Effect of androgen levels on in vitro fertilization cycles

Androgens (dehydroepiandrosterone or testosterone) for women undergoing assisted reproduction

BACKGROUND

Practitioners in the field of assisted reproductive technology (ART) continually seek alternative or adjunct treatments to improve ART outcomes. This Cochrane review investigates the adjunct use of synthetic versions of two naturally produced hormones, dehydroepiandrosterone (DHEA) and testosterone (T), in assisted reproduction. Steroid hormones are proposed to increase conception rates by positively affecting follicular response to gonadotrophin stimulation. This may lead to a greater oocyte yield and, subsequently, an increased chance of pregnancy.

OBJECTIVES

To assess the effectiveness and safety of DHEA and T as pre- or co-treatments in infertile women undergoing assisted reproduction.

SEARCH METHODS

We searched the following electronic databases up to 8 January 2024: the Gynaecology and Fertility Group (CGF) Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, and trial registries for ongoing trials. We also searched citation indexes, Web of Science, PubMed, and OpenGrey. We searched the reference lists of relevant studies and contacted experts in the field for any additional trials. There were no language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing DHEA or T as an adjunct treatment to any other active intervention, placebo, or no treatment in women undergoing assisted reproduction.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted relevant data, and assessed risk of bias. We pooled data from studies using fixed-effect models. We calculated odds ratios (ORs) for each dichotomous outcome. Analyses were stratified by type of treatment. We assessed the certainty of evidence for the main findings using GRADE methods.

MAIN RESULTS

We included 29 RCTs. There were 1599 women in the intervention group and 1469 in the control group. Apart from three trials, the trial participants were women identified as 'poor responders' to standard in vitro fertilisation (IVF) protocols. The included trials compared either T or DHEA treatment with placebo or no treatment. Pre-treatment with DHEA versus placebo/no treatment: DHEA likely results in little to no difference in live birth/ongoing pregnancy rates (OR 1.30, 95% confidence interval (CI) 0.95 to 1.76; I² = 16%, 9 RCTs, N = 1433, moderate certainty evidence). This suggests that in women with a 12% chance of live birth/ongoing pregnancy with placebo or no treatment, the live birth/ongoing pregnancy rate in women using DHEA will be between 12% and 20%. DHEA likely does not decrease miscarriage rates (OR 0.85, 95% CI 0.53 to 1.37; I² = 0%, 10 RCTs, N =1601, moderate certainty evidence). DHEA likely results in little to no difference in clinical pregnancy rates (OR 1.18, 95% CI 0.93 to 1.49; I² = 0%, 13 RCTs, N = 1886, moderate certainty evidence). This suggests that in women with a 17% chance of clinical pregnancy with placebo or no treatment, the clinical pregnancy rate in women using DHEA will be between 16% and 24%. We are very uncertain about the effect of DHEA on multiple pregnancy (OR 3.05, 95% CI 0.47 to 19.66; 7 RCTs, N = 463, very low certainty evidence). Pre-treatment with T versus placebo/no treatment: T likely improves live birth rates (OR 2.53, 95% CI 1.61 to 3.99; I² = 0%, 8 RCTs, N = 716, moderate certainty evidence). This suggests that in women with a 10% chance of live birth with placebo or no treatment, the live birth rate in women using T will be between 15% and 30%. T likely does not decrease miscarriage rates (OR 1.63, 95% CI 0.76 to 3.51; I² = 0%, 9 RCTs, N = 755, moderate certainty evidence). T likely increases clinical pregnancy rates (OR 2.17, 95% CI 1.54 to 3.06; I² = 0%, 13 RCTs, N = 1152, moderate certainty evidence). This suggests that in women with a 12% chance of clinical pregnancy with placebo or no treatment, the clinical pregnancy rate in women using T will be between 17% and 29%. We are very uncertain about the effect of T on multiple pregnancy (OR 2.56, 95% CI 0.59 to 11.20; 5 RCTs, N = 449, very low certainty evidence). We are uncertain about the effect of T versus oestradiol or T versus oestradiol + oral contraceptive pills. The certainty of the evidence was moderate to very low, the main limitations being lack of blinding in the included trials, inadequate reporting of study methods, and low event and sample sizes in the trials. Data on adverse events were sparse; any reported events were minor.

AUTHORS' CONCLUSIONS

Pre-treatment with T likely improves, and pre-treatment with DHEA likely results in little to no difference, in live birth and clinical pregnancy rates in women undergoing IVF who have been identified as poor responders. DHEA and T probably do not decrease miscarriage rates in women under IVF treatment. The effects of DHEA and T on multiple pregnancy are uncertain. Data regarding adverse events were very limited; any reported events were minor. Research is needed to identify the optimal duration of treatment with T. Future studies should include data collection on adverse events and multiple pregnancy.

Effect of basal serum testosterone level on the ovarian response and the cumulative live birth rate in infertile women undergoing in vitro fertilization

PURPOSE

To evaluate the effect of basal serum testosterone levels on the ovarian response and the cumulative live birth rate of infertile women undergoing in vitro fertilization (IVF).

METHODS

It is a retrospective study in a university-affiliated assisted reproduction center in Hong Kong. Infertile women undergoing the first IVF cycle in the center between December 2012 and November 2016 with archived serum samples and available information on cumulative live birth were included for the analysis.

RESULTS

A total of 1122 women were included for analysis. The median basal serum testosterone level was 0.53 (25-75th percentile: 0.40-0.67) nmol/L. Women with higher basal serum testosterone levels required a lower total dosage of gonadotrophin and a shorter duration of stimulation and had more oocytes retrieved. The cumulative live birth rates did not differ among women with serum testosterone levels in the four quartiles. Basal serum testosterone level was not a significant independent predictor of the cumulative live birth after adjusted for the women's age and number of normally fertilized oocytes in a binary logistic regression. The areas under the receiver operative characteristics (ROC) curves in predicting low or high ovarian response and the cumulative live birth were all below 0.6.

CONCLUSION

Higher basal serum testosterone levels were associated with a better ovarian response but had no effect on the cumulative live birth rate of infertile women undergoing IVF.

Basal serum level of Δ4-androstenedione reflects the ovaries' ability to respond to stimulation in IVF cycles: setting up a new reliable index of both ovarian reserve and response

PURPOSE

Adequate androgen levels are necessary for regular follicular growth, progression beyond the pre-antral stage, and prevention of follicular atresia. The main purpose of this study was to investigate whether baseline androgen levels had a predictive value on stimulation outcomes in IVF cycles. The secondary purpose was to compare the possible predictive value of androgens with that of already known markers.

METHODS

The study included 91 infertile patients aged 30-45 years awaiting the first IVF cycle. All women underwent the same stimulation protocol and the same starting dose of recombinant FSH. As stimulation outcomes, the number of follicles recruited, estradiol and progesterone levels on the day of trigger, the total dose of gonadotropins administered, and the number of oocytes collected were recorded. Multiple linear regression and multivariate logistic regression were used to evaluate the significant predictive value of the variables for response to controlled ovarian stimulation (COS). By studying the reliability of different markers, an attempt was made to develop a single index with the highest predictive value.

RESULTS

Pearson's correlation revealed a statistically significant inverse correlation between oocytes collected and age (r =  - 0.333, p < 0.001) and a positive correlation with AMH (anti-müllerian hormone) (r = 0.360, p < 0.001), antral follicle count (AFC) (r = 0.639, p < 0.001), and androstenedione (Δ4-A) (r = 0.359, p < 0.001). No significant correlation was reported with FSH (r =  - 0.133, p = 0.207) and total testosterone (r = 0.180, p = 0.088). In COS good responders, the G-index (= AMH ng/mL*AFC/Δ4-A ng/dL) revealed a significantly higher level (p < 0.001) than AMH, AFC, and Δ4-A alone.

CONCLUSION

Baseline serum Δ4-A, presumably crucial for ensuring a regular follicular growth, is a reliable marker of ovarian response to stimulation. Since the ovarian capacity to respond to gonadotropins does not depend exclusively on the presence of follicles, we suggest a new index, the G-index, able to contemplate both the ovarian reserve and the Δ4-A level.

Effects of letrozole co-treatment on outcomes of gonadotropin-releasing hormone antagonist cycles in POSEIDON groups 3 and 4 expected poor responders

PURPOSE

To evaluate the effects of adjuvant letrozole administration on outcomes of gonadotropin-releasing hormone (GnRH) antagonist cycles with intra-cytoplasmic sperm injection in POSEIDON groups 3 and 4 expected poor responder women.

METHODS

This study was conducted by retrospective analysis of patients with expected poor ovarian response (POSEIDON groups 3 and 4) that underwent GnRH antagonist cycles with intra-cytoplasmic sperm injection between 2010 and 2020. A total of 488 patients with letrozole co-administration and 2564 patients without any adjuvant treatment that underwent GnRH antagonist cycles within the selected period of time were included in the study.

