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

Analytical Validation of the IMMULITE® 2000 XPi Progesterone Assay for Quantitative Analysis in Ovine Serum

Monitoring circulating progesterone (P4) concentration is an important component of basic and applied reproduction research and clinical settings. IMMULITE® 2000 XPi (Siemens) is a newly upgraded fully automated immunoassay system marketed for human use to measure concentrations of different analytes including P4. Our objective was therefore to characterize the analytical performance of the IMMULITE® 2000 XPi P4 immunoassay across the reportable range in ovine serum. This validation of analytical performance included determining (1) linearity, (2) precision through within-run, and between-run coefficient of variation (CV) calculations, (3) accuracy through bias calculations for spiking-recovery bias and interlaboratory (range and average based) bias for two laboratories across the reportable range (0.2−40 ng/mL). The average within-run and between-run precision (CV%) across the reportable range of the IMMULITE® 2000 XPi P4 immunoassay for serum P4 concentration were both <5%, ranging between 2−8%. The average Observed Total Analytic Error (TEo) reported here for serum P4 concentration across the reportable range was ~30%, ranging from 14.8−59.4%, regardless of the considered bias. Based on these data we conclude that the automated IMMULITE® 2000 XPi P4 immunoassay provides a precise, accurate, reliable, and safe method for measuring P4 concentration ovine serum.

Postmenopausal hyperandrogenism due to an ovarian sex cord-stromal tumour causing elevated dehydroepiandrosterone sulphate: a case report

BACKGROUND

The source of excess androgen can be obscure in postmenopausal women with new-onset hyperandrogenism. If serum dehydroepiandrosterone sulphate (DHEAS) is raised, it is presumed to be of adrenal origin because DHEAS is exclusively produced from adrenal cortical cells. This reports an elderly female presenting with new-onset hyperandrogenism due to an ovarian sex cord-stromal tumour, associated with increased serum DHEAS levels.

CASE DESCRIPTION

A 76-year-old female with long-standing diabetes and hypertension presented with hirsutism and male type alopecia for six months. She had menopause at 55 years of age. There was a pelvic mass on examination. Total testosterone was 6.106 ng/ml (0.124-0.357) and DHEAS was > 1000 µg/dL (35-430). Contrast-enhanced computed tomography of the abdomen and pelvis showed a heterogeneously enhancing complex mass measuring 11 × 8 cm in the left adnexal region. Adrenal glands were normal. She underwent total abdominal hysterectomy, bilateral salphingo-oophorectomy, and omentectomy. Both testosterone and DHEAS normalised following surgery. Histology revealed a sex cord-stromal tumour, likely a steroid cell tumour with malignant potential. Fluorodeoxyglucose-Positron emission tomography did not show any additional lesions.

CONCLUSIONS

Due to the lack of sulfotransferase in ovarian tissue, markedly elevated DHEAS originating from an ovarian neoplasm is unusual. This phenomenon has not been described except in a patient with a steroid cell tumour causing Cushing syndrome and hyperandrogenism. The mechanism of this rare occurrence remains elusive. Knowledge of this unusual presentation would enable the clinicians to be cautious in localising the androgen source in women with hyperandrogenism.

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.

Reproducibility of saliva progesterone measured by immunoassay compared to liquid chromatography mass spectrometry

Immunoassay overestimates progesterone in blood, but no studies have tested whether this occurs in saliva. We measured progesterone in saliva using immunoassay and mass spectrometry. We tested the immunoassay for cross reactivity with dehydroepiandrosterone sulfate (DHEA-S) and 17α-hydroxyprogesterone (17α-OHP). Progesterone was significantly higher in immunoassay compared to mass spectrometry. Immunoassay progesterone levels increased in when incremental levels of 17α-OHP standard was added. This effect was not observed with the addition of DHEA-S. Research using salivary progesterone immunoassay techniques should be wary, particularly with individuals taking steroid supplementation or with high levels of progesterone metabolites.

The role of progesterone/estradiol ratio in exploring the mechanism of late follicular progesterone elevation in low ovarian reserve women

