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Naik S, Lepine S, Nagels HE, Siristatidis CS, Kroon B, McDowell S. Androgens (dehydroepiandrosterone or testosterone) for women undergoing assisted reproduction. Cochrane Database Syst Rev 2024; 6:CD009749. [PMID: 38837771 PMCID: PMC11152211 DOI: 10.1002/14651858.cd009749.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
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 28 RCTs. There were 1533 women in the intervention groups and 1469 in the control groups. Apart from three trials, 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 estradiol or T versus estradiol + 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. Research is needed to identify the optimal duration of treatment with T. Future studies should include data collection on adverse events and multiple pregnancy.
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Affiliation(s)
- Sandeep Naik
- Obstetrics and Gynaecology, Capital Coast District Heath Board, Wellington, New Zealand
| | - Sam Lepine
- Department of Obstetrics and Gynaecology, Capital and Coast District Health Board, Wellington, New Zealand
| | - Helen E Nagels
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Charalampos S Siristatidis
- Assisted Reproduction Unit, 2nd Department of Obstetrics and Gynaecology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Ben Kroon
- Queensland Fertility Group Research Foundation, Brisbane, Australia
- The University of Queensland, Brisbane, Australia
| | - Simon McDowell
- Obstetrics and Gynaecology, Capital Coast District Heath Board, Wellington, New Zealand
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Aliakbar VH, Tanha FD, Asbagh FA, Ebrahimi M, Shahraki Z. The effect of methyltestosterone on in vitro fertilization outcomes: A randomized clinical trial on patients with low ovarian response. Clin Exp Reprod Med 2024; 51:158-162. [PMID: 38812245 PMCID: PMC11140261 DOI: 10.5653/cerm.2023.05946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 11/01/2023] [Accepted: 11/27/2023] [Indexed: 05/31/2024] Open
Abstract
OBJECTIVE The aim of this study was to compare the outcomes of in vitro fertilization (IVF) in patients with a poor ovarian response who used methyltestosterone, versus those using a placebo, in an infertility clinic setting. METHODS This clinical trial included 120 women who had undergone IVF with intracytoplasmic sperm injection due to poor ovarian reserve and infertility. The study took place at the Yas Infertility Center in Tehran, Iran, between January 1, 2018 and January 1, 2019. In the intervention group, 25 mg of methyltestosterone was administered daily for 2 months prior to the initiation of assisted reproductive treatment. The control group was given placebo tablets for the same duration before starting their cycle. Each group was randomly assigned 60 patients. All analyses were performed using SPSS ver. 23 (IBM Corp.). RESULTS The endometrial thickness in the intervention group was 7.57±1.22 mm, whereas in the control group, it was 7.11±1.02 (p=0.028). The gonadotropin number was significantly higher in the control group (64.7±13.48 vs. 57.9±9.25, p=0.001). However, there was no significant difference between the two groups in the antral follicular count. The chemical and clinical pregnancy rates in the intervention group were 18.33% and 15% respectively, compared to 8.33% and 6.67% in the control group. The rate of definitive pregnancy was marginally higher in the intervention group (13.3% vs. 3.3%, p=0.05). CONCLUSION The findings of this study suggest that pretreatment with methyltestosterone significantly increases endometrium thickness and is associated with an increase in the definitive pregnancy rate.
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Affiliation(s)
- Venus Haj Aliakbar
- Department of Obstetrics and Gynecology, Arash Women’s Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Davari Tanha
- Department of Obstetrics and Gynecology, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Firouzeh Akbari Asbagh
- Department of Obstetrics and Gynecology, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahbod Ebrahimi
- Department of Obstetrics and Gynecology, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Zahra Shahraki
- Department of Obstetrics and Gynecology, Amir-Al-Momenin Hospital, Zabol University of Medical Sciences, Zabol, Iran
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Zhang Y, Xu Y, Zhang X, Zheng B, Hu W, Yuan G, Si G. 8Spheres conformal microspheres as embolic agents for symptomatic uterine leiomyoma therapy in uterine artery embolization (UAE): A prospective clinical trial. Medicine (Baltimore) 2023; 102:e33099. [PMID: 36862859 PMCID: PMC9981361 DOI: 10.1097/md.0000000000033099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/04/2023] Open
Abstract
To evaluate the treatment efficacy of uterine artery embolization (UAE) using 8Spheres conformal microspheres for symptomatic uterine leiomyoma. In this prospective observational study, 15 patients were enrolled and underwent UAE by 2 experienced interventionalists from September 1, 2018, to September 1, 2019. All patients underwent menstrual bleeding scores, the symptom severity domain of the Uterine Fibroid Symptom and Quality of Life questionnaire scores (with lower scores indicating mild symptoms), pelvic contrast-enhanced magnetic resonance imaging, ovarian reserve tests (estradiol, prolactin, testosterone, follicle-stimulating, luteinizing, and progesterone), and other appropriate preoperative examinations within 1 week before UAE. During follow-up, menstrual bleeding scores and the symptom severity domain of the Uterine Fibroid Symptom and Quality of Life questionnaire scores were recorded at 1, 3, 6, and 12 months after UAE to assess the efficacy of symptomatic uterine leiomyoma. Pelvic contrast-enhanced magnetic resonance imaging was performed 6 months after the interventional therapy. Biomarkers of ovarian reserve function were reviewed at 6 and 12 months after treatment. All 15 patients successfully underwent UAE, without severe adverse effects. Six patients experienced abdominal pain, nausea, or vomiting, all of which improved significantly after symptomatic treatment. The menstrual bleeding scores declined from baseline (350.2 ± 61.9 mL) to (131.8 ± 42.7 mL), (140.3 ± 42.4 mL), (68.0 ± 22.8 mL), and (64.43 ± 17.0 mL) at 1, 3, 6, and 12 months, respectively. The symptom severity domain scores at 1, 3, 6, and 12 months postoperatively were significantly lower and statistically significant compared to the preoperative scores. The uterus and dominant leiomyoma volumes decreased from baseline (340.0 ± 35.8 cm3), (100.6 ± 24.3 cm3) to (266.6 ± 30.9 cm3), (56.1 ± 17.3 cm3) at 6 months after UAE, respectively. Moreover, the ratio of leiomyoma volumes and uterus decreased from (27.4 ± 4.5%) to (18.7 ± 3.9%). At the same time, there was no significant effect on changes in the biomarkers of ovarian reserve levels. Only the changes in testosterone levels before and after UAE were statistically significant (P < .05). 8Spheres conformal microspheres are ideal embolic agents for UAE therapy. This study showed that 8Spheres conformal microsphere embolization for symptomatic uterine leiomyoma could effectively relieve heavy menstrual bleeding, improve the symptom severity of patients, reduce the volume of leiomyoma, and have no significant effect on ovarian reserve function.
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Affiliation(s)
- Yiwen Zhang
- Department of Interventional Radiology, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, China
| | - Yanneng Xu
- Department of Interventional Radiology, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, China
| | - Xun Zhang
- Department of Interventional Radiology, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, China
| | - Bo Zheng
- Department of Interventional Radiology, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, China
| | - Wei Hu
- Department of Interventional Radiology, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, China
| | - Gang Yuan
- Department of Interventional Radiology, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, China
| | - Guangyan Si
- Department of Interventional Radiology, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, China
- *Correspondence: Guangyan Si, Department of Interventional Radiology, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou 646000, China (e-mail )
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Higher live birth rate following transdermal testosterone pretreatment in poor responders: a systematic review and meta-analysis. Reprod Biomed Online 2023; 46:81-91. [PMID: 36369150 DOI: 10.1016/j.rbmo.2022.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 09/08/2022] [Accepted: 09/26/2022] [Indexed: 11/05/2022]
Abstract
A systematic review and meta-analysis was performed aiming to identify good-quality randomized controlled trials (RCT) evaluating testosterone pretreatment in poor responders. Eight RCTs were analysed, evaluating 797 women. Transdermal testosterone gel was used in all studies, with a dose ranging from 10 to 12.5 mg/day for 10-56 days. The main outcome measure was achievement of pregnancy, expressed as clinical pregnancy or live birth. Testosterone pretreatment was associated with a significantly higher live birth (risk ratio [RR] 2.07, 95% confidence interval [CI] 1.09-3.92) and clinical pregnancy rate (RR 2.25, 95% CI 1.54-3.30), as well as a significant increase in the number of cumulus-oocyte complexes retrieved. Significantly fewer days to complete ovarian stimulation, a lower total dose of gonadotrophins, a lower cancellation rate due to poor ovarian response and a thicker endometrium on the day of triggering of final oocyte maturation were observed. No significant differences were observed in oestradiol concentration, the numbers of follicles ≥17 mm, metaphase II oocytes, two-pronuclear oocytes and embryos transferred, and the proportion of patients with embryo transfer. The current study suggests that the probability of pregnancy is increased in poor responders pretreated with transdermal testosterone who are undergoing ovarian stimulation for IVF.