RESULTS

Implantation rates, clinical pregnancy rates and live birth delivery rates were significantly higher in letrozole administered patients in comparison to controls among POSEIDON group 3 women (0.39 ± 0.46 vs 0.27 ± 0.40, p = 0.01; 46.1% vs 33%, p = 0.014; 42.7% vs 31.5%, p = 0.034, respectively). Mean total doses of gonadotropins required per cycle were significantly lower in letrozole administered patients among both POSEIDON groups 3 and 4 women (2864.65 ± 878.47 IU vs 3757.27 ± 1088.89 IU, p < 0.001; 3286.06 ± 770.16 IU vs 3666.48 ± 959.66 IU, p < 0.001, respectively).

CONCLUSION

Adjuvant letrozole co-administration in intra-cytoplasmic sperm injection cycles following GnRH antagonist protocol appears to improve implantation, clinical pregnancy and live birth delivery rates in women with POSEIDON group 3 expected poor ovarian response.

Therapeutic effect of prolonged testosterone pretreatment in women with poor ovarian response: A randomized control trial

PURPOSE

This study compared the therapeutic effects of transdermal testosterone gel (TTG) application at 4 and 6 weeks before controlled ovarian hyperstimulation (COH) in women with poor ovarian response (POR).

METHODS

In this randomized control trial, infertile women with POR who underwent in vitro fertilization (IVF) were recruited and randomly classified into 4 week (n = 42) and 6 week (n = 38) TTG treatment groups and control group (n = 42). The primary outcome was total number of retrieved mature oocytes. The secondary outcomes were the biochemical pregnancy rate, clinical pregnancy rate, and ongoing pregnancy rate.

RESULTS

No significant differences were observed in the number of oocytes retrieved, mature oocytes and embryos between all groups. Human chorionic gonadotropin (hCG) positive, clinical, and ongoing pregnancy rates were significantly higher in the TTG pretreatment groups than in the control group but no differences were observed between the 4- and 6 week groups.

CONCLUSIONS

Applying TTG in infertile women with POR may ameliorate the outcomes of IVF. The extended application of TTG to 6 weeks did not improve the response to ovarian stimulation regarding the number of retrieved oocytes nor pregnancy outcomes compared to the 4 week pretreatment.

Endometriosis and polycystic ovary syndrome are diametric disorders

Evolutionary and comparative approaches can yield novel insights into human adaptation and disease. Endometriosis and polycystic ovary syndrome (PCOS) each affect up to 10% of women and significantly reduce the health, fertility, and quality of life of those affected. PCOS and endometriosis have yet to be considered as related to one another, although both conditions involve alterations to prenatal testosterone levels and atypical functioning of the hypothalamic-pituitary-gonadal (HPG) axis. Here, we propose and evaluate the novel hypothesis that endometriosis and PCOS represent extreme and diametric (opposite) outcomes of variation in HPG axis development and activity, with endometriosis mediated in notable part by low prenatal and postnatal testosterone, while PCOS is mediated by high prenatal testosterone. This diametric disorder hypothesis predicts that, for characteristics shaped by the HPG axis, including hormonal profiles, reproductive physiology, life-history traits, and body morphology, women with PCOS and women with endometriosis will manifest opposite phenotypes. To evaluate these predictions, we review and synthesize existing evidence from developmental biology, endocrinology, physiology, life history, and epidemiology. The hypothesis of diametric phenotypes between endometriosis and PCOS is strongly supported across these diverse fields of research. Furthermore, the contrasts between endometriosis and PCOS in humans parallel differences among nonhuman animals in effects of low versus high prenatal testosterone on female reproductive traits. These findings suggest that PCOS and endometriosis represent maladaptive extremes of both female life-history variation and expression of sexually dimorphic female reproductive traits. The diametric disorder hypothesis for endometriosis and PCOS provides novel, unifying, proximate, and evolutionary explanations for endometriosis risk, synthesizes diverse lines of research concerning the two most common female reproductive disorders, and generates future avenues of research for improving the quality of life and health of women.

Low basal serum testosterone level is detrimental to the embryo implantation in the patients with severe endometriosis

AIM

Androgens have been reported to be associated with female fertility. The mean serum testosterone concentration in the patients with endometriosis was reported to be significantly lower than that without endometriosis. Our study was designed to investigate the influence of basal serum testosterone levels on the clinical outcome of in vitro fertilization (IVF) in the patients with III-IV stage endometriosis.

METHODS

This retrospective cohort study included 407 patients with III-IV stage endometriosis diagnosed by laparoscopic surgery. We studied the association of the basal serum testosterone level and the reproductive outcome of IVF.

RESULTS

The basal serum testosterone concentration was significantly higher in the pregnant group of patients with III-IV stage endometriosis. The further analyses demonstrated that the implantation rate of the basal serum testosterone concentration < 0.305 ng/mL group was significantly lower than the testosterone ≥ 0.305 ng/mL group (24.1% vs. 32.7%, p = 0.007). The clinical pregnancy and live birth rate of the basal serum testosterone < 0.305 ng/mL group were also lower than that of the testosterone ≥ 0.305 ng/mL group. Both initial and total dose of gonadotropins in the testosterone <0.305 ng/mL group are significantly higher than that of the testosterone ≥0.305 ng/mL group.

CONCLUSIONS

Our study demonstrated, for the first time, that the basal serum testosterone <0.305 ng/mL had an adverse impact on pregnancy outcomes of IVF-embryo transfer in the patients with III-IV stage endometriosis. Besides, the basal serum testosterone is also helpful in making individual stimulation protocol for the patients with advanced endometriosis before entering IVF cycles.

Androgenicity and fertility treatment in women with unexplained infertility

OBJECTIVE

To determine whether biochemical or clinical markers of androgenic activity predict live birth rate with ovarian stimulation in the unexplained infertility population.

DESIGN

Secondary analysis of the Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation (AMIGOS) clinical trial.

SETTING

Multicenter university-based clinical practices.

PATIENT(S)

Nine hundred couples with unexplained infertility were included. Women were 18-40 years old with regular menses, a normal uterine cavity, at least one patent fallopian tube, and a male partner with ≥5 million motile sperm. Women were randomized to receive gonadotropin, clomiphene, or letrozole with IUI for four or fewer four treatment cycles. Women were evaluated for biochemical (total testosterone, DHEAS, and free androgen index) and clinical markers of androgenic activity (sebum, acne, and hirsutism). Multivariable logistic regression models adjusting for treatment group, maternal age, and body mass index were performed.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The primary outcome was live birth. Secondary outcomes included conception, clinical pregnancy, and pregnancy loss.

RESULT(S)

When comparing 900 women in the AMIGOS trial based on quartiles of serum TT, women were of younger age, higher body mass index, and higher waist circumference with increasing TT. Increasing quartiles of TT also showed increasing DHEAS and free androgen index values. Serum androgens were not associated with outcomes of live birth, conception, clinical pregnancy, or pregnancy loss. Clinical androgen markers were not associated with pregnancy outcomes.

CONCLUSION(S)

In a randomized cohort of women with unexplained infertility, biochemical and clinical measures of androgens did not predict live birth rate after ovarian stimulation treatment.

CLINICAL TRIAL REGISTRATION NUMBER

NCT 01044862.

What is new in the management of poor ovarian response in IVF?

PURPOSE OF REVIEW

The management and treatment of patients with poor ovarian response is still a controversial issue in IVF. Increasing evidences demonstrate that the number of oocytes retrieved after a controlled ovarian stimulation (COS) greatly influences the clinical outcome in terms of cumulative live birth per started cycle. For this reason, any COS should aim to optimize the number of oocytes according to the ovarian reserve of the patient. The aim of this review is to provide an overview of new strategies proposed to manage poor responders according to the novel POSEIDON classification.

RECENT FINDINGS

Gonadotrophins cannot compensate for the absence of follicles in the ovary, therefore, COS in poor responders may benefit from the exploitation of multiple follicular waves within a single ovarian cycle, for instance, through luteal phase stimulation or double stimulation (follicular plus luteal) in the same ovarian cycle (DuoStim) protocols.

SUMMARY

Many strategies have been proposed to manage poor responder patients, however, a consensus upon which is the most beneficial has not been yet reached. DuoStim is the most promising approach to increase the number of oocytes collected in a single ovarian cycle; however, more embryological and clinical data is required, as well as an analysis of its cost-effectiveness.

Testosterone therapy for women with poor ovarian response undergoing IVF: a meta-analysis of randomized controlled trials

PURPOSE

The aim of the present systematic review and meta-analysis was to summarize evidence on the effectiveness of testosterone supplementation for poor ovarian responders (POR) on IVF outcomes. The primary outcome was live birth rate (LBR); secondary outcomes were clinical pregnancy rate (CPR), miscarriage rate (MR), total and MII oocytes, and total embryos.

