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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 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.
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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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Lissaman AC, Girling JE, Cree LM, Campbell RE, Ponnampalam AP. Androgen signalling in the ovaries and endometrium. Mol Hum Reprod 2023; 29:gaad017. [PMID: 37171897 PMCID: PMC10663053 DOI: 10.1093/molehr/gaad017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 04/27/2023] [Indexed: 05/14/2023] Open
Abstract
Currently, our understanding of hormonal regulation within the female reproductive system is largely based on our knowledge of estrogen and progesterone signalling. However, while the important functions of androgens in male physiology are well known, it is also recognized that androgens play critical roles in the female reproductive system. Further, androgen signalling is altered in a variety of gynaecological conditions, including endometriosis and polycystic ovary syndrome, indicative of regulatory roles in endometrial and ovarian function. Co-regulatory mechanisms exist between different androgens, estrogens, and progesterone, resulting in a complex network of steroid hormone interactions. Evidence from animal knockout studies, in vitro experiments, and human data indicate that androgen receptor expression is cell-specific and menstrual cycle stage-dependent, with important regulatory roles in the menstrual cycle, endometrial biology, and follicular development in the ovaries. This review will discuss the expression and co-regulatory interactions of androgen receptors, highlighting the complexity of the androgen signalling pathway in the endometrium and ovaries, and the synthesis of androgens from additional alternative pathways previously disregarded as male-specific. Moreover, it will illustrate the challenges faced when studying androgens in female biology, and the need for a more in-depth, integrative view of androgen metabolism and signalling in the female reproductive system.
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Affiliation(s)
- Abbey C Lissaman
- Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Jane E Girling
- Department of Anatomy, School of Biomedical Sciences, University of Otago, Dunedin, New Zealand
| | - Lynsey M Cree
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
| | - Rebecca E Campbell
- Department of Physiology and Centre for Neuroendocrinology, University of Otago, Dunedin, New Zealand
| | - Anna P Ponnampalam
- Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Pūtahi Manawa-Healthy Hearts for Aotearoa New Zealand, Centre of Research Excellence, New Zealand
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3
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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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AOP key event relationship report: Linking decreased androgen receptor activation with decreased granulosa cell proliferation of gonadotropin-independent follicles. Reprod Toxicol 2022; 112:136-147. [PMID: 35868514 DOI: 10.1016/j.reprotox.2022.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/14/2022] [Accepted: 07/16/2022] [Indexed: 02/08/2023]
Abstract
We recently proposed to formally recognize Key Event Relationships (KERs) as building blocks of Adverse Outcome Pathways (AOPs) that can be independently developed and peer-reviewed. Here, we follow this approach and provide an independent KER from AOP345, which describes androgen receptor (AR) antagonism leading to decreased female fertility. This KER connects AR antagonism to reduced granulosa cell proliferation of gonadotropin-independent follicles (KER2273). We have developed both the KER and the two adjacent Key Events (KEs). A systematic approach was used to ensure that all relevant supporting evidence for KER2273 was retrieved. Supporting evidence for the KER highlights the importance of AR action during the early stages of follicular development. Both biological plausibility and empirical evidence are presented, with the latter also assessed for quality. We believe that tackling isolated KERs instead of whole AOPs will accelerate the AOP development. Faster AOP development will lead to the development of simple test methods that will aid screening of chemicals, endocrine disruptor identification, risk assessment, and subsequent regulation.
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5
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Neves AR, Montoya-Botero P, Polyzos NP. Androgens and diminished ovarian reserve: the long road from basic science to clinical implementation. A comprehensive and systematic review with meta-analysis. Am J Obstet Gynecol 2022; 227:401-413.e18. [PMID: 35364061 DOI: 10.1016/j.ajog.2022.03.051] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 03/16/2022] [Accepted: 03/24/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE This study aimed to present a narrative review regarding androgen production, androgens' role in folliculogenesis, and the available therapeutic approaches for androgen supplementation, and to perform a systematic review and meta-analysis regarding the impact of androgens (dehydroepiandrosterone/testosterone) compared with placebo or no treatment on ovarian response and pregnancy outcomes in patients with diminished ovarian reserve and/or poor ovarian responders. DATA SOURCES An electronic search of MEDLINE, Embase, Cochrane Library, Cochrane Central Register of Controlled Trials, Scopus, ClinicalTrials.gov, the ISRCTN registry, and the World Health Organization International Clinical Trials Registry, was conducted for studies published until September 2021. STUDY ELIGIBILITY CRITERIA Randomized controlled trials that compared ovarian response and/or pregnancy outcomes between the different in vitro fertilization protocols using androgens (ie, dehydroepiandrosterone and testosterone) and conventional in vitro fertilization stimulation in patients with diminished ovarian reserve and/or poor ovarian responders were included. METHODS The quality of each study was evaluated with the revised Cochrane risk-of-bias tool for randomized trials (RoB 2). The meta-analysis used random-effects models. All results were interpreted on the basis of intention-to-treat analysis (defined as the inclusion of all randomized patients in the denominator). Risk ratios and 95% confidence intervals were used and combined for meta-analysis. RESULTS No significant differences were found regarding the number of oocytes retrieved (mean difference, 0.76; 95% confidence interval, -0.35 to 1.88), mature oocytes retrieved (mean difference, 0.25; 95% confidence interval, -0.27 to 0.76), clinical pregnancy rate (risk ratio, 1.17; 95% confidence interval, 0.87-1.57), live-birth rate (risk ratio, 0.97; 95% confidence interval, 0.47-2.01), or miscarriage rate (risk ratio, 0.80; 95% confidence interval, 0.29-2.22) when dehydroepiandrosterone priming was compared with placebo or no treatment. Testosterone pretreatment yielded a higher number of oocytes retrieved (mean difference, 0.94; 95% confidence interval, 0.46-1.42), a higher clinical pregnancy rate (risk ratio, 2.07; 95% confidence interval, 1.33-3.20), and higher live-birth rate (risk ratio, 2.09; 95% confidence interval, 1.11-3.95). CONCLUSION Although dehydroepiandrosterone did not present a clear effect on outcomes of assisted reproductive techniques, we found a potentially beneficial effect of testosterone priming on ovarian response and pregnancy outcomes. However, results should be interpreted with caution, taking into account the low to moderate quality of the available evidence.
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Affiliation(s)
- Ana Raquel Neves
- Department of Obstetrics, Gynecology and Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain; Autonomous University of Barcelona, Cerdanyola del Vallès, Spain
| | - Pedro Montoya-Botero
- Conceptum - Unidad de Fertilidad del Country, Bogotá, Colombia; Department of Epidemiology and Biostatistics, Fundación Universitaria de Ciencias de la Salud - FUCS, 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), Ghent, Belgium.
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Testosterone does not improve ovarian response in Bologna poor responders: a randomized controlled trial (TESTOPRIM). Reprod Biomed Online 2021; 43:466-474. [PMID: 34312088 DOI: 10.1016/j.rbmo.2021.05.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/28/2021] [Accepted: 05/24/2021] [Indexed: 11/23/2022]
Abstract
RESEARCH QUESTION Does testosterone, either in a long or short course, before IVF increase the number of mature oocytes retrieved in poor ovarian response? DESIGN Single-centre, single-blinded, randomized controlled trial. Poor ovarian response is defined according to Bologna criteria. Sixty-three participants were included and assigned to three arms: group 1 (long testosterone [n = 17]) 12.5 mg/day testosterone gel for 56 days before ovarian stimulation; group 2 (short testosterone [n = 16]) 12.5 mg/day testosterone gel for 10 days before ovarian stimulation; and group 3 (control, no intervention). Primary outcome was number of mature oocytes retrieved. Secondary outcomes included other cycle parameters (duration of stimulation, antral follicle count, number of follicles >16 mm, total oocytes retrieved and testosterone levels). RESULTS The number of mature oocytes retrieved did not differ between the three groups (2.16, 2.71 and 2.91, P = 0.719, groups 1, 2 and 3, respectively). No other significant differences were found in the remaining cycle parameters, except for testosterone levels at the beginning of ovarian stimulation, which were higher in both testosterone groups and relatively higher in group 2 (1.67 and 3.03, respectively versus 0.14 control group, P = 0.01). A Poisson regression model showed no significant differences for the primary outcome (group 3 versus group 2: 0.925, 95% CI 0.572 to 1.508, P = 0.753; group 3 versus group 1: 0.873, 95% CI 0.534 to 1.426, P = 0.587). CONCLUSIONS The use of testosterone, even when applied for a prolonged period, does not improve the number of mature oocytes in poor ovarian response.