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Jiang R, Cao M, Hao H, Jia R, Chen P, Liu Y, Zhao Z. Effects of follicular output rate on cumulative clinical pregnancy rate and cumulative live birth rate in PCOS patients with different characteristics. Front Endocrinol (Lausanne) 2022; 13:1079502. [PMID: 36601009 PMCID: PMC9806261 DOI: 10.3389/fendo.2022.1079502] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 12/06/2022] [Indexed: 12/23/2022] Open
Abstract
Objective We aim to explore the effects of follicular output rate (FORT) on cumulative clinical pregnancy rate (CCPR) and cumulative live birth rate (CLBR) in polycystic ovary syndrome (PCOS) patients with different characteristics undergoing in vitro fertilization (IVF) treatment. Methods This retrospective study analyzed 454 patients with PCOS undergoing their first IVF cycle at our center from January 2016 to December 2020. FORT was calculated as pre-ovulatory follicle count (PFC) × 100/antral follicle count (AFC). Multivariate regression analyses were conducted to explore the relationships between FORT and CCPR and CLBR. Curve fitting and threshold effect analyses were established to find nonlinear relationships. Effect modification in different subgroups were examined by stratification analyses. Results Based on the FORT values, individuals were classified into the following three groups: low-FORT group, middle-FORT group and high-FORT group. Multivariate regression analyses revealed that FORT was an independent factor affecting the CCPR and CLBR significantly (OR = 1.015, 95% CI: 1.001, 1.030 and OR = 1.010, 95% CI:1.001, 1.020). Curve fitting and threshold effect analyses showed that the CCPR and CLBR had a positive correlation with FORT when the FORT was less than 70% (OR = 1.039, 95% CI: 1.013, 1.065 and OR = 1.024, 95% CI: 1.004, 1.044). Stratification analyses showed that the CLBR increased by 1.3% with each additional unit of FORT for patients with hyperandrogenic manifestations (OR = 1.013, 95% CI: 1.001, 1.025). Compared with the low-FORT group, in the high-FORT group, CCPR increased 1.251 times for patients with polycystic ovarian morphology, while CCPR and CLBR increased 1.891 times and 0.99 times for those with ovulation disorder, respectively (OR = 2.251, 95% CI: 1.008, 5.028 and OR = 2.891, 95% CI: 1.332, 6.323 and OR = 1.990, 95% CI: 1.133, 3.494). Conclusion In patients with PCOS, cumulative IVF outcomes have a positive correlation with FORT when the FORT is less than 70%. For PCOS patients with polycystic ovarian morphology, ovulation disorder or hyperandrogenic manifestations, a high FORT could be conductive to achieving better pregnancy outcomes.
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Affiliation(s)
- Rulan Jiang
- Department of Reproductive Medicine, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Mingya Cao
- Department of Reproductive Medicine, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Haomeng Hao
- Department of Reproductive Medicine, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Rui Jia
- Department of Reproductive Medicine, The Second Hospital of Hebei Medical University, Shijiazhuang, China
- Shenzhen Key Laboratory of Reproductive Immunology for Peri-Implantation, Shenzhen Zhongshan Institute for Reproduction and Genetics, Shenzhen Zhongshan Urology Hospital, Shenzhen, China
| | - Peipei Chen
- Department of Gynecology and Obstetrics, Handan First Hospital, Handan, China
| | - Yuanyuan Liu
- Department of Reproductive Medicine, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhiming Zhao
- Department of Reproductive Medicine, The Second Hospital of Hebei Medical University, Shijiazhuang, China
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The effect of androgen administration on in vitro fertilization outcome in poor responders undergoing ovarian stimulation with microdose protocol: A randomized clinical trial. Eur J Obstet Gynecol Reprod Biol 2022; 279:72-76. [DOI: 10.1016/j.ejogrb.2022.09.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 09/10/2022] [Accepted: 09/25/2022] [Indexed: 11/23/2022]
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Pretreatment: Does it improve quantity or quality? Fertil Steril 2022; 117:657-663. [DOI: 10.1016/j.fertnstert.2022.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 01/25/2022] [Accepted: 01/25/2022] [Indexed: 11/24/2022]
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Roy S, Huang B, Sinha N, Wang J, Sen A. Androgens regulate ovarian gene expression by balancing Ezh2-Jmjd3 mediated H3K27me3 dynamics. PLoS Genet 2021; 17:e1009483. [PMID: 33784295 PMCID: PMC8034747 DOI: 10.1371/journal.pgen.1009483] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 04/09/2021] [Accepted: 03/12/2021] [Indexed: 02/07/2023] Open
Abstract
Conventionally viewed as male hormone, androgens play a critical role in female fertility. Although androgen receptors (AR) are transcription factors, to date very few direct transcriptional targets of ARs have been identified in the ovary. Using mouse models, this study provides three critical insights about androgen-induced gene regulation in the ovary and its impact on female fertility. First, RNA-sequencing reveals a number of genes and biological processes that were previously not known to be directly regulated by androgens in the ovary. Second, androgens can also influence gene expression by decreasing the tri-methyl mark on lysine 27 of histone3 (H3K27me3), a gene silencing epigenetic mark. ChIP-seq analyses highlight that androgen-induced modulation of H3K27me3 mark within gene bodies, promoters or distal enhancers have a much broader impact on ovarian function than the direct genomic effects of androgens. Third, androgen-induced decrease of H3K27me3 is mediated through (a) inhibiting the expression and activity of Enhancer of Zeste Homologue 2 (EZH2), a histone methyltransferase that promotes tri-methylation of K27 and (b) by inducing the expression of a histone demethylase called Jumonji domain containing protein-3 (JMJD3/KDM6B), responsible for removing the H3K27me3 mark. Androgens through the PI3K/Akt pathway, in a transcription-independent fashion, increase hypoxia-inducible factor 1 alpha (HIF1α) protein levels, which in turn induce JMJD3 expression. Furthermore, proof of concept studies involving in vivo knockdown of Ar in the ovary and ovarian (granulosa) cell-specific Ar knockout mouse model show that ARs regulate the expression of key ovarian genes through modulation of H3K27me3.
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Affiliation(s)
- Sambit Roy
- Reproductive and Developmental Sciences Program, Department of Animal Sciences, Michigan State University, East Lansing, MI, United States of America
| | - Binbin Huang
- Department of Computational Mathematics, Science and Engineering, Michigan State University, East Lansing, MI, United States of America
| | - Niharika Sinha
- Reproductive and Developmental Sciences Program, Department of Animal Sciences, Michigan State University, East Lansing, MI, United States of America
| | - Jianrong Wang
- Department of Computational Mathematics, Science and Engineering, Michigan State University, East Lansing, MI, United States of America
| | - Aritro Sen
- Reproductive and Developmental Sciences Program, Department of Animal Sciences, Michigan State University, East Lansing, MI, United States of America
- * E-mail:
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Neves AR, Montoya-Botero P, Polyzos NP. The Role of Androgen Supplementation in Women With Diminished Ovarian Reserve: Time to Randomize, Not Meta-Analyze. Front Endocrinol (Lausanne) 2021; 12:653857. [PMID: 34079524 PMCID: PMC8165260 DOI: 10.3389/fendo.2021.653857] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 04/23/2021] [Indexed: 11/24/2022] Open
Abstract
The management of patients with diminished ovarian reserve (DOR) remains one of the most challenging tasks in IVF clinical practice. Despite the promising results obtained from animal studies regarding the importance of androgens on folliculogenesis, the evidence obtained from clinical studies remains inconclusive. This is mainly due to the lack of an evidence-based methodology applied in the available trials and to the heterogeneity in the inclusion criteria and IVF treatment protocols. In this review, we analyze the available evidence obtained from animal studies and highlight the pitfalls from the clinical studies that prevent us from closing the chapter of this line of research.
