Does dehydroepiandrosterone have any benefit in fertility treatment?

The Effect of Dehydroepiandrosterone (DHEA) Supplementation on IVF or ICSI: A Meta-Analysis of Randomized Controlled Trials

Introduction A systematic review and meta-analysis were conducted to evaluate the efficacy of dehydroepiandrosterone (DHEA) supplementation in patients with diminished ovarian reserve (DOR) and/or poor ovarian response (POR) who were undergoing in vitro fertilization or intracytoplasmic sperm injection (IVF/ICSI).

Patients and Methods We searched the PubMed, EMBASE, Web of Science, and Cochrane Library electronic databases for literature published until July 2018. The analysis included randomized controlled trials (RCTs) of the effects of DHEA versus placebo on IVF or ICSI. Two independent reviewers extracted information from the reports and evaluated the quality of the studies. Overall, we identified nine prospective RCTs involving 833 patients.

Results Compared to the controls, patients treated with DHEA exhibited increases in the number of retrieved oocytes (mean difference, 0.91; 95% confidence interval [CI], 0.23 – 1.59; p = 0.009), clinical pregnancy rate (relative risk [RR] = 1.27; 95% CI, 1.01 – 1.61; p = 0.04), and live birth rate (RR, 1.76; 95% CI, 1.17 – 2.63; p = 0.006). However, there was no intergroup difference in the miscarriage rate (RR, 0.37; 95% CI, 0.12 – 1.13; p = 0.08).

Conclusion DHEA supplementation improved the outcomes of IVF/ICSI in women with DOR or POR.

The use of coenzyme Q10 and DHEA during IUI and IVF cycles in patients with decreased ovarian reserve

OBJECTIVE

The objective of this study is to compare the combination of dehydroepiandrosterone (DHEA) and coenzyme Q10 (CoQ10) (D + C) with DHEA alone (D) in intrauterine insemination (IUI) and in vitro fertilization (IVF) cycles among patients with decreased ovarian reserve.

METHODS

We retrospectively extracted data from patients charts treated by DHEA with/without CoQ10 during IUI or IVF between February 2006 and June 2014. Prestimulation parameters included age, BMI, day 3 FSH and antral follicular count (AFC). Ovarian response parameters included total gonadotropins dosage, peak serum estradiol, number of follicles > 16 mm and fertilization rate. Clinical outcomes included clinical and ongoing pregnancy rates.

RESULTS

Three hundred and thirty IUI cycles involved D + C compared with 467 cycles of D; 78 IVF cycles involved D + C and 175 D. In both IUI and IVF, AFC was higher with D + C compared with D (7.4 ± 5.7 versus 5.9 ± 4.7, 8.2 ± 6.3 versus 5.2 ± 5, respectively, p < 0.05). D + C resulted in a more follicles > 16 mm during IUI cycles (3.3 ± 2.3 versus 2.9 ± 2.2, respectively, p = 0.01), while lower mean total gonadotropin dosage was administered after D + C supplementation compared with D (3414 ± 1141 IUs versus 3877 ± 1143 IUs respectively, p = 0.032) in IVF cycles. Pregnancy and delivery rates were similar for both IUI and IVF.

CONCLUSION

D + C significantly increases AFC and improves ovarian responsiveness during IUI and IVF without a difference in clinical outcome.

A meta-analysis of dehydroepiandrosterone supplementation among women with diminished ovarian reserve undergoing in vitro fertilization or intracytoplasmic sperm injection

BACKGROUND

Evidence for the efficacy of dehydroepiandrosterone (DHEA) in improving ovarian responsiveness among poor responders, especially women with diminished ovarian reserve (DOR), remains inconsistent.

OBJECTIVES

To evaluate the effectiveness of DHEA in women with DOR undergoing in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI).

SEARCH STRATEGY

PubMed and Embase were searched for reports published in any language before October 31, 2014, using keywords such as "DHEA," "poor ovarian response," "diminished ovarian reserve," and "premature ovarian aging."

SELECTION CRITERIA

Studies that explored the effects of DHEA in women with DOR undergoing IVF/ICSI were included if they evaluated the number of oocytes retrieved and/or the rates of clinical pregnancy, implantation, and spontaneous abortion.

DATA COLLECTION AND ANALYSIS

Risk ratios (RRs) and standardized mean differences with 95% confidence intervals (CIs) were calculated, combined with subgroup and sensitivity analyses.

MAIN RESULTS

Eight studies were included. The use of DHEA increased the clinical pregnancy rate (RR 2.13; 95% CI 1.12-4.08). Similar results were obtained in subgroup analyses including randomized controlled trials and case-control studies (RR 2.57; 95% CI 1.43-4.63) and self-controlled studies (RR 3.95; 95% CI 1.28-12.19). However, the effects of DHEA on oocyte retrieval, implantation, and abortion were not significant.

CONCLUSIONS

Supplementation with DHEA has a positive effect in women undergoing IVF/ICSI treatment for DOR.

