Effects of dehydroepiandrosterone supplementation on women with poor ovarian response: A preliminary report and review

Efficacy of dehydroepiandrosterone priming in women with poor ovarian response undergoing IVF/ICSI: a meta-analysis

Background

Dehydroepiandrosterone (DHEA) may improve the outcomes of patients with poor ovarian response (POR) or diminished ovarian reserve (DOR) undergoing IVF/ICSI. However, the evidence remains inconsistent. This study aimed to investigate the efficacy of DHEA supplementation in patients with POR/DOR undergoing IVF/ICSI.

Methods

PubMed, Web of Science, Cochrane Library, China National Knowledge Infrastructure (CNKI) were searched up to October 2022.

Results

A total of 32 studies were retrieved, including 14 RCTs, 11 self-controlled studies and 7 case-controlled studies. In the subgroup analysis of only RCTs, DHEA treatment significantly increased the number of antral follicle count (AFC) (weighted mean difference : WMD 1.18, 95% confidence interval(CI): 0.17 to 2.19, P=0.022), while reduced the level of bFSH (WMD -1.99, 95% CI: -2.52 to -1.46, P<0.001), the need of gonadotropin (Gn) doses (WMD -382.29, 95% CI: -644.82 to -119.76, P=0.004), the days of stimulation (WMD -0.90, 95% CI: -1.34 to -0.47, P <0.001) and miscarriage rate (relative risk : RR 0.46, 95% CI: 0.29 to 0.73, P=0.001). The higher clinical pregnancy and live birth rates were found in the analysis of non-RCTs. However, there were no significant differences in the number of retrieved oocytes, the number of transferred embryos, and the clinical pregnancy and live birth rates in the subgroup analysis of only RCTs. Moreover, meta-regression analyses showed that women with lower basal FSH had more increase in serum FSH levels (b=-0.94, 95% CI: -1.62 to -0.25, P=0.014), and women with higher baseline AMH levels had more increase in serum AMH levels (b=-0.60, 95% CI: -1.15 to -0.06, P=0.035) after DHEA supplementation. In addition, the number of retrieved oocytes was higher in the studies on relatively younger women (b=-0.21, 95% CI: -0.39 to -0.03, P=0.023) and small sample sizes (b=-0.003, 95% CI: -0.006 to -0.0003, P=0.032).

Conclusions

DHEA treatment didn't significantly improve the live birth rate of women with DOR or POR undergoing IVF/ICSI in the subgroup analysis of only RCTs. The higher clinical pregnancy and live birth rates in those non-RCTs should be interpreted with caution because of potential bias. Further studies using more explicit criteria to subjects are needed.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD 42022384393.

The effect of medication on serum anti-müllerian hormone (AMH) levels in women of reproductive age: a meta-analysis

OBJECTIVE

The study aims to address whether serum anti-müllerian hormone (AMH) levels fluctuate in the short term after medication application, including oral contraceptives (OCs), metformin (MET), Gonadotropin-releasing hormone agonist (GnRH-a), dehydroepiandrosterone (DHEA), vitamin D (VD), clomiphene citrate (CC), and letrozole (LET).

METHODS

Published literature from PubMed, Embase, and Cochrane central was retrieved up until 19 September 2021. A total of 51 self-control studies with an average Newcastle-Ottawa quality assessment scale (NOS) score of 6.90 were analyzed. The extracted data were entered into Stata software, and the weighted mean difference/standardized mean difference (WMD/SMD) and 95% confidence interval (CI) were used for data analysis.

RESULTS

After OCs treatment the AMH level showed a significant decline in women with normal ovarian function, which was significant within 3 months (WMD = -1.43, 95% CI: -2.05 to -0.80, P < 0.00001). After MET treatment, the serum AMH decreased in polycystic ovary syndrome (PCOS) patients (WMD = -1.79, 95% CI: -2.32 to -1.26, P < 0.00001), in both obese and non-obese patients. GnRH-a treatment in endometriosis patients led to dynamic changes in the serum AMH levels, that is, ascent at 1 month (P = 0.05), and descent at 3 months (P = 0.02). After DHEA treatment the serum AMH increased in diminished ovarian reserve (DOR) / poor ovarian response (POR) patients (WMD = 0.18, 95% CI: 0.09 to 0.27, P < 0.0001). After VD treatment the serum AMH increased, and it was obvious in non-PCOS patients (WMD = 0.78, 95% CI: 0.34 to 1.21, P = 0.0004). After CC treatment the serum AMH decreased significantly in PCOS patients, specifically in non-obese patients (WMD = -1.24, 95% CI: -1.87 to -0.61, P = 0.0001).