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Solernou R, Peralta S, Casals G, Guimera M, Solsona M, Borras A, Manau D, Fàbregues F. The Follicular Output Rate (FORT) as a method to evaluate transdermal testosterone efficacy in poor responders. JBRA Assist Reprod 2021; 25:229-234. [PMID: 33507716 PMCID: PMC8083864 DOI: 10.5935/1518-0557.20200086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Objective: Follicular Output Rate (FORT) is an efficient quantitative and qualitative marker of ovarian responsiveness to gonadotropins. Transdermal testosterone (TT) has been used as adjuvant therapy to gonadotrophins in order to improve ovarian response in poor responders (PR). The aim of this study was to analyze whether TT can improve follicular sensitivity to gonadotropins using FORT. Methods: This retrospective study, held in a tertiary-care university hospital included 90 PR patients, according to the Bologna criteria. Patients in Group 1 (n = 46) received transdermal application of testosterone preceding gonadotrophin ovarian stimulation under pituitary suppression. In Group 2 (n = 44) ovarian stimulation was carried out with high-dose gonadotrophin in association with minidose GnRH agonist protocol. We analyzed ovarian stimulation parameters and IVF outcomes. We determined antral follicle count (AFC) (3-8 mm) before ovarian stimulation, pre-ovulatory follicle count (PFC) (16-22 mm) and the day of hCG administration. We calculated the FORT using the PFCx100/AFC ratio. Results: Baseline characteristics and ovarian reserve parameters were similar in both groups. FORT and oocytes retrieved were significantly higher in group 1 vs group 2. There were no significant differences in pregnancy rates. In group 1 there was a significant correlation between FORT and AFC. Conclusions: This study suggests that the potential beneficial mechanism of TT in poor responder patients may be based on increasing the antral follicle sensitivity to gonadotrophin. FORT is an excellent tool to demonstrate this.
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Affiliation(s)
- Roser Solernou
- Institute Clinic of Gynecology, Obstetrics and Gynecology. Hospital Clinic. Barcelona, Spain
| | - Sara Peralta
- Institute Clinic of Gynecology, Obstetrics and Gynecology. Hospital Clinic. Barcelona, Spain
| | - Gemma Casals
- Institute Clinic of Gynecology, Obstetrics and Gynecology. Hospital Clinic. Barcelona, Spain
| | - Marta Guimera
- Institute Clinic of Gynecology, Obstetrics and Gynecology. Hospital Clinic. Barcelona, Spain
| | - Marina Solsona
- Institute Clinic of Gynecology, Obstetrics and Gynecology. Hospital Clinic. Barcelona, Spain
| | - Aina Borras
- Institute Clinic of Gynecology, Obstetrics and Gynecology. Hospital Clinic. Barcelona, Spain
| | - Dolores Manau
- Institute Clinic of Gynecology, Obstetrics and Gynecology. Hospital Clinic. Barcelona, Spain
| | - Francesc Fàbregues
- Institute Clinic of Gynecology, Obstetrics and Gynecology. Hospital Clinic. Barcelona, Spain
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8
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Astapova O, Seger C, Hammes SR. Ligand Binding Prolongs Androgen Receptor Protein Half-Life by Reducing its Degradation. J Endocr Soc 2021; 5:bvab035. [PMID: 33869982 PMCID: PMC8043068 DOI: 10.1210/jendso/bvab035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Indexed: 11/30/2022] Open
Abstract
Androgens are important in female reproduction, but the molecular actions of androgens in female reproductive tissues are not fully understood. We investigated the androgen-responsive transcriptome in human and mouse granulosa cells (GCs) and surprisingly found that the gene-regulation activity of androgen receptor (AR) in these cells is negligible. We then investigated extranuclear actions of AR and found that in human and mouse GCs, as well as in prostate cancer cells, dihydrotestosterone (DHT) dramatically increases the half-life of its own receptor protein. Using the human granulosa-like KGN cells, we show that this effect is not the result of increased AR gene transcription or protein synthesis, nor is it fully abrogated by proteasome inhibition. Knockdown of PTEN, which contributes to degradation of cytoplasmic AR, did not diminish AR accumulation in the presence of DHT. Using immunofluorescence cellular localization studies, we show that nuclear AR is selectively protected from degradation in the presence of DHT. Knockdown of importin 7 expression, a potential regulator of AR nuclear import, does not affect DHT-mediated nuclear accumulation of AR, suggesting importin 7-independent nuclear import of AR in GCs. Further, DNA binding is not required for this protective mechanism. In summary, we show that ligand binding sequesters AR in the nucleus through enhanced nuclear localization independent of DNA binding, thereby protecting it from proteasome degradation in the cytoplasm. This phenomenon distinguishes AR from other sex steroid receptors and may have physiological significance through a positive feedback loop in which androgen induces its own activity in male and female reproductive tissues.
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Affiliation(s)
- Olga Astapova
- Division of Endocrinology and Metabolism, Department of Medicine, University of Rochester Medical Center, Rochester, New York 14642, USA
| | - Christina Seger
- Division of Endocrinology and Metabolism, Department of Medicine, University of Rochester Medical Center, Rochester, New York 14642, USA
| | - Stephen R Hammes
- Division of Endocrinology and Metabolism, Department of Medicine, University of Rochester Medical Center, Rochester, New York 14642, USA
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Pasado presente y futuro de la estimulación ovárica en el tratamiento de la infertilidad. REVISTA MÉDICA CLÍNICA LAS CONDES 2021. [DOI: 10.1016/j.rmclc.2021.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
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10
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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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Zhang Y, Zhang C, Shu J, Guo J, Chang HM, Leung PCK, Sheng JZ, Huang H. Adjuvant treatment strategies in ovarian stimulation for poor responders undergoing IVF: a systematic review and network meta-analysis. Hum Reprod Update 2020; 26:247-263. [PMID: 32045470 DOI: 10.1093/humupd/dmz046] [Citation(s) in RCA: 99] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 11/10/2019] [Accepted: 11/19/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Despite great advances in assisted reproductive technology, poor ovarian response (POR) is still considered as one of the most challenging tasks in reproductive medicine. OBJECTIVE AND RATIONALE The aim of this systemic review is to evaluate the role of different adjuvant treatment strategies on the probability of pregnancy achievement in poor responders undergoing IVF. Randomized controlled trials (RCTs) comparing 10 adjuvant treatments [testosterone, dehydroepiandrosterone (DHEA), letrozole, recombinant LH, recombinant hCG, oestradiol, clomiphene citrate, progesterone, growth hormone (GH) and coenzyme Q10 (CoQ10)] were included. SEARCH METHODS Relevant studies published in the English language were comprehensively selected using PubMed, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL) until 11 July 2018. We included studies that investigated various adjuvant agents, including androgen and androgen-modulating agents, oestrogen, progesterone, clomiphene citrate, GH and CoQ10, during IVF treatment and reported subsequent pregnancy outcomes. The administration of GnRH analogs and gonadotrophins without adjuvant treatment was set as the control. We measured study quality based on the methodology and categories listed in the Cochrane Collaboration Handbook. This review protocol was registered with PROSPERO (CRD42018086217). OUTCOMES Of the 1124 studies initially identified, 46 trials reporting on 6312 women were included in this systematic review, while 19 trials defining POR using the Bologna criteria reporting 2677 women were included in the network meta-analysis. Compared with controls, DHEA and CoQ10 treatments resulted in a significantly higher chance of clinical pregnancy [odds ratio (OR) 2.46, 95% CI 1.16 to 5.23; 2.22, 1.08-4.58, respectively]. With regard to the number of retrieved oocytes, HCG, oestradiol and GH treatments had the highest number of oocytes retrieved [weighted mean difference (WMD) 2.08, 0.72 to 3.44; 2.02, 0.23 to 3.81; 1.72, 0.98 to 2.46, compared with controls, respectively]. With regard to the number of embryos transferred, testosterone and GH treatment led to the highest number of embryos transferred (WMD 0.72, 0.11 to 1.33; 0.67, 0.43 to 0.92; compared with controls, respectively). Moreover, GH resulted in the highest oestradiol level on the HCG day (WMD 797.63, 466.45 to 1128.81, compared with controls). Clomiphene citrate, letrozole and GH groups used the lowest dosages of gonadotrophins for ovarian stimulation (WMD 1760.00, -2890.55 to -629.45; -1110.17, -1753.37 to -466.96; -875.91, -1433.29 to -282.52; compared with controls, respectively). CoQ10 led to the lowest global cancelation rate (OR 0.33, 0.15 to 0.74, compared with controls). WIDER IMPLICATIONS For patients with POR, controlled ovarian stimulation protocols using adjuvant treatment with DHEA, CoQ10 and GH showed better clinical outcomes in terms of achieving pregnancy, and a lower dosage of gonadotrophin required for ovulation induction. Furthermore, high-level RCT studies using uniform standards for POR need to be incorporated into future meta-analyses.
