes that no changes occurred in the genomic regions targeted by the reference s. It is strongly recommended to use reference and patient samples of the same sex to minimize variation, as intersex comparison makes analysis more difficult. Sex determination can also be done by visual examination of the electropherogram. Data normalisation should be performed within one experiment. Only samples purified by the same method should be compared. Confirmation of most exons deletions and amplifications can be done by e.g. Southern blotting, long range PCR, qpcr, FISH. Note that Coffalyser, the MLPA analysis tool developed at, can be downloaded free of charge from our website Many copy number alterations in healthy individuals are described in the database of genomic variants: For example, a duplication of a complete gene might not be pathogenic, while a partial duplication or a deletion may result in disease. For some genes, certain in-frame deletions may result in a very mild, or no disease. Copy number changes of reference s are unlikely to be the cause of the condition tested for. Users should always verify the latest scientific literature when interpreting their findings. This mix was developed at. Info / remarks / suggestions for improvement: info@mlpa.com. SALSA P185 Intersex mix Page 2 of 7

3 Table 1. P185-C2 Intersex mix Chromosomal position reference SOX9 chr X/Y NR0B1 WNT4 NR5A Q-fragments: DNA quantity; only visible with less than 100 ng sample DNA D-fragments: Low signal of 88 or 96 nt fragment indicates incomplete denaturation 100 X-fragment: Specific for the X chromosome 105 Y-fragment: Specific for the Y chromosome 118 ZFY S0135-L16766 Yp Reference L q ± SOX L Reference L q NR0B L Reference L q ± SOX L ± NR5A L Reference L p ± WNT L PHEX L08286 Xp SOX L28791 Upstream 214 UTY L12607 Yq SOX L12188 Upstream 228 COL4A L28792 Xq NR0B L UTY L28790 Yq Reference L p ± SOX L Reference L q WNT L ± NR5A L WNT L SOX L09981 Upstream 310 NR0B L WNT L Ж NR5A SP0424-L ± SOX L ± NR5A L SRY L19672 Yp Reference L q Ж SOX SP0425-L20003 Upstream 382 SOX L09980 Upstream 390 Ж NR5A SP0426-L WNT L ± NR5A L NR5A L GJB L02097 Xq PQBP L07700 Xp Reference L q NR0B L16506 NR0B1 region 463 CXorf L16507 NR0B1 region 474 CXorf L16508 NR0B1 region 481 NR0B L16509 NR0B1 region 494 Reference L p15 Changed in version C2 (from lot C onwards). Small change in length, no change in sequence detected. ± These s are located within, or close to, a very strong CpG island. A low signal of these s can be due to incomplete sample DNA denaturation, e.g. due to the presence of salt in the sample DNA. Ж This consists of three parts and has two ligation sites. SALSA P185 Intersex mix Page 3 of 7

4 Table 2. P185 s arranged according to chromosomal location Table 2a. NR0B1 and other chromosome X s Gene / L28792 COL4A L02097 GJB L07700 PQBP in NM_ in NM_ in NM_ L16508 CXorf kb before CXorf21; 522 kb after last DMD exon L16507 CXorf21 NM_ ; 132 nt after exon 1 reverse L16509 NR0B kb upstream NR0B L16506 NR0B kb upstream NR0B1 start codon (ex 1) L05503 NR0B1 10 nt before exon 1, 1 26 nt before ATG L12569 NR0B in 1 NM_ L05505 NR0B in 2 NM_ stop codon (ex 2) CTTGCTTCAACT-GCATTGGAACTG ACAAGGTCCACA-TCTCAGGGACAC GCTCTCCCCACA-TGACCCCAACTC TGCCATCACAAT-AATTAGTCGTCT TCTGATATGGTA-AGCTAGAAAAGC TTAGCTCAAATC-AAAGCTCCTAAC CCACATTTTCTG-TAGCTAATTTAT GCCACTGGGCAG-AACTGGGCTACG TTCGAGACTGTG-GAAGTCTCGGAG TCATCGAACTTA-ATAGTACCCTTT kb kb kb SALSA P185 Intersex mix Page 4 of kb kb kb 17.7 kb 1.0 kb 3.7 kb 8126 kb in L08286 PHEX CTCGCAAGTATT-TAGCACAGTCTG NM_ The NM_ sequence is a reference standard in the NCBI RefSeqGene project. Flanking. Included to facilitate the determination of the extent of a deletion/duplication. Copy number alterations of flanking and reference s are unlikely to be related to the condition tested. Table 2b. Chromosome Y s Gene NM_ L19672 SRY in NM_ CAACAGGTTGTA-CAGGGATGACTG kb 118 S0135-L16766 ZFY in NM_ TCATAGAGGAGG-ATGTTCAGTGCT kb 105 S0369-L12720 UTY TCGACAACCACA-TGGTGCTCTGAC kb L28790 UTY CTTCGGTAGCTT-AAGTCTTTGCCT kb L12607 UTY 125 kb upstream AGGATCCTGGAT-ATTCCACTACCA The NM_ sequence is a reference standard in the NCBI RefSeqGene project. Table 2c. WNT4 WNT4 NM_ start codon (ex 1) 187 ± L reverse CTTACAGCCAGT-TGCTCGCGGCGG 13.1 kb L GCGAGAAACTCA-AGGGCCTGATCC 8.3 kb L AGCTGGAGAAGT-GCGGCTGTGACA 0.2 kb L TGCGGGAGAGAA-GCAAGGGGGCCT 2.8 kb L GACATGCATGGA-TCAAGACCTTGC stop codon (ex 5) ± This is located within, or close to, a very strong CpG island. A low signal of these s can be due to incomplete sample DNA denaturation, e.g. due to the presence of salt in the sample DNA. The NM_ sequence is a reference standard in the NCBI RefSeqGene project.

