Heyan Kuntai capsule versus dehydroepiandrosterone in treating Chinese patients with infertility caused by diminished ovarian reserve: a multicenter, randomized controlled trial

Androgens (dehydroepiandrosterone or testosterone) for women undergoing assisted reproduction

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Kuntai capsule attenuates premature ovarian insufficiency by activating the FOXO3/SIRT5 signaling pathway in mice: A comprehensive study using UHPLC-LTQ-Orbitrap and integrated pharmacology

ETHNOPHARMACOLOGICAL RELEVANCE

Classical prescriptions are not only a primary method of clinical treatment in traditional Chinese medicine (TCM) but also represent breakthroughs in the inheritance and development of this field. Kuntai capsule (KTC), a formulation based on a classical prescription, comprises six TCMs: Rehmanniae Radix Praeparata, Coptidis Rhizoma, Paeoniae Radix Alba, Scutellariae Radix, Asini Corii Colla, and Poria. This formulation possesses various beneficial effects, such as nourishing yin and blood, clearing heat and purging fire, and calming the nerves and relieving annoyance. The investigation of the efficacy and mechanism of KTC in regulating anti-aging factors in the treatment of premature ovarian insufficiency (POI) is not only a prominent topic in classical prescription research but also a crucial issue in the treatment of female reproductive aging using TCM.

AIM OF THE STUDY

To evaluate the therapeutic effect of KTC on POI and its underlying mechanism.

MATERIALS AND METHODS

Healthy and specific pathogen-free (SPF) female Kunming mice aged 6-8 weeks were selected. After acclimatization, the mice were randomly divided into a control, model, and high, middle, and low dose groups of KTC (1.6, 0.8, and 0.4 mg/kg, respectively). Except for the control group, the animals in the other groups were administered a single intraperitoneal injection of 120 mg/kg cyclophosphamide and 30 mg/kg Busulfan to induce the model of POI. After modeling, the mice were treated with the corresponding drugs for 7 days. Serum and ovarian tissues were collected, and the levels of serum follicle-stimulating hormone (FSH), estradiol (E2), and superoxide dismutase 2 (SOD2) were determined using enzyme-linked immunosorbent assay (ELISA). The chemical composition of KTC was characterized and analyzed using ultra-high-pressure liquid chromatography-linear ion trap-Orbitrap tandem mass spectrometry. A "drug-component-target-pathway-disease" network was constructed using network pharmacology research methods to identify the key active components of KTC in treating POI and to elucidate its potential mechanism. The protein expression of the FOXO3/SIRT5 pathway was detected by western blotting.

RESULTS

Compared to the model group, the high-dose group of KTC showed a significant increase in ovarian index, significant increase in levels of E2 and SOD2, and a significant decrease in FSH levels. Through systematic analysis of the chemical constituents of KTC, 69 compounds were identified, including 7 organic acids, 14 alkaloids, 28 flavonoids, 15 terpenoids, 2 lignans, 2 phenylpropanoids, and 1 sugar. Based on network pharmacology research methods, it was determined that KTC exerts its therapeutic effect on POI through multiple components (paeoniflorin and malic acid), multiple targets (FOXO3 and SIRT5), and multiple pathways (prolactin signaling pathway, longevity regulating pathway, and metabolic pathways). The accuracy of the network pharmacology prediction was further validated by detecting the protein expression of SIRT5 and FOXO3a, which showed a significant increase in the middle and high-dose groups of KTC compared to the model group.

CONCLUSIONS

KTC may effectively treat POI through a multi-component, multi-target, multi-pathway approach, providing an experimental basis for using KTC based on classical prescriptions in the treatment of POI.

Herbal therapeutics for female infertility: A systematic review and meta-analysis

ETHNOPHARMACOLOGICAL RELEVANCE

Infertility is a global public health issue related to gynecological diseases and psychological disorders such as stress, depression, and fatigue. Prescriptions of various herbs in traditional East Asian medicine (TEAM) have recently gained attention among patients as a complementary alternative therapy for female infertility. However, studies on systemic analysis of the use of herbal medicines according to TEAM patterns or the therapeutic effects of herbal medicines on female infertility are limited.

AIM OF THE STUDY

We aimed to systematically investigate the single herb and TEAM patterns that are commonly used for treating female infertility using network analysis. Additionally, we performed a meta-analysis to assess the effect of herbal medicine on the pregnancy rate in women with infertility.

MATERIALS AND METHODS

PubMed, EMBASE, Korean Studies Information Service System, Science ON, Research Information Sharing Service, and Oriental Medicine Advanced Searching Integrated System were searched for randomized controlled trials (RCTs) reporting the pregnancy rate of herbal medicine for infertility until July 2021. Following identifying the top three herbs used in treating female infertility, a network analysis was performed to reveal the TEAM pattern relationships between each herb. A meta-analysis was performed to evaluate the therapeutic effect of herbal medicine on pregnancy rate. Moreover, the methodological quality of RCTs was analyzed using Consolidated Standards of Reporting Trials (CONSORT) extension guidelines and the Risk of bias (RoB) tool.