METHODS

This meta-analysis of randomized controlled trials (RCTs) evaluates the effects of testosterone administration before/during COS compared with a control group in patients defined as POR. The primary outcome was live birth rate (LBR); secondary outcomes were clinical pregnancy rate (CPR), miscarriage rate (MR), total and MII oocytes, and total embryos. Pooled results were expressed as risk ratio (RR) or mean differences (MD) with 95% confidence interval (95% CI). Sources of heterogeneity were investigated through sensitivity and subgroup analysis. All analyses were performed by using the random-effects model.

RESULTS

Women receiving testosterone showed higher LBR (RR 2.29, 95% CI 1.31-4.01, p = 0.004), CPR (RR 2.32, 95% CI 1.47-3.64, p = 0.0003), total oocytes (MD = 1.28 [95% CI 0.83, 1.73], p < 0.00001), MII oocytes (MD = 0.96 [95% CI 0.28, 1.65], p = 0.006), and total embryos (MD = 1.17 [95% CI 0.67, 1.67], p < 0.00001) in comparison to controls, with no difference in MR (p = ns). Sensitivity and subgroup analysis did not provide statistical changes to the pooled results.

CONCLUSIONS

Testosterone therapy seems promising to improve the success at IVF in POR patients. Further RCTs with rigorous methodology and inclusion criteria are still mandatory.

Advanced Maternal Age in IVF: Still a Challenge? The Present and the Future of Its Treatment

Advanced maternal age (AMA; >35 year) is associated with a decline in both ovarian reserve and oocyte competence. At present, no remedies are available to counteract the aging-related fertility decay, however different therapeutic approaches can be offered to women older than 35 year undergoing IVF. This review summarizes the main current strategies proposed for the treatment of AMA: (i) oocyte cryopreservation to conduct fertility preservation for medical reasons or "social freezing" for non-medical reasons, (ii) personalized controlled ovarian stimulation to maximize the exploitation of the ovarian reserve in each patient, (iii) enhancement of embryo selection via blastocyst-stage preimplantation genetic testing for aneuploidies and frozen single embryo transfer, or (iv) oocyte donation in case of minimal/null residual chance of pregnancy. Future strategies and tools are in the pipeline that might minimize the risks of AMA through non-invasive approaches for embryo selection (e.g., molecular analyses of leftover products of IVF, such as spent culture media). These are yet challenging but potentially ground-breaking perspectives promising a lower clinical workload with a higher cost-effectiveness. We also reviewed emerging experimental therapeutic approaches to attempt at restoring maternal reproductive potential, e.g., spindle-chromosomal complex, pronuclear or mitochondrial transfer, and chromosome therapy. In vitro generation of gametes is also an intriguing challenge for the future. Lastly, since infertility is a social issue, social campaigns, and education among future generations are desirable to promote the awareness of the impact of age and lifestyle habits upon fertility. This should be a duty of the clinical operators in this field.

Predictive value of basal androgen levels on ongoing pregnancy rates during in vitro fertilization cycles

We aimed to evaluate the impact of elevated basal androgen levels on the endometrial receptivity. This study retrospectively enrolled 5278 fresh in vitro fertilization (IVF) cycles and sought to determine whether increased basal androgen levels are associated with adverse outcomes in regard to ongoing pregnancy rates. The results showed that the average age of our sample was 29.31 years. Almost 61.6% of all embryo transfers were with Day 3 embryos and the remaining 38.4% were with Day 5 embryos. The ongoing pregnancy rate was 56.4%. The ongoing pregnancy rates according to the various ordinal serum androgen intervals (<10.00, 10.00-19.99, 20.00-29.99, 30.00-39.99, and ≥40.00 ng/dL) were 60.12, 56.62, 58.64, 55.48, and 50.17%, respectively. The ongoing pregnancy rates were significantly lower in patients with high basal androgen levels (e40 ng/dL) (p < .05). Multivariate regression analysis showed that age, BMI, and endometrial thickness were inversely associated with basal androgen levels (p < .0001 for all). In conclusion, elevated serum basal androgen levels on cycle Day 3 before IVF is associated with reduced ongoing pregnancy rates.

A pharmacogenetic approach to improve low ovarian response: The role of CAG repeats length in the androgen receptor gene

The AR (androgen receptor) polymorphism is associated with POR risk. Furthermore, the use of androgens in POR remains controversial. Our data could clarify the effectiveness of androgen pretreatment. AR genotyping could help us to identify patients at risk for POR and POR patients that will be benefited of androgen pretreatment.

OBJECTIVE

The aim of this project was to investigate if the AR (androgen receptor) polymorphism could be used to identify patients at risk for POR and that will benefit from androgens pretreatment.

STUDY DESIGN

To evaluate the POR risk we performed a cohort study including 231 patients (54 POR and 177 control). Moreover, we included 88 IVF-cycles performed by 44 POR-patients to assess the effect on ovarian response. All patients performed two cycles: a standard ovarian stimulation and a second one with androgen preparation. We compare the results in pair from each.

RESULTS

POR showed the highest frequency of CAG repeats at 24 vs 22 in controls. Only 33% of POR have alleles with a repeat number below 23, compared with 50% of controls (p < 0.05). According to AR polymorphism ovarian response differences were shown. Patients that carried CAG repeats in AR gene between 22 and 24 showed an increased in the number of oocytes (2.61 in cycles without androgens vs 5.11 when they were pretreated with androgens; p < 0.05). For the patients that carried repeats lower than 22 and higher than 24, no differences were reported in the number of oocytes obtained in the cycle with or without androgens (2.94 vs 2.56; p = 0.88). Similar results were obtained for mature oocytes in patients that carry a number of CAG repeats between 22 and 24 (1.86 MII in cycles without androgens vs 4.04 MII when they were pretreated with androgens; p < 0.05). No differences in the number of MII oocytes were found in patients that get out of 22 and 24 repeats between the two cycles (2.31 vs 2.13; p = 0.88).

CONCLUSION

The AR polymorphism is associated with POR risk, patients with repeats greater than 22 show a higher risk. Our data suggest that AR genotype could play a role in natural ovarian aging. Furthermore, the use of androgens in POR remains controversial. Our data suggest that the AR genotype could clarify the effectiveness of the androgen pretreatment. AR genotyping could help us to identify patients at risk of POR and POR patients that could benefit from transdermal testosterone pretreatment.

Low level of basal testosterone: a significant risk factor for poor oocyte yield after ovulation induction

The objective of this study was to further investigate the association of low androgen levels and poor ovarian response or negative pregnancy outcome in in vitro fertilisation treatment using a retrospective cohort study. Chinese women (n=1950) of relatively young age, with normal range of basal FSH and antral follicle count undergoing an in vitro fertilisation cycle were selected and testosterone and dehydroepiandrosterone sulfate levels were measured on Day 3 of the menstrual cycle before subsequent in vitro fertilisation treatment. The main outcome measures of the study were ovarian stimulation parameters and clinical pregnancy. Basal testosterone levels of poor responders and non-pregnant women were significantly lower than normal responders and pregnant women, respectively. Patients with low basal testosterone levels had significantly lower number of mature oocytes, cleavage-stage embryos, frozen embryos, lower fertilisation and pregnancy rates and required higher doses of gonadotrophins. Androgen levels had no correlation with early spontaneous abortion rates. Multivariable logistic analysis revealed that low basal testosterone (<0.88nmolL(-1)) was an independent risk factor for poor oocyte yield (odds ratio: 1.61; 95% confidence interval: 1.01-2.57; P=0.045). In conclusion, a low level of basal testosterone was a significant risk factor for poor oocyte yield after ovarian stimulation and might negatively influence pregnancy chances with in vitro fertilisation. Basal dehydroepiandrosterone sulfate levels were not predictive for poor ovarian response or negative pregnancy outcome in this population.

Basal serum testosterone levels correlate with ovarian reserve and ovarian response in cycling women undergoing in vitro fertilization

This study aimed to investigate the association between basal serum testosterone levels and in vitro fertilization (IVF) parameters in cycling women. A retrospective cohort study was performed at a clinical IVF center, and 495 women with regular menstruation were enrolled. Serum testosterone levels were measured before the start of IVF treatment cycle. We found that basal serum testosterone levels were negatively associated with female age and FSH/LH ratios. In contrast, we found a positive correlation between serum testosterone levels and the number of oocytes and available embryos. However, there was no significant association between testosterone levels and pregnancy outcome. Our results suggest that basal serum testosterone levels were significantly related to certain classic indicators of ovarian reserve, such as age and FSH/LH ratios. Increased testosterone levels improved ovarian response in cycling women, but they fail to predict pregnancy and miscarriage rate.

