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

BCORL1, POF1B, and USP9X copy number variation in women with idiopathic diminished ovarian reserve

PURPOSE

To analyze the copy number variation (CNV) in the X-linked genes BCORL1, POF1B, and USP9X in idiopathic diminished ovarian reserve (DOR).

METHODS

This case-control study included 47 women, 26 with DOR and 21 in the control group. Age, weight, height, BMI, and FSH level were evaluated, as well as antral follicle count (AFC), oocyte retrieval after controlled ovarian stimulation, and metaphase II (MII) oocytes. The CNVs of BCORL1, USP9X, and POF1B genes were measured by quantitative real time PCR (qPCR) using two reference genes, the HPRT1 (X-linked) and MFN2 (autosomal). Protein-protein interaction network and functional enrichment analysis were performed using the STRING database.

RESULTS

The mean age was 36.52 ± 4.75 in DOR women and 35.38 ± 4.14 in control. Anthropometric measures did not differ between the DOR and control groups. DOR women presented higher FSH (p = 0.0025) and lower AFC (p < .0001), oocyte retrieval after COS (p = 0.0004), and MII oocytes (p < .0001) when compared to the control group. BCORL1 and POF1B did not differ in copy number between DOR and control. However, DOR women had more copies of USP9X than the control group (p = 0.028).

CONCLUSION

The increase in the number of copies of the USP9X gene may lead to overexpression in idiopathic DOR and contribute to altered folliculogenesis and oocyte retrieval.

TEAS, DHEA, CoQ10, and GH for poor ovarian response undergoing IVF-ET: a systematic review and network meta-analysis

BACKGROUND

Assisted reproductive technology (ART) has brought good news to infertile patients, but how to improve the pregnancy outcome of poor ovarian response (POR) patients is still a serious challenge and the scientific evidence of some adjuvant therapies remains controversial.

AIM

Based on previous evidence, the purpose of this systematic review and network meta-analysis was to evaluate the effects of DHEA, CoQ10, GH and TEAS on pregnancy outcomes in POR patients undergoing in vitro fertilization and embryo transplantation (IVF-ET). In addition, we aimed to determine the current optimal adjuvant treatment strategies for POR.

METHODS

PubMed, Embase, The Cochrane Library and four databases in China (CNKI, Wanfang, VIP, SinoMed) were systematically searched up to July 30, 2022, with no restrictions on language. We included randomized controlled trials (RCTs) of adjuvant treatment strategies (DHEA, CoQ10, GH and TEAS) before IVF-ET to improve pregnancy outcomes in POR patients, while the control group received a controlled ovarian stimulation (COS) regimen only. This study was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The surface under the cumulative ranking curve (SUCRA) was used to provide a pooled measure of cumulative ranking for each outcome.

RESULTS

Sixteen RCTs (2323 women) with POR defined using the Bologna criteria were included in the network meta-analysis. Compared with the control group, CoQ10 (OR 2.22, 95% CI: 1.05 to 4.71) and DHEA (OR 1.92, 95% CI: 1.16 to 3.16) had obvious advantages in improving the clinical pregnancy rate. CoQ10 was the best in improving the live birth rate (OR 2.36, 95% CI: 1.07 to 5.38). DHEA increased the embryo implantation rate (OR 2.80, 95%CI: 1.41 to 5.57) and the high-quality embryo rate (OR 2.01, 95% CI: 1.07 to 3.78) and number of oocytes retrieved (WMD 1.63, 95% CI: 0.34 to 2.92) showed a greater advantage, with GH in second place. Several adjuvant treatment strategies had no significant effect on reducing the cycle canceling rate compared with the control group. TEAS was the least effective of the four adjuvant treatments in most pooled results, but the overall effect appeared to be better than that of the control group.

CONCLUSION

Compared with COS regimen, the adjuvant use of CoQ10, DHEA and GH before IVF may have a better clinical effect on the pregnancy outcome of POR patients. TEAS needs careful consideration in improving the clinical pregnancy rate. Future large-scale RCTs with direct comparisons are needed to validate or update this conclusion.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022304723.

Accumulated Vitrified Embryos Could Be a Method for Increasing Pregnancy Rates in Patients with Poor Ovarian Response

We aimed to assess the efficacy of accumulated embryo transfer (ACC-ET) through several controlled ovarian hyperstimulation (COS) cycles to increase the rates of pregnancy in patients with poor ovarian response (POR). We retrospectively reviewed the medical records of 588 patients with POR under 43-years old who underwent embryo transfer from January 2010 to December 2015. We compared the pregnancy rate (PR), clinical pregnancy rate (CPR), and live birth rate (LBR) between ACC-ET (frozen-thawed: 47; fresh + frozen-thawed: 24) group (n = 71) and fresh ET groups (n = 517). Characteristics of ACC-ET patients were similar to those of fresh ET groups (Age: 38.1 ± 3.5 vs. 38.2 ± 3.7, p = 0.88; Anti Müllerian Hormone (AMH; ng/mL): 0.5 ± 0.4 vs. 0.6 ± 0.6, p = 0.38; follicle stimulating hormone (FSH: mIU/mL): 11.9 ± 8.0 vs. 10.8 ± 9.0, p = 0.35). The total number of transferred embryos (3.1 ± 0.9 vs. 1.5 ± 0.7, p = 0.00), PR (29.6% (21/71) vs. 18.8% (97/517), p = 0.040), and CPR (23.5% (16/68) vs. 14.0% (71/508) p = 0.047) were significantly higher in the ACC-ET group than in the fresh ET group. In addition, PR, CPR, and LBR increased with the number of ET in the fresh ET group. However, there were no significant differences observed in LBR between ACC-ET and fresh ET groups (14.9% (10/67) vs. 9.8% (50/508), p = 0.203). From our knowledge, there is no clinical evidence reported to prove that transfer of multiple embryos of adequate quality obtained through multiple cycles can compensate for the limited number of retrieved oocytes from POR patients. We concluded that ACC-ET from several COS cycles could be an alternative method to increase PR and CPR in <43-year-old patients with POR.