CONCLUSIONS

Serum AMH levels may be affected in the short term after drug application. Specifically, OC, MET and CC lead to decreased AMH level, DHEA and VD lead to increased AMH level, and GnRH-a leads to dynamic variation, which is correlated with PCOS, obesity, age, and duration of medication. The impacts of these medications should be taken into consideration when AMH is used as a marker of ovarian reserve.

Randomized Controlled Study of the Effects of DHEA on the Outcome of IVF in Endometriosis

Objective

To investigate the effect of dehydroepiandrosterone (DHEA) on the outcome of in vitro fertilization (IVF) in patients with endometriosis (EMT).

Methods

Female patients diagnosed with EMT in our hospital from May 2018 to May 2019 were selected. The patients were divided into the control group (n = 22) and the DHEA group (n = 22) according to the random number table. Patients in the control group received placebo and patients in the DHEA group received DHEA. Patients in both groups received either DHEA (25 mg) or placebo orally 3 times a day for 90 days from the first day of menstruation. Patients were subsequently treated with an IVF cycle. In the control group, 22 patients completed the first cycle and 13 patients completed the second cycle. In the DHEA group, 22 patients completed the first cycle and 11 patients completed the second cycle. Serum sex hormone levels including serum E2 on hCG day, mean progesterone on hCG day, FSH on day 2, AMH on day 2, and gonadotropin dose were determined using a chemiluminescent immunoassay kit. The number of antral follicles of the bilateral ovaries was counted by transvaginal B-ultrasound, and the maximum length and transverse diameter of the ovaries were measured at the same time, to calculate the average diameter of the ovaries, observe the morphology of endometrium, and measure the thickness of the endometrium. The implantation rate, clinical pregnancy rate, persistent pregnancy rate, and live birth rate were compared between the two groups.

Results

There were no significant differences in serum E2, progesterone, endometrial thickness, recovered oocytes, mean number of transferred embryos, and mean score of leading embryo transfer between the DHEA group and the women who completed the first and second cycles (P > 0.05). The AMH, antral follicle count, serum E2 on hCG day, the number of recovered oocytes, fertilized oocytes, and the fertilization rate in the DHEA group were higher than those in the control group (P < 0.05). The doses of FSH on day 2, COH on day 3, and gonadotropin were lower than those in the control group (P < 0.05). There was no significant difference in the total number of embryos, the number of high-quality embryos, and the number of transplanted embryos between the two groups (P > 0.05). The implantation rate, clinical pregnancy rate, persistent pregnancy rate, and live birth rate in the DHEA group were higher than those in the control group (P < 0.05).

Conclusion

DHEA can significantly increase serum E2 level and improve IVF outcome by regulating the hormone synthesis process, thus improving oocyte and embryo quality.

The Molecular Regulation in the Pathophysiology in Ovarian Aging

The female reproductive system is of great significance to women’s health. Aging of the female reproductive system occurs approximately 10 years prior to the natural age-associated functional decline of other organ systems. With an increase in life expectancy worldwide, reproductive aging has gradually become a key health issue among women. Therefore, an adequate understanding of the causes and molecular mechanisms of ovarian aging is essential towards the inhibition of age-related diseases and the promotion of health and longevity in women. In general, women begin to experience a decline in ovarian function around the age of 35 years, which is mainly manifested as a decrease in the number of ovarian follicles and the quality of oocytes. Studies have revealed the occurrence of mitochondrial dysfunction, reduced DNA repair, epigenetic changes, and metabolic alterations in the cells within the ovaries as age increases. In the present work, we reviewed the possible factors of aging-induced ovarian insufficiency based on its clinical diagnosis and performed an in-depth investigation of the relevant molecular mechanisms and potential targets to provide novel approaches for the effective improvement of ovarian function in older women.