5 Table 2d. NR5A1 NR5A1 NM_ start codon (ex 1) 343 ± L GCTGCTTCCGCT-TCGTAAGTGAGG 3.9 kb 171 ± L reverse CGTACGAATAGT-CCATGCCCGCGG 0.2 kb 283 ± L AGAACAACAAGC-ACTACACGTGCA 3.1 kb 408 ± L CCGACCAGACCT-TCATCTCCATCG 7.0 kb 328 Ж SP0424-L ; ATGACGCTGCTG-26nt spanning 1108 oligo -GTTCGACCACAT 2.0 kb 390 Ж SP0426-L ; 21nt TCATCCTCTTCA-27nt spanning after exon 6 oligo -GAGAGGTGGAGA 8.2 kb L AAGGAGTACCTG-TACCACAAGCAC stop codon (ex 7) ± These s are located within, or close to, a very strong CpG island. A low signal of these s can be due to incomplete sample DNA denaturation, e.g. due to the presence of salt in the sample DNA. Ж This consists of three parts and has two ligation sites. The NM_ sequence is a reference standard in the NCBI RefSeqGene project. Table 2e. SOX9 SOX9 NM_ * L kb before exon 1 CGTGTCAGAAAT-ATCCAGTGAGAA 0.4 kb 202 * L kb before exon1 CAGTCTAGGGCT-GCTGTTTTATTG kb 382 * L kb before exon 1 AAGGGCCATCAT-TCTGGACAGTGC kb 301 * L kb before exon 1 CCTGCAGGACAA-ATCTGATCACTG kb 373 Ж * SP0425-L kb before exon 1 TTCTGGCAGCTA-31nt spanning oligo -GGTCCTCCCTTA kb start codon (ex 1) 165 ± L AACTGACTGGAA-ACTTCAGTGGCG 0.7 kb 136 ± L reverse GGCGTTGTGCAA-GTGCGGGTACTG 1.1 kb 256 ± L ACGCCATCTTCA-AGGCGCTGCAGG 2.5 kb 337 ± L AGGCAGATGCCT-GCTCGCTCTGTC stop codon (ex 3) ± These s are located within, or close to, a very strong CpG island. A low signal of these s can be due to incomplete sample DNA denaturation, e.g. due to the presence of salt in the sample DNA. Ж This consists of three parts and has two ligation sites. * Deletions and other rearrangements in the upstream region of SOX9 have been described as having a similar effect as SOX9 deletions. This is due to the presence of strong SOX9 enhancer sequences in this region. We have no information on the effects of a copy number change of a single in this region. The NM_ sequence is a reference standard in the NCBI RefSeqGene project. Note: numbering used here may differ from literature! Complete sequences are available at Please notify us of any mistakes: info@mlpa.com. SALSA P185 Intersex mix Page 5 of 7

6 mix P185-C2 Intersex sample pictures Figure 1. Capillary electrophoresis pattern of a sample of approximately 50 ng human male control DNA analysed with mix P185-C2 Intersex (lot C2-1015). Figure 2. Capillary electrophoresis pattern of a sample of approximately 50 ng human female control DNA analysed with mix P185-C2 Intersex (lot C2-1015). SALSA P185 Intersex mix Page 6 of 7

7 Implemented Changes compared to the previous product description versions Version July 2016 (55) - New references added on page 2. - Various minor textual changes. Version November 2015 (55) - Product description adapted to a new product version (version number changed, lot number added, changes in Table 1 and Table 2, new picture included). Version May 2015 (54) - New references added on page 2. - Electropherogram pictures using the old MLPA buffer removed. - Various minor textual changes. Version 07 (48) - Electropherogram pictures using the new MLPA buffer (introduced in December 2012) added. Version 06 (48) - Product description adapted to a new product version (version number changed, lot number added, changes in Table 1 and Table 2, new picture included). - Various minor textual changes. - Remark on RefSeqGene standard added below Table 2. - Reference added on page 2. Version 05 (46) - Product description adapted to a new product version (version number changed, lot number added, small changes in Table 1 and Table 2, new picture included). - Various minor layout changes. - Warning added in table 1, 328 nt (09677-L12238) and 418 nt (09606-L09979). Version 04 (46) - Table 1 layout improved. - Warning added in Table 1 and 2, 265 nt L04181 and 172 nt L s of the s targeting the NR0B1 gene updated according to new version of the NM_reference sequence. - Small changes of lengths in Table 1 and 2 in order to better reflect the true lengths of the amplification products. - Data analysis method has been modified. - Various minor textual changes on page 1. - Various minor layout changes. SALSA P185 Intersex mix Page 7 of 7

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