Simple reversed-phase liquid chromatographic assay for simultaneous quantification of free mycophenolic acid and its glucuronide metabolite in human plasma

A reversed-phase HPLC-UV method, involving simple instrumental setup and mobile phase without ion-pairing reagent, was developed and validated for direct simultaneous quantification of free mycophenolic acid (MPA) and its major metabolite MPA-glucuronide (MPAG) in human plasma. Both free MPA and MPAG were isolated from plasma samples using ultrafiltration prior to analysis. Each chromatographic run was completed within 13 min. The optimized method showed good performance in terms of specificity, linearity (r(2)=0.9999), sensitivity (limit of quantitation (LOQ): 0.005 mg/L for MPA; 1 mg/L for MPAG), and intra- and inter-day precision (R.S.D.<7%). This assay was successfully applied to free MPA and MPAG measurements in clinical samples.     

Quantification of free mycophenolic acid and its glucuronide metabolite in human plasma by liquid-chromatography using mass spectrometric and ultraviolet absorbance detection

The immunosuppressant drug mycophenolic acid (MPA) and its major metabolite, mycophenolic acid glucuronide (MPAG), are highly bound to albumin. An HPLC-tandem-MS (HPLC/MS/MS) and an HPLC-UV assay were developed to measure free (unbound) concentrations of MPA and MPAG, respectively. Ultrafiltrate was prepared from plasma (500 microl) by ultrafiltration at 3000 x g for 20 min (20 degrees C). Both MPA and MPAG were isolated from ultrafiltrate (100 microl) by acidification and C18 solid-phase extraction. Free MPA was measured by electrospray tandem mass spectrometry using selected reactant monitoring (MPA: m/z 338.2--> 206.9) in positive ionisation mode. Chromatography was performed on a PFPP column (50 mm x 2 mm, 5 microm). Total analysis time was 7 min. The assay was linear over the range 1-200 microg/l with a limit of quantification of 1 microg/l. The inter-day accuracy and imprecision of quality controls (7.5, 40, 150 microg/l) were 94-99% and < 7%, respectively. Free MPAG was chromatographed on a C18 Nova-Pak column (150 mm x 3.9 mm, 5 microm) using a binary gradient over 20 min. The eluent was monitored at 254 nm. The assay was linear over the range 1-50 mg/l with the limit of quantification at 2.5 mg/l. The inter-day accuracy and imprecision of quality controls (5, 20, 45 mg/l) was 101-107% and < 8% (n = 4), respectively. For both methods no interfering substances were found in ultrafiltrate from patients not receiving MPA. The methods described have a suitable dynamic linear range to facilitate the investigation of free MPA and MPAG pharmacokinetics in transplant patients. Further, this is the first reported HPLC-UV method to determine free MPAG concentrations.     

Sensitive high-performance liquid chromatography-tandem mass spectrometry method for quantitative analysis of mycophenolic acid and its glucuronide metabolites in human plasma and urine

A method to determine total and free mycophenolic acid (MPA) and its metabolites, the phenolic (MPAG) and acyl (AcMPAG) glucuronides, using HPLC and mass spectrometry was developed. Mean recoveries in plasma and urine samples were >85%, and the lower limits of quantification for MPA, MPAG and AcMPAG were 0.05, 0.05 and 0.01 mg/L, respectively. For plasma, the assay was linear over 0.05-50 mg/L for MPA and MPAG, and from 0.01 to 10mg/L for AcMPAG. A validation study demonstrated good inter- and intra-day precision (CV相似文献   

Simultaneous determination of free mycophenolic acid and its glucuronide in serum of patients under mycophenolate mophetil therapy by ion-pair reversed-phase liquid chromatography with diode array UV detection