Androgens (dehydroepiandrosterone or testosterone) for women undergoing assisted reproduction

BACKGROUND

Infertility is a condition affecting 10% to 15% of couples of reproductive age. It is generally defined as "the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse". The treatment of infertility may involve manipulation of gametes or of the embryos themselves. These techniques are together known as assisted reproductive technology (ART). Practitioners are constantly seeking alternative or adjunct treatments, or both, in the hope that they may improve the outcome of assisted reproductive techniques. This Cochrane review focusses on the adjunct use of synthetic versions of two naturally-produced hormones, dehydroepiandrosterone (DHEA) and testosterone (T), in assisted reproduction.DHEA and its derivative testosterone are steroid hormones proposed to increase conception rates by positively affecting follicular response to gonadotrophin stimulation, leading to greater oocyte yields and, in turn, increased chance of pregnancy.

OBJECTIVES

To assess the effectiveness and safety of DHEA and testosterone as pre- or co-treatments in subfertile women undergoing assisted reproduction.

SEARCH METHODS

We searched the following electronic databases, trial registers and websites up to 12 March 2015: the Cochrane Central Register of Controlled Trials (CENTRAL), the Menstrual Disorders and Subfertility Group (MDSG) Specialised Register, MEDLINE, EMBASE, PsycINFO, CINAHL, electronic trial registers for ongoing and registered trials, citation indexes, conference abstracts in the Web of Science, PubMed and OpenSIGLE. We also carried out handsearches. There were no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing DHEA or testosterone as an adjunct treatment to any other active intervention, placebo, or no treatment in women undergoing assisted reproduction.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted relevant data and assessed them for risk of bias. We pooled studies using fixed-effect models. We calculated odds ratios (ORs) for each dichotomous outcome. Analyses were stratified by type of treatment. There were no data for the intended groupings by dose, mode of delivery or after one/more than one cycle.We assessed the overall quality of the evidence for the main findings using the GRADE working group methods.

MAIN RESULTS

We included 17 RCTs with a total of 1496 participants. Apart from two trials, the trial participants were women identified as 'poor responders' to standard IVF protocols. The included trials compared either testosterone or DHEA treatment with placebo or no treatment.When DHEA was compared with placebo or no treatment, pre-treatment with DHEA was associated with higher rates of live birth or ongoing pregnancy (OR 1.88, 95% CI 1.30 to 2.71; eight RCTs, N = 878, I² statistic = 27%, moderate quality evidence). This suggests that in women with a 12% chance of live birth/ongoing pregnancy with placebo or no treatment, the live birth/ongoing pregnancy rate in women using DHEA will be between 15% and 26%. However, in a sensitivity analysis removing trials at high risk of performance bias, the effect size was reduced and no longer reached significance (OR 1.50, 95% CI 0.88 to 2.56; five RCTs, N = 306, I² statistic = 43%). There was no evidence of a difference in miscarriage rates (OR 0.58, 95% CI 0.29 to 1.17; eight RCTs, N = 950, I² statistic = 0%, moderate quality evidence). Multiple pregnancy data were available for five trials, with one multiple pregnancy in the DHEA group of one trial (OR 3.23, 95% CI 0.13 to 81.01; five RCTs, N = 267, very low quality evidence).When testosterone was compared with placebo or no treatment we found that pre-treatment with testosterone was associated with higher live birth rates (OR 2.60, 95% CI 1.30 to 5.20; four RCTs, N = 345, I² statistic = 0%, moderate evidence). This suggests that in women with an 8% chance of live birth with placebo or no treatment, the live birth rate in women using testosterone will be between 10% and 32%. On removal of studies at high risk of performance bias in a sensitivity analysis, the remaining study showed no evidence of a difference between the groups (OR 2.00, 95% CI 0.17 to 23.49; one RCT, N = 53). There was no evidence of a difference in miscarriage rates (OR 2.04, 95% CI 0.58 to 7.13; four RCTs, N = 345, I² = 0%, low quality evidence). Multiple pregnancy data were available for three trials, with four events in the testosterone group and one in the placebo/no treatment group (OR 3.09, 95% CI 0.48 to 19.98; three RCTs, N = 292, very low quality evidence).One study compared testosterone with estradiol and reported no evidence of a difference in live birth rates (OR 2.06, 95% CI 0.43 to 9.87; one RCT, N = 46, very low quality evidence) or miscarriage rates (OR 0.70, 95% CI 0.11 to 4.64; one RCT, N = 46, very low quality evidence).The quality of the evidence was moderate, the main limitations being lack of blinding in the included trials, inadequate reporting of study methods, and low event and sample sizes in some trials.

AUTHORS' CONCLUSIONS

In women identified as poor responders undergoing ART, pre-treatment with DHEA or testosterone may be associated with improved live birth rates. The overall quality of the evidence is moderate. There is insufficient evidence to draw any conclusions about the safety of either androgen. Definitive conclusions regarding the clinical role of either androgen awaits evidence from further well-designed studies.

Ovarian Features after 2 Weeks, 3 Weeks and 4 Weeks Transdermal Testosterone Gel Treatment and Their Associated Effect on IVF Outcomes in Poor Responders

This study was performed to investigate the effect of of transdermal testosterone gel (TTG) on controlled ovarian stimulation (COS) and IVF outcomes and ovarian morphology according to pretreatment duration in poor responders. A total of 120 women were recruited for this pilot study. They were randomized into control, 2 weeks, 3 weeks or 4 weeks TTG treatment groups. For three TTG treatment groups, 12.5 mg TTG was applied daily for 2 weeks, 3 weeks or 4 weeks in preceding period of study stimulation cycle. After 3 weeks of TTG pretreatment, significant increase of antral follicle count (AFC) and significant decreases of mean follicular diameter (MFD) and resistance index (RI) value of ovarian stromal artery were observed (p=0.026, p<0.001, p<0.01, respectively). The total dose of rhFSH administered for COS significantly decreased after 3 and 4 weeks TTG treatment both compared with control group (p<0.001, p<0.001). The numbers of oocytes retrieved and mature oocytes were significanty higher in 3 and 4 weeks TTG treatment groups than control group (p<0.001, p<0.001 in the number of oocytes retrieved; p<0.001, p<0.001 in the number of mature oocytes). The clinical pregnancy rate and live birth rate were increased only in 4 weeks TTG treatment group compared with control group (p=0.030 and p=0.042, respectively). These data demonstrated that TTG pretreatment for 3 to 4 weeks increases AFC and ovarian stromal blood flow, thereby potentially improving the ovarian response to COS and IVF outcome in poor responders undergoing IVF/ICSI.

Poor responders in IVF: an update in therapy

INTRODUCTION

Assisted reproduction techniques are the frequent treatment of infertility. Despite the advances in science and technology, the management of poor responder patients is still considered as one of the most urgent problems. The lack of unified definition makes the management of the poor responder patients very difficult. The aim of this review is to examine and compare the different studies done about the problem of poor responder patients.

METHODS

On an online research of MEDLINE/PUBMED, we found several studies on pharmacological treatment for poor responders' patients.

RESULTS

Our review shows that in the years numerous therapies for the management of these patients who do not respond to ovarian stimulation have been evaluated and studied, but the main problem is the large and still not well-defined meaning of poor responder women.

CONCLUSION

The management of the poor responder patients is very difficult. Currently, there is no any standard treatment for poor responder patients. Considering the importance of the problem, it is important to identify a diagnostic and therapeutic target. Our review shows that there are many studies with different therapeutic approaches which deserve further in-depth study to standardize diagnostic and therapeutic target.

Ovarian and adrenal androgens may be useful markers to predict oocyte competence and embryo development in older women

The aim of this retrospective analysis was to evaluate the association between serum levels of various hormones and in vitro fertilization (IVF) parameters in poor responder patients. Serum levels of anti-Müllerian hormone (AMH), dehydroepiandrosterone sulfate (DHEAS), androstenedione and testosterone were measured before the start of IVF treatment cycle. We found that serum AMH and DHEAS levels were positively correlated with the number of mature oocytes, fertilized oocytes and developed embryos, both in pregnant and in non-pregnant patients. In contrast, we found a positive correlation between serum androstenedione levels and IVF parameters in pregnant, but not in non-pregnant patients. In this latter group, androstenedione levels were positively associated with the number of mature oocytes and were negatively correlated with the number of fertilized oocytes. No correlation was observed with developed embryos. Finally, we reported a negative correlation between serum levels of testosterone and IVF parameters in pregnant women whereas no correlation was observed in non-pregnant patients. Our results suggest that serum AMH and DHEAS could be predictive for oocyte retrieval and embryo development. Moreover, the positive correlation between serum androstenedione levels and IVF parameters in pregnant patients, together with the lack of a consistent correlation in non-pregnant women seem to identify androstenedione as a more predictive marker for pregnancy outcome than testosterone. In addition, in our analysis testosterone shows a negative correlation with IVF parameters.