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Affiliation(s)
- Yu Zhang
- International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200030, China.,Department of Reproductive Endocrinology, Zhejiang Provincial People's Hospital, Hangzhou Medical College, Hangzhou 310014, China.,Shanghai Key Laboratory of Embryo Original Diseases, Shanghai 200030, China.,Department of Obstetrics and Gynaecology, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia V5Z 4H4, Canada
| | - Chao Zhang
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan 442000, China
| | - Jing Shu
- Department of Reproductive Endocrinology, Zhejiang Provincial People's Hospital, Hangzhou Medical College, Hangzhou 310014, China
| | - Jing Guo
- Department of Reproductive Endocrinology, Zhejiang Provincial People's Hospital, Hangzhou Medical College, Hangzhou 310014, China
| | - Hsun-Ming Chang
- Department of Obstetrics and Gynaecology, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia V5Z 4H4, Canada
| | - Peter C K Leung
- Department of Obstetrics and Gynaecology, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia V5Z 4H4, Canada
| | - Jian-Zhong Sheng
- Department of Pathology and Pathophysiology, School of Medicine, Zhejiang University, Hangzhou 310058, China
| | - Hefeng Huang
- International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200030, China.,Shanghai Key Laboratory of Embryo Original Diseases, Shanghai 200030, China
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Vaitsopoulou CI, Kolibianakis EM, Bosdou JK, Neofytou E, Lymperi S, Makedos A, Savvaidou D, Chatzimeletiou K, Grimbizis GF, Lambropoulos A, Tarlatzis BC. Expression of genes that regulate follicle development and maturation during ovarian stimulation in poor responders. Reprod Biomed Online 2020; 42:248-259. [PMID: 33214084 DOI: 10.1016/j.rbmo.2020.05.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 03/12/2020] [Accepted: 05/18/2020] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Christine I Vaitsopoulou
- Unit for Human Reproduction, Laboratory of Genetics, 1st Department of Obstetrics and Gynaecology, School of Medicine, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Ring Road, Nea Efkarpia Thessaloniki 56403, Greece.
| | - Efstratios M Kolibianakis
- Unit for Human Reproduction, Laboratory of Genetics, 1st Department of Obstetrics and Gynaecology, School of Medicine, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Ring Road, Nea Efkarpia Thessaloniki 56403, Greece
| | - Julia K Bosdou
- Unit for Human Reproduction, Laboratory of Genetics, 1st Department of Obstetrics and Gynaecology, School of Medicine, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Ring Road, Nea Efkarpia Thessaloniki 56403, Greece
| | - Eirini Neofytou
- Unit for Human Reproduction, Laboratory of Genetics, 1st Department of Obstetrics and Gynaecology, School of Medicine, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Ring Road, Nea Efkarpia Thessaloniki 56403, Greece
| | - Stefania Lymperi
- Unit for Human Reproduction, Laboratory of Genetics, 1st Department of Obstetrics and Gynaecology, School of Medicine, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Ring Road, Nea Efkarpia Thessaloniki 56403, Greece
| | - Anastasios Makedos
- Unit for Human Reproduction, Laboratory of Genetics, 1st Department of Obstetrics and Gynaecology, School of Medicine, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Ring Road, Nea Efkarpia Thessaloniki 56403, Greece
| | - Despina Savvaidou
- Unit for Human Reproduction, Laboratory of Genetics, 1st Department of Obstetrics and Gynaecology, School of Medicine, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Ring Road, Nea Efkarpia Thessaloniki 56403, Greece
| | - Katerina Chatzimeletiou
- Unit for Human Reproduction, Laboratory of Genetics, 1st Department of Obstetrics and Gynaecology, School of Medicine, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Ring Road, Nea Efkarpia Thessaloniki 56403, Greece
| | - Grigoris F Grimbizis
- Unit for Human Reproduction, Laboratory of Genetics, 1st Department of Obstetrics and Gynaecology, School of Medicine, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Ring Road, Nea Efkarpia Thessaloniki 56403, Greece
| | - Alexandros Lambropoulos
- Unit for Human Reproduction, Laboratory of Genetics, 1st Department of Obstetrics and Gynaecology, School of Medicine, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Ring Road, Nea Efkarpia Thessaloniki 56403, Greece
| | - Basil C Tarlatzis
- Unit for Human Reproduction, Laboratory of Genetics, 1st Department of Obstetrics and Gynaecology, School of Medicine, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Ring Road, Nea Efkarpia Thessaloniki 56403, Greece
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13
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Zhu J, Wang Y, Chen L, Liu P, Li R, Qiao J. Growth Hormone Supplementation May Not Improve Live Birth Rate in Poor Responders. Front Endocrinol (Lausanne) 2020; 11:1. [PMID: 32038495 PMCID: PMC6990136 DOI: 10.3389/fendo.2020.00001] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 01/06/2020] [Indexed: 11/13/2022] Open
Abstract
Backgrounds: Growth hormone (GH) was used for many years to increase ovarian response in poor ovarian responders (PORs). Although meta-analysis suggested that GH therapy improve early clinical outcomes, the benefit of GH usage on chance of live birth was still widely debated. This study was to determine whether or not GH supplementation influences the live birth rate (LBR). Methods: A total of 3,080 expected PORs receiving and not receiving (control) GH adjuvant therapy at Peking University Third Hospital from January 2017 to March 2018 were retrospectively analyzed. The basal characteristics of patients were compared using analysis of variance (continuous variables) and categorical variables were evaluated with a chi-square test. Logistic regression analyses were used to evaluate potential associations of LBR with GH treatment while adjusting other confounding factors. Results: No statistically significant differences existed in miscarriage rate (5.3 vs. 12.5%; p = 0.076) and LBR (37.7 vs. 34.5%; p = 0.426) in young expected PORs (< 35 years of age). Moreover, no significant differences existed in the miscarriage rate (25.6 vs. 23.3%; p = 0.681), and LBR (17.8 vs. 17.9%; p = 0.977) in the old expected PORs (≥35 years of age). Logistic regression suggested that GH adjuvant therapy did not improve the LBR in young (OR, 1.27; 95% CI, 0.88-1.85; p = 0.203) and elderly expected PORs (OR, 1.20; 95% CI, 0.82-1.76; p = 0.342), while GH was not associated with risk of miscarriage in young (OR, 0.37; 95% CI, 0.11-1.24; p = 0.108) and elderly expected PORs (OR, 0.91; 95% CI, 0.43-1.93; p = 0.813). In subgroup analysis, GH treatment significantly increased the day 3 embryos available rate in the subgroup of young PORs with the long down-regulation (63.11 vs. 49.35%; p = 0.004), while significantly reduced the risk of miscarriage in the subgroup of young PORs with GnRH antagonist protocol (0.00 vs. 12. %; p = 0.023). There was no significant difference for LBR in PORs with GnRH antagonist (<35 years [35.19 vs. 28.45%; p = 0.183]; ≥35 years [12.96 vs. 14.03%; p = 0.707]), GnRH-a long (<35 years [33.33 vs. 36.99%; p = 0.597]; ≥35 years [17.44 vs. 20.28%; p = 0.574]) and long down-regulation (<35 years [58.82 vs. 41.90%; p = 0.193]; ≥35 years [43.33 vs. 25.30%; p = 0.065]). Conclusions: Growth hormone treatment may not improve live birth rate in expected poor responders.
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Affiliation(s)
- Jinliang Zhu
- Department of Obstetrics and Gynecology, Center for Reproductive Medicine, Peking University Third Hospital, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Beijing, China
| | - Ying Wang
- Department of Obstetrics and Gynecology, Center for Reproductive Medicine, Peking University Third Hospital, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Beijing, China
| | - Lixue Chen
- Department of Obstetrics and Gynecology, Center for Reproductive Medicine, Peking University Third Hospital, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Beijing, China
| | - Ping Liu
- Department of Obstetrics and Gynecology, Center for Reproductive Medicine, Peking University Third Hospital, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Beijing, China
| | - Rong Li
- Department of Obstetrics and Gynecology, Center for Reproductive Medicine, Peking University Third Hospital, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Beijing, China
| | - Jie Qiao
- Department of Obstetrics and Gynecology, Center for Reproductive Medicine, Peking University Third Hospital, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Beijing, China
- *Correspondence: Jie Qiao
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14
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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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Abstract
PURPOSE OF REVIEW The management and treatment of patients with poor ovarian response is still a controversial issue in IVF. Increasing evidences demonstrate that the number of oocytes retrieved after a controlled ovarian stimulation (COS) greatly influences the clinical outcome in terms of cumulative live birth per started cycle. For this reason, any COS should aim to optimize the number of oocytes according to the ovarian reserve of the patient. The aim of this review is to provide an overview of new strategies proposed to manage poor responders according to the novel POSEIDON classification. RECENT FINDINGS Gonadotrophins cannot compensate for the absence of follicles in the ovary, therefore, COS in poor responders may benefit from the exploitation of multiple follicular waves within a single ovarian cycle, for instance, through luteal phase stimulation or double stimulation (follicular plus luteal) in the same ovarian cycle (DuoStim) protocols. SUMMARY Many strategies have been proposed to manage poor responder patients, however, a consensus upon which is the most beneficial has not been yet reached. DuoStim is the most promising approach to increase the number of oocytes collected in a single ovarian cycle; however, more embryological and clinical data is required, as well as an analysis of its cost-effectiveness.