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Affiliation(s)
- Ana Raquel Neves
- Department of Obstetrics, Gynecology and Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain
- Faculty of Medicine, Autonomous University of Barcelona, Cerdanyola del Vallès, Spain
| | - Pedro Montoya-Botero
- Department of Reproductive Medicine, Conceptum – Unidad de Fertilidad del Country, Bogotá, Colombia
| | - Nikolaos P. Polyzos
- Department of Obstetrics, Gynecology and Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain
- Faculty of Medicine and Health Sciences, Ghent University (UZ Gent), Gent, Belgium
- *Correspondence: Nikolaos P. Polyzos,
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The Benefits of Testosterone Therapy in Poor Ovarian Responders Undergoing In Vitro Fertilisation (IVF). EUROPEAN MEDICAL JOURNAL 2020. [DOI: 10.33590/emj/20-00095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Introduction: Poor ovarian responders are the most challenging patients in reproductive medicine and no successful treatment has been proposed. Androgens are thought to play an important role during early folliculogenesis and diminished levels are associated with decreased ovarian sensitivity to follicle-stimulating hormone. This study aimed to determine whether pretreatment with testosterone improves the results in poor responders undergoing in vitro fertilisation (IVF). Materials and methods: This observational pilot study enrolled 33 poor responders undergoing IVF. Eleven patients were pretreated with 250 mg intramuscular testosterone and compared to a control group of 22 patients. The participants were tested for free testosterone, dehydroepiandrosterone sulfate, sex hormone binding globulin, and anti-mullerian hormone (AMH). Results: The two groups had similar baseline characteristics. Significant improvement was reached in the hormones free testosterone, dehydroepiandrosterone sulfate, and sex hormone binding globulin in the testosterone-pretreatment group. No difference was detected in antral follicle count (5.06 versus 4.24); AMH (0.51 versus 0.53), mature oocytes (2.2 versus 2.32), and the number of embryos (1.2 versus 1.33) between the study and control groups, respectively. There was a slow improvement in fertilisation rate but without any significance (62.97% versus 57.61%). However, the cancellation rate of the ovarian stimulation was much greater in the control group (18.18%) in comparison with the study group (0.0%). Pregnancy rate (PR) in the testosterone group was higher than controls (PR per cycle: 27.3% versus 4.6; p=0.09). Conclusion: Based on the limited number of patients studied, pretreatment with testosterone seems to improve PR and cancellation rate in poor responders but failed to affect antral follicle count, AMH, and the number of mature oocytes and embryos. Given these results, further research would provide more certainty.
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Abstract
PURPOSE OF REVIEW The purpose of this review is to provide an overview of androgen supplementation in ART with the most updated evidence, from animal studies to its clinical applications in poor ovarian responders (POR) and the future studies to be published. RECENT FINDINGS Animal studies, has shown that testosterone supplementation, can be an option to increase the recruitable follicular pool in POR. However, the potential mechanism of action, dose, and duration of treatment is still under investigation. Early studies in humans reported promising results in favor of androgens [dehydroepiandrosterone (DHEA) or testosterone] in POR. Nevertheless, recent evidence does not appear to follow the initial results, whereas the type, dose, and duration of testosterone administration appear to be crucial for treatment effect. SUMMARY Testosterone seems to play an essential role in regulating ovarian function. However, it is worrisome that androgens are used off-label, despite that the available evidence is weak. Although testosterone supplementation may be beneficial in POR, published studies have used inconsistent doses and duration of administration. An ongoing trial (T-TRANSPORT trial) for the first time aims to provide conclusive evidence on whether transdermal testosterone administration can improve the reproductive outcomes in patients undergoing IVF/ICSI.
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A review of the physiology behind letrozole applications in infertility: are current protocols optimal? J Assist Reprod Genet 2020; 37:2093-2104. [PMID: 32712844 PMCID: PMC7492298 DOI: 10.1007/s10815-020-01892-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 07/13/2020] [Indexed: 11/23/2022] Open
Abstract
Letrozole is a targeted aromatase inhibitor which has primarily been used in post-menopausal women with breast cancer. Recently, it has been utilized in infertile pre-menopausal women because of its ability to enhance FSH production for ovulation induction. However, the ovarian follicle’s response to FSH is only a part of the endocrine events occurring in a developing follicle. The health of the small antral follicles is driven primarily by androgens, which contribute to granulosa cell mitosis, sensitivity to FSH, and resistance to atresia. In contrast, elevated androgens in the late antral to pre-ovulatory follicle have a negative impact on follicle health and lead to atresia and cystic follicle formation. This ovarian physiologic data suggests that current applications of letrozole to infertility may be squandering some of the primary benefits available in using letrozole to promote follicle development. Four applications of letrozole to infertility that have appeared in the medical literature are reviewed. Androgen-related benefits are reviewed and various questions put forward about how letrozole could be more effectively used to help patients in these settings.
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Monteiro CDS, Scheffer BB, Carvalho RFD, Scheffer JB. The impact of dehydroepiandrosterone in poor ovarian responders on assisted reproduction technology treatment. JBRA Assist Reprod 2019; 23:414-417. [PMID: 31251010 PMCID: PMC6798587 DOI: 10.5935/1518-0557.20190045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
One in six couples worldwide will experience at least one infertility problem
during their reproductive years. Between 5.6% and 35.1% of women will exhibit
poor ovarian response. A variety of methods have been applied to improve ovarian
response, including dehydroepiandrosterone. In the ovaries,
dehydroepiandrosterone promotes follicular development and granulosa cell
proliferation by increasing intraovarian androgen concentrations while
simultaneously enhancing the level of follicular insulin-like growth factor-1,
which promotes folliculogenesis. Dehydroepiandrosterone supplementation may
improve in vitro fertilization outcomes and ovarian response in
patients with poor ovarian response. However, a few questions still loom over
the effectiveness of dehydroepiandrosterone.
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Affiliation(s)
| | - Bruno Brum Scheffer
- Brazilian Institute of Assisted Reproduction (IBRRA), Belo Horizonte, MG, Brazil
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Kunicki M, Skowrońska P, Pastuszek E, Jakiel G, Smolarczyk R, Łukaszuk K. Do serum androgens influence blastocysts ploidy in karyotypically normal women? Syst Biol Reprod Med 2019; 65:281-287. [PMID: 30994373 DOI: 10.1080/19396368.2019.1601295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 03/03/2019] [Accepted: 03/22/2019] [Indexed: 10/27/2022]
Abstract
The aim of the study was to determine if serum testosterone (T) and dehydroepiandrosterone (DHEAS) levels are a factor in determining increased risk for embryonic aneuploidy in karyotypically normal women undergoing in vitro fertilization (IVF) and preimplantation genetic testing screening for aneuploidy (PGT-A). This is a retrospective cohort study of IVF cycles with PGT-A performed during 2015-2016. A total of 256 cycles with 725 embryos were initially considered for inclusion. A total of 208 cycles and 595 embryos determined to be either euploid or aneuploid were included in the analysis. The mean age of women was 37.4 ± 4.4 years. There were 193 (32.44%) euploid, and 338 (56.81%) aneuploid blastocysts. Sixty-four (10.76%) had 'no diagnosis' after PGT-A. The 32 embryos with 'no diagnosis' after first PGT-A were biopsied again and after the second analysis, 7 were found to be euploid and 3 aneuploid. The remaining 32 embryos were not reanalyzed due to the lack of patients' consent for the second biopsy. The relationship between embryo ploidy and levels of serum testosterone and dehydroepiandrosterone sulfate was assessed using ordinal multivariable regression analysis. The model, adjusted for both anti-Mullerian hormone (AMH) and age, showed no association between ploidy status and serum levels of the two hormones. We concluded that the serum levels of testosterone and DHEAS do not influence embryo ploidy in karyotypically normal women undergoing IVF. Abbreviations: T: testosterone; DHEAS: dehydroepiandrosterone; IVF: in vitro fertilization; PGT-A: preimplantation genetic testing screening for aneuploidy; AMH: anti-Mullerian hormone; FSH: follicle-stimulating hormone; LH: luteinizing hormone; E2: oestradiol; P: progesterone.