RESULTS

Eighteen RCTs with 2,662 participants were included. Cuscuta chinensis Lam. (Tusizi) is the most commonly used herb for treating female infertility, followed by Angelica gigas Nakai (Danggui) and Cyperus rotundus L. (Xiangfuzi). These herbs were mainly used to treat patients with kidney deficiency or kidney deficiency combined with blood stasis or Phlegm-dampness on the TEAM pattern. The meta-analysis revealed that the effect of herbal medicine led to a significant increase in pregnancy rates compared to the placebo treatment. Adverse events in the included studies were generally mild and infrequent. The methodological quality of RCTs using CONSORT extension was poor, while the RoB of the included RCTs was generally low.

CONCLUSIONS

The findings of this review suggest that herbal medicine will be beneficial for treating female infertility by improving pregnancy rates. However, more carefully designed studies on herbal medicines are encouraged to improve the quality of herbal medicine research in the future.

Chinese herbal medicines as complementary therapy to in vitro fertilization-embryo transfer in women with infertility: protocols and applications

In vitro fertilization-embryo transfer (IVF-ET) is a very common treatment for couples with infertility. However, IVF-ET still has a limited success rate with high costs. Chinese herbal medicines (CHM) have been used as complementary treatments for infertility to improve the reproductive outcomes during different stages of the IVF-ET cycle. This review provides an up to date evidence on CHM treatments. We summarize the treatment protocols based on the stages of IVF-ET cycle and discuss its clinical applications in IVF-ET treatment. The possible underlying mechanisms of CHM include improving ovarian function, promoting endometrial receptivity, regulating immune function, inhibiting oxidation, and reducing mental stress and discomfort during treatment. This review aims to provide information and guidance on the potential clinical applications of CHM as an adjuvant therapy during IVF-ET treatment.

Identification of the active ingredients and pharmacological effects of Kuntai capsules in the treatment of primary ovarian insufficiency: A review

Kuntai capsules are effective in controlling primary ovarian insufficiency (POI). However, the precise mechanisms underlying the pharmacological effects of Kuntai capsules remain unclear. This study aimed to screen the active components and underlying mechanisms of Kuntai capsules for POI treatment using network pharmacology protocols and molecular docking technology. Potential active constituents in the chemical composition of Kuntai capsules were obtained from the Traditional Chinese Medicine System Pharmacology Database. Targets for POI were obtained from the Online Mendelian Inheritance in Man and Gene Cards database. All target data were integrated to identify the active ingredients of POI treatment. Enrichment analyses were performed using the Database for Annotation, Visualization, and Integrated Discovery database. The STRING database and Cytoscape software were used for protein-protein interaction network construction and core target identification. Finally, a molecular docking analysis of the active components and core targets was performed. A total of 157 ingredients related to POI were identified. Enrichment analysis showed that these components might participate in the mitogen-activated protein kinase, tumor necrosis factor, phosphoinositide-3-kinase/AKT serine/threonine kinase 1, and forkhead box O signaling pathways. Further protein-protein interaction network analysis revealed that the core targets were Jun proto-oncogene, AKT serine/threonine kinase 1, tumor protein P53, interleukin 6, and the epidermal growth factor receptor. Molecular docking analysis showed that baicalein was the most active ingredient with the highest affinity for the core targets. This study identified baicalein as the core functional component and elucidated the potential pharmacological effects of Kuntai capsule in the treatment of POI.

Treatment Progress in Diminished Ovarian Reserve: Western and Chinese Medicine

Diminished ovarian reserve (DOR), generally defined as a decreased number or quality of oocytes, has a significant impact on quality of life and fertility in women. In recent years, the incidence of DOR has been increasing and the ages of patients are younger. The search for an effective DOR treatment has emerged as one of the preeminent research topics in reproductive health. An effective DOR therapy would improve ovarian function, fertility, and quality of life in patients. In this review we evaluated DOR treatment progress both in Western medicine and Chinese medicine, and elucidated the characteristics of each treatment.

Herbal medicine in women undergoing in vitro fertilization/ intracytoplasmic sperm injection: A systematic review and meta-analysis

A combination of in vitro fertilization (IVF) and herbal medicine (HM) has been widely used in Asian countries. We conducted a systematic review of randomized controlled trials (RCTs) that evaluated the effects of HM as an adjunct to IVF and reported the pregnancy outcomes, including the live birth rate (LBR) and clinical pregnancy rate (CPR). HM was consistently more likely to increase the LBR (RR 1.34, 95 % CI 1.05-1.72) and CPR (RR 1.38, 95 % CI 1.29-1.49) than those not receiving adjunctive treatment. The CPR in the HM treatment group was also improved compared to the placebo group (RR 1.85, 95 % CI 1.42-2.42). The adverse events were not significantly different between the HM and control groups. These findings indicate that HM may have beneficial effects on pregnancy outcomes in females undergoing IVF. Large-scale, long-term RCTs with robust methodological inputs are needed to clarify the role of HM.