Genetics of androgen metabolism in women with infertility and hypoandrogenism

Hypoandrogenism in women with low functional ovarian reserve (LFOR, defined as an abnormally low number of small growing follicles) adversely affects fertility. The androgen precursor dehydroepiandrosterone (DHEA) is increasingly used to supplement treatment protocols in women with LFOR undergoing in vitro fertilization. Due to differences in androgen metabolism, however, responses to DHEA supplementation vary between patients. In addition to overall declines in steroidogenic capacity with advancing age, genetic factors, which result in altered expression or enzymatic function of key steroidogenic proteins or their upstream regulators, might further exacerbate variations in the conversion of DHEA to testosterone. In this Review, we discuss in vitro studies and animal models of polymorphisms and gene mutations that affect the conversion of DHEA to testosterone and attempt to elucidate how these variations affect female hormone profiles. We also discuss treatment options that modulate levels of testosterone by targeting the expression of steroidogenic genes. Common variants in genes encoding DHEA sulphotransferase, aromatase, steroid 5α-reductase, androgen receptor, sex-hormone binding globulin, fragile X mental retardation protein and breast cancer type 1 susceptibility protein have been implicated in androgen metabolism and, therefore, can affect levels of androgens in women. Short of screening for all potential genetic variants, hormonal assessments of patients with low testosterone levels after DHEA supplementation facilitate identification of underlying genetic defects. The genetic predisposition of patients can then be used to design individualized fertility treatments.

Is there a role for DHEA supplementation in women with diminished ovarian reserve?

PURPOSE

Poor ovarian reserve and poor ovarian response presents a challenge to IVF centers. Dehydroepiandrosterone (DHEA) supplementation is increasingly being used by many IVF centers around the world in poor responders despite the lack of convincing data. We therefore examined the rationale for the use of DHEA in poor responders, address the relevant studies, present new data, and address its potential mechanisms of action.

METHODS

All published articles on the role of DHEA in infertile women from 1990 to April 2013 were reviewed.

RESULTS

Several studies have suggested an improvement in pregnancy rates with the use of DHEA. Potential mechanisms include improved follicular steroidogenesis, increased IGF-1, acting as a pre-hormone for follicular testosterone, reducing aneuploidy, and increasing AMH and antral follicle count. While the role of DHEA is intriguing, evidence-based recommendations are lacking.

CONCLUSIONS

While nearly 25 % of IVF programs use DHEA currently, large randomized prospective trials are sorely needed. Until (and if) such trials are conducted, DHEA may be of benefit in suitable, well informed, and consented women with diminished ovarian reserve.

Efficacy of dehydroepiandrosterone to improve ovarian response in women with diminished ovarian reserve: a meta-analysis

Women with diminished ovarian reserve often respond poorly to controlled ovarian stimulation resulting in retrieval of fewer oocytes and reduced pregnancy rates. It has been proposed that pre-IVF Dehydroepiandrosterone (DHEA) adjuvant therapy may improve ovarian response and pregnancy rates in women with diminished ovarian reserve. This meta-analysis aims to investigate efficacy of DHEA as an adjuvant to improve ovarian response and IVF outcome in women with diminished ovarian reserve. Electronic databases were searched under the following terms: (DHEA) and (diminished ovarian reserve) and/or (poor response). Studies were included if they reported at least one of the following outcomes; clinical pregnancy rate, number of oocytes retrieved, miscarriage rate. We identified 22 publications determining effects of DHEA in clinical trials. Only 3 controlled studies were eligible for meta-analysis. There was no significant difference in the clinical pregnancy rate and miscarriage rates between women pre-treated with DHEA compared to those without DHEA pre-treatment (RR 1.87, 95% CI 0.96-3.64; and RR 0.59, 95% CI 0.21-1.65, respectively). The number of oocytes retrieved (WMD -1.88, 95% CI -2.08, 1.67; P < 0.001) was significantly lower in the DHEA group. In conclusion, based on the limited available evidence from a total of approximately 200 IVF cycles, there are insufficient data to support a beneficial role of DHEA as an adjuvant to controlled ovarian stimulation in IVF cycle. Well-designed, randomised controlled trials as well as more exact knowledge about DHEA mechanisms of action are needed to support use of DHEA in standard practice for poor-responders.

Hype or hope? Ethical and practical considerations with clinical research in women with diminished ovarian reserve

This communication suggests that investigations of treatments for women with diminished functional ovarian reserve (DOR) call for specific practical and ethical considerations, as women with DOR, because of limited remaining reproductive life spans, appropriately feel under time constraints. Another medical journal recently published an opinion piece on the use of dehydroepiandrosterone in women with DOR, raising important questions about what approaches should be taken to develop best available evidence in such patients. Their manuscript offers an excellent opportunity to consider ethical and clinical aspects of study design in clinical circumstances where patients have little to lose but face the promise of considerable gains in clinical pregnancy chances if effective treatments can be developed. This commentary concludes that, in such circumstances, common sense as well as ethical considerations support the introduction of new treatments into the clinical mainstream even in absence of prospectively randomized studies if lower levels of evidence are supportive of positive treatment effects.