Management of poor responders in IVF: is there anything new?

Despite the fact that in the last two decades an enormous number of papers on the topic of poor ovarian response have been published in the literature, so far it has been impossible to identify any efficient treatment to improve the ovarian response and the clinical outcome of this group of patients. The incidence of poor ovarian responders among infertile women has been estimated at 9–24% but according to recent reviews, it seems to have slightly increased. The limitation in quantifying the incidence of these patients among the infertile population is due to the difficulty of a clear definition in literature. A recent paper by the Bologna ESHRE working group on poor ovarian response has been the first real attempt to find a common definition. Current literature proposes new risk factors which could be the cause of a reduction in ovarian reserve, which also includes genetic factors. This represents the first necessary step towards finding applicable solutions for these patients. To date, there is a substantial lack of literature that identifies an ideal protocol for these patients. The use of the “Bologna criteria” and the introduction of long acting gonadotropin in clinical practice have given rise to new promising stimulation protocols for this group of patients.

Basal serum testosterone levels correlate with ovarian response but do not predict pregnancy outcome in non-PCOS women undergoing IVF

PURPOSE

To evaluate basal testosterone (T) levels in women undergoing in vitro fertilization (IVF) cycles and examine the association between basal T levels and ovarian response or IVF pregnancy outcome.

METHODS

We retrospectively analyzed 1413 infertile Chinese women undergoing their first IVF treatment at our institution's reproductive center from March 2011 to May 2013. The basal testosterone (T) levels in women undergoing in vitro fertilization (IVF) and the relationship between basal T levels and ovarian response or IVF pregnancy outcome were determined. These patients did not have polycystic ovary syndrome (PCOS) or endometriosis, and were treated with a long luteal down-regulation protocol. Subjects were divided into 2 groups according to basal testosterone (T) levels: Group 1, basal T values <20 ng/dl (n = 473), and Group 2, basal T values >20 ng/dl (n = 940). We evaluated the association of basal T levels with ovarian response and IVF outcome in the two groups.

RESULTS

In this study, BMI, basal follicle-stimulating hormone (FSH) levels, basal luteinizing hormone (LH) levels, antral follicle count (AFC), days of stimulation, total gonadotrophin dose, basal FSH/LH ratio, and the number of follicles >14 mm were significantly different (P < 0.05) between the two groups. Basal T level positively correlated with ovarian reserve function, number of follicles >14 mm on human chorionic gonadotrophin (HCG) day, and total gonadotropin dose. However, basal T levels play no role in predicting IVF pregnancy outcome.

CONCLUSION

Basal T level can be used as a good predictor for ovarian response and the number of large follicles on HCG day. Additionally, we may use basal T level as a marker to predict FSH dosage. In general women, lower level of T might relate with potential poor ovarian response. However, based on our data, basal T levels do not predict pregnancy outcome.

Effect of pretreatment with transdermal testosterone on poor ovarian responders undergoing IVF/ICSI: A meta-analysis

In order to identify and describe the effectiveness of transdermal testosterone pretreatment on poor ovarian responders, MEDLINE, EMBASE, the Cochrane library and the Chinese biomedical database were searched for randomized controlled trials (RCTs). Three RCTs, which compared the outcomes of female pretreatment with transdermal testosterone prior to in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) with those of control groups, were included in the present review. The three RCTs enrolled a total of 221 randomized subjects. The meta-analysis revealed that females who received transdermal testosterone treatment prior to their IVF/ICSI cycle had a two-fold increase in live birth rate [risk ratio (RR)=2.01, 95% confidence interval (CI) 1.03–3.91], clinical pregnancy rate (RR=2.09, 95% CI 1.14–3.81) and a significantly more oocyte retrieved [mean difference (MD)=1.36, 95% CI 0.82–1.90]. The current findings provide evidence that pretreatment with transdermal testosterone may improve the clinical outcomes for poor ovarian responders undergoing IVF/ICSI. However, the results should be interpreted with caution due to the small sample size of the studies used and the heterogeneities. Further good quality RCTs would be needed to reach further conclusions.

Low testosterone levels in women with diminished ovarian reserve impair embryo implantation rate: a retrospective case-control study

OBJECTIVE

To investigate the association of basal testosterone (T) levels with the outcome of in vitro fertilization (IVF) in women with diminished ovarian reserve (DOR).

METHODS

Complete clinical data on the first 223 IVF cycles in women with DOR were retrospectively analyzed. The associations of basal follicle stimulating hormone, luteinizing hormone, estradiol, and T levels with ovarian response and IVF outcome were studied.

RESULTS

Basal T levels were significantly different between pregnant and non-pregnant women. However, basal T levels showed no correlation with controlled ovarian hyperstimulation parameters after adjusting for age. The association of basal T levels with pregnancy rate was significant after adjusting for other impact factors. Using receiver operating characteristic (ROC) analysis, the basal T level of 1.115 nmol/L for predicting pregnancy outcome had a sensitivity of 82.80 % and specificity of 58.09 %. The women were divided into two groups based on this value; although the clinical characteristics and ovarian stimulation parameters were similar, the clinical pregnancy (16.18 % (11/68) vs. 40.15 % (53/132), respectively, p = 0.000) and implantation rates (10.07 % (15/149) vs. 22.41 % (65/290), respectively, p = 0.002) were significantly different in the low and high T level groups.

CONCLUSION

In women with DOR, the basal T level presented a positive association with pregnancy outcome in IVF. The poor reproductive outcome observed in women with lower basal T levels may be due to the decreased implantation rate.

Androgens modulate the morphological characteristics of human endometrial stromal cells decidualized in vitro

The activated androgen receptor (AR) in decidualizing human endometrial stromal cells (HESCs) regulates genes involved in cytoskeletal organization, cell motility, and cell cycle progression. Androgens also enhance the secretion of prolactin, a widely used marker of decidualized HESCs. The purpose of the present study was to investigate the direct effects of androgens on the ultrastructural changes associated with decidual transformation of HESCs. Primary HESC cultures were established and propagated, and confluent cultures were decidualized for 6 days with 8-bromoadenosine 3',5'-cyclic monophosphate (8-br-cAMP) and progesterone (P4) in the presence or absence of dihydrotestosterone (DHT). Phase-contrast image analysis demonstrated that DHT increases the shape index of decidualizing cells, which was reversed upon cotreatment with the AR antagonist flutamide. Electron microscopy demonstrated that DHT enhances many of the ultrastructural changes induced by 8-br-cAMP and P4 in HESCs. Decidualizing cells are characterized by an abundant cytoplasm, multiple cell surface projections and, unlike undifferentiated HESCs, form 2 or more cell layers. The DHT further stimulated cytoplasmic expansion, lipid droplet formation, the production of an abundant extracellular matrix, and gap junction formation in decidualized HESCs. The present study demonstrates that androgen signaling has an impact on the morphological and ultrastructural changes associated with the decidual process. Our findings show that androgens promote the development and expansion of cytoplasmic organelles and gap junctions in decidualizing HESCs. These results suggest that androgens in early pregnancy play an important role in promoting the cellular transformation associated with decidualization.

Is there a role for DHEA supplementation in women with diminished ovarian reserve?

PURPOSE

Poor ovarian reserve and poor ovarian response presents a challenge to IVF centers. Dehydroepiandrosterone (DHEA) supplementation is increasingly being used by many IVF centers around the world in poor responders despite the lack of convincing data. We therefore examined the rationale for the use of DHEA in poor responders, address the relevant studies, present new data, and address its potential mechanisms of action.

METHODS

All published articles on the role of DHEA in infertile women from 1990 to April 2013 were reviewed.

RESULTS

Several studies have suggested an improvement in pregnancy rates with the use of DHEA. Potential mechanisms include improved follicular steroidogenesis, increased IGF-1, acting as a pre-hormone for follicular testosterone, reducing aneuploidy, and increasing AMH and antral follicle count. While the role of DHEA is intriguing, evidence-based recommendations are lacking.

CONCLUSIONS

While nearly 25 % of IVF programs use DHEA currently, large randomized prospective trials are sorely needed. Until (and if) such trials are conducted, DHEA may be of benefit in suitable, well informed, and consented women with diminished ovarian reserve.

Diminished Ovarian Reserve, Causes, Assessment and Management

Diminished ovarian reserve predicts diminished ovarian response to stimulation but does not predict cycle fecundity. It has been recently defined by ESHRE, the Bologna's criteria, according to which at least two of the following three features should be present: (1) Age >40 years/any other risk factor for DOR, (2) abnormal ovarian reserve test, i.e. antral follicle count, AMH, (3) poor ovarian response in a previous stimulated cycle, i.e. less than three follicles after standard gonadotropin stimulation. Poor response to maximal stimulation on two previous occasions also defines DOR.

