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Naik S, Lepine S, Nagels HE, Siristatidis CS, Kroon B, McDowell S. Androgens (dehydroepiandrosterone or testosterone) for women undergoing assisted reproduction. Cochrane Database Syst Rev 2024; 6:CD009749. [PMID: 38837771 PMCID: PMC11152211 DOI: 10.1002/14651858.cd009749.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
BACKGROUND Practitioners in the field of assisted reproductive technology (ART) continually seek alternative or adjunct treatments to improve ART outcomes. This Cochrane review investigates the adjunct use of synthetic versions of two naturally produced hormones, dehydroepiandrosterone (DHEA) and testosterone (T), in assisted reproduction. Steroid hormones are proposed to increase conception rates by positively affecting follicular response to gonadotrophin stimulation. This may lead to a greater oocyte yield and, subsequently, an increased chance of pregnancy. OBJECTIVES To assess the effectiveness and safety of DHEA and T as pre- or co-treatments in infertile women undergoing assisted reproduction. SEARCH METHODS We searched the following electronic databases up to 8 January 2024: the Gynaecology and Fertility Group (CGF) Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, and trial registries for ongoing trials. We also searched citation indexes, Web of Science, PubMed, and OpenGrey. We searched the reference lists of relevant studies and contacted experts in the field for any additional trials. There were no language restrictions. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing DHEA or T as an adjunct treatment to any other active intervention, placebo, or no treatment in women undergoing assisted reproduction. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, extracted relevant data, and assessed risk of bias. We pooled data from studies using fixed-effect models. We calculated odds ratios (ORs) for each dichotomous outcome. Analyses were stratified by type of treatment. We assessed the certainty of evidence for the main findings using GRADE methods. MAIN RESULTS We included 29 RCTs. There were 1599 women in the intervention group and 1469 in the control group. Apart from three trials, the trial participants were women identified as 'poor responders' to standard in vitro fertilisation (IVF) protocols. The included trials compared either T or DHEA treatment with placebo or no treatment. Pre-treatment with DHEA versus placebo/no treatment: DHEA likely results in little to no difference in live birth/ongoing pregnancy rates (OR 1.30, 95% confidence interval (CI) 0.95 to 1.76; I² = 16%, 9 RCTs, N = 1433, moderate certainty evidence). This suggests that in women with a 12% chance of live birth/ongoing pregnancy with placebo or no treatment, the live birth/ongoing pregnancy rate in women using DHEA will be between 12% and 20%. DHEA likely does not decrease miscarriage rates (OR 0.85, 95% CI 0.53 to 1.37; I² = 0%, 10 RCTs, N =1601, moderate certainty evidence). DHEA likely results in little to no difference in clinical pregnancy rates (OR 1.18, 95% CI 0.93 to 1.49; I² = 0%, 13 RCTs, N = 1886, moderate certainty evidence). This suggests that in women with a 17% chance of clinical pregnancy with placebo or no treatment, the clinical pregnancy rate in women using DHEA will be between 16% and 24%. We are very uncertain about the effect of DHEA on multiple pregnancy (OR 3.05, 95% CI 0.47 to 19.66; 7 RCTs, N = 463, very low certainty evidence). Pre-treatment with T versus placebo/no treatment: T likely improves live birth rates (OR 2.53, 95% CI 1.61 to 3.99; I² = 0%, 8 RCTs, N = 716, moderate certainty evidence). This suggests that in women with a 10% chance of live birth with placebo or no treatment, the live birth rate in women using T will be between 15% and 30%. T likely does not decrease miscarriage rates (OR 1.63, 95% CI 0.76 to 3.51; I² = 0%, 9 RCTs, N = 755, moderate certainty evidence). T likely increases clinical pregnancy rates (OR 2.17, 95% CI 1.54 to 3.06; I² = 0%, 13 RCTs, N = 1152, moderate certainty evidence). This suggests that in women with a 12% chance of clinical pregnancy with placebo or no treatment, the clinical pregnancy rate in women using T will be between 17% and 29%. We are very uncertain about the effect of T on multiple pregnancy (OR 2.56, 95% CI 0.59 to 11.20; 5 RCTs, N = 449, very low certainty evidence). We are uncertain about the effect of T versus oestradiol or T versus oestradiol + oral contraceptive pills. The certainty of the evidence was moderate to very low, the main limitations being lack of blinding in the included trials, inadequate reporting of study methods, and low event and sample sizes in the trials. Data on adverse events were sparse; any reported events were minor. AUTHORS' CONCLUSIONS Pre-treatment with T likely improves, and pre-treatment with DHEA likely results in little to no difference, in live birth and clinical pregnancy rates in women undergoing IVF who have been identified as poor responders. DHEA and T probably do not decrease miscarriage rates in women under IVF treatment. The effects of DHEA and T on multiple pregnancy are uncertain. Data regarding adverse events were very limited; any reported events were minor. Research is needed to identify the optimal duration of treatment with T. Future studies should include data collection on adverse events and multiple pregnancy.