Correlation of serum anti-Mullerian hormone with hormonal and environmental parameters in Brazilian climacteric women

This study aimed to identify the correlation among anti-Mullerian Hormone serum levels and 25-OH-D, obesity, metabolic syndrome (MetS), and sexual hormones in climacteric women classified according to stages of reproductive aging (SRA). A cross-sectional study was conducted with a total of 177 Brazilian climacteric women between 40 and 64 years old. Concentrations of AMH were measured using the Access 2 Immunoassay System. A multiple linear regression analysis was used to identify the relationship among AMH, 25-OH-D, obesity, MetS, sexual hormones, sociodemographic and lifestyle factors. AMH levels decreased with increased age (B = - 0.059; p < 0.001), and reproductive aging (B = - 0.483; p < 0.001). Obesity indicators, lifestyle characters, 25-OH-D levels and MetS were not significantly associated with AMH serum concentration. Negative correlation was found for FSH (B = - 0.009; p < 0.001) and LH (B = - 0.006; p = 0.004); positive correlation for E2 (B = 0.001; p = 0.011), DHEAS (B = 0.003; p < 0.001) and SHBG (B = 0.003; p = 0.005). In the model adjusted for SRA, FSH levels (p < 0.001) and DHEAS (p = 0.014) were associated with AMH. Although, with the adjustment for age, only FSH remained with a significant association (p = 0.001). Of the other analytes, none was associated with AMH, regardless of the model fit. Our findings confirm that serum AMH level decreased with age and FSH levels, but there is no correlation between AMH with obesity, 25-OH-D, MetS or other sexual hormones in Brazilian climacteric women.

Treatment Progress in Diminished Ovarian Reserve: Western and Chinese Medicine

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

The Immunoregulatory Actions of DHEA in Tuberculosis, A Tool for Therapeutic Intervention?

Dehydroepiandrosterone (DHEA) is an androgen synthesized by the adrenal cortex, which is an intermediary in the biosynthesis of sex hormones, such as testosterone and estradiol. DHEA mostly circulates as a conjugated ester, in the form of sulfate (DHEA-S). There exist several endogenous factors able to influence its synthesis, the most common ones being the corticotrophin-releasing hormone (CRH), adrenocorticotrophin (ACTH), growth factors, and proinflammatory cytokines, among others. Like other steroid hormones, DHEA, can alter the functioning of immune cells and therefore the course of diseases exhibiting an immune-inflammatory component, mostly from autoimmune or infectious nature. We herein review the role played by DHEA during a major infectious disease like tuberculosis (TB). Data recorded from TB patients, mouse models, or in vitro studies show that DHEA is likely to be implied in better disease control. This provides a stimulating background for carrying out clinical studies aimed at assessing the usefulness of DHEA as an adjuvant in TB patients.

Dehydroepiandrosterone (DHEA) role in enhancement and maintenance of implantation (DREAM): randomised double-blind placebo-controlled trial-study protocol

INTRODUCTION

Dehydroepiandrosterone (DHEA) is an important precursor of androgen and has been studied and researched extensively for improving the various outcome measures of ovarian stimulation in women with advanced age or poor ovarian response. Androgens also play an important role in the enhancement of endometrial and decidual function by regulating both the transcriptome and secretome of the endometrial stromal cells and have a positive effect on various factors like insulin-like growth factor binding protein 1, homeobox genes (HOXA10, HOXA11), secreted phosphoprotein 1, prolactin which are necessary for implantation. It is well-known that the circulating 'precursor pool' of DHEA declines with age more so in poor ovarian reserve patients and exogenous supplementation may be beneficial in such cases. This double-blinded randomised controlled trial (RCT) aims to test the hypothesis whether transient targeted supplementation of DHEA as an adjuvant to progesterone in frozen embryo transfer (FET) cycles, for women with low serum testosterone, helps in improving live birth rate.

METHODS AND ANALYSIS

This study is planned as a double-blinded, placebo-controlled randomised trial and the sample size, calculated for the primary outcome measure-live birth rate, is 140. All participants will be having a flexible antagonist protocol for controlled ovarian stimulation and an elective freeze-all policy for the embryos as per the hospital protocol after written informed consent. For FET, the endometrium will be prepared by hormone replacement treatment protocol. During the FET cycle, the intervention group will be receiving DHEA 25 mg two times a day for 15 days from the day of starting progesterone supplementation and the control group will be receiving a placebo.

ETHICS AND DISSEMINATION

The approval of the study was granted by the Clinical Trials Registry-India and the Institutional Ethical Committee of CRAFT Hospital and Research Center. All participants will provide written informed consent before being randomised into allocated treatment groups. The results will be disseminated to doctors and patients through conference presentations, peer-reviewed publications, social media and patient information booklets.

TRIAL REGISTRATION NUMBERS

CTRI/2020/06/025918; ECR/1044/Inst/KL/2018.

Adipose-Derived Mesenchymal Stem Cells: A Promising Tool in the Treatment of pre mature ovarian failure

Despite being rare, primary ovarian insufficiency (POI) is a significant cause of infertility and deficiency of ovarian hormone in women. Several health risks are also associated with POI, which include dry eye syndrome, reduced density of bones and enhanced fracture risks, troublesome menopausal symptoms, early development of cardiovascular disease, and psychological effects such as declined cognition, reduced perceived psychological support, anxiety, and depression. Replacing premenopausal levels of ovarian sex steroids through proper hormone replacement therapy could improve the quality of life for POI women and ameliorate related health risks. Herein, POI and its complications, in addition to hormone replacement therapies, which are safe and effective, are discussed. It is proposed that the use of HRT) Hormone replacement therapy (formulations which mimic normal production of ovarian hormones could reduce POI-associated morbidity rates if they are continued by the age 50, which is approximately the natural age of menopause. Particular populations of POI women are also addressed, which include those with enhanced risk of ovarian or breast cancer, those with Turner syndrome, those approaching natural menopause, and those who are breastfeeding. It is generally predicted that stem cell-based therapies would be both safe and effective. In fact, several types of cells have been described as safe, though their effectiveness and therapeutic application are yet to be defined. Several factors exist which could affect the results of treatment, such as cell handling, ex-vivo preparation strategies, variations in tissue of origin, potency, and immunocompatibility. Accordingly, cell types potentially effective in regenerative medicine could be recognized. Notably, products of MSCs from various sources of tissues show different levels of regenerative capabilities. The ultimate focus of the review is on adipose tissue-derive MCSs (ADMSCs), which possess exceptional features such as general availability, great ability to proliferate and differentiate, immunomodulatory capabilities, and low immunogenicity.

Importance of Dehydroepiandrosterone Sulfate Assessment with Special Attention for Adrenal Tumours and Arterial Hypertension

OBJECTIVE

To investigate the significance of DHEAS assessment in males of different ages.

METHODS

Retrospective cohort study of patients investigated in two large academic centres.