An high performance liquid chromatography (HPLC)-UV method for the simultaneous determination of the free forms of mycophenolic acid (MPA) and its phenol glucuronide (MPAG) in human serum samples was developed for the first time. Chromatographic separation was performed on octadecylsilane based stationary phase in combination with a mobile phase of methanol/buffered tetrabutylammonium (TBA) salt mixture. Sample pretreatment consisted of an ultrafiltration step followed by clean-up/enrichment on a C(18) solid-phase extraction (SPE) cartridge. Average recoveries of (99.7 +/- 0.2)% and (64.1 +/- 6.9)% for free MPA and MPAG, respectively, were estimated in the concentration range from 0.5 to 10 microg/ml. The within-day and between-days coefficients of variation were 0.4 and 0.8% for free MPA (0.1 microg/ml spiking level) and 0.8 and 1.6% for free MPAG (5 microg/ml spiking level), respectively. The linear ranges for free MPA and MPAG were 0.06-1 and 0.2-10microg/ml, respectively. Detection limits of 4 and 17 ng/ml for free MPA and MPAG were estimated in spiked serum. The same HPLC method was also capable of a simultaneous determination of the total concentration of MPA and MPAG when coupled to a proper sample pretreatment step. The potential of the method is demonstrated by excretion kinetics measurement in serum of patients receiving MMF therapy.     

Simultaneous determination of mycophenolic acid and its phenolic glucuronide in human plasma using an isocratic high-performance liquid chromatography procedure

Simultaneous determination of mycophenolic acid (MPA) and mycophenolic acid glucuronide (MPAG) in plasma was accomplished by isocratic HPLC with UV detection. After protein precipitation and phase separation with saturated sodium dihydrogenphosphate, chromatographic separation was achieved on a monolithic column "Chromolith Performance RP-18e", with acetonitrile/0.01 M phosphate buffer, pH 3, (25:75, v/v), as the mobile phase; flow rate 3.3 ml/min and measurement at 214 nm. Linearity was verified up to 40 mg/l for MPA and up to 400 mg/l for MPAG. Detection limits based on the analysis of 50 microl plasma were 0.05 and 0.5 mg/l for MPA and MPAG, respectively. Accuracy was 99.6-104% for MPA and 95.6-105% for MPAG and total imprecision (CV) was <7% for both compounds. Analytical recovery was >95% for MPA and MPAG. The method is simple, rapid, accurate and suitable for routine determination of MPA and MPAG in plasma.     

Determination of total mycophenolic acid and its glucuronide metabolite using liquid chromatography with ultraviolet detection and unbound mycophenolic acid using tandem mass spectrometry

Two simple, sensitive and reproducible methods for determination of total mycophenolic acid (MPA) and its glucuronide metabolite (MPAG) as well as unbound MPA (fMPA) was developed by the use of HPLC-UV and LC-MS/MS methods, respectively. For the total MPA/MPAG method, the analytes were extracted using Isolute C(2) solid-phase extraction (SPE) cartridges and analyzed at 254 nm over a Zorbax Rx C(8) column (150 mm x 4.6 mm, 5 microm). The mobile phase was a gradient mixture of methanol and water (containing 0.1% (v/v) phosphoric acid). The total run time was 18 min and the extraction recovery was 77% for MPA and 84% for MPAG. The method was precise and accurate with a lower limit of quantification (LLOQ) of 0.5 mg/l for MPA and 5.0 mg/l for MPAG. For the fMPA method, plasma was subjected to ultrafiltration followed by SPE using C(18) cartridges. Analytical column was the same as the HPLC-UV method and the mobile phase was a gradient composition of methanol:0.05% formic acid with a flow rate of 0.6 ml/min for the first 3 min and 0.7 ml for the last 4 min. The chromatographic method separated MPA from its metabolites MPAG and Acyl-MPAG. Mass transitions in negative ionization mode for MPA and the internal standard, indomethacin were m/z: 319-->190.9 and m/z: 356-->312.2, respectively. The assay was linear in the concentration range of 1-1000 microg/l for fMPA with a LLOQ of 1 microg/l and an accuracy of >95%. The two methods reported have an adequate degree of robustness and dynamic concentration range for the measurement of MPA, MPAG and fMPA for therapeutic drug monitoring purposes or pharmacokinetics investigations.     

Quantification of total and free mycophenolic acid in human plasma by liquid chromatography with fluorescence detection

A simple high-performance liquid chromatographic (HPLC) method was developed for the assay of total and free mycophenolic acid (MPA) in human plasma. Prior to analysis, total mycophenolic acid was extracted by protein precipitation and free drug was isolated from plasma samples using ultrafiltration. The extracts were injected onto a Kromasil C8 column at 30 degrees C with excitation and emission wavelengths set at 342 and 425 nm, respectively. The mobile phase was consisted of acetonitrile-32 mM glycine buffer, pH 9.2 (20:80, v/v), at a flow rate of 1.0 ml/min. The method was found to be linear over the concentration range investigated, 0.05-40 mg/l for total mycophenolic acid (r>0.999) and 5-1000 microg/l (r>0.99) for free drug. The percentage error of the analytical method was below 10.9%. The intra- and inter-day reproducibility was adequate with the coefficients of variation of 8.28% or below. The run time were 4 and 6 min for free and total MPA, respectively. The method thus can be effectively applied to measure mycophenolic acid concentrations in clinical samples.     