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Abstract
Medications to stimulate the ovaries may be used to induce ovulation in patients with anovulatory infertility or to hyperstimulate the ovaries in a controlled fashion in ovulatory patients as part of assisted reproductive treatments (ART). The pharmacology of all current major medications used to stimulate ovarian function is reviewed in this article, including letrozole, clomiphene citrate, gonadotropins, and pulsatile gonadotropin releasing hormone (GnRH). Novel potential compounds and adjuvant treatment approaches are also discussed, such as kisspeptin agonists and androgens.
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Affiliation(s)
- Alexander M Quaas
- University Hospital, University of Basel, Clinic for Reproductive Medicine and Gynecologic Endocrinology, Basel, Switzerland; Reproductive Partners San Diego, San Diego, CA, USA; Division of Reproductive Endocrinology and Infertility, University of California, San Diego, CA, USA.
| | - Richard S Legro
- Department of Obstetrics and Gynecology, Penn State University College of Medicine, Hershey, PA, USA
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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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Vaiarelli A, Cimadomo D, Trabucco E, Vallefuoco R, Buffo L, Dusi L, Fiorini F, Barnocchi N, Bulletti FM, Rienzi L, Ubaldi FM. Double Stimulation in the Same Ovarian Cycle (DuoStim) to Maximize the Number of Oocytes Retrieved From Poor Prognosis Patients: A Multicenter Experience and SWOT Analysis. Front Endocrinol (Lausanne) 2018; 9:317. [PMID: 29963011 PMCID: PMC6010525 DOI: 10.3389/fendo.2018.00317] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 05/28/2018] [Indexed: 01/15/2023] Open
Abstract
A panel of experts known as the POSEIDON group has recently redefined the spectrum of poor responder patients and introduced the concept of suboptimal response. Since an ideal management for these patients is still missing, they highlighted the importance of tailoring the ovarian stimulation based on the chance of each woman to obtain an euploid blastocyst. Interestingly, a novel pattern of follicle recruitment has been defined: multiple waves may arise during a single ovarian cycle. This evidence opened important clinical implications for the treatment of poor responders. For instance, double stimulation in the follicular (FPS) and luteal phase (LPS) of the same ovarian cycle (DuoStim) is an intriguing option to perform two oocyte retrievals in the shortest possible time. Here, we reported our 2-year experience of DuoStim application in four private IVF centers. To date, 310 poor prognosis patients completed a DuoStim protocol and underwent IVF with blastocyst-stage preimplantation-genetic-testing. LPS resulted into a higher mean number of oocytes collected than FPS; however, their competence (i.e., fertilization, blastocyst, euploidy rates, and clinical outcomes after euploid single-embryo-transfer) was comparable. Importantly, the rate of patients obtaining at least one euploid blastocyst increased from 42.3% (n = 131/310) after FPS to 65.5% (n = 203/310) with the contribution of LPS. A summary of the putative advantages and disadvantages of DuoStim was reported here through a Strengths-Weaknesses-Opportunities-Threats analysis. The strengths of this approach make it very promising. However, more studies are needed in the future to limit its weaknesses, shed light on its putative threats, and realize its opportunities.
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Affiliation(s)
- Alberto Vaiarelli
- Clinica Valle Giulia, G.en.e.r.a. Centers for Reproductive Medicine, Rome, Italy
| | - Danilo Cimadomo
- Clinica Valle Giulia, G.en.e.r.a. Centers for Reproductive Medicine, Rome, Italy
| | - Elisabetta Trabucco
- Clinica Ruesch, G.en.e.r.a. Centers for Reproductive Medicine, Naples, Italy
| | - Roberta Vallefuoco
- Clinica Ruesch, G.en.e.r.a. Centers for Reproductive Medicine, Naples, Italy
| | - Laura Buffo
- G.en.e.r.a. Veneto, G.en.e.r.a. Centers for Reproductive Medicine, Marostica, Italy
| | - Ludovica Dusi
- G.en.e.r.a. Veneto, G.en.e.r.a. Centers for Reproductive Medicine, Marostica, Italy
| | - Fabrizio Fiorini
- G.en.e.r.a. Umbria, G.en.e.r.a. Centers for Reproductive Medicine, Umbertide, Italy
| | - Nicoletta Barnocchi
- G.en.e.r.a. Umbria, G.en.e.r.a. Centers for Reproductive Medicine, Umbertide, Italy
| | | | - Laura Rienzi
- Clinica Valle Giulia, G.en.e.r.a. Centers for Reproductive Medicine, Rome, Italy
- Clinica Ruesch, G.en.e.r.a. Centers for Reproductive Medicine, Naples, Italy
- G.en.e.r.a. Veneto, G.en.e.r.a. Centers for Reproductive Medicine, Marostica, Italy
- G.en.e.r.a. Umbria, G.en.e.r.a. Centers for Reproductive Medicine, Umbertide, Italy
| | - Filippo Maria Ubaldi
- Clinica Valle Giulia, G.en.e.r.a. Centers for Reproductive Medicine, Rome, Italy
- Clinica Ruesch, G.en.e.r.a. Centers for Reproductive Medicine, Naples, Italy
- G.en.e.r.a. Veneto, G.en.e.r.a. Centers for Reproductive Medicine, Marostica, Italy
- G.en.e.r.a. Umbria, G.en.e.r.a. Centers for Reproductive Medicine, Umbertide, Italy
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Walters KA, Handelsman DJ. Role of androgens in the ovary. Mol Cell Endocrinol 2018; 465:36-47. [PMID: 28687450 DOI: 10.1016/j.mce.2017.06.026] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 06/28/2017] [Accepted: 06/30/2017] [Indexed: 11/18/2022]
Abstract
It has been well established for decades that androgens, namely testosterone (T) plays an important role in female reproductive physiology as the precursor for oestradiol (E2). However, in the last decade a direct role for androgens, acting via the androgen receptor (AR), in female reproductive function has been confirmed. Deciphering the specific roles of androgens in ovarian function has been hindered as complete androgen resistant females cannot be generated by natural breeding. In addition, androgens can be converted into estrogens which has caused confusion when interpreting findings from pharmacological studies, as observed effects could have been mediated via the AR or estrogen receptor. The creation and analysis of genetic mouse models with global and cell-specific disruption of the Ar gene, the sole mediator of pure androgenic action, has now allowed the elucidation of a role for AR-mediated androgen actions in the regulation of normal and pathological ovarian function. This review aims to summarize findings from clinical, animal, pharmacological and novel genetic AR mouse models to provide an understanding of the important roles androgens play in the ovary, as well as providing insights into the human implications of these roles.
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Affiliation(s)
- K A Walters
- Discipline of Obstetrics & Gynaecology, School of Women's & Children's Health, University of New South Wales, Sydney, New South Wales 2052, Australia.
| | - D J Handelsman
- Andrology Laboratory, ANZAC Research Institute, University of Sydney, Sydney, New South Wales 2139, Australia
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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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Doan HT, Quan LH, Nguyen TT. The effectiveness of transdermal testosterone gel 1% (androgel) for poor responders undergoing in vitro fertilization. Gynecol Endocrinol 2017; 33:977-979. [PMID: 28562099 DOI: 10.1080/09513590.2017.1332586] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
The study was conducted on 110 poor responders undergoing in vitro fertilization (IVF) from October 2015 to July 2016 at the IVF Center of Millitary Medical University, Vietnam. Its aim is to investigate the effectiveness of transdermal androgel before using controlled ovarian stimulation on patients undergoing IVF. A prospective, descriptive study was conducted to compare between the group of patients who used testosterone gel and the group of those who did not in terms of the following indicators: the number of oocytes retrieved, MII oocytes, fertilization rate, number of embryos, pregnancy rate, and embryo implantation rate. The number of oocytes retrieved, number of embryos, pregnancy rate, and embryo implantation rate of the group of patients using transdermal androgel before Controlled Ovarian Stimulation (COS) were found higher than those of the control group, with statistical significance. The use of androgel before stimulating ovarian can improve the responsiveness of poor responders when undergoing IVF.