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Affiliation(s)
- Sandeep Naik
- Obstetrics and Gynaecology, Capital Coast District Heath Board, Wellington, New Zealand
| | - Sam Lepine
- Department of Obstetrics and Gynaecology, Capital and Coast District Health Board, Wellington, New Zealand
| | - Helen E Nagels
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Charalampos S Siristatidis
- Assisted Reproduction Unit, 2nd Department of Obstetrics and Gynaecology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Ben Kroon
- Queensland Fertility Group Research Foundation, Brisbane, Australia
- The University of Queensland, Brisbane, Australia
| | - Simon McDowell
- Obstetrics and Gynaecology, Capital Coast District Heath Board, Wellington, New Zealand
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Aliakbar VH, Tanha FD, Asbagh FA, Ebrahimi M, Shahraki Z. The effect of methyltestosterone on in vitro fertilization outcomes: A randomized clinical trial on patients with low ovarian response. Clin Exp Reprod Med 2024; 51:158-162. [PMID: 38812245 PMCID: PMC11140261 DOI: 10.5653/cerm.2023.05946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 11/01/2023] [Accepted: 11/27/2023] [Indexed: 05/31/2024] Open
Abstract
OBJECTIVE The aim of this study was to compare the outcomes of in vitro fertilization (IVF) in patients with a poor ovarian response who used methyltestosterone, versus those using a placebo, in an infertility clinic setting. METHODS This clinical trial included 120 women who had undergone IVF with intracytoplasmic sperm injection due to poor ovarian reserve and infertility. The study took place at the Yas Infertility Center in Tehran, Iran, between January 1, 2018 and January 1, 2019. In the intervention group, 25 mg of methyltestosterone was administered daily for 2 months prior to the initiation of assisted reproductive treatment. The control group was given placebo tablets for the same duration before starting their cycle. Each group was randomly assigned 60 patients. All analyses were performed using SPSS ver. 23 (IBM Corp.). RESULTS The endometrial thickness in the intervention group was 7.57±1.22 mm, whereas in the control group, it was 7.11±1.02 (p=0.028). The gonadotropin number was significantly higher in the control group (64.7±13.48 vs. 57.9±9.25, p=0.001). However, there was no significant difference between the two groups in the antral follicular count. The chemical and clinical pregnancy rates in the intervention group were 18.33% and 15% respectively, compared to 8.33% and 6.67% in the control group. The rate of definitive pregnancy was marginally higher in the intervention group (13.3% vs. 3.3%, p=0.05). CONCLUSION The findings of this study suggest that pretreatment with methyltestosterone significantly increases endometrium thickness and is associated with an increase in the definitive pregnancy rate.
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Affiliation(s)
- Venus Haj Aliakbar
- Department of Obstetrics and Gynecology, Arash Women’s Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Davari Tanha
- Department of Obstetrics and Gynecology, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Firouzeh Akbari Asbagh
- Department of Obstetrics and Gynecology, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahbod Ebrahimi
- Department of Obstetrics and Gynecology, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Zahra Shahraki
- Department of Obstetrics and Gynecology, Amir-Al-Momenin Hospital, Zabol University of Medical Sciences, Zabol, Iran
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Hugues JN. Subtle perturbations of ovarian steroidogenesis in patients classified as Poseidon Group 3. Which consequences for therapeutic strategy? Front Endocrinol (Lausanne) 2024; 15:1231585. [PMID: 38384970 PMCID: PMC10879926 DOI: 10.3389/fendo.2024.1231585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 01/09/2024] [Indexed: 02/23/2024] Open
Abstract
The optimal strategy for stimulation of young women with a low ovarian reserve is still a challenging issue because the physio-pathogeny of this disorder is often unknown. As androgen production by the ovary plays a crucial role in folliculogenesis, it was tempting to speculate that subtle perturbations in ovarian steroidogenesis might participate to the low responsiveness to gonadotrophins. Indeed, in vitro analysis of human luteinized granulosa cells has recently provided evidence for some enzymatic deficits in steroidogenesis and altered response to gonadotrophins. Therefore, improving androgen environment of women classified in Poseidon Group 3 should be considered. In this clinical situation, the potential benefit of androgen supplementation or stimulation of theca cells by LH-activity products are respectively discussed.