Liquid chromatographic method for simultaneous determination of mycophenolic acid and its phenol- and acylglucuronide metabolites in plasma

A simple, sensitive and reproducible HPLC method is presented for the simultaneous determination of mycophenolic acid (MPA) and its metabolites phenolic MPA-glucuronide (MPAG) and acyl glucuronide (AcMPAG) in human plasma. Sample purification requires protein precipitation with 0.1 M phosphoric acid/acetonitrile in the presence of Epilan D as an internal standard (IS). Separation was performed by reversed-phase HPLC, using a Zorbax SB-C18 column, 32% acetonitrile and a 40 mM phosphoric acid buffer at pH 3.0 as mobile phase; column temperature was 50 degrees C, flow rate 1.4 ml/min, and measurement by UV detection was at 215 nm (run time 12 min). The method requires only 50 microl plasma. Detection limits were 0.1 microg/ml for MPA and AcMPAG, and 2.0 microg/ml for MPAG, respectively. Mean absolute recovery of all three analytes was >95%. This analytical method for the determination of MPA and its metabolites is a reliable and convenient procedure that meets the criteria for application in routine clinical drug monitoring and pharmacokinetic studies.     

Simple reversed-phase ion-pair liquid chromatography assay for the simultaneous determination of mycophenolic acid and its glucuronide metabolite in human plasma and urine

A simple and reproducible reversed-phase ion-pair high-performance liquid chromatographic (HPLC) method using isocratic elution with UV absorbance detection is presented for the simultaneous quantitation of mycophenolic acid (MPA) and MPA-glucuronide (MPAG) in human plasma and urine. The sample preparation procedures involved simple protein precipitation for plasma and 10-fold dilution for urine. Each analytical run was completed within 15min, with MPAG and MPA being eluted at 3.8 and 11.4min, respectively. The optimized method showed good performance in terms of specificity, linearity, detection and quantitation limits, precision and accuracy. This assay was demonstrated to be applicable for clinical pharmacokinetic studies.     

Determination of mycophenolic acid and its phenol glucuronide metabolite in human plasma and urine by high-performance liquid chromatography

Simultaneous determination of mycophenolic acid (MPA) and mycophenolate phenol glucuronide (MPAG) in plasma and urine was accomplished by isocratic HPLC with UV detection. Plasma was simply deproteinated with acetonitrile and concentrated, whereas urine was diluted prior to analysis. Linearity was observed from 0.2 to 50 μg/ml for both MPA and MPAG in plasma and from 1 to 50 μg/ml of MPA and 5 to 2000 μg/ml MPAG in urine with extraction recovery from plasma greater than 70%. Detection limits using 0.25 ml plasma were 0.080 and 0.20 μg/ml for MPA and MPAG, respectively. The method is more rapid and simple than previous assays for MPA and MPAG in biological fluids from patients.     

Manual and automated (robotic) high-performance liquid chromatography methods for the determination of mycophenolic acid and its glucuronide conjugate in human plasma

A manual and an automated (Zymark PyTechnology robot) HPLC method for simultaneous determination of plasma mycophenolic acid (MPA) and its glucuronide conjugate (MPAG) are described here. Both methods are reproducible and accurate, and both are equivalent in all respects, including quantification limits (MPA, 0.100 μg/ml; MPAG, 4.00 μg/ml), range (using 0.05–0.5 ml of plasma: MPA, 0.0500–20.0 μg/aliquot; MPAG, 2.00–200 μg/aliquot), precision, and accuracy. MPA and MPAG were stable under the conditions used with both methods. Results from aliquots of paired control samples, analyzed by the manual method over three years at six analytical laboratories, showed excellent agreement in precision and accuracy.     