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Affiliation(s)
- Michał Kunicki
- a INVICTA Fertility and Reproductive Center , Warsaw , Poland
- b Department of Gynecological Endocrinology , Medical University of Warsaw , Warsaw , Poland
| | - Patrycja Skowrońska
- c Department of Obstetrics and Gynecological Nursing, Faculty of Health Sciences , Medical University of Gdansk , Gdańsk , Poland
| | - Ewa Pastuszek
- c Department of Obstetrics and Gynecological Nursing, Faculty of Health Sciences , Medical University of Gdansk , Gdańsk , Poland
- d INVICTA Fertility and Reproductive Center , Gdansk , Poland
| | - Grzegorz Jakiel
- a INVICTA Fertility and Reproductive Center , Warsaw , Poland
- e Department of Obstetrics and Gynecology , The Centre of Postgraduate Medical Education , Warsaw , Poland
| | - Roman Smolarczyk
- b Department of Gynecological Endocrinology , Medical University of Warsaw , Warsaw , Poland
| | - Krzysztof Łukaszuk
- a INVICTA Fertility and Reproductive Center , Warsaw , Poland
- b Department of Gynecological Endocrinology , Medical University of Warsaw , Warsaw , Poland
- c Department of Obstetrics and Gynecological Nursing, Faculty of Health Sciences , Medical University of Gdansk , Gdańsk , Poland
- d INVICTA Fertility and Reproductive Center , Gdansk , Poland
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Fàbregues F, Solernou R, Ferreri J, Guimerá M, Peralta S, Casals G, Peñarrubia J, Creus M, Manau D. Comparison of GnRH agonist versus luteal estradiol GnRH antagonist protocol using transdermal testosterone in poor responders. JBRA Assist Reprod 2019; 23:130-136. [PMID: 30614665 PMCID: PMC6501741 DOI: 10.5935/1518-0557.20180090] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objective: Transdermal testosterone has been used in different doses and in different
stimulation protocols in poor responders. The aim of the present study is to
compare the luteal estradiol/GnRH antagonists protocol
versus long GnRH agonists in poor responder patients
according to the Bologna criteria, in which transdermal testosterone has
been used prior to the stimulation with gonadotropins. Methods: In this retrospective analysis, a total of 141 poor responder patients
according to the Bologna criteria were recruited. All patients were treated
with transdermal testosterone preceding ovarian stimulation with
gonadotropins during 5 days. In 53 patients we used the conventional
antagonist protocol (Group 1). In 88 patients (GrH pituitary suppression was
achieved by leuprolide acetate according to the conventional long protocol
(Group 2). We analyzed the ovarian stimulation parameters and IVF
outcomes. Results: Comparing groups 1 and 2, there were no significant differences between
cancellation rates and number of oocytes retrieved. However the total
gonadotropin dose used and the mean length of stimulation were significantly
lower in group 1 when compared to group 2. There were no significant
differences in pregnancy outcomes; however, there was a slight increase in
the implantation rate in group 1 vis-a-vis group 2, although statistical
significance was not achieved. Conclusion: TT in poor responder patients can be effective both with the conventional
agonist's long protocol and with the conventional antagonist's protocol.
However, short regimes with previous estradiol antagonists in the luteal
phase facilitate ovarian stimulation by shortening the days of treatment and
the consumption of gonadotropins
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Affiliation(s)
- Francesc Fàbregues
- Institut Clinic de Ginecologia, Obstetricia y Neonatología (ICGON). Hospital Clinic de Barcelona. Institut de Investigacions Biomédiques August Pi iSunyer (IDIBAPS)
| | - Roser Solernou
- Institut Clinic de Ginecologia, Obstetricia y Neonatología (ICGON). Hospital Clinic de Barcelona. Institut de Investigacions Biomédiques August Pi iSunyer (IDIBAPS)
| | - Janisse Ferreri
- Institut Clinic de Ginecologia, Obstetricia y Neonatología (ICGON). Hospital Clinic de Barcelona. Institut de Investigacions Biomédiques August Pi iSunyer (IDIBAPS)
| | - Marta Guimerá
- Institut Clinic de Ginecologia, Obstetricia y Neonatología (ICGON). Hospital Clinic de Barcelona. Institut de Investigacions Biomédiques August Pi iSunyer (IDIBAPS)
| | - Sara Peralta
- Institut Clinic de Ginecologia, Obstetricia y Neonatología (ICGON). Hospital Clinic de Barcelona. Institut de Investigacions Biomédiques August Pi iSunyer (IDIBAPS)
| | - Gemma Casals
- Institut Clinic de Ginecologia, Obstetricia y Neonatología (ICGON). Hospital Clinic de Barcelona. Institut de Investigacions Biomédiques August Pi iSunyer (IDIBAPS)
| | - Joana Peñarrubia
- Institut Clinic de Ginecologia, Obstetricia y Neonatología (ICGON). Hospital Clinic de Barcelona. Institut de Investigacions Biomédiques August Pi iSunyer (IDIBAPS)
| | - Montserrat Creus
- Institut Clinic de Ginecologia, Obstetricia y Neonatología (ICGON). Hospital Clinic de Barcelona. Institut de Investigacions Biomédiques August Pi iSunyer (IDIBAPS)
| | - Dolors Manau
- Institut Clinic de Ginecologia, Obstetricia y Neonatología (ICGON). Hospital Clinic de Barcelona. Institut de Investigacions Biomédiques August Pi iSunyer (IDIBAPS)
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Norman RJ, Alvino H, Hull LM, Mol BW, Hart RJ, Kelly TL, Rombauts L. Human growth hormone for poor responders: a randomized placebo-controlled trial provides no evidence for improved live birth rate. Reprod Biomed Online 2019; 38:908-915. [PMID: 30954433 DOI: 10.1016/j.rbmo.2019.02.003] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 01/18/2019] [Accepted: 02/05/2019] [Indexed: 01/19/2023]
Abstract
RESEARCH QUESTION Does the addition of human growth hormone (HGH) to an IVF cycle improve the live birth rate in previously documented poor responders to FSH? DESIGN Double-blind, placebo-controlled, randomized clinical trial comparing HGH to placebo in maximal stimulation in an IVF cycle. The study was stopped after 4 years. Women receiving ovarian stimulation in one IVF cycle, having failed to produce more than 5 eggs in a previous cycle with more than 250 IU/day of FSH were included. Basal FSH was ≤15 IU/l, body mass index <33 kg/m2, age <41 years. HGH or placebo were added from the start of the cycle in a double-blinded manner. The primary outcome was live birth rate. MAIN RESULTS The live birth rates following an IVF cycle were 9/62 (14.5%) for growth hormone and 7/51 (13.7%) for the placebo group (risk difference 0.8%, 95% confidence interval [CI] -12.1 to 13.7%; odds ratio [OR] 1.07, 95% CI 0.37-3.10). There was a greater odds of oocyte retrieval with growth hormone (OR 5.67, 95% CI 1.54-20.80) but no better chance of embryo transfer (OR 1.42, 95% CI 0.50-4.00). Birth weights were comparable. CONCLUSIONS Planned participant numbers were not reached. It was not possible to demonstrate an increase in live birth rate from the addition of growth hormone in women with a previous poor ovarian response to IVF.
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Affiliation(s)
- Robert J Norman
- University of Adelaide, Robinson Research Institute, North Adelaide, SA 5006, Australia; , Fertility SA, 431 King William Road, Adelaide, SA 5000, Australia.
| | - Helen Alvino
- University of Adelaide, Robinson Research Institute, North Adelaide, SA 5006, Australia
| | - Louise M Hull
- University of Adelaide, Robinson Research Institute, North Adelaide, SA 5006, Australia
| | - Ben W Mol
- University of Adelaide, Robinson Research Institute, North Adelaide, SA 5006, Australia; South Australian Health and Medical Research Institute, Robinson Research Institute, North Adelaide, SA 5006; Monash University, Clayton, VIC 3800, Australia
| | - Roger J Hart
- Fertility Specialists of Western Australia, Claremont, WA 6010; The University of Western Australia, Crawley, WA 6009, Australia
| | - Thu-Lan Kelly
- Adelaide Health Technology Assessment, School of Public Health, The University of Adelaide, Adelaide, SA 5006; Quality Use of Medicines Pharmacy Research Centre, University of South Australia, Adelaide, SA 5001, Australia
| | - Luk Rombauts
- Monash IVF, Monash Surgical Private Hospital, Clayton, VIC 3168, Australia
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17
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Noventa M, Vitagliano A, Andrisani A, Blaganje M, Viganò P, Papaelo E, Scioscia M, Cavallin F, Ambrosini G, Cozzolino M. Testosterone therapy for women with poor ovarian response undergoing IVF: a meta-analysis of randomized controlled trials. J Assist Reprod Genet 2019; 36:673-683. [PMID: 30610664 DOI: 10.1007/s10815-018-1383-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 11/27/2018] [Indexed: 11/29/2022] Open
Abstract
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.