The treatment options are limited. Avoiding the GnRH agonist long protocol and stimulation with microdose flare or antagonist protocol yields better results. Adjuvant therapy with LH, DHEAS and growth hormone shows some benefit in improving the oocyte yield. It is advisable to perform ICSI for all obtained oocytes and some advocate assisted hatching. Pregnancy rates are, however, poor and often these patients require ovum donation. Developing tests that will diagnose DOR in a low-risk population will allow women to plan their reproductive careers early.

How to cite this article

Kaur M, Arora M. Diminished Ovarian Reserve, Causes, Assessment and Management. Int J Infertility Fetal Med 2013;4(2):45-55.

Starting and resulting testosterone levels after androgen supplementation determine at all ages in vitro fertilization (IVF) pregnancy rates in women with diminished ovarian reserve (DOR)

PURPOSE

To investigate whether androgen conversion rates after supplementation with dehydroepiandrosterone (DHEA) differ, and whether differences between patients with diminished ovarian reserve (DOR) are predictive of pregnancy chances in association with in vitro fertilization (IVF).

METHODS

In a prospective cohort study we investigated 213 women with DOR, stratified for age (≤ 38 or >38 years) and ovarian FMR1 genotypes/sub-genotypes. All women were for at least 6 weeks supplemented with 75 mg of DHEA daily prior to IVF, between initial presentation and start of 1st IVF cycles. Levels of DHEA, DHEA-sulfate (DHEAS), total T (TT) and free T (FT) at baseline ((BL)) and IVF cycle start ((CS)) were then compared between conception and non-conception cycles.

RESULTS

Mean age for the study population was 41.5 ± 4.4 years. Forty-seven IVF cycles (22.1 %) resulted in clinical pregnancy. Benefits of DHEA on pregnancy rates were statistically associated with efficiency of androgen conversion from DHEA to T and amplitude of T gain. Younger women converted significantly more efficiently than older females, and selected FMR1 genotypes/sub-genotypes converted better than others. FSH/androgen and AMH/androgen ratios represent promising new predictors of IVF pregnancy chances in women with DOR.

CONCLUSIONS

DOR at all ages appears to represent an androgen-deficient state, benefitting from androgen supplementation. Efficacy of androgen supplementation with DHEA, however, varies depending on female age and FMR1 genotype/sub-genotype. Further clarification of FMR1 effects should lead to better individualization of androgen supplementation, whether via DHEA or other androgenic compounds.

Assessment of theca cell function: a prerequisite to androgen or luteinizing hormone supplementation in poor responders

Poor responders are a heterogeneous population, with some patients displaying a diminished ovarian reserve and others a poor ovarian reserve with preserved granulosa cell function. Androgen and LH/hCG supplementation has been advocated for poor responders, mainly those >40 years old. Although androgens synergistically act with FSH to support folliculogenesis, and ovarian androgen secretion declines with age, there is still no evidence that androgen therapy is actually effective to improve ovarian FSH sensitivity. The main reason seems to be that theca cell function has not been appropriately assessed in patients at risk of poor response. The definition of theca insufficiency is hampered by methodologic shortcomings in routine bioassays. Provocative tests for theca cells might help to identify those patients who could benefit from androgen supplementation. The lack of data regarding theca cells in these patients might contribute to explaining the absence of evidence for a positive effect of androgen therapy.

The role of androgens and the androgen receptor in cycling endometrium

Androgens and the androgen receptor (AR) are not only required for male reproductive function, they are also essential for female reproductive physiology. Widely expressed in female reproductive tissues, AR levels fluctuate in a regulated manner in the cycling endometrium. Female androgen production depends on the adrenal glands and expression of key enzymes in the endometrium that facilitate local androgen biosynthesis and conversion. Moreover, levels of circulating androgens, in women of reproductive age, fluctuate in a cycle-dependent manner and a mid-cycle peak is associated with conception. AR and androgen signalling have a decisive role in the differentiation of human endometrial stromal cells into decidual cells. Compelling evidence for androgen signalling in the regulation of endometrial function pertaining to implantation and pregnancy is provided by epidemiological studies demonstrating a strong association between polycystic ovary syndrome, premature ovarian failure or advanced maternal age and adverse pregnancy outcome. Thus, androgen signalling is an essential component of normal endometrial physiology and its perturbation is associated with reproductive failure.

Human chorionic gonadotrophin stimulation test as a predictor of ovarian response and pregnancy in IVF cycles stimulated with GnRH agonist gonadotrophin treatment: a pilot study

BACKGROUND

Recent evidence supports a specific and broad role of androgen produced by theca cells in reproductive physiology. This pilot study evaluated the usefulness of hCG theca stimulation test in predicting ovarian response and pregnancy.

METHODS

Prospective cohort study including 80 infertile women treated with IVF/ICSI. On Day 3 of the menstrual cycle preceding, the first IVF/ICSI cycle a blood sample was drawn to evaluate baseline FSH, estradiol (E(2)), 17-hydroxy-progesterone, androstenedione and testosterone levels. All women then received 250 µg recombinant hCG s.c. and underwent a second blood sampling 24 h after hCG injection to measurement steroid serum levels.

RESULTS

Percentage increment of E(2) but not its precursors was significantly higher in normo-responders and pregnancy cycles than in poor responders and non-pregnancy cycles (P = 0.03 and P = 0.02, respectively) diagnostic accuracy being 67 and 75%, respectively. The percentage increase in E(2) thus still fails in as many as 33 and 25% of patients in predicting ovarian response and pregnancy, respectively. In addition, E(2) concentrations are poorly reproducible and a wide range of variation in all serum steroids investigated-including E(2)-after hCG injection was observed.

CONCLUSIONS

The predictive power of the hCG test is based on E(2) but not androgen response to hCG injection. This test cannot be recommended in routine clinical practice because it is too laborious for screening purposes, shows great variability in the response obtained and its overall accuracy is not better than that reported for other available markers of ovarian reserve. The use of the currently available markers, antral follicle count and anti-Müllerian hormone, is therefore recommended.

The use of androgens or androgen-modulating agents in poor responders undergoing in vitro fertilization: a systematic review and meta-analysis

BACKGROUND

The aim of this meta-analysis was to evaluate the role of androgens or androgen-modulating agents on the probability of pregnancy achievement in poor responders undergoing IVF.

METHODS

Medline, EMBASE, CENTRAL, Scopus and Web of Science databases were searched for the identification of randomized controlled trials evaluating the administration of testosterone, dehydroepiandrosterone (DHEA), aromatase inhibitors, recombinant luteinizing hormone (rLH) and recombinant human chorionic gonadotrophin (rhCG) before or during ovarian stimulation of poor responders.

RESULTS

In two trials involving 163 patients, pretreatment with transdermal testosterone was associated with an increase in clinical pregnancy [risk difference (RD): +15%, 95% confidence interval (CI): +3 to +26%] and live birth rates (RD: +11%, 95% CI: +0.3 to +22%) in poor responders undergoing ovarian stimulation for IVF. No significant differences in clinical pregnancy and live birth rates were observed between patients who received DHEA and those who did not. Similarly, (i) the use of aromatase inhibitors, (ii) addition of rLH and (iii) addition of rhCG in poor responders stimulated with rFSH for IVF were not associated with increased clinical pregnancy rates. In the only eligible study that provided data, live birth rate was increased in patients who received rLH when compared with those who did not (RD: +19%, 95% CI:+1 to +36%).

CONCLUSIONS

Based on the limited available evidence, transdermal testosterone pretreatment seems to increase clinical pregnancy and live birth rates in poor responders undergoing ovarian stimulation for IVF. There is insufficient data to support a beneficial role of rLH, hCG, DHEA or letrozole administration in the probability of pregnancy in poor responders undergoing ovarian stimulation for IVF.

The role of androgens in follicle maturation and ovulation induction: friend or foe of infertility treatment?

BACKGROUND

Effects of androgens on follicle maturation have been controversial for some time. Here, we review the potential of their applications in improving human ovulation induction, based on human and animal data, reported in the literature.

METHODS

We reviewed the published literature for the years 2005-2011, using relevant key words, in PubMed, Medline and Cochrane reviews, and then performed secondary reviews of referenced articles, which previously had not been known or preceded the searched time period. A total of 217 publications were reviewed.

RESULTS

Contrary to widely held opinion, recent data, mostly developed in the mouse, convincingly demonstrate essential contribution of androgens to normal follicle maturation and, therefore, female fertility. Androgens appear most engaged at preantral and antral stages, primarily affect granulosa cells, and exert effects via androgen receptors (AR) through transcriptional regulation but also in non-genomic ways, with ligand-activated AR modulating follicle stimulating hormone (FSH) activity in granulosa cells. While some androgens, like testosterone (T) and dehydroepiandrosterone (DHEA), appear effective in improving functional ovarian reserve (FOR) in women with diminished ovarian reserve (DOR), others may even exert opposite effects. Such differences in androgens may, at least partially, reflect different levels of agonism to AR.