RESULTS

The data of DHEAS assessment of 3533 patients (3013 females and 520 males) was analysed. DHEAS was 1.6 - 13.5 times more frequently investigated in women than in men. A peak of DHEAS evaluation test for women was at 25 years old and distribution was uniform in males over decades, excepting being lower in 0-9 and 75+ages. In the age group 10-24 years, DHEAS levels were higher in females. After 45 years, DHEAS was higher in men than in women. Analysis of 510 case records showed low DHEAS levels in boys (0-9 years) and in men aged 65 - 84+. Higher DHEAS levels were detected as a peak at 30 years old, but never after 55 years. In individuals with low DHEAS levels prevailed congenital adrenal hyperplasia (32%), adrenal tumours (30%) and primary or secondary adrenal insufficiency (19%). High DHEAS levels prevailed in patients with arterial hypertension (26%), overweight-obesity -(19%), non-toxic goiter (17%) and alopecia (9%). In the normal DHEAS miscellaneous diagnoses were met most frequently - 40%. Disorders exceeding 5% were non-toxic goiter (19%), adrenal tumours - 17%, overweight/obesity - 16% and arterial hypertension- 8%. In 71 women and 124 men adrenal neoplasms were detected. Higher frequency of these was observed in women in their 30s. A peak of adrenal neoplasms in men was at their 70s. This gender difference was not conditioned by earlier attempts to seek medical care by women. A significant correlation of DHEAS, weight, body mass index and systolic blood pressure with diastolic blood pressure was found.

CONCLUSION

Our study permits to determine which DHEAS secretion and clinical pattern might be associated in males of different ages.

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

The management of patients with diminished ovarian reserve (DOR) remains one of the most challenging tasks in IVF clinical practice. Despite the promising results obtained from animal studies regarding the importance of androgens on folliculogenesis, the evidence obtained from clinical studies remains inconclusive. This is mainly due to the lack of an evidence-based methodology applied in the available trials and to the heterogeneity in the inclusion criteria and IVF treatment protocols. In this review, we analyze the available evidence obtained from animal studies and highlight the pitfalls from the clinical studies that prevent us from closing the chapter of this line of research.

A narrative review of adjuvants in in vitro fertilisation: evidence for good clinical practice

A review of studies published between January 1, 1984 and January 31, 2019 was performed with the aim of analysing the efficacy and adverse effects of commonly used adjuvants to in vitro fertilisation. The authors preferentially selected recent systematic reviews and randomised control trials (where available) from an electronic literature search. The review showed that low molecular weight heparin, corticosteroids and embryo glue may be of use in selected patient groups. Other adjuncts (such as growth hormone, assisted hatching, endometrial disruption and dehydroepiandrosterone) cannot currently be recommended as collated results showed no overall benefit to clinical pregnancy rates or live birth rates. There is a significant lack of robust evidence in this field, and areas in particular need of further research have been highlighted. In conclusion, caution should be exercised in prescribing adjuvants in in vitro fertilisation, either individually or in combination as further research is needed to ascertain their efficacy. Many adjuvants carry the risk of adverse effects which should also be considered. Patients should be clearly informed of the evidence, and where it is lacking, for these treatments. There is a need for further good quality trials to address the questions regarding best practice.

Ovarian stimulation modalities in poor responders

In a group of IVF/ICSI cycles, despite the appropriate ovarian stimulation, the number of oocytes collected is below the expected value. This condition is defined as poor ovarian response (POR) to stimulation. POR brings the risk of cycle cancellation with an estimated rate of 20%. Infertility experts are trying to improve cycle outcomes of POR cases with multiple modifications. This review article will present the latest modifications on the management of POR. The studies performed for improving cycle outcome in POR cases were evaluated and their notable results were presented. The first intervention among infertility specialists is to make a standard definition for POR. The BOLOGNA criteria and the subsequent POSEIDON group definitions are the latest updates in POR management. GnRH antagonists, estradiol priming, double stimulation, letrozole administration, DHEA, and herbal therapy supplementations are the recent modifications done to improve oocyte retrieval and subsequent embryo transfer for POR cases. This review article presents the encouraging methods applied for POR cases to improve cycle outcome.

Acupuncture for diminished ovarian reserve: Protocol for a systematic review and meta-analysis

BACKGROUND

The choice of treatments for diminished ovarian reserve (DOR) still remains a challenging clinical problem in reproductive medicine. Acupuncture could be beneficial for patients with DOR. This study aims to systematically investigate the efficacy and safety of the acupuncture for women with DOR.

METHODS

We will search electronic databases including PubMed (1946 to present), EMBASE (1974 to present), Cochrane Central Register of Controlled Trials (CENTRAL, all years), Web of Science (1900 to present), Chinese Biomedical Literatures Database (CBM, 1978 to present), China National Knowledge Infrastructure (CNKI, 1979 to present), WANFANG Data (from 2000 to present) to identify potentially eligible studies. Only randomized controlled trials (RCTs) will be included. Experimental interventions include traditional or contemporary acupuncture. Control interventions include no treatment, sham acupuncture, placebo acupuncture, or another active therapy. The primary outcomes include ongoing pregnancy rate and serum anti-Müllerian hormone level. A meta-analysis will be used to estimate a pooled intervention effect if possible.

RESULTS

The results will be published in a peer-reviewed journal.

CONCLUSION

The findings will provide further evidence for the management of DOR.

PROSPERO REGISTRATION NUMBER

CRD42018114385.

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.

Influence of androgen levels on conception probability in patients undergoing fertility treatment: a retrospective cohort study

PURPOSE

Primary and secondary sterility have become an issue of increasing importance due to demographic and social changes in society. Data regarding the association between female androgen levels and the probability of successful conception after fertility treatment are sparse and contradictive. This study was designed to assess this clinical question.

METHODS

In this retrospective single-center cohort study concentrations of androgens androstenedione, dehydroepiandrosteronsulfat (DHEAS) and testosterone (ng/ml) were investigated in the serum of patients presenting for sterility at the department of reproductive medicine of Saarland University hospital Homburg between January 2015 and December 2017. Androgen levels were correlated with reproductive outcomes. Statistical analysis was performed with the aid of SPSS version 24. Significance for conception rates in dependence of androgen concentration was assessed using Kruskal-Wallis test (significance was estimated with p < 0.05).

RESULTS

The laboratory values of a total of 301 patients were examined (64% primary, 36% secondary sterility). Median age at first visit at the fertility department was 32.7 years (range 20-47 years). 64 pregnancies were observed during the study period (conception rate 21.3%). 23 out of 301 patients (7.6%) suffered from hypoandrogenaemia, 248 (82.4%) had normal androgen levels and 30 (10%) showed hyperandrogenaemia (p = 0.25). Regarding patients in whom fertility treatment was successful 3 (4.7%) showed hypoandrogenaemia, 54 (84.4%) were normoandrogenaemic and 7 (10.9%) had hyperandrogenaemia (p = 0.40 Kruskal-Wallis test).

CONCLUSIONS

We found no association between female androgen levels and sterility and reproductive outcomes.

