Androgen priming before ovarian stimulation for IVF

Dehydroepiandrosterone administration before IVF in poor responders: a prospective cohort study

The use of dehydroepiandrosterone (DHEA) may improve ovarian stimulation outcomes in women of advanced reproductive age and could reduce embryo aneuploidy. In this prospective study, 48 women diagnosed with poor ovarian response received DHEA supplementation for at least 12 weeks. These women were compared with a group of poor responders (n = 113) who did not receive supplementation. During the study period, patients taking day 2 FSH and oestradiol were measured monthly before and after treatment. Stimulation characteristics, stimulation outcome and clinical outcome (clinical pregnancy and live birth rates) were reported. Evaluation of anti-Müllerian hormone (AMH) was carried out before initiation of treatment and immediately before the subsequent stimulation. Supplementation with DHEA for at least 12 weeks resulted in a modest, but statistically significant, increase in AMH levels and decrease in baseline FSH (P < 0.001 and P = 0.007, respectively). Administration of DHEA had no effect on any of the stimulation parameters nor was there any difference in clinical pregnancy rates and live birth rates between the two groups. Supplementation with DHEA significantly affects women with poor prognosis undergoing ovarian stimulation for IVF. Patients should be counselled about the uncertain effectiveness, potential side-effects and cost of this treatment.

Dehydroepiandrosterone improves follicular fluid bone morphogenetic protein-15 and accumulated embryo score of infertility patients with diminished ovarian reserve undergoing in vitro fertilization: a randomized controlled trial

Objective

To evaluate the effect of dehydroepiandrosterone (DHEA) on infertility patients with diminished ovarian reserve undergoing in vitro fertilization.

Methods

This is a prospective study. Ninety-five patients with diminished ovarian reserve were included in this study. Of them, 42 patients were randomly allocated to the DHEA group, who received DHEA 75 mg daily for three consecutive menstrual cycles prior to IVF cycles, and 53 patients were allocated to the control group, who entered IVF cycles directly. All patients were treated with the same ovarian stimulation protocol. Follicular fluid samples from both groups were collected for bone morphogenetic protein-15 (BMP-15) and growth differentiation factor-9 (GDF-9). Fluid from the first aspirated follicle without any visible blood contamination was carefully collected. In addition, day 3 Blood samples were collected pre- and post-treatment of DHEA for serum anti-Mullerian hormone (AMH), follicle stimulating hormone (FSH) and estradiol (E₂) in the DHEA group.

Results

The level of BMP-15 in follicular fluid samples from the DHEA group was significantly higher than that of the control samples (P=.000). Patients after DHEA treatment demonstrated a significantly higher level of AMH and a significantly lower level of FSH, E₂ compared to themselves prior to DHEA therapy (P=.015; P=.036; P=.002; respectively). Moreover, the accumulated score of embryos was significantly higher in the DHEA group (P=.033).

Conclusions

These observations confirm the beneficial effect of DHEA for infertility patients with diminished ovarian reserve.

Trial registration

ChiCTR-TRC-14005002

Effect of pretreatment with transdermal testosterone on poor ovarian responders undergoing IVF/ICSI: A meta-analysis

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.

FSH receptor in vitro modulation by testosterone and hCG in human luteinized granulosa cells

OBJECTIVE

To investigate the effect of testosterone and hCG on FSH receptor (FSHR) protein and mRNA expression in human granulosa cells (GC) in vitro.

STUDY DESIGN

Experimental in vitro cell culture obtained from healthy women undergoing IVF/ICSI due to male factor infertility. Human follicular fluid samples were obtained and after cumulus-oocyte complexes were identified, fluids were pipetted onto Ficoll gradients and centrifuged for 15 min at 400 × g at room temperature. Cells at the interface were removed and plated in 24-well plates for 3 days in M-199 with 10% FBS. Cells were treated with different concentrations of testosterone and hCG. After purification, cells were labeled with specific antibodies and the protein expression of the FSHR was evaluated by flow cytometry in the GC population. Also, total RNA was extracted from confluent GC and the FSHR gene expression was evaluated by RT-PCR.

RESULTS

FSHR expression was modulated by treating GC in vitro at different testosterone/hCG concentrations. When compared with untreated GC, we observed a significant effect of testosterone and hCG on the expression of the FSHR at the protein level. Time course experiments confirmed that the gene expression of the FSHR peaked at 12-24h when testosterone or hCG was used as a stimulus.

CONCLUSIONS

Both testosterone and hCG are able to positively modulate FSHR expression at gene and protein level in human GC in vitro.

DHEA for poor responders: can treatment be justified in the absence of evidence?

Evidence-based medicine is the application of science to the practice of healthcare, leading to reproducibility and transparency in the science supporting healthcare practice. Dehydroepiandrosterone (DHEA) has been proposed as a treatment for improving ovarian reserve in poor responding women undergoing IVF. However, there is a lack of evidence of its effectiveness as data is derived mostly from retrospective studies and one questionable randomized trial. DHEA appears to be devoid of major side effects, however, due lack of data supporting its effectiveness, its wide scale use cannot be currently recommended.

Dehydroepiandrosterone inhibits glucose flux through the pentose phosphate pathway in human and mouse endometrial stromal cells, preventing decidualization and implantation

Endometrial stromal cells (ESC) must undergo a hormone-driven differentiation to form decidual cells as a requirement of proper embryo implantation. Recent studies from our laboratory have demonstrated that decidualizing cells require glucose transporter 1 expression and an increase in glucose use to complete this step. The present study focuses on the glucose-dependent molecular and metabolic pathways, which are required by ESC for decidualization. Inhibition of glycolysis had no effect on decidualization. However, blockade of the pentose phosphate pathway (PPP) with pharmacologic inhibitors 6-aminonicotinamide or dehydroepiandrosterone (DHEA), and short hairpin RNA-mediated knockdown of glucose-6-phosphate dehydrogenase, the rate-limiting step in the PPP, both led to strong decreases in decidual marker expression in vitro and decreased decidualization in vivo. Additionally, the studies demonstrate that inhibition is due, at least in part, to ribose-5-phosphate depletion, because exogenous nucleoside administration restored decidualization in these cells. The finding that PPP inhibition prevents decidualization of ESC is novel and clinically important, because DHEA is an endogenous hormone produced by the adrenal glands and elevated in a high proportion of women who have polycystic ovary syndrome, the most common endocrinopathy in reproductive age women. Together, this data suggest a mechanistic link between increased DHEA levels, use of glucose via the PPP, and pregnancy loss.