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Affiliation(s)
- Hang Thi Doan
- a Centre for Human Reproduction and Embryology , Millitary Medical University , Hanoi , Vietnam
| | - Lam Hoang Quan
- a Centre for Human Reproduction and Embryology , Millitary Medical University , Hanoi , Vietnam
| | - Tung Thanh Nguyen
- a Centre for Human Reproduction and Embryology , Millitary Medical University , Hanoi , Vietnam
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Abide Yayla C, Ozkaya E, Kayatas Eser S, Sanverdi I, Devranoglu B, Kutlu T. Association of basal serum androgen levels with ovarian response and ICSI cycle outcome. Ir J Med Sci 2017; 187:409-415. [DOI: 10.1007/s11845-017-1665-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 07/17/2017] [Indexed: 01/05/2023]
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Walters KA, Edwards MC, Jimenez M, Handelsman DJ, Allan CM. Subfertility in androgen-insensitive female mice is rescued by transgenic FSH. Reprod Fertil Dev 2017; 29:1426-1434. [DOI: 10.1071/rd16022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 05/30/2016] [Indexed: 12/25/2022] Open
Abstract
Androgens synergise with FSH in female reproduction but the nature of their interaction in ovarian function and fertility is not clear. In the present study, we investigated this interaction, notably whether higher endogenous FSH can overcome defective androgen actions in androgen receptor (AR)-knockout (ARKO) mice. We generated and investigated the reproductive function of mutant mice exhibiting AR resistance with or without expression of human transgenic FSH (Tg-FSH). On the background of inactivated AR signalling, which alone resulted in irregular oestrous cycles and reduced pups per litter, ovulation rates and antral follicle health, Tg-FSH expression restored follicle health, ovulation rates and litter size to wild-type levels. However, Tg-FSH was only able to partially rectify the abnormal oestrous cycles observed in ARKO females. Hence, elevated endogenous FSH rescued the intraovarian defects, and partially rescued the extraovarian defects due to androgen insensitivity. In addition, the observed increase in litter size in Tg-FSH females was not observed in the presence of AR signalling inactivation. In summary, the findings of the present study reveal that FSH can rescue impaired female fertility and ovarian function due to androgen insensitivity in female ARKO mice by maintaining follicle health and ovulation rates, and thereby optimal female fertility.
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Steroid hormone pretreatments in assisted reproductive technology. Fertil Steril 2016; 106:1608-1614. [DOI: 10.1016/j.fertnstert.2016.09.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 09/06/2016] [Accepted: 09/07/2016] [Indexed: 01/22/2023]
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The role of steroid hormone supplementation in non–assisted reproductive technology treatments for unexplained infertility. Fertil Steril 2016; 106:1600-1607. [DOI: 10.1016/j.fertnstert.2016.09.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 08/18/2016] [Accepted: 09/07/2016] [Indexed: 11/23/2022]
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Castelo-Branco C, Hernández-Angeles C, Alvarez-Olivares L, Balasch J. Long-term satisfaction and tolerability with low-dose flutamide: a 20-year surveillance study on 120 hyperandrogenic women. Gynecol Endocrinol 2016; 32:723-727. [PMID: 27176209 DOI: 10.1080/09513590.2016.1184640] [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: 10/21/2022] Open
Abstract
OBJECTIVE To evaluate the long-term safety, satisfaction and tolerability of flutamide therapy for female hyperandrogenism. DESIGN A 20-year surveillance study. METHODS Setting: Gynecology Department in a teaching hospital. PATIENTS Hyperandrogenic women complaining for hirsutism treatment were followed between February 1995 and April 2015. INTERVENTIONS Women received flutamide 125 or 250 mg/day alone (n = 55) or combined with oral contraceptives (n = 65). MAIN OUTCOME MEASURES Adverse events, safety, tolerability satisfaction and efficacy were assessed every 6 months during all the follow-up. Lab tests including liver and lipid profiles were also recorded in each control. RESULTS Patients under flutamide therapy showed significant improvements in hirsutism scores after 6 months of treatment with a maximum effect at 12 months that was maintained during all the therapy time. Satisfaction reported by patients with the efficacy of the drug in a visual scale was also high. A total of 54.2 % women presented one or more adverse effects during the follow-up; 33.3% showed at least one adverse effect possibly related with the study drug; and 24.1% withdrew from the study because of adverse effects. During the follow-up, as many as 89.9 % of patients abandoned flutamide. Reasons include: questions linked to medical problems (50%), attempt pregnancy (4%) and significant improvement in the symptomatology (35.8%). CONCLUSIONS Flutamide is very effective for hirsutism treatment; however, adverse effects are very frequent and affect compliance.
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Affiliation(s)
- Camil Castelo-Branco
- a Clinic Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona , Barcelona , Spain and
| | - Claudio Hernández-Angeles
- b Hospital Ginecoobstetricia Número 4 "Luis Castelazo Ayala", Instituto Mexicano del Seguro Social , México DF , Mexico
| | - Lina Alvarez-Olivares
- a Clinic Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona , Barcelona , Spain and
| | - Juan Balasch
- a Clinic Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona , Barcelona , Spain and
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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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Abstract
Androgens mediate their actions via the androgen receptor (AR), a member of the nuclear receptor superfamily. AR-mediated androgen action is essential in male reproductive development and function; however, only in the last decade has the suspected but unproven role for AR-mediated actions in female reproduction been firmly established. Deciphering the specific roles and precise pathways by which AR-mediated actions regulate ovarian function has been hindered by confusion on how to interpret results from pharmacological studies using androgens that can be converted into oestrogens, which exert actions via the oestrogen receptors. The generation and analysis of global and cell-specific femaleArknockout mouse models have deduced a role for AR-mediated actions in regulating ovarian function, maintaining female fertility, and have begun to unravel the mechanisms by which AR-mediated androgen actions regulate follicle health, development and ovulation. Furthermore, observational findings from human studies and animal models provide substantial evidence to support a role for AR-mediated effects not only in normal ovarian function but also in the development of the frequent ovarian pathological disorder, polycystic ovarian syndrome (PCOS). This review focuses on combining the findings from observational studies in humans, pharmacological studies and animal models to reveal the roles of AR-mediated actions in normal and pathological ovarian function. Together these findings will enable us to begin understanding the important roles of AR actions in the regulation of female fertility and ovarian ageing, as well as providing insights into the role of AR actions in the androgen-associated reproductive disorder PCOS.
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Luo S, Li S, Li X, Qin L, Jin S. Effect of pretreatment with transdermal testosterone on poor ovarian responders undergoing IVF/ICSI: A meta-analysis. Exp Ther Med 2014; 8:187-194. [PMID: 24944620 PMCID: PMC4061182 DOI: 10.3892/etm.2014.1683] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Accepted: 04/01/2014] [Indexed: 11/12/2022] Open
Abstract
In order to identify and describe the effectiveness of transdermal testosterone pretreatment on poor ovarian responders, MEDLINE, EMBASE, the Cochrane library and the Chinese biomedical database were searched for randomized controlled trials (RCTs). Three RCTs, which compared the outcomes of female pretreatment with transdermal testosterone prior to in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) with those of control groups, were included in the present review. The three RCTs enrolled a total of 221 randomized subjects. The meta-analysis revealed that females who received transdermal testosterone treatment prior to their IVF/ICSI cycle had a two-fold increase in live birth rate [risk ratio (RR)=2.01, 95% confidence interval (CI) 1.03–3.91], clinical pregnancy rate (RR=2.09, 95% CI 1.14–3.81) and a significantly more oocyte retrieved [mean difference (MD)=1.36, 95% CI 0.82–1.90]. The current findings provide evidence that pretreatment with transdermal testosterone may improve the clinical outcomes for poor ovarian responders undergoing IVF/ICSI. However, the results should be interpreted with caution due to the small sample size of the studies used and the heterogeneities. Further good quality RCTs would be needed to reach further conclusions.