Effects of metformin treatment on pregnancy outcomes in patients with polycystic ovary syndrome

INTRODUCTION

This review covers the current evidence regarding the use of metformin as a therapeutic intervention for optimizing pregnancy outcomes in women with polycystic ovary syndrome (PCOS).

AREAS COVERED

After searching Medline, Embase and CINAHL, all important large clinical trials and observational studies plus systematic reviews, meta-analyses and Cochrane reviews have been summarized here. The results have been compared to culminate in a thorough review and discussion on the use of metformin in relation to reproductive outcomes for women with PCOS. The role of metformin in PCOS is explored both in terms of achieving conception and during pregnancy. The existing evidence around metformin use is summarized both during the preconceptual period and during pregnancy, in relation to reproductive outcomes.

EXPERT OPINION

Metformin is a widely used medication, often prescribed to improve reproductive outcomes for women with PCOS. However, the evidence remains equivocal regarding its efficacy both in optimizing fertility and pregnancy outcomes. More research is required with special emphasis on metformin use within different populations, including ethnic groups and women with varying BMI ranges.

The Role of Androgen Supplementation in Women With Diminished Ovarian Reserve: Time to Randomize, Not Meta-Analyze

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.

Sigma-1 receptor is involved in diminished ovarian reserve possibly by influencing endoplasmic reticulum stress-mediated granulosa cells apoptosis

Sigma non-opioid intracellular receptor 1 (sigma-1 receptor), a non-opioid transmembrane protein, is located on cellular mitochondrial membranes and endoplasmic reticulum. Current research has demonstrated that sigma-1 receptor is related to human degenerative diseases. This study is focused on the effects of sigma-1 receptor on the pathophysiological process of diminished ovarian reserve (DOR) and granulosa cells (GCs) apoptosis. Sigma-1 receptor concentration in follicular fluid (FF) and serum were negatively correlated with basal follicle-stimulating hormone (FSH) and positively correlated with anti-mullerian hormone (AMH), antral follicle count (AFC). Sigma-1 receptor reduction in GCs was accompanied by endoplasmic reticulum stress (ERS)-mediated apoptosis in women with DOR. Plasmid transfection was used to establish SIGMAR1-overexpressed and SIGMAR1-knockdown human granulosa-like tumor (KGN) cell and thapsigargin (TG) was used to induce ERS KGN cells. We found that KGN cells treated with endogenous sigma-1 receptor ligand dehydroepiandrosterone (DHEA) and sigma-1 receptor agonist PRE-084 showed similar biological effects to SIGMAR1-overexpressed KGN cells and opposite effects to SIGMAR1-knockdown KGN cells. DHEA may improve DOR patients' pregnancy outcomes by upregulating sigma-1 receptor and downregulating ERS-mediated apoptotic genes in GCs. Thus, sigma-1 receptor may be a potential ovarian reserve biomarker, and ligand-mediated sigma-1 receptor activation could be a future approach for DOR therapy.

The impact of dehydroepiandrosterone in poor ovarian responders on assisted reproduction technology treatment

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.

Correlation between luteinizing hormone receptor gene expression in human granulosa cells with oocyte quality in poor responder patients undergoing in vitro fertilization: A cross-sectional study