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Affiliation(s)
- Marco Noventa
- Department of Women and Children's Health, Clinic of Gynecology and Obstetrics, University of Padua, Via Giustiniani 3, 35128, Padova, Italy.
| | - Amerigo Vitagliano
- Department of Women and Children's Health, Clinic of Gynecology and Obstetrics, University of Padua, Via Giustiniani 3, 35128, Padova, Italy
| | - Alessandra Andrisani
- Department of Women and Children's Health, Clinic of Gynecology and Obstetrics, University of Padua, Via Giustiniani 3, 35128, Padova, Italy
| | - Mija Blaganje
- Division of Gynaecology and Obstetrics, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Paola Viganò
- Obstetrics and Gynaecology Department, IRCCS San Raffaele Scientific Institute, 20132, Milano, Italy
| | - Enrico Papaelo
- Obstetrics and Gynaecology Department, IRCCS San Raffaele Scientific Institute, 20132, Milano, Italy
| | - Marco Scioscia
- Department of Obstetrics and Gynecology, Policlinico Hospital of Abano Terme, Padova, Italy
| | | | - Guido Ambrosini
- Department of Women and Children's Health, Clinic of Gynecology and Obstetrics, University of Padua, Via Giustiniani 3, 35128, Padova, Italy
| | - Mauro Cozzolino
- Instituto Valenciano de Infertilidad, IVI-RMA Global, Avenida del Talgo 68-70, 28023, Madrid, Spain.,Department of Gynecology and Obstetrics, Rey Juan Carlos University, Avenida de Atenas s/n, Alcorcón, Madrid, 28922, Spain
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18
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Haahr T, Dosouto C, Alviggi C, Esteves SC, Humaidan P. Management Strategies for POSEIDON Groups 3 and 4. Front Endocrinol (Lausanne) 2019; 10:614. [PMID: 31572298 PMCID: PMC6749147 DOI: 10.3389/fendo.2019.00614] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 08/23/2019] [Indexed: 12/13/2022] Open
Abstract
In the POSEIDON classification, patients belonging to groups 3 and 4 share the same common feature of a poor ovarian reserve which independently of age renders them at high risk of a poor reproductive outcome. Overall, POSEIDON groups 1-4 constitute approximately 47% of patients attending assisted reproductive technology (ART) treatment. With the increasing delay in childbearing, POSEIDON group 4 seems to increase in numbers now in some centers constituting more than 50% of the total POSEIDON population, whereas group 3 patients constitute approximately 10%. Both POSEIDON groups 3 and 4 patients require special attention as regards pre-treatment strategy, ovarian stimulation, adjuvant treatment, and ovulation trigger strategy in order to optimize the probability of having at least one euploid blastocyst for transfer. Although more evidence is needed, recent advances seem to have increased the reproductive outcomes in the poor prognosis patient. The key to success is individualization in all steps of ART treatment. Herein, we review the recent evidence for the management of POSEIDON groups 3 and 4.
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Affiliation(s)
- Thor Haahr
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- The Fertility Clinic Skive, Skive Regional Hospital, Skive, Denmark
- *Correspondence: Thor Haahr
| | - Carlos Dosouto
- Hospital de la Santa Creu i Sant Pau- Fundació Puigvert, Obstetrics, Gynecology and Reproductive Medicine, Barcelona, Spain
- Faculty of Medicine, Autonomous University of Barcelona, Barcelona, Spain
| | - Carlo Alviggi
- Department of Neuroscience, Reproductive Science, and Odontostomatology, University of Naples Federico II, Naples, Italy
- Consiglio Nazionale Delle Ricerche, Istituto per L'Endocrinologia e L'Oncologia Sperimentale, Naples, Italy
| | - Sandro C. Esteves
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- The Fertility Clinic Skive, Skive Regional Hospital, Skive, Denmark
- ANDROFERT, Andrology and Human Reproduction Clinic, Campinas, Brazil
- Department of Surgery, University of Campinas, Campinas, Brazil
| | - Peter Humaidan
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- The Fertility Clinic Skive, Skive Regional Hospital, Skive, Denmark
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19
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Polyzos NP, Drakopoulos P. Management Strategies for POSEIDON's Group 1. Front Endocrinol (Lausanne) 2019; 10:679. [PMID: 31632353 PMCID: PMC6779707 DOI: 10.3389/fendo.2019.00679] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 09/18/2019] [Indexed: 12/19/2022] Open
Affiliation(s)
- Nikolaos P. Polyzos
- Department of Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain
- Department of Surgical and Clinical Science, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
- *Correspondence: Nikolaos P. Polyzos ;
| | - Panagiotis Drakopoulos
- Department of Surgical and Clinical Science, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
- Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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20
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Lledo B, Llácer J, Ortiz JA, Martinez B, Morales R, Bernabeu R. A pharmacogenetic approach to improve low ovarian response: The role of CAG repeats length in the androgen receptor gene. Eur J Obstet Gynecol Reprod Biol 2018; 227:41-45. [PMID: 29886316 DOI: 10.1016/j.ejogrb.2018.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 04/04/2018] [Accepted: 06/02/2018] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Belén Lledo
- Instituto Bernabeu Biotech, 03016, Alicante, Spain.
| | - Joaquín Llácer
- Instituto Bernabeu of Fertility and Gynecology, 03016, Alicante, Spain
| | - Jose A Ortiz
- Instituto Bernabeu Biotech, 03016, Alicante, Spain
| | | | - Ruth Morales
- Instituto Bernabeu Biotech, 03016, Alicante, Spain
| | - Rafael Bernabeu
- Instituto Bernabeu Biotech, 03016, Alicante, Spain; Instituto Bernabeu of Fertility and Gynecology, 03016, Alicante, Spain
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21
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Haahr T, Esteves SC, Humaidan P. Individualized controlled ovarian stimulation in expected poor-responders: an update. Reprod Biol Endocrinol 2018; 16:20. [PMID: 29523204 PMCID: PMC5845159 DOI: 10.1186/s12958-018-0342-1] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 03/06/2018] [Indexed: 12/29/2022] Open
Abstract
Controlled ovarian stimulation with subsequent multi-follicular development continues to be a keystone in ART. Evidence supports an individualized approach to ovarian stimulation, usually involving combinations of ovarian reserve tests, body mass index and age to tailor the exogenous gonadotropin dose, and potentially adjuvant treatment aiming for high safety and a shortening of time to live birth. While stimulation and trigger concepts have been developed successfully in normo- and hyperresponder patients, the poor responder patient remains difficult to manage. However, recent advances in definition and classification of the expected poor ovarian responder patient might enable a more accurate and clinically useful interpretation of new treatment concepts in a more homogenous study population. In the present review, we discuss the classification of the expected poor ovarian responder patient as well as clinically useful measurements of efficacy for controlled ovarian stimulation, and finally, we discuss the evidence for clinical management of patients with expected poor ovarian response, including adjuvant treatments such as growth hormone, androgens, and LH activity.In conclusion, the best available evidence supports that the treatment of the expected poor ovarian response patient should be individualized in all steps of ART, including the choice of GnRH analogue, the gonadotropin type and dose, ovulation trigger, and the possible use of adjuvant therapies.
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Affiliation(s)
- Thor Haahr
- Department of Clinical Medicine, Aarhus University, Denmark and the Fertility Clinic Skive, Skive Regional Hospital, Skive, Denmark
| | - Sandro C Esteves
- Department of Clinical Medicine, Aarhus University, Denmark and the Fertility Clinic Skive, Skive Regional Hospital, Skive, Denmark
- ANDROFERT, Andrology and Human Reproduction Clinic, Campinas, Brazil
- Department of Surgery (Division of Urology), Faculty of Medical Sciences, University of Campinas (UNICAMP), Campinas, Brazil
| | - Peter Humaidan
- Department of Clinical Medicine, Aarhus University, Denmark and the Fertility Clinic Skive, Skive Regional Hospital, Skive, Denmark.
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22
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Bercaire L, Nogueira SM, Lima PC, Alves VR, Donadio N, Dzik A, Cavagna M. ANDRO-IVF: a novel protocol for poor responders to IVF controlled ovarian stimulation. JBRA Assist Reprod 2018; 22:52-55. [PMID: 29303236 PMCID: PMC5844660 DOI: 10.5935/1518-0557.20180011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Objective This study aimed to assess a novel protocol designed to improve poor ovarian
response through intra-ovarian androgenization. The endpoints were: number
of oocytes and mature oocytes retrieved, fertilization, cancellation and
pregnancy rates. Methods This prospective crossover study enrolled poor responders from previous
ovarian stimulation cycles submitted to a novel protocol called ANDRO-IVF.