DISCUSSION

Selective androgens appear capable of improving early stages of folliculogenesis. They, therefore, may represent forerunners of a completely new class of ovulation-inducing medications, which, in contrast to gonadotropins, affect follicle maturation at much earlier stages.

The value of human chorionic gonadotropin stimulation test in predicting ovarian response during in-vitro fertilization

PURPOSE

To assess the predictive value of human Chorionic Gonadotropin (hCG) theca-stimulation test for ovarian reserve in women undergoing in-vitro fertilization (IVF) treatments.

METHODS

39 women were included in the study. All participants received a single hCG 10000 IU injection on cycle day 2-3. Serum levels of estradiol, testosterone, androstenedione and 17-OH progesterone were measured prior to the injection and on days 1, 3 and 7 following the injection. hCG-induced hormone levels were compared with ovarian response during the subsequent IVF cycle.

RESULTS

There were 11 good responders (>10 oocytes) and 22 low responders (<3 oocytes). Before hCG stimulation serum E2 levels were higher in low responders compared to good responders (370.3 ± 443 vs. 138.3 ± 54 pmol/ml). Following hCG stimulation, day 3 androstendione levels showed an increase in good responders compared to low responders. The ratio between day 3 androstendione and day 0 estradiol was significantly different between the two groups (p = 0.03). ROC analysis of this test revealed area = 0.837 (good prediction), which was much better than day 3 FSH (area = 0.635, poor prediction).

CONCLUSIONS

These preliminary results demonstrate the potential use of the hCG theca stimulation test in differentiating between good and poor responders. Larger series are needed for further verification of the test in routine clinical application.

Dehydroepiandrosterone (DHEA) supplementation in diminished ovarian reserve (DOR)

BACKGROUND

With infertility populations in the developed world rapidly aging, treatment of diminished ovarian reserve (DOR) assumes increasing clinical importance. Dehydroepiandrosterone (DHEA) has been reported to improve pregnancy chances with DOR, and is now utilized by approximately one third of all IVF centers world-wide. Increasing DHEA utilization and publication of a first prospectively randomized trial now warrants a systematic review.

METHODS

PubMed, Cochrane and Ovid Medline were searched between 1995 and 2010 under the following strategy: [<dehydroepiandrosterone or DHEA or androgens or testosterone > and <ovarian reserve or diminished ovarian reserve or ovarian function >]. Bibliographies of relevant publications were further explored for additional relevant citations. Since only one randomized study has been published, publications, independent of evidence levels and quality assessment, were reviewed.

RESULTS

Current best available evidence suggests that DHEA improves ovarian function, increases pregnancy chances and, by reducing aneuploidy, lowers miscarriage rates. DHEA over time also appears to objectively improve ovarian reserve. Recent animal data support androgens in promoting preantral follicle growth and reduction in follicle atresia.

DISCUSSION

Improvement of oocyte/embryo quality with DHEA supplementation potentially suggests a new concept of ovarian aging, where ovarian environments, but not oocytes themselves, age. DHEA may, thus, represent a first agent beneficially affecting aging ovarian environments. Others can be expected to follow.

Association of basal serum testosterone levels with ovarian response and in vitro fertilization outcome

BACKGROUND

To evaluate basal testosterone (T) levels during follicular phase of the menstrual cycle as a predictor for ovarian response and in vitro fertilization (IVF) outcome.

METHOD

We analyzed data retrospectively from hospital-based IVF center including one thousand two hundred and sixty Chinese Han women under their first IVF cycle reached the ovum pick-up stage, without polycystic ovary syndrome (PCOS) or endometriosis undergoing long IVF protocol. Patients were divided into 2 groups. Group 1: patients with diminished ovarian reserve (basal FSH >10 IU/L) (n = 187); Group 2: patients with normal ovarian reserve (basal FSH < = 10 IU/L) (n = 1073). We studied the association of basal T levels with ovarian response and IVF outcome in the two groups. Long luteal down-regulation protocol was used in all patients, that is, the gonadotropin releasing hormone agonist was administered in the midluteal phase of the previous cycle and use of recombinant FSH was started when satisfactory pituitary desensitization was achieved.

RESULTS

Basal T levels were markly different between pregnant and non-pregnant women in Group 1; whereas not in Group 2. A testosterone level of 47.85 ng/dl was shown to predict pregnancy outcome with a sensitivity of 52.8% and specificity of 65.3%; and the basal T was correlated with the numbers of large follicles (> 14 mm) on HCG day in Group 1. Significantly negative correlations were observed between basal T, days of stimulation and total dose of gonadotropins after adjusting for confounding factors in both groups.

CONCLUSION

In women with diminished ovarian reserve, basal T level was a predictor for the number of large follicles on HCG day and pregnancy outcome; but could not in those with normal serum FSH. Basal T levels were associated with both days of stimulation and total dose of gonadotropins, indicating that lower level of T might relate with potential ovarian poor response.

Role of androgens in the treatment of patients with low ovarian response

The objective of the current report was to provide a summary of knowledge concerning the treatment of women with poor ovarian response with androgens and androgen modulating agents. This involved a review of the literature. The literature search was performed using PubMed. Information concerning the role of androgens and androgen modulating agents in treating women with poor ovarian response is limited. The search of the literature yielded five studies and one case report concerning the treatment of poor responders with androgens. The variations in patient selection, type of androgens employed and the different duration of exposure preclude drawing any definite conclusions. Aromatase inhibitors block the conversion of androgens to oestrogens, thereby promoting an androgen-rich intrafollicular environment. The evidence presented in this review suggests a potential beneficial role for the use of aromatase inhibitors in treating women who have previously experienced failure of standard IVF protocols. The optimal dose and duration of this treatment is yet to be determined. Although the results of studies concerning LH supplementation in poor responders are conflicting, the latest Cochrane review on the use of recombinant LH for ovarian stimulation supports its use in poor responders, based on pooled pregnancy estimates.

Effects of exogenous testosterone supplementation in gonadotrophin stimulated cycles

BACKGROUND

Various experiments suggest that ovarian follicular recruitment and growth may be increased by testosterone priming. Our aim was to determine the effects of exogenous testosterone supplementation in older women on ovarian folliculogenesis and steroidogenesis.

METHODS

A prospective randomized double-blind placebo-controlled crossover study was carried out. Twelve regularly menstruating non-obese women aged 38-45 years received a 12-day course of transdermal testosterone (2.5 mg per patch) or placebo patch, followed by 7 days of gonadotrophin stimulation. After at least a 1 month washout period, subjects underwent the same protocol using the opposite treatment. The main outcomes were follicular development (ultrasound measures) and hormone levels.

RESULTS

Following gonadotrophin stimulation, there were no differences in average number of follicles over 10 mm diameter in cycles pre-treated with testosterone versus placebo [2.10 (95% confidence interval (CI) 1.11, 3.22) versus 2.08 (95% CI 1.03, 3.14), P = 0.55]. No crossover, period (first or second test) or sequence (order of treatment) effects were noted. As expected, total and free testosterone levels were increased following testosterone treatment (312.7 +/- 122.4 versus 12.3 +/- 4.5 ng/dl and 45.5+/- 16.7 versus 1.4 +/- 0.5 ng/dl, respectively, P < 0.001) but no differences in free or total testosterone were noted by period. LH, FSH, estradiol and antral follicle counts before gonadotrophin stimulation were not altered by testosterone pretreatment or by period.

CONCLUSIONS

Despite increased testosterone levels, a short course of androgens had no significant effect on the number of follicles over 10 mm during stimulation with FSH in women of late reproductive age.

Assessment of theca cell function prior to controlled ovarian stimulation: the predictive value of serum basal/stimulated steroid levels

BACKGROUND

Serum androgen levels correlate with ovarian sensitivity to follicle-stimulating hormone (FSH) but in practice, standard baseline serum testosterone (T) levels prior to in-vitro fertilization (IVF) may not be the most appropriate marker for determination.

METHODS

Infertile women enrolled in an IVF programme were included in this study. Serum T and Delta4-androstenedione (A), and the androgen precursor 17-hydroxyprogesterone (17-OHP) were measured before and 24 h after a gonadotrophin-releasing hormone agonist stimulation test (GAST). An early follicular phase antral follicle count (AFC) was also performed. Patients were subsequently enrolled in a long gonadotrophin-releasing hormone agonist protocol with a standard FSH dose (150 IU) for 7 days to assess the association between androgen levels and ovarian responsiveness to FSH.

RESULTS

The GAST elicited a significant increase in serum androgen levels that was well correlated with AFC. 17-OHP showed the greatest response to GAST and strongest correlation with AFC. The 17-OHP response to GAST differentiated patients with high ovarian reserve (OR) from those with low or normal OR as assessed by AFC, whereas only the estradiol response could differentiate those with low AFC. GAST-stimulated serum levels of 17-OHP were also correlated with ovarian response to FSH. Using receiver operating characteristic curve analysis, stimulated 17-OHP levels were predictive of the ovarian response to controlled ovarian stimulation, with similar power to that observed with AFC but lower power than with anti-Müllerian hormone.