Late follicular progesterone (P) elevation continues to complicate a significant part of assisted reproductive technologies (ART) cycles, despite the ardent employment of gonadotropin releasing hormone (GnRH) analogues. In women with good ovarian reserve, late follicular P elevation is believed to be the result of the controlled ovarian stimulation (COS) itself, multiple follicular development and excessive ovarian steroidogenic activity. These mechanisms do not seem to be plausible in women with low ovarian reserve. In these women, excessive COS achieve a small number of pre-ovulatory follicles, which is not coupled to considerable ovarian steroidogenic activity. Therefore, other mechanisms should be pursued and explored. Delicate paracrine and autocrine mechanisms within the oocyte-cumulus complex were suggested to preserve the integrity of the pre-ovulatory follicle, including inhibition of P increase and follicular luteinization. However, clinical studies to demonstrate the disruption of these mechanisms in cases with low ovarian reserve and ageing oocytes are still lacking. Late follicular progesterone/estradiol (P/E₂) ratio was introduced into clinical practice as a more appropriate way to analyze P rise in women undergoing COS to control for the E₂ increase. The current hypothesis claims that in a follicular environment were the mechanism that prevent premature luteinization is disrupted, independent to LH surge; P rise at the late follicular phase may relatively bypass normal E₂ production, at the pre-ovulatory stage of steroidogenesis, causing a rise in the P/E₂ ratio. Therefore, in women with low ovarian reserve and few pre-ovulatory follicles, undergoing conventional COS, a negative (reverse) correlation between number of maturing follicles and P/E₂ ratio may support the existence of such a mechanism as its disruption, while a no or a positive correlation may disapprove it.

The curious case of premature luteinization

PURPOSE

Premature luteinization (PL) affects 12.3-46.7% of fresh in vitro fertilization cycles, and there is accumulating evidence confirming its negative effect on success rates. However, despite its clinical significance, PL is poorly understood and defined. This narrative review aims to provide a fresh look at the phenomenon of PL by summarizing the existing evidence and re-evaluating fundamental issues.

METHODS

A thorough electronic search was conducted covering the period from 1978 until January 2018 in PubMed, Embase, and Medline databases, and references of relevant studies were cross-checked. Meeting proceedings of the European Society of Human Reproduction and Embryology and the American Society for Reproductive Medicine were also hand searched.

RESULTS

In the curious case of PL, one should go back to the beginning and re-consider every step of the way. The pathogenesis, definition, measurement methods, clinical implications, and management strategies are discussed in detail, highlighting controversies and offering "food for thought" for future directions.

CONCLUSIONS

Authors need to speak the same language when studying PL in order to facilitate comparisons. The terminology, progesterone cut-off, measurement methods and days of measurement should be standardized and globally accepted; otherwise, there can be no scientific dialog. Future research should focus on specific patient profiles that may require a tailored approach. Progesterone measurements throughout the follicular phase possibly depict the progesterone exposure better than an isolated measurement on the day of hCG. Adequately powered randomized controlled trials should confirm which the best prevention and management plan of PL is, before introducing any strategy into clinical practice.

Accuracy of Two Progesterone Immunoassays for Monitoring In Vitro Fertilization

BACKGROUND

Progesterone concentrations are routinely monitored during in vitro fertilization cycles. Immunoassay-based platforms are used most often in this setting because they are simple to use and amenable to same-day sample collection and result-reporting. However, immunoassay methods are subject to variation in specificity between different assay manufacturers. In this study, a set of unexpectedly high progesterone concentrations led to a method comparison between two in-house immunoassay platforms relative to the reference method.

METHODS

Progesterone was measured in 28 serum samples from women undergoing IVF cycles using the Siemens ADVIA Centaur Immunoassay system and the Abbott Architect i1000SR analyzer. A subset of these samples was selected for progesterone measurement by liquid chromatography-tandem mass spectrometry to define the accuracy of each immunoassay.

RESULTS

The Siemens ADVIA Centaur immunoassay system overestimated progesterone concentrations by 19% and the Abbott Architect overestimated progesterone concentrations by 5%.

CONCLUSIONS

The Abbott Architect progesterone immunoassay provides a more accurate measurement of serum progesterone than the Centaur immunoassay at concentrations relevant for monitoring in vitro fertilization populations.

Insights from clinical experience in treating IVF poor responders

'Poor responders' is a term used to describe a subpopulation of IVF patients who do not respond well to ovarian stimulation with gonadotrophins. While there is no standard definition of a poor responder, these patients tend to be of advanced maternal age (≥40 years), have a history of poor ovarian response with conventional stimulation protocols, and/or have low ovarian reserve. Despite the heterogeneity of this patient group, there are characteristics and needs common to many poor responders that can be addressed through a holistic approach. Stimulation during the earlier stages of follicle maturation may help synchronize follicle development for improved response to later gonadotrophin stimulation, and supplementation with dehydroepiandrosterone or human growth hormone may promote early follicle development in poor responders. IVF protocols should be specifically tailored to poor responders to complement the patient's natural cycle. Because poor responders tend to have high levels of stress and anxiety, patients should receive psychological counselling and support, both prior to and during IVF cycles, to ensure optimal outcomes and improve patients' experience. It is important to set realistic expectations with poor responders and their partners to help patients make informed decisions and better manage their distress and anxiety.