DHEA use to improve likelihood of IVF/ICSI success in patients with diminished ovarian reserve: A systematic review and meta-analysis

The aim of this review is to determine if the use of DHEA increases the likelihood of success in patients with POR. We searched MEDLINE and EMBASE using the terms "DHEA and diminished ovarian reserve", "DHEA and poor response", "DHEA and premature ovarian aging". A fixed effects model was used and Peto's method to get the odds ratio (OR) with 95% confidence intervals (CI 95%). For quantitative variables, Cohen's method was used to present the standardized mean differences (SMD) with their corresponding confidence intervals. Only five studied fulfilled the selection criteria. DHEA was administered in 25 mg doses, three times a day. In all studies, the authors corrected for the presence of confounding variables such as partner's age, infertility diagnosis and number of transferred embryos. The meta-analysis of the five selected studies assessed a total of 910 patients, who underwent IVF/ICSI, of which 413 had received DHEA. DHEA use was associated with a significant increase in pregnancy likelihood (OR 1.8, CI 95% 1.29 to 2.51, p=0.001). When analyzing the association between DHEA use and the likelihood of abortion, we found low heterogeneity between studies (I²=0.0%) and the use of DHEA to be associated to a significant reduction in the likelihood of abortion (OR 0.25, CI 0.07 to 0.95; p=0.045). Analysis of the association of DHEA with average oocyte retrieval showed high variability between studies (I²=98.6%), as well as no association between DHEA use and the number of oocytes retrieved (SMD -0.01, CI 95% -0.16 to 0.13; p<0.05).

Effects of Dehydroepiandrosterone on In Vitro Fertilization Among Women Aging Over 35 Years and Normal Ovarian Reserve

Objective: The fertility potential of women declines with aging and the likelihood of infertility and stillbirth increase. Treatment protocols involving dehydroepiandrosterone (DHEA) provide pathways on improving fertility and live birth rate. This randomized clinical trial aimed to evaluate the effect of DHEA on In Vitro Fertilization (IVF) outcomes in women over 35 years and normal ovarian reserve. Materials and methods: One hundred and six consecutive women with advanced reproductive age undergoing IVF due to infertility were enrolled in the study. Participants in the intervention group received 75 mg/day of DHEA orally 8 weeks before starting the cycle of ovulation induction. Participants in placebo group received placebo tablets during the same period. After 8 weeks, routine procedure of IVF was initiated then Clinical pregnancy, Miscarriage, Endometrial thickness and Duration of stimulation were evaluated for all the participants in both groups. Results: There is no significant difference between groups in terms of age and BMI. Mean endometrial thickness was significantly lower in DHEA group (9.63 ± 0.70vs.8.05 ± 0.70; p < 0.001) while Duration of stimulation was higher (8.98 ± 1.29vs.10.59 ± 1.43; p < 0.001). There was no significant difference between pregnancy rate, and miscarriage rate of the groups. Conclusion: According to the result of this study, DHEA supplementation may improve IVF outcomes in infertile women. Although additional larger and placebo-controlled studies using different DHEA protocols are required to support our present findings.

Efficacy of dehydroepiandrosterone (DHEA) supplementation for in vitro fertilization and embryo transfer cycles: a systematic review and meta-analysis

Dehydroepiandrosterone (DHEA) supplementation might hold some promise in vitro fertilization and embryo transfer cycles. However, the results remain controversial. We conducted a systematic review and meta-analysis to evaluate the efficacy of DHEA in patients for in vitro fertilization. PubMed, EMbase, Web of science, EBSCO and Cochrane library databases were systematically searched. Randomized controlled trials (RCTs) assessing the effect of DHEA versus placebo on in vitro fertilization were included. Two investigators independently searched articles, extracted data and assessed the quality of included studies. The primary outcomes were clinical pregnancy and live birth rate. Meta-analysis was performed using random-effect model. Six RCTs involving 745 patients were included in the meta-analysis. Overall, compared with placebo, DHEA supplementation was associated with the significant increase in clinical pregnancy (OR = 1.45; 95% CI = 1.04-2.03; p = .03), live birth rate (OR = 2.70; 95% CI = 1.24-5.85; p = .01) and endometrial thickness (Std. mean difference = 0.67; 95% CI = 0.02-1.32; p = .04) but showed no influence on E₂ on hCG day (Std. mean difference = 0.69; 95% CI =  -0.46 to 1.85; p = .24), embryos transferred (Std. mean difference = 0.42; 95% CI =  -0.04 to 0.88; p = .07) and miscarriage rate (OR = 0.43; 95% CI = 0.03-6.66; p = .55). DHEA supplementation could significantly improve clinical pregnancy, live birth rate, endometrial thickness and retrieved oocytes but failed to alter E₂ on hCG day, embryos transferred and miscarriage rate.

DHEA Supplementation Confers No Additional Benefit to that of Growth Hormone on Pregnancy and Live Birth Rates in IVF Patients Categorized as Poor Prognosis

BACKGROUND

In vitro fertilization (IVF) patients receive various adjuvant therapies to enhance success rates, but the true benefit is actively debated. Growth hormone (GH) and dehydroepiandrosterone (DHEA) supplementation were assessed in women undergoing fresh IVF transfer cycles and categorized as poor prognosis from five criteria.

METHODS

Data were retrospectively analyzed from 626 women undergoing 626 IVF cycles, where they received no adjuvant, GH alone, or GH-DHEA in combination. A small group received DHEA alone. The utilization of adjuvants was decided between the attending clinician and the patient depending on various factors including cost.

RESULTS

Despite patients being significantly older with lower ovarian reserve, live birth rates were significantly greater with GH alone (18.6%) and with GH-DHEA (13.0%) in comparison to those with no adjuvant (p < 0.003). No significant difference was observed between the GH groups (p = 0.181). Overall, patient age, quality of the transferred embryo, and GH treatment were the only significant independent predictors of live birth chance. Following adjustment for patient age, antral follicle count, and quality of transferred embryo, GH alone and GH-DHEA led to a 7.1-fold and 5.6-fold increase in live birth chance, respectively (p < 0.000).

CONCLUSION

These data indicated that GH adjuvant may support more live births, particularly in younger women, and importantly, the positive effects of GH treatment were still observed even if DHEA was also used in combination. However, supplementation with DHEA did not indicate any potentiating benefit or modify the effects of GH treatment. Due to the retrospective design, and the risk of a selection bias, caution is advised in the interpretation of the data.