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Affiliation(s)
- Shan Luo
- Reproductive Medical Center, Department of Obstetrics and Gynecology, West China Second University Hospital of Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - Shangwei Li
- Reproductive Medical Center, Department of Obstetrics and Gynecology, West China Second University Hospital of Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - Xiaohong Li
- Reproductive Medical Center, Department of Obstetrics and Gynecology, West China Second University Hospital of Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - Lang Qin
- Reproductive Medical Center, Department of Obstetrics and Gynecology, West China Second University Hospital of Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - Song Jin
- Reproductive Medical Center, Department of Obstetrics and Gynecology, West China Second University Hospital of Sichuan University, Chengdu, Sichuan 610041, P.R. China
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Meldrum DR, Chang RJ, Giudice LC, Balasch J, Barbieri RL. Role of decreased androgens in the ovarian response to stimulation in older women. Fertil Steril 2013; 99:5-11. [DOI: 10.1016/j.fertnstert.2012.10.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Revised: 10/03/2012] [Accepted: 10/03/2012] [Indexed: 11/16/2022]
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Moawad A, Shaeer M. Long-term androgen priming by use of dehydroepiandrosterone (DHEA) improves IVF outcome in poor-responder patients. A randomized controlled study. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2012. [DOI: 10.1016/j.mefs.2012.11.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Effects of transdermal testosterone in poor responders undergoing IVF: systematic review and meta-analysis. Reprod Biomed Online 2012; 25:450-9. [DOI: 10.1016/j.rbmo.2012.07.011] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Revised: 07/13/2012] [Accepted: 07/18/2012] [Indexed: 11/20/2022]
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Hugues JN, Massart P, Cedrin-Durnerin I. Assessment of theca cell function: a prerequisite to androgen or luteinizing hormone supplementation in poor responders. Fertil Steril 2012; 99:333-6. [PMID: 23058685 DOI: 10.1016/j.fertnstert.2012.09.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Revised: 09/06/2012] [Accepted: 09/10/2012] [Indexed: 11/17/2022]
Abstract
Poor responders are a heterogeneous population, with some patients displaying a diminished ovarian reserve and others a poor ovarian reserve with preserved granulosa cell function. Androgen and LH/hCG supplementation has been advocated for poor responders, mainly those >40 years old. Although androgens synergistically act with FSH to support folliculogenesis, and ovarian androgen secretion declines with age, there is still no evidence that androgen therapy is actually effective to improve ovarian FSH sensitivity. The main reason seems to be that theca cell function has not been appropriately assessed in patients at risk of poor response. The definition of theca insufficiency is hampered by methodologic shortcomings in routine bioassays. Provocative tests for theca cells might help to identify those patients who could benefit from androgen supplementation. The lack of data regarding theca cells in these patients might contribute to explaining the absence of evidence for a positive effect of androgen therapy.
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Affiliation(s)
- Jean-Noël Hugues
- Reproductive Medicine Unit, Jean Verdier Hospital, University of Paris XIII, Bondy, France.
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de los Santos MJ, Garcia-Laez V, Beltran D, Labarta E, Zuzuarregui JL, Alama P, Gamiz P, Crespo J, Bosch E, Pellicer A. The follicular hormonal profile in low-responder patients undergoing unstimulated cycles: is it hypoandrogenic? Hum Reprod 2012; 28:224-9. [DOI: 10.1093/humrep/des349] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Hossein G, Arabzadeh S, Hossein-Rashidi B, Hosseini MA. Relations between steroids and AMH: impact of basal and intrafollicular steroids to AMH ratios on oocyte yield and maturation rate in women with or without polycystic ovary undergoing in vitro fertilization. Gynecol Endocrinol 2012; 28:413-7. [PMID: 21992510 DOI: 10.3109/09513590.2011.613964] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE This study sought to determine the relationships between serum or intrafollicular ovarian steroids and anti-mullerian hormone (AMH) and to predict impact of steroids to AMH ratios on oocyte quantity and metaphase II (MII) oocyte rate in normo-ovulatory (control) and polycystic ovary syndrome (PCOS) patients. DESIGN Prospective study. SETTING University hospital and research center. PATIENTS Thirty-two patients with PCOS and 37 controls undergoing IVF-ET. METHODS Serum (day 3) and follicular fluid (FF) from more than one follicle ≥ 17 mm on the day of oocyte retrieval were collected from each patients. MAIN OUTCOME MEASURES Serum or follicular fluid steroids, AMH, retrieved oocytes number and maturation rate. RESULTS In control group, intrafollicular AMH levels were positively related to P4 and T levels (p = .002, p = .011, respectively). Multiple linear regression analysis showed serum basal AMH and T levels as independent positive predictors while T/AMH ratio and intrafollicular AMH were negative predictors for both retrieved and MII oocyte number. The presence of PCOS and intrafollicular P4/AMH ratio revealed as important negative factors influencing oocyte maturation rate. CONCLUSIONS Serum basal T, AMH as well as their ratio and intrafollicular P4/AMH ratio may be used as predictors for retrieved oocyte number and their nuclear maturation rate, respectively.
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Affiliation(s)
- Ghamartaj Hossein
- Department of Developmental Biology, School of Biology, University College of Science, University of Tehran, Tehran, Iran.
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Bosdou JK, Venetis CA, Kolibianakis EM, Toulis KA, Goulis DG, Zepiridis L, Tarlatzis BC. The use of androgens or androgen-modulating agents in poor responders undergoing in vitro fertilization: a systematic review and meta-analysis. Hum Reprod Update 2012; 18:127-45. [PMID: 22307331 DOI: 10.1093/humupd/dmr051] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND The aim of this meta-analysis was to evaluate the role of androgens or androgen-modulating agents on the probability of pregnancy achievement in poor responders undergoing IVF. METHODS Medline, EMBASE, CENTRAL, Scopus and Web of Science databases were searched for the identification of randomized controlled trials evaluating the administration of testosterone, dehydroepiandrosterone (DHEA), aromatase inhibitors, recombinant luteinizing hormone (rLH) and recombinant human chorionic gonadotrophin (rhCG) before or during ovarian stimulation of poor responders. RESULTS In two trials involving 163 patients, pretreatment with transdermal testosterone was associated with an increase in clinical pregnancy [risk difference (RD): +15%, 95% confidence interval (CI): +3 to +26%] and live birth rates (RD: +11%, 95% CI: +0.3 to +22%) in poor responders undergoing ovarian stimulation for IVF. No significant differences in clinical pregnancy and live birth rates were observed between patients who received DHEA and those who did not. Similarly, (i) the use of aromatase inhibitors, (ii) addition of rLH and (iii) addition of rhCG in poor responders stimulated with rFSH for IVF were not associated with increased clinical pregnancy rates. In the only eligible study that provided data, live birth rate was increased in patients who received rLH when compared with those who did not (RD: +19%, 95% CI:+1 to +36%). CONCLUSIONS Based on the limited available evidence, transdermal testosterone pretreatment seems to increase clinical pregnancy and live birth rates in poor responders undergoing ovarian stimulation for IVF. There is insufficient data to support a beneficial role of rLH, hCG, DHEA or letrozole administration in the probability of pregnancy in poor responders undergoing ovarian stimulation for IVF.
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Affiliation(s)
- J K Bosdou
- Unit for Human Reproduction, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Androgens and poor responders: are we ready to take the plunge into clinical therapy? Fertil Steril 2011; 96:1062-5. [PMID: 22036049 DOI: 10.1016/j.fertnstert.2011.09.050] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2011] [Accepted: 09/28/2011] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To review and summarize data from the scientific literature on the use of androgens to improve ovarian function. DESIGN Review of pertinent literature. SETTING University hospital. PATIENT(S) Women exposed to androgens. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Critical review of the literature. RESULT(S) The artificial increase of intra-ovarian androgen concentrations constitutes an attractive concept for improving the deficient ovarian function of poor responders. Data from studies conducted in animals treated with high-dose androgens, together with observations made in hyperandrogenic women or female-to-male transsexuals receiving virilizing androgen doses, indicate that androgens may increase follicle responsiveness to FSH and/or the number of growing follicles in the ovary. Yet, definite clinical demonstration of such a concept still is not available. CONCLUSION(S) Current clinical approaches aiming at increasing androgen availability in the ovary showed conflicting results. Therefore, additional studies using proper strategies to achieving higher intra-ovarian androgen concentrations for longer intervals are required to define the clinical efficiency of androgens in poor responders.
