Predictive value of androgens and multivariate model for poor ovarian response

The effect of letrozole overlapped with gonadotropin on IVF outcomes in women with DOR or aged over 40 years old with repeated cycles

BACKGROUND

Evaluating the efficacy of letrozole overlapped with gonadotropin-modified letrozole protocol (mLP) for diminished ovarian reserve (DOR) or advanced-age women with repeated cycles.

METHODS

This is a retrospectively registered, paired-match study including 243 women with DOR and 249 women aged over 40 years old who received in vitro fertilization (IVF) treatment. 123 women received stimulation with mLP (mLP group). GnRH agonist (GnRH-a) long, GnRH antagonist (GnRH-anta), and mild stimulation protocol were used as controls with 123 women in each group. We further analyzed 50 of 123 patients in the mLP group who have experienced more than one failed cycles with other ovarian stimulation protocols (non-mLP group). Clinical pregnancy rate (CPR), cumulative clinical pregnancy rate (CCPR), and live birth rate (LBR) were main outcomes.

RESULTS

The CPR in the mLP group (38.46%) was significantly higher than mild stimulation (17.11%), but not significantly different from GnRH-a long (26.13%) and GnRH-anta (29.17%) group. The CCPR showed an increasing trend in the mLP group (33.33%) although without significance when compared with controls. The CCRP of GnRH-a long, GnRH-anta, mild stimulation group were 21.68%, 29.03%, and 13.04%, respectively. In women with repeated cycles, mLP achieved the higher available embryo rate (P < 0.05), the top-quality embryo rate, the CPR (P < 0.001), and the LBR (P < 0.001). Further study showed a positive correlation between testosterone and the number of oocytes retrieved in the mLP group (r = 0.395, P < 0.01).

CONCLUSION

The mLP may be effective for aged or DOR women who have experienced previous cycle failure by improving the quality of embryos, the CPR, and the LBR. An increasing serum testosterone level may reflect follicular growth during ovarian stimulation.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Revisiting the physiological role of androgens in women

INTRODUCTION

Extensive research underlines the critical functions of androgens in females. Nevertheless, the precise mechanisms of their action are poorly understood. Here, we review the existing literature regarding the physiological role of androgens in women throughout life.

AREAS COVERED

Several studies show that androgen receptors (ARs) are broadly expressed in numerous female tissues. They are essential for many physiological processes, including reproductive, sexual, cardiovascular, bone, muscle, and brain health. They are also involved in adipose tissue and liver function. Androgen levels change with the menstrual cycle and decrease in the first decades of life, independently of menopause.

EXPERT OPINION

To date, studies are limited by including small numbers of women, the difficulty of dosing androgens, and their cyclical variations. In particular, whether androgens play any significant role in regulating the establishment of pregnancy is poorly understood. The neural functions of ARs have also been investigated less thoroughly, although it is expressed at high levels in brain structures. Moreover, the mechanism underlying the decline of dehydroepiandrosterone (DHEA) and dehydroepiandrosterone sulfate (DHEAS) with age is unclear. Other factors, including estrogen's effect on adrenal androgen production, reciprocal regulation of ARs, and non-classical effects of androgens, remain to be determined.

The role of androgens in women's health and wellbeing

Androgens in women, as well as in men, are intrinsic to maintenance of (i) reproductive competency, (ii) cardiac health, (iii) appropriate bone remodeling and mass retention, (iii) muscle tone and mass, and (iv) brain function, in part, through their mitigation of neurodegenerative disease effects. In recognition of the pluripotency of endogenous androgens, exogenous androgens, and selected congeners, have been prescribed off-label for several decades to treat low libido and sexual dysfunction in menopausal women, as well as, to improve physical performance. However, long-term safety and efficacy of androgen administration has yet to be fully elucidated. Side effects often observed include (i) hirsutism, (ii) acne, (iii) deepening of the voice, and (iv) weight gain but are associated most frequently with supra-physiological doses. By contrast, short-term clinical trials suggest that the use of low-dose testosterone therapy in women appears to be effective, safe and economical. There are, however, few clinical studies, which have focused on effects of androgen therapy on pre- and post-menopausal women; moreover, androgen mechanisms of action have not yet been thoroughly explained in these subjects. This review considers clinical effects of androgens on women's health in order to prevent chronic diseases and reduce cancer risk in gynecological tissues.