Background: This study was performed to evaluate the role of luteinizing hormone (LH) and granulosa cell LH receptor (LH-R) in poor responder patients who underwent controlled ovarian stimulation. Expression levels of LH-R mRNA in granulosa cells was investigated and compared with oocyte morphology, oocyte maturity and fertilization rate.  Methods: Granulosa cells were obtained from 30 patients who underwent in vitro fertilization (IVF) at Dr. Cipto Mangunkusumo Hospital, Jakarta. The patients were divided into two groups: group I (n=10) poor responders; and group II (n=20) non-poor responders. After the extraction of total RNA from granulosa cells, semi-quantitative RT-PCR was performed and the amount of LH-R mRNA was quantified. The relative values were calculated as the ratio of LH-R mRNA and actin beta mRNA. Statistical analysis was performed using Mann-Whitney test and Spearman correlation.  Results: The relative value of LH-R mRNA was higher in group I compared with group II (27.37[0.00-28939.37] vs 0.00[0.00-7196.12]). Oocyte maturity (r=0.267) and morphology (r=0.267) in group I consistently showed a positive correlation with LH-R mRNA; in group II a negative correlation with LH-R mRNA was shown for oocyte maturity (r= -0.552) and morphology (r= -0.164). Group I had a positive correlation between LH-R expression with fertilization rate (r=0.430), and group II showed a negative correlation (r=-0.340).  Conclusions: The expression of LH-R mRNA has a positive correlation with oocyte quality in poor responder patients and a negative correlation in non-poor responders. Our study suggests an optimal expression of LH- R mRNA in granulosa cells during controlled ovarian stimulation to obtain good quality oocytes.

Dehydroepiandrosterone Research: Past, Current, and Future

The discovery of "oestrus-producing" hormones was a major research breakthrough in biochemistry and pharmacology during the early part of the 20th century. The elucidation of the molecular weight and chemical structure of major oxidative metabolites of dehydroepiandrosterone (DHEA) led to the award of the Nobel Prize in 1939 to Adolf Frederick Johann Butenandt and Leopold Ruzicka. Considered a bulk androgen in the circulation, DHEA and its sulfated metabolite DHEA-S can be taken up by most tissues where the sterols are metabolized to active androgenic and estrogenic compounds needed for growth and development. Butenandt's interactions with the German pharmaceutical company Schering led to production of gram quantities of these steroids and other chemically modified compounds of this class. Sharing chemical expertise allowed Butenandt's laboratory at the Kaiser Wilhelm Institute to isolate and synthesize many steroid compounds in the elucidation of the pathway leading from cholesterol to testosterone and estrogen derivatives. As a major pharmaceutical company worldwide, Schering AG sought these new biological sterols as pharmacological agents for endocrine-related diseases, and the European medical community tested these compounds in women for conditions such as postmenopausal depression, and in men for increasing muscle mass. Since it was noted that circulating DHEA-S levels decline as a function of age, experimental pathology experiments in animals were performed to determine how DHEA may protect against cancer, diabetes, aging, obesity, immune function, bone density, depression, adrenal insufficiency, inflammatory bowel disease, diminished sexual function/libido, AIDS/HIV, chronic obstructive pulmonary disease, coronary artery disease, chronic fatigue syndrome, and metabolic syndrome. While the mechanisms by which DHEA ameliorates these conditions in animal models have been elusive to define, even less is known about its role in human disease, other than as a precursor to other sterols, e.g., testosterone and estradiol. Our groups have shown that DHEA and many of its oxidative metabolites serve as a low-affinity ligands for hepatic nuclear receptors, such as the pregnane X receptor, the constitutive androstane receptor, and estrogen receptors α/β (ERα/ERβ) as well as G protein-coupled ER (GPER1). This chapter highlights the founding research on DHEA from a historical perspective, provides an overview of DHEA biosynthesis and metabolism, briefly summarizes the early work on the beneficial effects attributed to DHEA in animals, and summarizes the human trials addressing the action of DHEA as a therapeutic agent. In general, most human studies involve weak correlations of circulating levels of DHEA and disease outcomes. Some support for DHEA as a therapeutic compound has been demonstrated for postmenopausal women, in vitro fertilization, and several autoimmune disorders, and adverse health effects, such as, acne, embryo virilization during pregnancy, and possible endocrine-dependent cancers.