The effect of DHEA on apoptosis and cohesin levels in oocytes in aged mice

Female fertility declines with age as the number of ovarian follicles decreases and aneuploidy increases. Degradation of the cohesin complex might be responsible for age-related aneuploidy. Dehydroepiandrosterone (DHEA) can improve the ovarian reserve and reduce the rate of aneuploidy, but the relationship between DHEA and cohesin levels in oocytes is still unknown. The aim of the current study was to evaluate the effect of the supplement DHEA on ovarian function, including the number of follicles and cohesin levels in oocytes. C57BL/6J mice at 3 weeks, 6 weeks, 12 weeks, 6 months, and 10 months of age were used to obtain a systematic view into follicle apoptosis and cohesin levels in oocytes. Nine-month-old C57BL/6J mice were administered saline (n = 5), 17β-estradiol (100 µg/kg per day, n = 5), or DHEA (5mg/Kg per day, n = 5). After 4 weeks, aged mice were weighed and sacrificed, and ovarian tissue samples were prepared. Anti-VASA staining and HE staining were used to count the number of follicles. Anti-γH2AX staining and TUNEL were used to measure follicle apoptosis and immunofluorescent staining was used to detect the levels of three oocyte cohesin subunits: REC8, SMC1β, and SMC3. Administration of the supplements 17β-estradiol and DHEA to aged mice increased the number of primordial and primary follicles and decreased the age-related apoptosis of follicles. Levels of the cohesin subunits REC8 and SMC1β declined with age, but DHEA and 17β-estradiol tended to delay that decline. The supplement DHEA increased the number of primordial and primary follicles in aged mice by inhibiting follicle apoptosis and tended to delay the decrease in cohesin levels in oocytes.

Efficacy of Dehydroepiandrosterone (DHEA) to overcome the effect of ovarian ageing (DITTO): A proof of principle double blinded randomized placebo controlled trial

OBJECTIVE

To evaluate the effect of DHEA supplementation on In-Vitro Fertilisation (IVF) outcome as assessed by ovarian response, oocyte developmental competence and live birth rates in women predicted to have poor ovarian reserve (OR). The feasibility of conducting a large trial is also assessed by evaluating the recruitment rates and compliance of the recruited participants with DHEA/placebo intake and follow-up rates.

STUDY DESIGN

A single centre, double blinded, placebo controlled, randomized trial was performed over two years with 60 women undergoing in-vitro fertilisation (IVF). Subjects were randomized, based on a computer-generated pseudo-random code to receive either DHEA or placebo with both capsules having similar colour, size and appearance. 60 women with poor OR based on antral follicle count or anti-Mullerian hormone thresholds undergoing IVF were recruited. They were randomised to receive DHEA 75mg/day or placebo for at-least 12 weeks before starting ovarian stimulation. They had long protocol using hMG 300 IU/day. Data analysed by "intention to treat". Ovarian response, live birth rates and molecular markers of oocyte quality were compared between the study and control groups.

RESULTS

The recruitment rate was 39% (60/154). A total of 52 participants (27 versus 25 in the study and placebo groups) were included in the final analysis after excluding eight. While the mean (standard deviation) DHEA levels were similar at recruitment (9.4 (5) versus 7.5 (2.4) ng/ml; P=0.1), the DHEA levels at pre-stimulation were higher in the study group than in the controls (16.3 (5.8) versus 11.1 (4.5) ng/ml; P<0.01). The number (median, range) of oocytes retrieved (4, 0-18 versus 4, 0-15 respectively; P=0.54) and live birth rates (7/27, 26% versus 8/25, 32% respectively; RR (95% CI): 0.74 (0.22-2.48) and mRNA expression of developmental biomarkers in granulosa and cumulus cells were similar between the groups.

CONCLUSION

Pre-treatment DHEA supplementation, albeit statistical power in this study is low, did not improve the response to controlled ovarian hyperstimulation or oocyte quality or live birth rates during IVF treatment with long protocol in women predicted to have poor OR.

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

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

Hormone replacement therapy in young women with primary ovarian insufficiency and early menopause

Primary ovarian insufficiency (POI) is a rare but important cause of ovarian hormone deficiency and infertility in women. In addition to causing infertility, POI is associated with multiple health risks, including bothersome menopausal symptoms, decreased bone density and increased risk of fractures, early progression of cardiovascular disease, psychologic impact that may include depression, anxiety, and decreased perceived psychosocial support, potential early decline in cognition, and dry eye syndrome. Appropriate hormone replacement therapy (HRT) to replace premenopausal levels of ovarian sex steroids is paramount to increasing quality of life for women with POI and ameliorating associated health risks. In this review, we discuss POI and complications associated with this disorder, as well as safe and effective HRT options. To decrease morbidity associated with POI, we recommend using HRT formulations that most closely mimic normal ovarian hormone production and continuing HRT until the normal age of natural menopause, ∼50 years. We address special populations of women with POI, including women with Turner syndrome, women with increased risk of breast or ovarian cancer, women approaching the age of natural menopause, and breastfeeding women.

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

Background

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

Methods

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

Results

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

Conclusion

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

Trial registration

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

The Steroid Metabolome in the Isolated Ovarian Follicle and Its Response to Androgen Exposure and Antagonism

The ovarian follicle is a major site of steroidogenesis, crucially required for normal ovarian function and female reproduction. Our understanding of androgen synthesis and metabolism in the developing follicle has been limited by the sensitivity and specificity issues of previously used assays. Here we used liquid chromatography-tandem mass spectrometry to map the stage-dependent endogenous steroid metabolome in an encapsulated in vitro follicle growth system, from murine secondary through antral follicles. Furthermore, follicles were cultured in the presence of androgen precursors, nonaromatizable active androgen, and androgen receptor (AR) antagonists to assess effects on steroidogenesis and follicle development. Cultured follicles showed a stage-dependent increase in endogenous androgen, estrogen, and progesterone production, and incubations with the sex steroid precursor dehydroepiandrosterone revealed the follicle as capable of active androgen synthesis at early developmental stages. Androgen exposure and antagonism demonstrated AR-mediated effects on follicle growth and antrum formation that followed a biphasic pattern, with low levels of androgens inducing more rapid follicle maturation and high doses inhibiting oocyte maturation and follicle growth. Crucially, our study provides evidence for an intrafollicular feedback circuit regulating steroidogenesis, with decreased follicle androgen synthesis after exogenous androgen exposure and increased androgen output after additional AR antagonist treatment. We propose that this feedback circuit helps maintain an equilibrium of androgen exposure in the developing follicle. The observed biphasic response of follicle growth and function in increasing androgen supplementations has implications for our understanding of polycystic ovary syndrome pathophysiology and the dose-dependent utility of androgens in in vitro fertilization settings.

Demographic, lifestyle, and other factors in relation to antimüllerian hormone levels in mostly late premenopausal women

OBJECTIVE

To identify reproductive, lifestyle, hormonal, and other correlates of circulating antimüllerian hormone (AMH) concentrations in mostly late premenopausal women.

DESIGN

Cross-sectional study.

SETTING

Not applicable.

PATIENT(S)

A total of 671 premenopausal women not known to have cancer.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Concentrations of AMH were measured in a single laboratory using the picoAMH ELISA. Multivariable-adjusted median (and interquartile range) AMH concentrations were calculated using quantile regression for several potential correlates.