Expression of genes that regulate follicle development and maturation during ovarian stimulation in poor responders

RESEARCH QUESTION

Sex hormone-binding globulin (SHBG), androgen receptor (AR), LH beta polypeptide (LHB), progesterone receptor membrane component 1 (PGRMC1) and progesterone receptor membrane component 2 (PGRMC2) regulate follicle development and maturation. Their mRNA expression was assessed in peripheral blood mononuclear cells (PBMC) of normal and poor responders, during ovarian stimulation.

DESIGN

Fifty-two normal responders and 15 poor responders according to the Bologna criteria were enrolled for IVF and intracytoplasmic sperm injection and stimulated with 200 IU of follitrophin alpha and gonadotrophin-releasing hormone antagonist. HCG was administered for final oocyte maturation. On days 1, 6 and 10 of stimulation, blood samples were obtained, serum hormone levels were measured, RNA was extracted from PBMC and real-time polymerase chain reaction was carried out to identify the mRNA levels. Relative mRNA expression of each gene was calculated by the comparative 2^-DDCt method.

RESULTS

Differences between mRNA levels of each gene on the same time point between the two groups were not significant. PGRMC1 and PGRMC2 mRNA levels were downregulated, adjusted for ovarian response and age. Positive correlations between PGRMC1 and AR (standardized beta = 0.890, P < 0.001) from day 1 to 6 and PGRMC1 and LHB (standardized beta = 0.806, P < 0.001) from day 1 to 10 were found in poor responders. PGRMC1 and PGRMC2 were positively correlated on days 6 and 10 in normal responders.

CONCLUSIONS

PGRMC1 and PGRMC2 mRNA are significantly decreased during ovarian stimulation, with some potential differences between normal and poor responders.

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

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

Serum dehydroepiandrosterone sulphate concentration is not a predictive factor in IVF outcomes before the first cycle of GnRH agonist administration in women with normal ovarian reserve

Objective

The aim of our study was to determine whether serum dehydroepiandrosterone sulphate (DHEAS) concentration and the models incorporating it could help clinicians to predict IVF outcomes in women with normal ovarian reserve undergoing their first long protocol.

Study Design

We performed a retrospective analysis of 459 women undergoing cycles of intracytoplasmic sperm injection (ICSI) for the first time in a long GnRH agonist protocol.

Results

Embryo transfer was performed in 407 women (88.7%). The fertilisation rate was 78.6%. The clinical pregnancy rate was 44.8% per started cycle and 50.6% per embryo transfer. Our univariate model revealed that the best predictors of clinical pregnancy were the number of mature oocytes, the number of embryos transferred and the number of good quality embryos, account for the clinical parameters that reflect ovarian reserve the best being AMH level and AFC. DHEAS did not predict clinical pregnancy (OR 1.001, 95% CI, 0.999–1.004). After adjusting for the number of embryos transferred and class of embryos in a multivariate model, the best predictors were age (OR 0.918, 95% CI, 0.867–0.972) and AFC (OR 1.022, 95% CI, 0.992–1.053). Serum DHEAS levels were positively correlated with AFC (r = 0.098, P<0.039) and testosterone levels (r = 0.371, P<0.001), as well as the number of mature oocytes (r = 0.109, P<0.019); serum DHEAS levels were negatively correlated with age (r = -0.220, P<0.001), follicle-stimulating hormone (FSH), (r = -0.116, P<0.015) and sex hormone-binding globulin (SHBG), (r = -0.193, P<0.001).

Conclusions

DHEAS concentration (in addition to the known factors of ovarian reserve) does not predict clinical pregnancy in women with normal ovarian reserve who are undergoing ICSI.