Dehydroepiandrosterone supplementation in women undergoing assisted reproductive technology with poor ovarian response. A prospective case-control study

Objective The effects of dehydroepiandrosterone (DHEA) supplementation in Saudi Arabian women with poor ovarian response (POR) is presently unknown. The present study aimed to assess the benefits of DHEA supplementation in women undergoing in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI). Methods This was a prospective case-control study involving 62 women who were diagnosed with POR and underwent IVF/ICSI between January 2012 and June 2016. The positive influence of DHEA in 34 women, compared with 28 women without supplementation, was defined as improvements in the number of oocytes retrieved, the fertilization rate, the number of grade I embryos generated and the pregnancy rate. Results Both groups were evenly matched for age, body mass index and laboratory test parameters. There were statistically significant differences between the groups with and without DHEA supplementation for oocyte yield (6.35 ± 2.41 versus 3.98 ± 3.2), Grade I embryos generated (55% versus 30%), positive pregnancy rate (21/34 versus 10/28), and live birth rate (18/34 versus 4/28). Conclusion DHEA supplementation in women with POR had a positive effect on hormonal profiles, the quality of the endometrium, the number of oocytes retrieved, the quality of embryos, and the pregnancy and live birth rates.

The effect of dehydroepiandrosterone supplementation on ovarian response is associated with androgen receptor in diminished ovarian reserve women

Background

Diminished ovarian reserve(DOR) is associated with female infertility and poor response to ovarian stimulation. Our objective was to assess the effect of dehydroepiandrosterone(DHEA) on DOR women and to explore whether the improvement of ovarian response after DHEA supplementation was dependent on the expression levels of androgen receptor(AR).

Methods

A prospective cohort study was performed in the Department of Human Reproductive Medicine, Beijing Obstetrics and Gynecology Hospital during August 2014 to August 2016. 103 DOR women who completed the study were divided into the DHEA group (n = 53), which received DHEA supplementation (25 mg three times a day) for 8 weeks, and the control group (n = 50), which did not receive DHEA, before the IVF cycles. Serum hormone levels(FSH, LH, E₂, T, DHEAs, AMH, INHB), antral follicle count(AFC) and the expression of AR and FSH receptor(FSHR) in granulosa cells(GCs) were measured, meanwhile ovarian response parameters and IVF outcomes were compared. The GCs from another 36 DOR women were cultured with different concentrations of DHEA in vitro. Then, we compared the expression of AR and FSHR in GCs according to the different numbers of oocytes retrieved both in DHEA and control group.

Results

In the present study, DHEA supplementation resulted in significantly higher levels of serum T(P = 0.047), DHEAs(P = 0.019) and AR mRNA expression in GCs(P = 0.049). In vitro experiment, the protein and mRNA expression of AR and FSHR in the preovulatory GCs were significantly increased in response to DHEA supplementation(P <0.05). No significant differences were found in ovarian reserve, ovarian response, or IVF outcomes between the two groups. Subgroup analyses showed the levels of AR and FSHR mRNA in GCs were significantly increased in DHEA group with ≥5 oocytes retrieved(P <0.05).

Conclusion

DHEA supplementation can increase the expression of AR in preovulatory GCs both in vivo and in vitro. The selective beneficial effects of DHEA supplementation on ovarian response in DOR women may depend on the increasing expression of AR and FSHR in GCs.

Trial registration

The Chinese Clinical Trial Registry (ChiCTR-IPR-15006126). Retrospectively Registered 19 March 2015.

Dehydroepiandrosterone improves the ovarian reserve of women with diminished ovarian reserve and is a potential regulator of the immune response in the ovaries

Diminished ovarian reserve (DOR) has a high morbidity rate worldwide and has become a primary cause of infertility. DOR is a daunting obstacle in in vitro fertilization (IVF) and leads to poor ovarian response, high cancellation rates, poor IVF outcomes, and low pregnancy rates. Abnormal autoimmune function may also contribute to DOR. Dehydroepiandrosterone (DHEA) is a C19 androgenic steroid. DHEA is secreted mainly by the adrenal gland, and its secretion declines with age. DHEA has a pro-inflammatory immune function that opposes cortisol. The cortisol to DHEA ratio increases with age, which may lead to decreased immune function. DHEA supplementation helps improve this situation. A number of clinical case control studies and several prospective randomized clinical trials have observed a positive effect of DHEA supplementation in women with DOR. However, the underlying mechanism by which DHEA improves ovarian reserve remains unclear. DHEA functions as an immune regulator in many different tissues in mammals and may also play an important role in regulating the immune response in the ovaries. The conversion of DHEA to downstream sex steroids may allow it to regulate the immune response there. DHEA can also enhance the Th1 immune response and regulate the balance of the Th1/Th2 response. DHEA treatment can increase selective T lymphocyte infiltration in mice, resulting in a decline in the CD4+ T lymphocyte population and an upregulation of the CD8+ T lymphocyte population in ovarian tissue, thus regulating the balance of CD4+/CD8+ T cells. This review mainly focuses on how DHEA supplementation affects regulation of the immune response in the ovaries.