The protocol included pretreatment with transdermal AndroGel(r) (Besins) 25
mg, oral letrozole 2.5 mg and subcutaneous hCG 2500 IU; cycle control was
performed with estradiol valerate and micronized progesterone; ovarian
stimulation was attained with gonadotropins FSH/LH 450 IU, GnRH antagonist
and hCG 5000 IU. Results Fourteen poor responders were enrolled. One patient did not meet the
inclusion criteria. Thirteen patients previously summited to the standard
protocol were offered the ANDRO-IVF Protocol.-Standard Protocol: Mean age:
35.30 years; cancellation rate: 61.53%; mean number of MII oocytes retrieved
per patient: 1.8; fertilization rate: 33.33%. Only two patients had embryo
transfers, and none got pregnant.-ANDRO-IVF Protocol: Mean age: 35.83 years;
cancellation rate: 7.69%; mean number of oocytes retrieved per patient:
5.58, MII oocytes: 3.91. ICSI was performed in 84.61% of the patients and a
mean of 1.5 embryos were transferred per patient. Fertilization rate: 62.5%;
cumulative pregnancy rate: 16.66%; mean duration of stimulation: 9.77
days. Conclusion ANDRO-IVF allows intra-ovarian androgenization by increasing serum and
intra-follicular androgen levels and preventing androgen aromatization. This
protocol apparently improved clinical outcomes of poor responders in
parameters such as number of oocytes retrieved and clinical pregnancy rates.
Further randomized controlled trials are needed to confirm these
findings.
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Affiliation(s)
| | | | | | - Vanessa R Alves
- IVF Centre - Hospital Pérola Byington, São Paulo - SP, Brazil
| | - Nilka Donadio
- IVF Centre - Hospital Pérola Byington, São Paulo - SP, Brazil
| | - Artur Dzik
- IVF Centre - Hospital Pérola Byington, São Paulo - SP, Brazil
| | - Mario Cavagna
- IVF Centre - Hospital Pérola Byington, São Paulo - SP, Brazil
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Saharkhiz N, Zademodares S, Salehpour S, Hosseini S, Nazari L, Tehrani HG. The effect of testosterone gel on fertility outcomes in women with a poor response in in vitro fertilization cycles: A pilot randomized clinical trial. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2018; 23:3. [PMID: 29456560 PMCID: PMC5813298 DOI: 10.4103/jrms.jrms_864_17] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 09/23/2017] [Accepted: 10/08/2017] [Indexed: 01/05/2023]
Abstract
Background In this study, the effect of testosterone gel administration during ovulation induction on the fertility rate was examined in women with a poor ovarian response in in vitro fertilization (IVF) cycles. Materials and Methods The current study is a single-blinded, randomized clinical trial. Patients who met inclusion (Bologna) criteria were placed in the antagonist cycle group. The patients were randomly divided into two groups each included 25 participants treated with a placebo (lubricant gel, the controls) and testosterone gel (intervention). Fertility outcomes were compared between two study groups. Results The mean ± standard deviation (SD) age of intervention (41.04 ± 3.77) versus control group (39.69 ± 3.29) was not statistically different. The two studied groups were not statistically different in terms of follicle-stimulating hormone; antral follicle count, IVF, anti-Mullerian hormone, and the duration of infertility. The mean ± SD of oocyte 2.48 ± 1.64 versus 1.17 ± 1.27 and embryo 1.60 ± 1.58 versus 0.39 ± 0.58 in intervention group was significantly higher than control group (P < 0.01). The rate of pregnancy 16% versus 0% and embryo of quality A-B was significantly higher in intervention group than control (60% versus 17.4%, P < 0.05). Conclusion The results of the current study showed that the testosterone gel has a significant impact on the fertility rate in women with a poor response in the IVF cycles. Further, randomized clinical trials with larger sample sized are recommended.
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Affiliation(s)
- Nasrin Saharkhiz
- Department of Obstetrics, Shahid Beheshti University, Tehran, Iran
| | | | - Saghar Salehpour
- Department of Obstetrics, Shahid Beheshti University, Tehran, Iran
| | - Sedighe Hosseini
- Department of Obstetrics, Shahid Beheshti University, Tehran, Iran
| | - Leyla Nazari
- Department of Obstetrics, Shahid Beheshti University, Tehran, Iran
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Affiliation(s)
- Lee Koren
- The Mina and Everard Goodman Faculty of Life Sciences, Bar-Ilan University, Ramat Gan, 5290002, Israel.
| | - Ilanit Gordon
- Department of Psychology and Gonda Brain Research Center, Bar-Ilan University, Ramat Gan, 5290002, Israel
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[Poor responders: How could we improve our results?]. ACTA ACUST UNITED AC 2017; 45:95-103. [PMID: 28368802 DOI: 10.1016/j.gofs.2016.12.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 12/12/2016] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Finding an efficient treatment for poor responders still poses a tremendous challenge for assisted reproductive technology. In 2011, an international consensus has been reached in Bologna on how to standardize the definition of poor ovarian response (POR) in a simple and reproducible manner. This article provides an objective assessment of the different treatment options currently available. METHODS A search of the database PUBMED was carried out for studies published in English between October 2000 and April 2016. RESULTS There is no ideal protocol to manage poor responders even though the antagonist protocol seems to have an advantage of clinicians. This is thanks to better patient tolerance and reduced total dose of gonadotrophin as well as shorter time of stimulation. It seems that there is no benefit in increasing the gonadotrophin daily doses over 300IU nor using any specific type of gonadotrophin. Today, there is insufficient evidence to recommend any additional treatment for poor responders. Only dehydroepiandrosterone (DHEA) seems to increase embryonic quality and pregnancy rate, however further exploration and complementary prospective studies are necessary. CONCLUSION New treatment strategies such as "oocyte banking" or double stimulation during the same cycle, could provide new prospects in poor responders management.
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Polyzos NP, Davis SR, Drakopoulos P, Humaidan P, De Geyter C, Vega AG, Martinez F, Evangelou E, van de Vijver A, Smitz J, Tournaye H, Barri P. Testosterone for Poor Ovarian Responders: Lessons From Ovarian Physiology. Reprod Sci 2016; 25:980-982. [PMID: 27489169 DOI: 10.1177/1933719116660849] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Testosterone, an androgen that directly binds to the androgen receptor, has been shown in previous small randomized controlled trials to increase the reproductive outcomes of poor ovarian responders. In most of these studies, transdermal testosterone in relatively high doses was administered before ovarian stimulation with a duration varying from 5 to 21 days. Nevertheless, the key question to be asked is whether, based on ovarian physiology and testosterone pharmacokinetics, a short course of testosterone administration of more than 10 mg could be expected to have any beneficial effect on reproductive outcome. The rationale for asking this question lies in the existing scientific evidence derived from basic research and animal studies regarding the action of androgens during folliculogenesis, showing that their main effect in follicular development is defined during the earlier developmental stages. In addition, extreme testosterone excess is not only likely to induce adverse events but has also the potential to be ineffective and even detrimental. Thus, evidence from clinical studies is not enough to either "reopen" or "close" the "androgen chapter" in poor responders, mainly because the short administration and the high dose of testosterone is not in line with the ovarian actions of androgens and the presence of androgen receptors during follicular development.