Rapid and simultaneous determination of mycophenolic acid and its glucuronide conjugate in human plasma by ion-pair reversed-phase high-performance liquid chromatography using isocratic elution

A high-performance liquid chromatographic method has been developed for the simultaneous determination of mycophenolic acid (MPA) and its glucuronide conjugate (MPAG) in human plasma. The method involves protein precipitation with acetonitrile, followed by ion-pair reversed-phase chromatography on C₁₈ column, with a 40 mM tetrabutyl ammonium bromide (TBA)–acetonitrile (65:35, v/v) mobile phase. A 20-μl volume of clear supernatant was injected after centrifugation, and the eluent was monitored at 304 nm. No interference was found either with endogenous substances or with many concurrently used drugs, indicating a good selectivity for the procedure. Calibration curves were linear over a concentration range of 0.5–20.0 μg/ml for MPA and 5–200 μg/ml for MPAG. The accuracy of the method is good, that is, the relative error is below 5%. The intra- and inter-day reproducibility of the analytical method is adequate with relative statistical deviations of 6% or below. The limits of quantification for MPA and MPAG were lower than 0.5 and 5.0 μg/ml, respectively, using 50 μl of plasma. The method was used to determine the pharmacokinetic parameters of MPA and MPAG following oral administration in a patient with renal transplantation.     

Simultaneous determination of cortisol, dexamethasone, methylprednisolone, prednisone, prednisolone, mycophenolic acid and mycophenolic acid glucuronide in human plasma utilizing liquid chromatography-tandem mass spectrometry

Chronic combination immunosuppressive regimens are commonly prescribed to renal transplant recipients. To develop an assay method for pharmacokinetic studies and therapeutic drug monitoring of multiple immunosuppressives, a liquid chromatography-tandem mass spectrometry (LC/MS/MS) approach for the simultaneous analysis of several glucocorticoids, mycophenolic acid (MPA) and mycophenolic acid glucuronide (MPAG) was investigated. The resultant method utilized a gradient reverse phase separation over a Symmetry C18 column using an ammonium acetate-methanol mobile phase at pH 3.5. The analytes were detected by coupling the chromatography system via electrospray to a triple quadrupole mass spectrometer. Multiple-reaction monitoring in the negative mode ion (MH-/product) was employed selecting MPA at 319.1/190.9, MPAG at 495.1/191.0, dexamethasone at 391.0/361.0, hydrocortisone at 361.1/331.1, methylprednisolone at 373.1/343.1, prednisone at 357.1/327.2, and prednisolone at 359.1/329.1. The calibration curve concentrations ranged from 3.60 ng/mL to 50 microg/mL with the lowest limit of quantitation for corticosteroids being 3.60-7.20 ng/mL and 0.656-6.75 microg/mL for MPA and MPAG, respectively. The relative standard deviation for quality control intraday variation and interday variation was between 0.76% and 9.57% for all analytes. This assay offers a versatile, unique method for multi-analyte immunosuppressive determinations during combination immunosuppression.     

Determination of mycophenolic acid glucuronide in microsomal incubations using high performance liquid chromatography-tandem mass spectrometry

A sensitive and specific HPLC-MS/MS method was developed for the analysis of mycophenolic acid glucuronide (MPAG) in incubations with human liver microsomes. Incubation samples were processed by protein precipitation with acetonitrile. MPAG and the internal standard phenolphthalein glucuronide were chromatographed on a C18 Synergi Fusion-RP column (100 mm x 2 mm, 4 microm) using gradient elution with a mixture of 1mM acetic acid in deionized water and 1mM acetic acid in acetonitrile at a flow rate of 0.22 mL/min. The mass spectrometer was operated with negative electrospray ionization and analysis was carried out in the single reaction monitoring (SRM) mode using the mass transitions of m/z 495-->319 and m/z 493-->175 for MPAG and phenolphthalein glucuronide, respectively. The MPAG calibration curve was linear over the concentration range of 1.0-20 microM. The within-day and between-day relative standard deviations ranged from 1.1 to 7.9% and accuracy was within 8%. The simple and reproducible method is suitable for measuring mycophenolic acid glucuronidation in microsomal incubations.     