Dehydroepiandrosterone treatment in women with poor ovarian response undergoing IVF or ICSI: a systematic review and meta-analysis

PURPOSE

We reviewed the influence of dehydroepiandrosterone (DHEA) supplementation in patients with poor ovarian response (POR) undergoing in vitro fertilization or intracytoplasmic sperm injection (IVF/ICSI).

METHODS

We searched Embase, MEDLINE, PubMed, and the Cochrane Library (1980-2015) for relevant papers and used the Newcastle-Ottawa Scale scoring system to evaluate study quality. Dichotomous data were expressed as pooled relative risk (RR) estimates with fixed or random effect models. Continuous variables were expressed as the weighted mean difference (WMD). All data were analyzed using Revman Software v. 5 and are shown with 95 % confidence intervals (CI).

RESULTS

Twenty-one studies met the inclusion criteria. DHEA pretreatment increased the clinical pregnancy rate (RR 1.53, 95 % CI 1.25-1.86), live birth rate (RR 1.87, 95 % CI 1.22-2.88), implantation rate (RR 1.56, 95 % CI 1.20-2.01), and antral follicle count (WMD 0.4, 95 % CI 0.14 to 0.66) while reducing miscarriages (RR 0.50, 95 % CI 0.27-0.90). After subgroup analysis, oocyte numbers and anti-Müllerian hormone levels were also enhanced after DHEA treatment. However, the endometrial thickness and estradiol levels on the day of injecting hCG to induce ovulation were similar between the DHEA supplementation groups and controls.

CONCLUSIONS

Based on the limited available evidence, DHEA supplementation seems to improve ovarian reserves and IVF/ICSI outcome in patients with POR. Further research is required to clarify the effect of DHEA exposure in assisted reproduction technology.

Does dehydroepiandrosterone improve pregnancy rate in women undergoing IVF/ICSI with expected poor ovarian response according to the Bologna criteria? A randomized controlled trial

OBJECTIVE

To provide the best available evidence on the role of dehydroepiandrosterone (DHEA) treatment in improving the outcome of in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) in women with poor ovarian response (POR).

STUDY DESIGN

A randomized controlled trial conducted in Cairo University hospitals and Dar Al-Teb subfertility and assisted conception centre, Giza, Egypt. 140 women undergoing IVF/ICSI with POR according to the Bologna criteria were randomly divided into 2 equal groups. The study group received DHEA 25mg three times daily for 12 weeks before the IVF/ICSI cycles and the control group did not receive DHEA. Controlled ovarian stimulation (COH) was started on the second day of menstruation using human menopausal gonadotropins, cetrotide 0.25mg was started when the leading follicle reached 14mm. The main outcome measures were the clinical pregnancy rate, ongoing pregnancy rate, retrieved oocytes, fertilization rate, gonadotropins doses and COH days.

RESULTS

The DHEA group had significantly higher clinical pregnancy rate (32.8% vs 15.7%, p=0.029), ongoing pregnancy rate (28.5% vs 12.8%), retrieved oocytes (6.9±3 vs 5.8±3.1, p=0.03), fertilization rate (62.3±27.4 vs 52.2±29.8, p=0.039), significantly less gonadotropins doses (3383±717.5IU vs 3653.5±856IU, p=0.045) and COH days (11.6±1.8 vs 12.6±1.06, p=0.001).

CONCLUSION

DHEA increases the number of oocytes, fertilization rate, fertilized oocytes, and clinical pregnancy rate and ongoing pregnancy rate in women with POR according to the Bologna criteria. DHEA was well tolerated by the patients and was associated with less COH days and gonadotropins doses.

REGISTRATION NUMBER

www.clinicaltrials.govNCT02151006.