RESULT(S)

Older women had significantly lower AMH concentrations (≥40 [n = 444] vs. <35 years [n = 64], multivariable-adjusted median 0.73 ng/mL vs. 2.52 ng/mL). Concentrations of AMH were also significantly lower among women with earlier age at menarche (<12 [n = 96] vs. ≥14 years [n = 200]: 0.90 ng/mL vs. 1.12 ng/mL) and among current users of oral contraceptives (n = 27) compared with never or former users (n = 468) (0.36 ng/mL vs. 1.15 ng/mL). Race, body mass index, education, height, smoking status, parity, and menstrual cycle phase were not significantly associated with AMH concentrations. There were no significant associations between AMH concentrations and androgen or sex hormone-binding globulin concentrations or with factors related to blood collection (e.g., sample type, time, season, and year of blood collection).

CONCLUSION(S)

Among premenopausal women, lower AMH concentrations are associated with older age, a younger age at menarche, and currently using oral contraceptives, suggesting these factors are related to a lower number or decreased secretory activity of ovarian follicles.

Effect of testosterone on the Connexin37 of sexual mature mouse cumulus oocyte complex

BACKGROUND

Recent researches demonstrate that pre-treatment with androgen could increase retrieved oocytes number and clinical pregnancy rate in poor ovarian response (POR) patients. In view of gap junction intercellular communication (GJIC) is important for follicular growth, and androgen plays an important role in improving prognosis of POR patients, we speculate that androgen can increase the expression of connexin in follicle cells, and improve ovarian microenvironment, thus can promote ovarian response. The objective of the research is to study the effect of testosterone on connexin37 (Cx37) expression so as to provide theoretical basis for adding testosterone in treatment of POR.

METHODS

Cumulus-oocyte-cells (COCs) were collected from ICR mice ovaries, and were cultured in vitro for 48 h and then treated with testosterone (T) at various concentration. To assess whether the effect of androgen on Cx37 expression is mediated through androgen receptor (AR) pathway, COCs were cultured in vitro with Flutamide (androgen receptor antagonist). The expression of Cx37 was determined by western blot.

RESULTS

The expression of Cx37 in COCs which were treated with testosterone was higher than that of control group. There were significant differences (P < 0.001;<0.001;<0.001;<0.001). Cx37 increased with the elevated testosterone concentrations. Cx37 was lower in androgen receptor antagonist group (2.57 ± 0.12) than the corresponding testosterone concentrations group (4.42 ± 0.28). There were significant differences between two groups (P < 0.001).

CONCLUSIONS

There was close relationship between gap junction protein and ovarian response, which suggested that androgen could promote ovarian response by increasing the expression of Cx37 in follicle. Androgen plays an important role in ovarian response through the AR pathway and non-AR pathway.

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

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

Evaluation of Dehydroepiandrosterone Supplementation on Diminished Ovarian Reserve: A Randomized, Double-Blinded, Placebo-Controlled Study

INTRODUCTION

We conducted a randomized, double-blinded, placebo-controlled study, to evaluate the effect of dehydroepiandrosterone (DHEA), on diminished ovarian reserve (DOR).

MATERIALS AND METHODS

Twenty patients with DOR received DHEA (oral 25 mg three times a day). Post-supplementation 12 weeks, D2/3 age-specific follicle-stimulating hormone (FSH), anti-mullerian hormone (AMH) levels, and antral follicle count (AFC), were repeated to evaluate response. Spontaneous pregnancy rates and regularization of menstrual cycles were also studied as secondary outcome.

RESULTS

Predominant risk factors were age >35 years (28 %) and poor responders to ovarian stimulation (23 %). There was significant improvement of AMH levels (1.15 ± 1.49 vs. 1.53 ± 1.62) found before and after supplementation in the DHEA group. When the AMH values between DHEA and placebo group were compared, pre- and post-supplementation, no significant difference was found. There was decrease in FSH levels and increase in AFC value post-supplementation in both DHEA and placebo groups which was not statically significant. DHEA supplementation benefited clinically, as evidenced by the improvement in the menstrual abnormality spontaneous conception in two cases each.

CONCLUSIONS

A significant improvement in AMH levels pre- and post-supplementation of DHEA was noted. The same was not seen for FSH and AFC values.

Effective treatment protocol for poor ovarian response: A systematic review and meta-analysis

Poor ovarian response represents an increasingly common problem. This systematic review was aimed to identify the most effective treatment protocol for poor response. We searched MEDLINE, EMBASE, and The Cochrane Library from 1980 to October 2015. Study quality assessment and meta-analyses were performed according to the Cochrane recommendations. We found 61 trials including 4997 cycles employing 10 management strategies. Most common strategy was the use of gonadotropin-releasing hormone antagonist (GnRHant), and was compared with GnRH agonist protocol (17 trials; n = 1696) for pituitary down-regulation which showed no significant difference in the outcome. Luteinizing hormone supplementation (eight trials, n = 847) showed no difference in the outcome. Growth hormone supplementation (seven trials; n = 251) showed significant improvement in clinical pregnancy rate (CPR) and live birth rate (LBR) with an odds ratio (OR) of 2.13 (95% CI 1.06-4.28) and 2.96 (95% CI 1.17-7.52). Testosterone supplementation (three trials; n = 225) significantly improved CPR (OR 2.4; 95% CI 1.16-5.04) and LBR (OR 2.18; 95% CI 1.01-4.68). Aromatase inhibitors (four trials; n = 223) and dehydroepiandrosterone supplementation (two trials; n = 57) had no effect on outcome.

Bu Shen Tiao Chong recipe restores diminished ovary reserve through the BDNF pathway

PURPOSE

The purpose of this study was to explore the molecular pathway of BSTCR (Bu Shen Tiao Chong recipe) in retrieving diminished ovary reserve (DOR).

METHODS

The DOR model was established through injecting cyclophosphamide and the effect of BSTCR was examined under this background.

RESULTS

BSTCR was shown to restore depleted brain-derived neurotrophic factor (BDNF), CDC2, cyclin B, GSH1, and P38 levels as well as impaired oocyte maturation and the higher apoptosis induced in DOR. BSTCR also enhances the response of oocytes to in vitro fertilization, with higher implantation rate, birth rate, and placenta weight.

CONCLUSION

BSTCR might exert its beneficial role in oocyte maturation and restore DOR through regulating the BDNF pathway. And this pathway itself is probably through the consequence on several serum hormones such as FSH, E2, Inhibin B, etc.