CONCLUSIONS

Serum androgen levels following GAST are correlated with AFC and ovarian response to FSH. Serum T is a less sensitive marker of theca cell function than 17-OHP.

Testosterone and dehydroepiandrosterone sulphate levels and IVF/ICSI results

OBJECTIVE

To determine the effect of serum androgens [testosterone and dehydroepiandrosterone sulphate (DHEAS)] on in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) outcomes.

STUDY DESIGN

This observational (cross sectional) study was conducted on 53 consecutive infertile women undergoing IVF cycles in an academic infertility clinic between September 2006 and August 2007. Basal testosterone and DHEAS were measured and on third day of IVF cycle and on 14th day of embryo transfer these values were re-checked. Serum beta-hCG analysis was done 12 days after embryo transfer and ultrasound scan was scheduled 2 weeks later.

RESULTS

Testosterone level was significantly elevated in pregnant women on 14th day of embryo transfer (p < 0.001). Testosterone and DHEAS concentrations on third day of IVF cycle and DHEAS concentration 2 weeks after embryo transfer had not significant correlation with IVF success, but mean androgens concentrations were higher in pregnant group.

CONCLUSION

Serum testosterone concentration on 14th day of embryo transfer can predict successful IVF cycles, so with regulating androgen levels, improved pregnancy rates can be expected.

Ovarian function: a theory of relativity

Kol and Homburg recently hypothesized in these pages that the change, rather than currently evaluated absolute hormone values, is important for biological processes. We fully agree, but wish, with this communication, to add to their concept: opposing forces, balancing each other, in order to maintain a system's stability, permeates nature. Loss of such equilibrium, in turn, results in systemic malfunctions with, at times, adverse consequences. Extrapolating to Kol and Homburg's hypothesis, this observation would suggest that not only changes in any given hormone carry biological messages, but that final message derives from hormonal ratios between hormones which oppose each other in physiological effects. In full concurrence to Kol and Homburg, this concept could give rise to better diagnosis and treatment of infertility problems.

Update on the use of dehydroepiandrosterone supplementation among women with diminished ovarian function

OBJECTIVE

We assessed the role of DHEA supplementation on pregnancy rates in women with diminished ovarian function.

DESIGN

This is a case control study of 190 women with diminished ovarian function. The study group includes 89 patients who used supplementation with 75 mg daily of oral, micronized DHEA for up to 4 months prior to entry into in vitro fertilization (IVF). The control group is composed of 101 couples who received infertility treatment, but did not use DHEA. The primary outcome was clinical pregnancy after the patient's initial visit. We developed a Cox proportional hazards model to compare the proportional hazards of pregnancy among women using DHEA with the controls group.

RESULTS

Cumulative clinical pregnancy rates were significantly higher in the study group (25 pregnancies; 28.4% vs. 11 pregnancies; 11.9%; relative hazard of pregnancy in study group (HR 3.8; 95% CI 1.2-11.8; p < 0.05).

CONCLUSIONS

DHEA treatment resulted in significantly higher cumulative pregnancy rates. These data support a beneficial effect of DHEA supplementation among women with diminished ovarian function.

Testosterone patch improves ovarian follicular response to gonadotrophins in a patient with Kallmann's syndrome: a case report

Achieving ovulation in women with Kallmann's syndrome requires both exogenous FSH and LH to successfully stimulate follicular maturation and ovarian steroidogenesis. We present a case of a woman with Kallmann's syndrome, who had poor ovarian response to stimulation by exogenous gonadotrophins. When she was given testosterone by patch before initiation of gonadotrophins, her stimulation dramatically improved. Once we ceased to pretreat her cycle with testosterone, she again had a poor stimulation. This suggests that testosterone administration may be a useful adjunct in improving ovarian response to gonadotrophins in Kallmann's syndrome patients.

Effect of dehydroepiandrosterone on oocyte and embryo yields, embryo grade and cell number in IVF

BACKGROUND

The aim of this study was to investigate the effect of treatment with dehydroepiandrosterone (DHEA) on fertility outcomes among women with diminished ovarian reserve.

MATERIALS AND METHODS

This is a case-control study in an academically affiliated private infertility centre. Twenty-five women with significantly diminished ovarian reserve had one IVF cycle before and after DHEA treatment, with otherwise identical hormonal stimulation. Women received 75 mg of DHEA daily (25 mg three times daily) for an average of 17.6 +/- 2.13 weeks. We performed a comparison of IVF outcome parameters, before and after DHEA treatment, including peak estradiol (E(2)) levels, oocyte and embryo numbers, oocyte and embryo quality and embryo transfer statistics.

RESULTS

Paired analysis of IVF cycle outcomes in 25 patients, who underwent cycles both before and after DHEA supplementation, demonstrated significant increases in fertilized oocytes (P < 0.001), normal day 3 embryos (P = 0.001), embryos transferred (P = 0.005) and average embryo scores per oocyte (P < 0.001) after DHEA treatment.

CONCLUSION

This study confirms the previously reported beneficial effects of DHEA supplementation on ovarian function in women with diminished ovarian reserve.

Basal and cycle androgen levels correlate with in vitro fertilization stimulation parameters but do not predict pregnancy outcome

OBJECTIVE

To evaluate androgen levels before and during IVF. To assess for an association between androgen levels and IVF stimulation parameters or IVF pregnancy outcome.

DESIGN

Prospective cohort study.

SETTING

Residency-based IVF program.

PATIENT(S)

One hundred seventeen infertility patients.

INTERVENTION(S)

Androgen levels were evaluated on basal day 3 and during the IVF stimulation cycle.

MAIN OUTCOME MEASURE(S)

Pregnancy outcome rates and IVF stimulation parameters.

RESULT(S)

Mean serum androgen levels did not differ among different pregnancy outcomes. Multiple linear regression analysis revealed that body mass index (BMI) and oocyte number had a significant positive association with basal testosterone levels. Mean ovarian volume correlated negatively and follicle number correlated positively with testosterone levels on day 6 of stimulation. Peak E(2) and BMI correlated positively with testosterone on day of hCG administration. The interval change in androgen levels throughout the IVF cycle was not associated with outcome rates. Likewise, threshold analysis did not reveal any significant androgen level that affected pregnancy outcome.

CONCLUSION(S)

Serum androgen levels during IVF correlate with IVF stimulation parameters. However, these data do not support an influence of serum androgen levels on IVF pregnancy outcome rates.

The science behind 25 years of ovarian stimulation for in vitro fertilization

To allow selection of embryos for transfer after in vitro fertilization, ovarian stimulation is usually carried out with exogenous gonadotropins. To compensate for changes induced by stimulation, GnRH analog cotreatment, oral contraceptive pretreatment, late follicular phase human chorionic gonadotropin, and luteal phase progesterone supplementation are usually added. These approaches render ovarian stimulation complex and costly. The stimulation of multiple follicular development disrupts the physiology of follicular development, with consequences for the oocyte, embryo, and endometrium. In recent years, recombinant gonadotropin preparations have become available, and novel stimulation protocols with less detrimental effects have been developed. In this article, the scientific background to current approaches to ovarian stimulation for in vitro fertilization is reviewed. After a brief discussion of the relevant aspect of ovarian physiology, the development, application, and consequences of ovarian stimulation strategies are reviewed in detail.

Pretreatment with transdermal testosterone may improve ovarian response to gonadotrophins in poor-responder IVF patients with normal basal concentrations of FSH

BACKGROUND

Treatment of poor-responder patients to controlled ovarian stimulation for assisted reproduction, who have normal basal FSH concentrations, is one of the most difficult challenges in reproductive medicine. This study investigated the usefulness of testosterone pretreatment in such patients.

METHODS

Prospective, therapeutic, self-controlled clinical trial including 25 consecutive infertile patients who had a background of the first and second IVF treatment cycle cancellations due to poor follicular response, in spite of vigorous gonadotrophin ovarian stimulation and having normal basal FSH levels. In the third IVF attempt, all patients received transdermal testosterone treatment (20 microg/kg per day) during the 5 days preceding gonadotrophin treatment.

RESULTS

Twenty patients (80%) showed an increase of over fivefold in the number of recruited follicles, produced 5.8+/-0.4 (mean+/-SEM) oocytes, received two or three embryos and achieved a clinical pregnancy rate of 30% per oocyte retrieval. There were 20% cancelled cycles.

CONCLUSION

Pretreatment with transdermal testosterone may be a useful approach for women known to be low responders on the basis of a poor response to controlled ovarian stimulation but having normal basal FSH concentrations.