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Metformin reduces risk of ovarian hyperstimulation syndrome in patients with polycystic ovary syndrome during gonadotropin-stimulated in vitro fertilization cycles: a randomized, controlled trial. Fertil Steril 2011; 96:1384-1390.e4. [DOI: 10.1016/j.fertnstert.2011.09.020] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Revised: 08/26/2011] [Accepted: 09/08/2011] [Indexed: 12/16/2022]
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Kamble L, Gudi A, Shah A, Homburg R. Poor responders to controlled ovarian hyperstimulation forin vitrofertilisation (IVF). HUM FERTIL 2011; 14:230-45. [DOI: 10.3109/14647273.2011.608241] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Lee VCY, Chan CCW, Ng EHY, Yeung WSB, Ho PC. Sequential use of letrozole and gonadotrophin in women with poor ovarian reserve: a randomized controlled trial. Reprod Biomed Online 2011; 23:380-8. [DOI: 10.1016/j.rbmo.2011.05.012] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2011] [Revised: 05/16/2011] [Accepted: 05/18/2011] [Indexed: 11/26/2022]
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Gleicher N, Weghofer A, Barad DH. The role of androgens in follicle maturation and ovulation induction: friend or foe of infertility treatment? Reprod Biol Endocrinol 2011; 9:116. [PMID: 21849061 PMCID: PMC3170254 DOI: 10.1186/1477-7827-9-116] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2011] [Accepted: 08/17/2011] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Effects of androgens on follicle maturation have been controversial for some time. Here, we review the potential of their applications in improving human ovulation induction, based on human and animal data, reported in the literature. METHODS We reviewed the published literature for the years 2005-2011, using relevant key words, in PubMed, Medline and Cochrane reviews, and then performed secondary reviews of referenced articles, which previously had not been known or preceded the searched time period. A total of 217 publications were reviewed. RESULTS Contrary to widely held opinion, recent data, mostly developed in the mouse, convincingly demonstrate essential contribution of androgens to normal follicle maturation and, therefore, female fertility. Androgens appear most engaged at preantral and antral stages, primarily affect granulosa cells, and exert effects via androgen receptors (AR) through transcriptional regulation but also in non-genomic ways, with ligand-activated AR modulating follicle stimulating hormone (FSH) activity in granulosa cells. While some androgens, like testosterone (T) and dehydroepiandrosterone (DHEA), appear effective in improving functional ovarian reserve (FOR) in women with diminished ovarian reserve (DOR), others may even exert opposite effects. Such differences in androgens may, at least partially, reflect different levels of agonism to AR. DISCUSSION Selective androgens appear capable of improving early stages of folliculogenesis. They, therefore, may represent forerunners of a completely new class of ovulation-inducing medications, which, in contrast to gonadotropins, affect follicle maturation at much earlier stages.
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Affiliation(s)
- Norbert Gleicher
- Center for Human Reproduction - New York, New York, USA
- Foundation for Reproductive Medicine, New York, New York, USA
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Andrea Weghofer
- Center for Human Reproduction - New York, New York, USA
- Department of Obstetrics and Gynecology, Medical University Vienna, Vienna, Austria
| | - David H Barad
- Center for Human Reproduction - New York, New York, USA
- Foundation for Reproductive Medicine, New York, New York, USA
- Departments of Epidemiology and Social Medicine and Obstetrics, Gynecology and Women's Health, Albert Einstein College of Medicine, Bronx, New York, USA
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Nardo LG, Fleming R, Howles CM, Bosch E, Hamamah S, Ubaldi FM, Hugues JN, Balen AH, Nelson SM. Conventional ovarian stimulation no longer exists: welcome to the age of individualized ovarian stimulation. Reprod Biomed Online 2011; 23:141-8. [DOI: 10.1016/j.rbmo.2011.05.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2010] [Revised: 04/29/2011] [Accepted: 05/03/2011] [Indexed: 01/20/2023]
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The value of human chorionic gonadotropin stimulation test in predicting ovarian response during in-vitro fertilization. J Assist Reprod Genet 2011; 28:893-9. [PMID: 21779785 DOI: 10.1007/s10815-011-9612-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Accepted: 07/11/2011] [Indexed: 10/18/2022] Open
Abstract
PURPOSE To assess the predictive value of human Chorionic Gonadotropin (hCG) theca-stimulation test for ovarian reserve in women undergoing in-vitro fertilization (IVF) treatments. METHODS 39 women were included in the study. All participants received a single hCG 10000 IU injection on cycle day 2-3. Serum levels of estradiol, testosterone, androstenedione and 17-OH progesterone were measured prior to the injection and on days 1, 3 and 7 following the injection. hCG-induced hormone levels were compared with ovarian response during the subsequent IVF cycle. RESULTS There were 11 good responders (>10 oocytes) and 22 low responders (<3 oocytes). Before hCG stimulation serum E2 levels were higher in low responders compared to good responders (370.3 ± 443 vs. 138.3 ± 54 pmol/ml). Following hCG stimulation, day 3 androstendione levels showed an increase in good responders compared to low responders. The ratio between day 3 androstendione and day 0 estradiol was significantly different between the two groups (p = 0.03). ROC analysis of this test revealed area = 0.837 (good prediction), which was much better than day 3 FSH (area = 0.635, poor prediction). CONCLUSIONS These preliminary results demonstrate the potential use of the hCG theca stimulation test in differentiating between good and poor responders. Larger series are needed for further verification of the test in routine clinical application.
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Elassar A, Engmann L, Nulsen J, Benadiva C. Letrozole and gonadotropins versus luteal estradiol and gonadotropin-releasing hormone antagonist protocol in women with a prior low response to ovarian stimulation. Fertil Steril 2011; 95:2330-4. [DOI: 10.1016/j.fertnstert.2011.03.103] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2010] [Revised: 03/02/2011] [Accepted: 03/31/2011] [Indexed: 10/18/2022]
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Gleicher N, Barad DH. Dehydroepiandrosterone (DHEA) supplementation in diminished ovarian reserve (DOR). Reprod Biol Endocrinol 2011; 9:67. [PMID: 21586137 PMCID: PMC3112409 DOI: 10.1186/1477-7827-9-67] [Citation(s) in RCA: 142] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Accepted: 05/17/2011] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND With infertility populations in the developed world rapidly aging, treatment of diminished ovarian reserve (DOR) assumes increasing clinical importance. Dehydroepiandrosterone (DHEA) has been reported to improve pregnancy chances with DOR, and is now utilized by approximately one third of all IVF centers world-wide. Increasing DHEA utilization and publication of a first prospectively randomized trial now warrants a systematic review. METHODS PubMed, Cochrane and Ovid Medline were searched between 1995 and 2010 under the following strategy: [<dehydroepiandrosterone or DHEA or androgens or testosterone > and <ovarian reserve or diminished ovarian reserve or ovarian function >]. Bibliographies of relevant publications were further explored for additional relevant citations. Since only one randomized study has been published, publications, independent of evidence levels and quality assessment, were reviewed. RESULTS Current best available evidence suggests that DHEA improves ovarian function, increases pregnancy chances and, by reducing aneuploidy, lowers miscarriage rates. DHEA over time also appears to objectively improve ovarian reserve. Recent animal data support androgens in promoting preantral follicle growth and reduction in follicle atresia. DISCUSSION Improvement of oocyte/embryo quality with DHEA supplementation potentially suggests a new concept of ovarian aging, where ovarian environments, but not oocytes themselves, age. DHEA may, thus, represent a first agent beneficially affecting aging ovarian environments. Others can be expected to follow.
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Affiliation(s)
- Norbert Gleicher
- Center for Human Reproduction (CHR) and Foundation for Reproductive Medicine, New York, NY, USA
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - David H Barad
- Center for Human Reproduction (CHR) and Foundation for Reproductive Medicine, New York, NY, USA
- Departments of Epidemiology and Social Medicine and Obstetrics, Gynecology and Women's Health, Albert Einstein College of Medicine, Bronx, NY, USA
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Carmona F, Martínez-Zamora MA, Rabanal A, Martínez-Román S, Balasch J. Ovarian cystectomy versus laser vaporization in the treatment of ovarian endometriomas: a randomized clinical trial with a five-year follow-up. Fertil Steril 2011; 96:251-4. [PMID: 21575941 DOI: 10.1016/j.fertnstert.2011.04.068] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2011] [Revised: 04/02/2011] [Accepted: 04/18/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To investigate the effect of two laparoscopic techniques for treatment of ovarian endometriomas on recurrence rate. DESIGN Prospective randomized clinical trial. SETTING University teaching hospital. PATIENT(S) Ninety women with ovarian endometriomas. INTERVENTION(S) Patients were randomly selected to undergo either laparoscopic cystectomy (group 1) or laser vaporization (group 2) of ovarian endometrioma. MAIN OUTCOME MEASURE(S) Recurrence, evaluated by ultrasound scan examination, was assessed at 12 and 60 months of follow-up. RESULT(S) Endometrioma recurrence rate was higher, though not significantly different, in group 2 at 60 months of follow-up. Nevertheless, at 12 months of follow-up recurrences were statistically higher in group 2. CONCLUSION(S) The comparison between laparoscopic laser ablation and laparoscopic cystectomy for ovarian endometriomas after long-term follow-up showed earlier recurrences and a higher recurrence rate in the laser group, although at 5 years of follow-up there were no statistically significant differences.
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Affiliation(s)
- Francisco Carmona
- Institut Clínic of Gynecology, Obstetrics, and Neonatology, Faculty of Medicine, University of Barcelona, Hospital Clínic-Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain.