The effect of dehydroepiandrosterone (DHEA) supplementation on women with diminished ovarian reserve (DOR) in IVF cycle: Evidence from a meta-analysis

To evaluate the effect of dehydroepiandrosterone (DHEA) therapy on the ovarian response and pregnancy outcome in patients with diminished ovarian reserve (DOR). Eligible studies, published before August 31, 2015, were identified from PubMed, EMBASE, the Cochrane library. Outcome measures were the number of retrieved oocytes, cancellation rate of IVF cycles, clinical pregnancy rate and miscarriage rate. We adopted Revman 5.0 software to pool the data from the eligible studies. A total of 9 studies, four were RCTs, four retrospective studies, one prospective studies, including 540 cases and 668 controls, were available for analysis. The pooled analysis showed that the clinical pregnancy rates were increased significantly in DOR patients who were pre-treated with DHEA (OR=1.47, 95% CI: 1.09-1.99), whereas no differences were found in the number of oocytes retrieved, the cancellation rate of IVF cycles and the miscarriage rate between the cases and controls (WMD= -0.69, 95% CI: -2.18-0.81; OR=0.74, 95% CI: 0.51-1.08; OR=0.34, 95% CI: 0.10-1.24). However, it is worth noting that when data were restricted to RCTs, there was a non-significant difference in the clinical pregnancy rate (OR=1.08, 95% CI: 0.67-1.73). We concluded that DHEA supplementation in DOR patients might improve the pregnancy outcomes. To further confirm this effect, more randomized controlled trials with large sample sizes are needed.

Electroacupuncture for reproductive hormone levels in patients with diminished ovarian reserve: a prospective observational study

Background

Effective methods for the treatment of reproductive dysfunction are limited. Previous studies have reported that acupuncture can modulate female hormone levels, improve menstrual disorders, alleviate depression and improve pregnancy rates. However, studies of acupuncture for diminished ovarian reserve (DOR) are lacking.

Objective

To carry out a prospective observational study aimed at assessing the effect of EA on the reproductive hormone levels of patients with DOR seeking fertility support and consider its safety.

Methods

Eligible patients with DOR received EA for 12 weeks: five times a week for 4 weeks followed by three times a week for 8 weeks. The primary outcome was the change in mean follicle-stimulating hormone (FSH) level at week 12. Mean luteinising hormone (LH) and serum oestradiol (E2) levels, FSH/LH ratios and symptom scale scores were simultaneously observed.

Results

Twenty-one patients with DOR were included in the final analysis. Mean FSH levels fell from 19.33±9.47 mIU/mL at baseline to 10.58±6.34 mIU/mL at week 12 and 11.25±6.68 mIU/mL at week 24. Change in mean FSH from baseline was −8.75±11.13 mIU/mL at week 12 (p=0.002) and −8.08±9.56 mIU/mL at week 24 (p=0.001). Mean E2 and LH levels, FSH/LH ratios and irritability scores were improved at weeks 12 and/or 24. Approximately 30% patients reported subjective increases in menstrual volume after treatment.

Conclusions

EA may modulate reproductive hormone levels and the effects seem to persist for at least 12 weeks after treatment with no significant side effects. EA may improve the ovarian reserve of patients with DOR, though further research is needed.

Trial registration number

NCT02229604; Results.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

REGISTRATION NUMBER

www.clinicaltrials.govNCT02151006.

Dehydroepiandrosterone (DHEA) supplementation results in supraphysiologic DHEA-S serum levels and progesterone assay interference that may impact clinical management in IVF

PURPOSE

Dehydroepiandrosterone (DHEA) is often prescribed for poor responders in IVF in an effort to improve response to ovarian stimulation. The effect of DHEA supplementation and resultant supraphysiologic DHEA-S serum levels on sex steroid assays has not been evaluated in this population. This study seeks to determine the relationship between DHEA supplementation and progesterone measurements to characterize the degree of interference with particular immunoassays.

METHODS

Characterization was accomplished in two phases. First, DHEA-S standard control reagents with no progesterone present were assayed for both DHEA-S and progesterone levels. Second, serum pools from 60 unique IVF patients' serum were used to create six pooled serum samples: three from patients on DHEA supplementation and three from patients not on DHEA supplementation. The three pools were composed of patients whose serum fell into low, medium, and high progesterone ranges. Baseline DHEA-S and progesterone were measured, and the mean level of DHEA-S in the mid-range progesterone pool was used as the mid-point for addition of DHEA-S standard to the serum pools from patients without DHEA supplementation. Progesterone from these pools was then measured on three commercially available immunoassay systems.

RESULTS

The first experiment revealed a linear increase in progesterone when analyzing the DHEA-S standard ranging from 0.5 μg/dL [corrected] in the blank control (no DHEA-S) to up to 2.0 μg/dL [corrected] in the high control (DHEA-S >700 μg/dL), [corrected] indicating that the DHEA-S cross-reacts with the progesterone assays. In the second experiment, patients' serum DHEA-S and progesterone were measured from pooled serum samples of those taking DHEA and those not taking DHEA. Adding DHEA-S to the pooled serum of those not taking DHEA resulted in a linear increase in progesterone levels on two of three commercially available immunoassays (p < 0.05).

CONCLUSIONS

DHEA-S can interfere with standard progesterone immunoassays used in clinical ART programs, and thus serum progesterone levels in IVF patients on DHEA supplementation may not reflect truly bioactive progesterone.

Effects of traditional Korean medicine on anti-Müllerian hormone in patients with diminished ovarian reserve: A retrospective study

OBJECTIVE

The purpose of the present study is to retrospectively evaluate the effect of traditional Korean medicine (TKM) on ovarian reserve by measuring serum anti-Müllerian hormone (AMH) levels in patients with diminished ovarian reserve (DOR).

STUDY DESIGN

We performed a retrospective chart review of patients with DOR who had received TKM for at least 2 months and had undergone serum AMH tests before and after TKM treatment. A total of 22 patients with DOR were included in the study.

RESULTS

There were no significant differences in AMH levels before and after TKM in all patients (n=22, p=0.237). However, when the study population was divided into two age groups (<38 (n=12) and ≥38 years (n=10)) to determine whether there was a age-related difference in the effect of TKM with DOR, a significant increase in AMH levels before and after TKM was observed in the age <38 (p<0.05).

CONCLUSIONS

TKM may provide an effective option for patients aged <38 years with DOR, but it should be interpreted cautiously as more rigorous research is needed. Further studies in a larger population are needed to confirm these results and to evaluate the effects of improved ovarian reserve on fertility outcomes following TKM in patients with DOR.

[Ovarian failure: New treatments in perspective?]

The premature loss of ovarian function may have physical and psychological consequences. A better understanding of its mechanism is therefore needed. Because they are affecting the oocyte quality, the decline of the ovarian reserve and high maternal age are implicated in many defects leading to chromosomal defects, modifications of gene expression or alterations of the mitochondrial pattern of the oocyte. However, cellular therapies such as ovarian follicle activation or isolation of ovarian stem cells are promising treatments of ovarian failure.

Dehydroepiandrosterone as an adjunct to gonadotropins in infertile Indian women with premature ovarian aging: A pilot study

BACKGROUND

Dehydroepiandrosterone (DHEA) supplementation is a relatively recent development that augments ovarian responsiveness in patients with poor ovarian reserve and premature ovarian aging (POA).