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Affiliation(s)
- Nikolaos P Polyzos
- 1 Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium.,2 Fertility Clinic, Skive Regional Hospital, Skive, Denmark, and Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Susan R Davis
- 3 Women's Health Research Program, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Panagiotis Drakopoulos
- 1 Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Peter Humaidan
- 2 Fertility Clinic, Skive Regional Hospital, Skive, Denmark, and Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Christian De Geyter
- 4 Clinic of Gynaecological Endocrinology and Reproductive Medicine, University Hospital, University of Basel, Basel, Switzerland
| | | | - Francisca Martinez
- 6 Department of Obstetrics, Gynecology and Reproduction, Hospital Universitari Dexeus, Barcelona, Spain
| | - Evangelos Evangelou
- 7 Imperial College London, London, United Kingdom.,8 Department of Hygiene and Epidemeology, University of Ioannina Medical School, Ioannina, Greece
| | - Arne van de Vijver
- 1 Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Johan Smitz
- 1 Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Herman Tournaye
- 1 Centre for Reproductive Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Pedro Barri
- 6 Department of Obstetrics, Gynecology and Reproduction, Hospital Universitari Dexeus, Barcelona, Spain
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Jeve YB, Bhandari HM. Effective treatment protocol for poor ovarian response: A systematic review and meta-analysis. J Hum Reprod Sci 2016; 9:70-81. [PMID: 27382230 PMCID: PMC4915289 DOI: 10.4103/0974-1208.183515] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Poor ovarian response represents an increasingly common problem. This systematic review was aimed to identify the most effective treatment protocol for poor response. We searched MEDLINE, EMBASE, and The Cochrane Library from 1980 to October 2015. Study quality assessment and meta-analyses were performed according to the Cochrane recommendations. We found 61 trials including 4997 cycles employing 10 management strategies. Most common strategy was the use of gonadotropin-releasing hormone antagonist (GnRHant), and was compared with GnRH agonist protocol (17 trials; n = 1696) for pituitary down-regulation which showed no significant difference in the outcome. Luteinizing hormone supplementation (eight trials, n = 847) showed no difference in the outcome. Growth hormone supplementation (seven trials; n = 251) showed significant improvement in clinical pregnancy rate (CPR) and live birth rate (LBR) with an odds ratio (OR) of 2.13 (95% CI 1.06-4.28) and 2.96 (95% CI 1.17-7.52). Testosterone supplementation (three trials; n = 225) significantly improved CPR (OR 2.4; 95% CI 1.16-5.04) and LBR (OR 2.18; 95% CI 1.01-4.68). Aromatase inhibitors (four trials; n = 223) and dehydroepiandrosterone supplementation (two trials; n = 57) had no effect on outcome.
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Affiliation(s)
- Yadava Bapurao Jeve
- Leicester Fertility Centre, University Hospitals of Leicester, LE1 5WW, United Kingdom
| | - Harish Malappa Bhandari
- Department of Reproductive Medicine, Sub-specialty Trainee in Reproductive Medicine and Surgery, Newcastle Fertility Centre at Life, Newcastle upon Tyne, NE1 4EP, United Kingdom
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Arnon L, Hazut N, Tabachnik T, Weller A, Koren L. Maternal testosterone and reproductive outcome in a rat model of obesity. Theriogenology 2016; 86:1042-1047. [PMID: 27125699 DOI: 10.1016/j.theriogenology.2016.03.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 03/15/2016] [Accepted: 03/19/2016] [Indexed: 01/22/2023]
Abstract
Global sex differences in obesity rates are persistent, suggesting the involvement of sex steroids. In addition, adipose tissue is a metabolic site for steroidogenesis. Here, we compared female reproductive parameters in a rat model of obesity, with the same parameters in its lean control strain, and tested for an association with integrated measures of corticosterone and testosterone. Steroids were extracted and quantified from 17 Otsuka Long Evans Tokushima Fatty (OLETF; an animal model for obesity) and 13 Long Evans Tokushima Otsuka (LETO; the lean control strain) hair samples that were collected after weaning offspring. The obese OLETF mothers had higher hair testosterone levels than the control LETO strain. Overall, testosterone, but not corticosterone, predicted litter sex ratios. Younger mothers with large litters and older mothers with small litters tended to have the highest sex ratios (i.e., male-biased litters). In the lean LETO strain, but not in the obese OLETF, maternal testosterone was positively associated with litter size and number of male pups. Corticosterone did not differ between the two strains and was not associated with testosterone or with reproductive parameters. This study suggests that long-term circulating testosterone is associated with female reproduction in multiple ways. The possible trade-off between litter size and sex ratio may be mediated by testosterone and influenced by body fat and composition, which influence the individual's well-being. Exploring the multiple roles of testosterone in females may also help explain the complex relationship between obesity and reproduction.
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Affiliation(s)
- Liat Arnon
- Faculty of Life Sciences, Bar Ilan University, Ramat-Gan 5290002, Israel
| | - Noa Hazut
- Faculty of Life Sciences, Bar Ilan University, Ramat-Gan 5290002, Israel; Gonda Brain Research Center, Bar Ilan University, Ramat-Gan 5290002, Israel
| | - Tzlil Tabachnik
- Faculty of Life Sciences, Bar Ilan University, Ramat-Gan 5290002, Israel; Gonda Brain Research Center, Bar Ilan University, Ramat-Gan 5290002, Israel
| | - Aron Weller
- Gonda Brain Research Center, Bar Ilan University, Ramat-Gan 5290002, Israel; Department of Psychology, Bar Ilan University, Ramat-Gan 5290002, Israel
| | - Lee Koren
- Faculty of Life Sciences, Bar Ilan University, Ramat-Gan 5290002, Israel.
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Xiao S, Li Y, Long L, Luo C, Mai Q. Basal serum testosterone levels correlate with ovarian reserve and ovarian response in cycling women undergoing in vitro fertilization. Gynecol Endocrinol 2016; 32:51-4. [PMID: 26299634 DOI: 10.3109/09513590.2015.1076784] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Shan Xiao
- a Reproductive Medicine Center, First Affiliated Hospital of Sun Yat-Sen University , Guangdong , People's Republic of China
- b Shenzhen Key Laboratory of Reproductive Immunology for Peri-implantation , Fertility Center, Shenzhen Zhongshan Urology Hospital , Guangdong , People's Republic of China
| | - Yubin Li
- a Reproductive Medicine Center, First Affiliated Hospital of Sun Yat-Sen University , Guangdong , People's Republic of China
| | - Lingli Long
- c Translational Medicine Center, First Affiliated Hospital of Sun Yat-Sen University , Guangdong , People's Republic of China , and
| | - Canqiao Luo
- d Department of Pathology , First Affiliated Hospital of Sun Yat-Sen University , Guangdong , People's Republic of China
| | - Qingyun Mai
- a Reproductive Medicine Center, First Affiliated Hospital of Sun Yat-Sen University , Guangdong , People's Republic of China
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Nagels HE, Rishworth JR, Siristatidis CS, Kroon B. Androgens (dehydroepiandrosterone or testosterone) for women undergoing assisted reproduction. Cochrane Database Syst Rev 2015; 2015:CD009749. [PMID: 26608695 PMCID: PMC10559340 DOI: 10.1002/14651858.cd009749.pub2] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
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.
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Affiliation(s)
- Helen E Nagels
- University of AucklandObstetrics and GynaecologyFMHS Park RoadGraftonAucklandNew Zealand1142
| | - Josephine R Rishworth
- University of AucklandObstetrics and GynaecologyFMHS Park RoadGraftonAucklandNew Zealand1142
| | - Charalampos S Siristatidis
- University of AthensAssisted Reproduction Unit, 3rd Department of Obstetrics and GynaecologyAttikon University Hospital,Rimini 1AthensChaidariGreece12462
| | - Ben Kroon
- Queensland Fertility Group Research Foundation55 Little Edward St, Level 2 Boundary CourtSpring HillBrisbaneQueenslandAustralia4000
- The University of QueenslandObstetrics & GynaecologyBrisbaneQueenslandAustralia4072
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Chen YP, Wu WH, Wu HM, Chen CK, Wang HS, Huang HY. Effects of anti-Müllerian hormone and follicle stimulating hormone levels on in vitro fertilization pregnancy rate. Taiwan J Obstet Gynecol 2015; 53:313-6. [PMID: 25286783 DOI: 10.1016/j.tjog.2013.06.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2013] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To analyze the relationship between in vitro fertilization (IVF) pregnancy rate and basal serum hormone levels before patients begin an IVF course. MATERIALS AND METHODS In this retrospective study, we analyzed patients with anti-Müllerian hormone (AMH) data and IVF data from January 2009 to October 2012. Pregnancy rates were calculated by AMH and follicle stimulating hormone quartiles and analyzed using the independent samples t test. Furthermore, patients were divided into three groups by age. The Chi-square test was used to assess the association between the parameters and IVF pregnancy rates. RESULTS From the 910 IVF treatment courses, 377 (41.4%) clinical pregnancies resulted. The pregnant and nonpregnant groups differed significantly in age and FSH and AMH levels. The pregnancy rate was 53.3% for patients aged <32 years and 22.1% for patients aged >38 years. The pregnancy rate was 53.4% for patients with FSH levels <5.6 mIU/mL and 25.8% for patients with FSH levels >8.9 mIU/mL. The pregnancy rate was 56.8% for patients with AMH levels >4.0 ng/mL and 20.0% for patients with AMH levels <1.1 ng/mL. Furthermore, among patients aged <40 years, AMH and FSH were significantly associated with pregnancy rate. Higher pregnancy rates were found among the groups with higher AMH levels than in groups with lower AMH levels. CONCLUSION For patients aged <40 years, basal serum AMH level and FSH level affected the IVF pregnancy rate, and patients with higher AMH levels had better pregnancy rates.