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Fábregues F, Castelo-Branco C, Carmona F, Guimerá M, Casamitjana R, Balasch J. The effect of different hormone therapies on anti-müllerian hormone serum levels in anovulatory women of reproductive age. Gynecol Endocrinol 2011; 27:216-24. [PMID: 20500102 DOI: 10.3109/09513590.2010.487595] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To investigate the effect of oral contraceptives (OC), metformin and ovulation induction with gonadotropins on circulating anti-müllerian hormone (AMH). DESIGN Prospective clinical study. PATIENTS Thirty patients with PCOS (Group 1), 15 normogonadotropic anovulatory infertile women (WHO 2) (Group 2) and 15 normoovulatory control women (Group 3). Patients in Group 1 received OC (n = 12), metformin (n = 11) or no-treatment (n = 7) for 6 months. Ovulation induction with FSH or hMG was used in Group 2. MAIN OUTCOME MEASURES Total follicle number (TFN) and hormonal (fasting insulin and glucose, testosterone, SHBG, LH, androstenedione and AMH) measurements at baseline and during therapy. RESULTS Basal AMH and TFN were higher in Groups 1 and 2 than in controls. Only TFN was significantly related to AMH level in Groups 1 and 2. AMH level was significantly reduced during OC treatment, and there was a trend for AMH decrease during metformin therapy. No significant changes in AMH level were observed during ovulation induction. TFN was the only parameter showing a significant positive correlation with circulating AMH over the 6-month treatment period in patients in Group 2. CONCLUSIONS AMH is an accurate marker of the antral follicle pool in WHO-2/PCOS women but the measurement of AMH is not likely to be helpful in the management of those patients.
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Affiliation(s)
- Francisco Fábregues
- Institut Clínic of Gynecology, Obstetrics and Neonatology, Faculty of Medicine, University of Barcelona, Spain
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Sunkara SK, Pundir J, Khalaf Y. Effect of androgen supplementation or modulation on ovarian stimulation outcome in poor responders: a meta-analysis. Reprod Biomed Online 2011; 22:545-55. [PMID: 21493151 DOI: 10.1016/j.rbmo.2011.01.015] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2010] [Revised: 01/24/2011] [Accepted: 01/26/2011] [Indexed: 11/15/2022]
Abstract
Many trials have evaluated the use of androgen supplements and androgen-modulating agents to improve outcome of poor responders undergoing IVF treatment. This study conducted a systematic review and meta-analysis of controlled trials of androgen adjuvants (testosterone, dehydroepiandrostereone) and the androgen-modulating agent (letrozole) in poor responders undergoing IVF treatment. Searches were conducted on MEDLINE, EMBASE, Cochrane Library, ISRCTN Register and ISI proceedings. All randomized and non-randomized controlled trials were included. Study selection, quality appraisal and data extraction were performed independently and in duplicate. The main outcome measure was clinical pregnancy rate. The secondary outcome measures were dose and duration of gonadotrophin use, cycles cancelled before oocyte retrieval, oocytes retrieved and ongoing pregnancy rates. A total of 2481 cycles in women considered as poor responders undergoing IVF/intracytoplasmic sperm injection (ICSI) treatment were included in nine controlled trials. Meta-analyses of these studies did not show any significant difference in the number of oocytes retrieved and ongoing pregnancy/live-birth rates with androgen supplementation or modulation compared with the control groups. There is currently insufficient evidence from the few randomized controlled trials to support the use of androgen supplementation or modulation to improve live birth outcome in poor responders undergoing IVF/ICSI treatment.
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Affiliation(s)
- Sesh Kamal Sunkara
- Assisted Conception Unit, Guy's Hospital, St. Thomas Street, London, UK.
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Qin Y, Zhao Z, Sun M, Geng L, Che L, Chen ZJ. Association of basal serum testosterone levels with ovarian response and in vitro fertilization outcome. Reprod Biol Endocrinol 2011; 9:9. [PMID: 21247501 PMCID: PMC3031218 DOI: 10.1186/1477-7827-9-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2010] [Accepted: 01/20/2011] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND To evaluate basal testosterone (T) levels during follicular phase of the menstrual cycle as a predictor for ovarian response and in vitro fertilization (IVF) outcome. METHOD We analyzed data retrospectively from hospital-based IVF center including one thousand two hundred and sixty Chinese Han women under their first IVF cycle reached the ovum pick-up stage, without polycystic ovary syndrome (PCOS) or endometriosis undergoing long IVF protocol. Patients were divided into 2 groups. Group 1: patients with diminished ovarian reserve (basal FSH >10 IU/L) (n = 187); Group 2: patients with normal ovarian reserve (basal FSH < = 10 IU/L) (n = 1073). We studied the association of basal T levels with ovarian response and IVF outcome in the two groups. Long luteal down-regulation protocol was used in all patients, that is, the gonadotropin releasing hormone agonist was administered in the midluteal phase of the previous cycle and use of recombinant FSH was started when satisfactory pituitary desensitization was achieved. RESULTS Basal T levels were markly different between pregnant and non-pregnant women in Group 1; whereas not in Group 2. A testosterone level of 47.85 ng/dl was shown to predict pregnancy outcome with a sensitivity of 52.8% and specificity of 65.3%; and the basal T was correlated with the numbers of large follicles (> 14 mm) on HCG day in Group 1. Significantly negative correlations were observed between basal T, days of stimulation and total dose of gonadotropins after adjusting for confounding factors in both groups. CONCLUSION In women with diminished ovarian reserve, basal T level was a predictor for the number of large follicles on HCG day and pregnancy outcome; but could not in those with normal serum FSH. Basal T levels were associated with both days of stimulation and total dose of gonadotropins, indicating that lower level of T might relate with potential ovarian poor response.
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Affiliation(s)
- Yingying Qin
- Center for Reproductive Medicine, Shandong Provincial Hospital, Shandong University, Jinan, 250021, PR China
- Key Laboratory of Reproductive Medicine, Shandong Province, PR China
| | - Zhiyi Zhao
- Center for Reproductive Medicine, Shandong Provincial Hospital, Shandong University, Jinan, 250021, PR China
- Key Laboratory of Reproductive Medicine, Shandong Province, PR China
| | - Mei Sun
- Center for Reproductive Medicine, Shandong Provincial Hospital, Shandong University, Jinan, 250021, PR China
- Key Laboratory of Reproductive Medicine, Shandong Province, PR China
| | - Ling Geng
- Center for Reproductive Medicine, Shandong Provincial Hospital, Shandong University, Jinan, 250021, PR China
- Key Laboratory of Reproductive Medicine, Shandong Province, PR China
| | - Li Che
- Case Western Reserve University, Cleveland, OH 44146, USA
| | - Zi-Jiang Chen
- Center for Reproductive Medicine, Shandong Provincial Hospital, Shandong University, Jinan, 250021, PR China
- Key Laboratory of Reproductive Medicine, Shandong Province, PR China
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Castelo-Branco C, Steinvarcel F, Osorio A, Ros C, Balasch J. Atherogenic metabolic profile in PCOS patients: role of obesity and hyperandrogenism. Gynecol Endocrinol 2010; 26:736-42. [PMID: 20569105 DOI: 10.3109/09513590.2010.481025] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To investigate glyco-lipidic metabolism and androgenic profile in a cohort of women with polycystic ovary syndrome (PCOS) divided according to Rotterdam phenotypes and body mass index (BMI). DESIGN A prospective case-control study. SETTING Gynecology department in a teaching hospital. Patients. A total of 223 PCOS women and 25 healthy control women were studied. METHODS Patients and controls were subdivided into three groups according to their BMI: normal weight (18.5 ≤ [BMI] ≤24.9 kg/m(2)), overweight (25.0 ≤ BMI ≤29.9 kg/m(2)), or obese (BMI ≥30.0 kg/m(2)) and according to Rotterdam criteria of PCOS. Main outcome measures. Pituitary-gonadal axis assessment including follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol, PRL, testosterone, androstenedione, DHEA-S, 17-hydroxyprogesterone and inhibin B. Metabolic parameters included cholesterol (Chol), high-density lipoprotein (HDL), low-density lipoprotein (LDL), triglycerides (TG) and apolipoproteins (APO) AII and B as well as serum fasting insulin, glucose and HOMA-IR. RESULTS Serum fasting insulin, glucose, HOMA-IR, TG and HDL were significantly higher in women with PCOS compared to controls. Additionally, serum levels of Chol, LDL and TG were significantly higher and HDL levels were significantly lower in obese PCOS women compared with overweight/normal PCOS irrespective of Rotterdam phenotypes. Free testosterone index but not androstenedione or total testosterone significantly correlated with TG, HDL and APO B. No significant correlations were detected between gonadotropins, inhibin B or estradiol with metabolic parameters studied. CONCLUSIONS Obesity but not overweight in PCOS is associated with dyslipidemia. Hyperandrogenic women showed the most atherogenic lipid profiles.
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Affiliation(s)
- Camil Castelo-Branco
- Faculty of Medicine, Institute Clinic of Gynecology, Obstetrics and Neonatology, University of Barcelona, Hospital Clinic-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS): Barcelona, Spain
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