Inhibitory effects of free ammonia on Anammox bacteria

Anammox bacteria can effectively treat high ammonia and nitrite concentrations under anoxic environments. However, the presence of high ammonia and nitrite concentrations may cause free ammonia and nitrous acid inhibition at high pH and temperature environments. In this study, the inhibitory effect of free ammonia on Anammox bacteria was investigated in a lab-scale upflow fixed-bed reactor with Kaldnes biofilm carriers. Results of continuous operation showed that inhibition was not observed in the Anammox reactor when the free ammonia concentration gradually increased up to 150?mg/L. However, Anammox activity suddenly dropped to 10 % when the free ammonia concentration reached to 190?mg/L. Nevertheless, high influent ammonia and nitrite concentrations up to 1,500 and 500?mg/L, respectively, did not noticeably inhibit the Anammox activity. Gradually decreasing Anammox activity was also supported by fluorescent in situ hybridization (FISH) analysis. FISH and 16S rRNA gene analysis results revealed that main Anammox organisms were phylogenetically related to Candidatus Kuenenia stuttgartiensis, Candidatus Jettenia asiatica and Candidatus Brocadia anammoxidans.     

Mycophenolic acid production in solid-state fermentation using a packed-bed bioreactor

Mycophenolic acid (MPA) was produced from Penicillium brevicompactum by solid-state fermentation (SSF) using pearl barley, and submerged fermentation (SmF) using mannitol. It was found that SSF was superior to SmF in terms of MPA concentration (1219 mg/L vs. 60 mg/L after 144 h fermentation), and the product yields were 6.1 mg/g pearl barley for SSF and 1.2 mg/g mannitol for SmF. The volumetric productivities were 8.5 and 0.42 mg/L h for SSF and SmF, respectively.The optimum solid substrate of SSF for MPA production was pearl barley, producing 5470 mg/kg compared with wheat bran (1601 mg/kg), oat (3717 mg/kg) and rice (2597 mg/kg). The optimum moisture content, incubation time and inoculum concentrations were 70%, 144 h and 6%, respectively. Neither the addition of mannitol or (NH4)₂HPO₄ nor adjustment of media pH within the range of 3–7 significantly enhanced MPA production.MPA production by SSF using a packed-bed bioreactor was performed and an increased maximum production of MPA 6.9 mg/g was achieved at 168 h incubation time. The higher volumetric productivity and concentrations makes SSF an attractive alternative to SmF for MPA production.     

Molecularly imprinted solid-phase extraction for rapid screening of mycophenolic acid in human plasma

A molecularly imprinted solid-phase extraction coupled with high performance liquid chromatography (MISPE-HPLC) method was developed for rapid screening of mycophenolic acid (MPA) in human plasma. MPA imprinted polymers (MPA-MIP) were synthesized and then tested for their performance both in organic and in aqueous solution. MPA was selectively trapped and preconcentrated on the MPA-MIP sorbent using different loading and washing conditions. The good selectivity of MPA-MIP enabled further clean-up of the interfering components in human plasma. For the proposed MISPE-HPLC method, the linearity between responses (peak area) and concentration was found over the range of 1-100microg/ml with a linear regression coefficient (R(2)) of 0.9989. The limit of detection (LOD) and theoretical limit of quantification (LOQ) for MPA in plasma were 0.10 and 0.32microg/ml, respectively. The precisions were 7.3, 3.5 and 4.7% RSD for intra-day assay and 9.2, 4.1 and 5.5% RSD for inter-day reproducibility, respectively, at three concentration levels of MPA in spiked plasma (1, 10 and 100microg/ml). Both recoveries for the extraction (more than 74%) and for the analytical method (more than 87%) were acceptable for screening MPA in plasma samples. Twelve-hour pharmacokinetic profile of MPA for a renal transplant recipient receiving chronic oral dosing of 500mg mycophenolate mofetil (MMF) was investigated. Results indicated that this method could be applied for therapeutic drug monitoring of mycophenolic acid in patient plasma.     