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Affiliation(s)
- Yi-Pin Chen
- Department of Gynecology, Center for Traditional Chinese Medicine, Chang Gung Memorial Hospital, Taoyuan County, Taiwan
| | - Wen-Hsiang Wu
- Department of Healthcare Management, Yuanpei University, Hsinchu, Taiwan
| | - Hsien-Ming Wu
- Department of Obstetrics and Gynecology, Chang Gung University College of Medicine, Linkou Medical Center, Taoyuan County, Taiwan
| | - Chun-Kai Chen
- Department of Obstetrics and Gynecology, Chang Gung University College of Medicine, Linkou Medical Center, Taoyuan County, Taiwan
| | - Hsin-Shih Wang
- Department of Obstetrics and Gynecology, Chang Gung University College of Medicine, Linkou Medical Center, Taoyuan County, Taiwan
| | - Hong-Yuan Huang
- Department of Obstetrics and Gynecology, Chang Gung University College of Medicine, Linkou Medical Center, Taoyuan County, Taiwan.
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Haydardedeoğlu B, Işık AZ, Bulgan Kılıçdağ E. The combination of dehydroepiandrosterone, transdermal testosterone, and growth hormone as an adjuvant therapy in assisted reproductive technology cycles in patients aged below 40 years with diminished ovarian reserve. Turk J Obstet Gynecol 2015; 12:60-65. [PMID: 28913044 PMCID: PMC5558377 DOI: 10.4274/tjod.32656] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 05/03/2015] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To evaluate to the efficacy of testosterone, dehydroepiandrosterone (DHEA) and growth hormone (GH) supplementations in patients with diminished ovarian reserve (DOR) in assisted reproductive technology (ART) cycles. MATERIALS AND METHODS A retrospective cohort including 33 women with 81 ART cycles were aged and ovarian reserve matched 52 women with 102 conventional in vitro fertilization (IVF)/intra-cytoplasmic sperm injection (ICSI) protocol. Administration of DHEA for 12 weeks and transdermal testosterone for 4 weeks as pretreatment adjuvant and luteal start GH in DOR patient treatment arm compared to conventional IVF/ICSI cycles. RESULTS The number of follicles >14 mm, number of oocytes, number of metaphase 2 oocytes and fertilisation rate were significantly higher in ISIK protocol (IP). The clinical pregnancy rate (CPR) per embryo transfer of the IP was 38.2% (13/34). The cancellation rate of cycles decreased significantly from 54.5 % (24/44) to 8.1% (3/37) with the IP, while the OPR was 35.3% (12/34). CONCLUSIONS Our study has shown that even the poorest responders could achieve clinical pregnancy after inducing ovarian folliculogenesis with a combination of transdermal testosterone, DHEA and GH.
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Affiliation(s)
- Bülent Haydardedeoğlu
- Başkent University Faculty of Medicine, Department of Obstetrics and Gynecology, Adana, Turkey
| | - Ahmet Zeki Işık
- İzmir University Faculty of Medicine, Department of Obstetrics and Gynecology, İzmir, Turkey
| | - Esra Bulgan Kılıçdağ
- Başkent University Faculty of Medicine, Department of Obstetrics and Gynecology, Adana, Turkey
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Kim CH, Ahn JW, Moon JW, Kim SH, Chae HD, Kang BM. Ovarian Features after 2 Weeks, 3 Weeks and 4 Weeks Transdermal Testosterone Gel Treatment and Their Associated Effect on IVF Outcomes in Poor Responders. Dev Reprod 2015; 18:145-52. [PMID: 25949183 PMCID: PMC4282212 DOI: 10.12717/dr.2014.18.3.145] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Revised: 07/28/2014] [Accepted: 08/04/2014] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- Chung-Hoon Kim
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, College of Medicine, University of Ulsan, Asan Medical Center, Seoul 138-736, Korea
| | - Jun-Woo Ahn
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, College of Medicine, University of Ulsan, Ulsan University Hospital, Ulsan 682-714, Korea
| | - Jei-Won Moon
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, College of Medicine, University of Ulsan, Asan Medical Center, Seoul 138-736, Korea
| | - Sung-Hoon Kim
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, College of Medicine, University of Ulsan, Asan Medical Center, Seoul 138-736, Korea
| | - Hee-Dong Chae
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, College of Medicine, University of Ulsan, Asan Medical Center, Seoul 138-736, Korea
| | - Byung-Moon Kang
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, College of Medicine, University of Ulsan, Asan Medical Center, Seoul 138-736, Korea
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In vitro fertilization versus conversion to intrauterine insemination in Bologna-criteria poor responders: how to decide which option? Fertil Steril 2014; 102:1596-601. [DOI: 10.1016/j.fertnstert.2014.08.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Revised: 08/10/2014] [Accepted: 08/14/2014] [Indexed: 11/21/2022]
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Abstract
For many decades, elevated androgens in women have been associated with poor reproductive health. However, recent studies have shown that androgens play a crucial role in women's fertility. The following review provides an overall perspective about how androgens and androgen receptor-mediated actions regulate normal follicular development, as well as discuss emerging concepts, latest perceptions, and controversies regarding androgen actions and signaling in the ovary.
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Affiliation(s)
- Hen Prizant
- Division of Endocrinology and MetabolismDepartment of Medicine, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, PO Box 693, Rochester, New York 14642, USACenter for Human ReproductionNew York, New York 10021, USA
| | - Norbert Gleicher
- Division of Endocrinology and MetabolismDepartment of Medicine, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, PO Box 693, Rochester, New York 14642, USACenter for Human ReproductionNew York, New York 10021, USA
| | - Aritro Sen
- Division of Endocrinology and MetabolismDepartment of Medicine, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, PO Box 693, Rochester, New York 14642, USACenter for Human ReproductionNew York, New York 10021, USADivision of Endocrinology and MetabolismDepartment of Medicine, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, PO Box 693, Rochester, New York 14642, USACenter for Human ReproductionNew York, New York 10021, USA
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Poor responders and androgen adjuvant treatment: "Still haven't found what I'm looking for...". Reprod Biomed Online 2014; 28:661-2. [PMID: 24899085 DOI: 10.1016/j.rbmo.2014.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Sun B, Wang F, Sun J, Yu W, Sun Y. Basal serum testosterone levels correlate with ovarian response but do not predict pregnancy outcome in non-PCOS women undergoing IVF. J Assist Reprod Genet 2014; 31:829-35. [PMID: 24849376 DOI: 10.1007/s10815-014-0246-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 05/05/2014] [Indexed: 01/13/2023] Open
Abstract
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.
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Affiliation(s)
- Bo Sun
- Reproductive Medical Center, First Affiliated Hospital of Zhengzhou University, Henan, China
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Bentov Y, Burstein E, Firestone C, Firestone R, Esfandiari N, Casper RF. Can cycle day 7 FSH concentration during controlled ovarian stimulation be used to guide FSH dosing for in vitro fertilization? Reprod Biol Endocrinol 2013; 11:12. [PMID: 23433095 PMCID: PMC3607851 DOI: 10.1186/1477-7827-11-12] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Accepted: 02/12/2013] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND When stimulating a patient with poor ovarian response for IVF, the maximal dose of gonadotropins injected is often determined by arbitrary standards rather than a measured response. The purpose of this study was to determine if serum FSH concentration during an IVF stimulation cycle reflects follicular utilization of FSH and whether serum FSH values may inform dose adjustments of exogenous FSH. METHODS In this retrospective cross sectional study we studied 155 consecutive IVF cycles stimulated only with recombinant human FSH. We only included long GnRH agonist protocols in which endogenous FSH levels were suppressed. We correlated the serum concentration of cycle day (CD) 7 FSH with the number of oocytes retrieved, cleaving embryos and pregnancy rate. RESULTS We found that a CD7 FSH concentration above 22 IU/L was associated with poor response regardless of the daily dose of FSH injected and a lower pregnancy rate. CONCLUSIONS We concluded that CD7 FSH concentration during stimulation could be used to guide FSH dosing in poor responders. If the CD7 FSH concentration is above 22 IU/L increasing the dose of FSH in an attempt to recruit more growing follicles is unlikely to be successful.
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Affiliation(s)
- Yaakov Bentov
- Toronto Centre for Advanced Reproductive Technology, Toronto, ON, Canada.
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