AIMS

To evaluate the efficacy of DHEA supplementation prior to gonadotropins for ovulation induction in women with POA.

DESIGN

Prospective randomized controlled study.

METHODS

Fifty infertile women with POA were randomized into two groups of 25 each. Group 1 received tablet DHEA 25 mg while group 2 received placebo thrice daily for 6 months. After 3 months, gonadotropin induction with intrauterine insemination was done.

STATISTICAL ANALYSIS

Groups were compared using t-test and Mann-Whitney U-test as appropriate. Pre- and post-parameters were compared using t-test -paired and Wilcoxon signed-rank tests as appropriate.

RESULTS

Of 50 patients, 62% (31/50) presented with primary and 38% (19/50) with secondary infertility. The mean age was 32.1 ± 4.7 years. Serum antimullerian hormone levels (1.5 ± 0.6-1.9 ± 0.4 ng/ml vs. 1.4 ± 0.5-1.5 ± 0.6 ng/ml) and antral follicle count (3.2 ± 1.0-9.3 ± 3.1 vs. 3.3 ± 1.1-3.4 ± 1.4) improved significantly in DHEA group after 3 months. Serum follicular stimulating hormone and estradiol levels though showed significant intra-group improvement (16.9 ± 5.5 mIU/ml to 14.7 ± 6.2 mIU/ml and 86.6 ± 57.5 pg/ml to 105.6 ± 54.3 pg/ml, respectively) with DHEA, the inter group difference was not significant. Ovulation increased from 48% to 86.3% in DHEA group versus 44-66% in placebo group. Six women (24%) conceived after DHEA in comparison to none in the placebo group.

CONCLUSIONS

DHEA supplementation may have a beneficial role as an adjunct to gonadotropins in the treatment of infertility with POA, but further evidence is required.

Novel dehydroepiandrosterone troche supplementation improves the serum androgen profile of women undergoing in vitro fertilization

Dehydroepiandrosterone (DHEA) is the most abundant steroid hormone in the circulation and has potent multifunctional activity. Epidemiological evidence suggests that levels of serum DHEA decrease with advancing age, and this has been associated with onset or progression of various age-related ailments, including cognitive decline and dementia, cardiovascular disease, and obesity. Consequently, these findings have sparked intense research interest in DHEA supplementation as an "antiaging" therapy. Currently, DHEA is being used by 25% of in vitro fertilization (IVF) clinicians as an adjuvant in assisted reproductive programs, yet the therapeutic benefit of DHEA is unclear. Here, we examined the use of novel DHEA-containing oral troches in patients undertaking IVF and investigated the impact of these troches on their serum androgen profile. This retrospective study determined the androgen profile of 31 IVF patients before (baseline) and after DHEA supplementation (with DHEA). Baseline serum measurements of testosterone (total and free), DHEA sulfate (DHEAS), sex hormone-binding globulin (SHBG), and androstenedione were made before and after supplementation. Each patient received DHEA troches containing 25 mg of micronized DHEA, and troches were administered sublingually twice daily for a period of no greater than 4 months. Adjuvant treatment with DHEA boosted the serum concentration of a number of androgen-related analytes, including total and free testosterone, androstenedione, and DHEAS, while serum SHBG remained unchanged. Supplementation also significantly increased the free-androgen index in IVF patients. Interestingly, the increase in serum analyte concentration following DHEA supplementation was found to be dependent on body mass index (BMI), but not individual age. Patients with the lowest BMI (<20.0 kg/m(2)) tended to have lower testosterone and DHEAS, but higher SHBG and androstenedione levels in comparison with other BMI groups postsupplementation. However, patients in the highest BMI group (>30.0 kg/m(2)) tended to have lower androgen responses following DHEA supplementation, but these were not statistically different from the corresponding baseline level. This method of DHEA administration results in a similar enhancement of testosterone, DHEAS, and androstenedione levels in comparison with other methods of administration. Furthermore, we showed that BMI significantly influences DHEA uptake and metabolism, and that BMI should be carefully considered during dosage calculation to ensure a significant and robust androgen-profile boost.

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.

Premature Menopause

A heterogeneous disorder, premature menopause is not an uncommon entity, affecting approximately 1% of women younger than 40 years. Multisystem implications are recognized as sequelae to the premature deprivation of ovarian steroids, posing unique health-related challenges in this population. An integrated management approach that addresses both the physical and psychological health concerns and the overall well-being of this relatively chronologically young population is paramount.

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.

Dehydroepiandrosterone (DHEA): hypes and hopes

Dehydroepiandrosterone (DHEA) and its sulfated form dehydroepiandrosterone sulfate (DHEAS) are the most abundant circulating steroid hormones in humans. In animal studies, their low levels have been associated with age-related involuntary changes, including reduced lifespan. Extrapolation of animal data to humans turned DHEA into a 'superhormone' and an 'anti-aging' panacea. It has been aggressively marketed and sold in large quantities as a dietary supplement. Recent double-blind, placebo-controlled human studies provided evidence to support some of these claims. In the elderly, DHEA exerts an immunomodulatory action, increasing the number of monocytes, T cells expressing T-cell receptor gamma/delta (TCRγδ) and natural killer (NK) cells. It improves physical and psychological well-being, muscle strength and bone density, and reduces body fat and age-related skin atrophy stimulating procollagen/sebum production. In adrenal insufficiency, DHEA restores DHEA/DHEAS and androstenedione levels, reduces total cholesterol, improves well-being, sexual satisfaction and insulin sensitivity, and prevents loss of bone mineral density. Normal levels of CD4+CD25(hi) and FoxP3 (forkhead box P3) are restored. In systemic lupus erythematosus, DHEA is steroid-sparing. In an unblinded study, it induced remission in the majority of patients with inflammatory bowel disease. DHEA modulates cardiovascular signalling pathways and exerts an anti-inflammatory, vasorelaxant and anti-remodelling effect. Its low levels correlate with increased cardiovascular disease and all-cause mortality. DHEA/DHEAS appear protective in asthma and allergy. It attenuates T helper 2 allergic inflammation, and reduces eosinophilia and airway hyperreactivity. Low levels of DHEAS accompany adrenal suppression. It could be used to screen for the side effects of steroids. In women, DHEA improves sexual satisfaction, fertility and age-related vaginal atrophy. Many factors are responsible for the inconsistent/negative results of some studies. Overreliance on animal models (DHEA is essentially a human molecule), different dosing protocols with non-pharmacological doses often unachievable in humans, rapid metabolism of DHEA, co-morbidities and organ-specific differences render data interpretation difficult. Nevertheless, a growing body of evidence supports the notion that DHEA is not just an overrated dietary supplement but a useful drug for some, but not all, human diseases. Large-scale randomised controlled trials are needed to fine-tune the indications and optimal dosing protocols before DHEA enters routine clinical practice.