Cell permeability: a factor in the biotin-oleate relationship in Lactobacillus arabinosus. II. Effect of oleic acid and other surfactants on free biotin uptake

Bound biotin-saturated cells were incubated in the presence of biotin and glucose (37 C, pH 7.5) with or without oleic acid, Tween 20, 40, 60, and 80, Aerosol OT, sodium dodecyl sulfate (SDS), cetyltrimethylammonium bromide, Triton X-100, Non-Ion-Ox, and Haemo-Sol. With low concentrations (up to 5 mug/ml) and short reaction times (up to 10 min), oleic acid stimulated free biotin accumulation. Increased concentrations (10 to 50 mug/ml) or reaction times (10 to 30 min) caused progressive reductions in uptake or increased release of previously accumulated vitamin. Combination of Tween 40 (1 mg/ml) with oleic acid (up to 50 mug/ml) detoxified oleic acid and stimulated free biotin uptake. Oleic acid (5 mug/ml or more) reduced cell viability, an effect which was overcome by Tween 40. All other surfactants tested stimulated free biotin accumulation at sublethal concentrations. Aerosol OT and SDS exhibited the same degree of stimulatory activity as detoxified oleic acid; however, at concentrations higher than 200 mum, a rapid decrease in vitamin accumulation was observed which paralleled that caused by increased oleic acid concentrations. The results suggest that oleic acid and other surfactants affect the permeability of cells of Lactobacillus plantarum (formerly called L. arabinosus) in a similar manner.     

Disinfection of bacteria in water systems by using electrolytically generated copper:silver and reduced levels of free chlorine

As an alternative disinfectant to chlorination, electrolytically generated copper:silver (400 and 40 micrograms/L copper and silver, respectively) with and without free chlorine (0.3 mg/L) was evaluated over a period of 4 weeks in indoor and outdoor water systems (100 L tap water with natural body flora and urine). Numbers of total coliform, pseudomonas, and staphylococci were all less than drinking water standards in systems treated with copper:silver and free chlorine and systems treated with free chlorine alone (1.0 mg/L). No significant differences (p less than or equal to 0.05) in bacterial numbers were observed between systems with copper:silver and free chlorine and those with free chlorine alone. Overall, free-chlorine treatments (0.3 or 1.0 mg/L) showed significantly lower heterotrophic plate numbers than those without free chlorine. When challenged with a natural Staphylococcus sp. isolate, water with copper:silver and free chlorine had a 2.4 log10 reduction in bacterial numbers within 2 min, while free chlorine alone or copper:silver alone showed 1.5 and 0.03 log10 reductions, respectively. Addition of copper:silver to water systems may allow the concentration of free chlorine to be reduced while still providing comparable sanitary quality of the water.     

Embryotoxicity of a single dose of medroxyprogesterone acetate (MPA) and maternal serum MPA concentrations in cynomolgus monkey (Macaca fascicularis)

A single dose of MPA (Depo-Provera; Upjohn Co., Kalamazoo, Michigan) was administered intramuscularly to 12 time-mated pregnant cynomolgus monkeys on day 27 (+/- 2) of gestation at 25 mg/kg or at 100 mg/kg. Maternal blood samples were collected immediately prior to MPA injection and then at regular intervals until cesarean section at term (day 152 +/- 3). Infants in both dose groups had external genital abnormalities. Female infants in the low-dose groups had partial or complete labial fusion, prominent median raphe, and clitoral hypertrophy; at high doses (100 mg/kg), the female infants had complete labial fusion and a distinct penile urethra. MPA had an opposite effect on external genitalia of male infants. The penis was short and the scrotal swelling was absent or less conspicuous, and two males had hypospadias. The adrenal glands were significantly smaller (P less than 0.05) in infants of both sexes treated with 100 mg/kg. One of the infants treated with 25 mg/kg of MPA had a muscular ventricular septal defect. Serum concentrations of MPA were determined by radioimmunoassay in eight pregnant monkeys. In the 25 mg/kg group the patterns of MPA profiles in the serum were similar in all four animals. An initial peak occurred at 24-48 hr postinjection (2.7-9.6 ng/ml), followed by a slight decrease at 3 days postinjection (gestational day 30), and then a steady increase to maximum levels of 10-14 ng/ml occurring between gestational days 37 and 50. Serum levels gradually declined to concentrations below 5 ng/ml by midgestation in three of four monkeys. By comparison, both the patterns and magnitude of MPA concentration showed great interanimal variation in the 100 mg/kg group. MPA was present in cord blood at measurable concentrations in infants at both dose groups; the levels ranged from 0.6 to 8.3 ng/ml, corresponding to 40-72% of the maternal concentrations. These results demonstrate that a single injection of MPA during early pregnancy causes selective embryotoxicity in both male and female fetuses. Presence of high levels of MPA in maternal sera during the critical period of genital development can cause specific genital defects; however, the exact mechanism by which MPA causes these paradoxical genital abnormalities is unknown.