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Zafardoust S, Kazemnejad S, Fathi-Kazerooni M, Darzi M, Sadeghi MR, Sadeghi Tabar A, Sehat Z. The effects of intraovarian injection of autologous menstrual blood-derived mesenchymal stromal cells on pregnancy outcomes in women with poor ovarian response. Stem Cell Res Ther 2023; 14:332. [PMID: 37968668 PMCID: PMC10647057 DOI: 10.1186/s13287-023-03568-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 11/09/2023] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND Assisted reproduction faces a significant obstacle in the form of poor ovarian response (POR) to controlled ovarian stimulation. To address this challenge, mesenchymal stem cell therapy has been proposed as a potential treatment for female infertility and/or restoration of ovarian function in POR women. Our previous research has demonstrated that menstrual blood-derived-mesenchymal stromal cells (MenSCs) injected into the ovaries of women with POR can increase pregnancy rates. The objective of this study was to examine whether MenSC therapy could enhance ovarian reserve parameters and pregnancy outcomes in a larger population of individuals with POR. METHOD This study consisted of 180 infertile individuals with POR who declined oocyte donation. Participants were divided into two groups: those who received bilateral MenSCs intraovarian injection and those who received no intervention. Our primary aim was to compare the rates of spontaneous pregnancy between the two groups, followed by an investigation of any alterations in the ovarian reserve parameters, such as serum FSH, AMH, and AFC levels, as well as the ICSI/IVF outcomes, in both groups of participants. RESULTS The MenSC therapy exhibited a favourable tolerability profile and did not raise any safety concerns. Following the 2-month follow-up period, women who received MenSC treatment demonstrated a significantly higher rate of spontaneous pregnancy (P < 0.005) and an improvement in anti-Müllerian hormone (AMH) levels (P = 0.0007) and antral follicle count (AFC) (P < 0.001), whereas the control group demonstrated a considerable decline in these parameters (Both P < 0.001). The MenSC therapy led to a greater number of mature oocytes and embryos among women who underwent ICSI/IVF. Our age subgroup analysis demonstrated a significant difference in the number of spontaneous pregnancies and ICSI/IVF outcomes between the treatment and control groups only among individuals below 40 years of age. CONCLUSION The results of our study indicate that MenSCs treatment may be a viable option for treating women experiencing POR. However, in order to be widely implemented in clinical practice, the clinical effectiveness of MenSCs therapy will need to be established through rigorous prospective randomized clinical trials. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05703308. Registered 01/26/2023, retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT05703308 . IRCT, IRCT20180619040147N4. Registered 08/01/2020.
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Affiliation(s)
- Simin Zafardoust
- Nanobiotechnology Research Center, Avicenna Research Institute, ACECR, Tehran, Iran.
| | - Somaieh Kazemnejad
- Nanobiotechnology Research Center, Avicenna Research Institute, ACECR, Tehran, Iran
| | | | - Maryam Darzi
- Avicenna Fertility Clinic, Avicenna Research Institute, ACECR, Tehran, Iran
| | - Mohammad Reza Sadeghi
- Reproductive Biotechnology Research Center, Avicenna Research Institute, ACECR, Tehran, Iran
| | - Ali Sadeghi Tabar
- Monoclonal Antibody Research Center, Avicenna Research Institute, ACECR, Tehran, Iran
| | - Zahra Sehat
- Avicenna Fertility Clinic, Avicenna Research Institute, ACECR, Tehran, Iran
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Rodriguez Esquivel M, Hayes E, Lakomy O, Hassan M, Foretz M, Stocco C. Salt-inducible kinases regulate androgen synthesis in theca cells by enhancing CREB signaling. Mol Cell Endocrinol 2023; 577:112030. [PMID: 37499999 PMCID: PMC10592241 DOI: 10.1016/j.mce.2023.112030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 07/18/2023] [Accepted: 07/24/2023] [Indexed: 07/29/2023]
Abstract
Ovulation is the pinnacle of folliculogenesis, a process that requires an interplay between the oocyte, the granulosa cells, and the theca cells (TCs). TCs are the only source of ovarian androgens, which play a vital role in female fertility. However, abnormally elevated androgen levels reduce fertility. Therefore, uncovering novel mechanisms regulating androgen synthesis in TCs is of great significance. We have shown that salt-inducible kinases (SIKs) regulate granulosa cell steroidogenesis. Here, we investigated whether SIKs regulate androgen production in TCs. SIK2 and SIK3 were detected in the TCs of mouse ovaries and isolated TCs. Next, TCs in culture were treated with luteinizing hormone (LH) in the presence or absence of a highly specific SIK inhibitor. SIK inhibition enhanced the stimulatory effect of LH on steroidogenic gene expression and androgen production in a concentration-dependent manner. SIK inhibition alone stimulated the expression of steroidogenic genes and increased androgen production. Activation of adenylyl cyclase with forskolin or emulation of increased intracellular cyclic AMP levels stimulated steroidogenesis, an effect that was enhanced by the inhibition of SIK activity. The stimulatory effect of downstream targets of cyclic AMP was also significantly augmented by SIK inhibition, suggesting that SIKs control targets downstream cyclic AMP. Finally, it is shown that SIK2 knockout mice have higher circulating testosterone than controls. This evidence shows that TCs express SIKs and reveal novel roles for SIKs in the regulation of TC function and androgen production. This information could contribute to uncovering therapeutic targets to treat hyperandrogenic diseases.
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Affiliation(s)
| | - Emily Hayes
- Department of Physiology and Biophysics, University of Illinois at Chicago, Chicago, IL, 60612, USA
| | - Oliwia Lakomy
- Department of Physiology and Biophysics, University of Illinois at Chicago, Chicago, IL, 60612, USA
| | - Mariam Hassan
- Department of Physiology and Biophysics, University of Illinois at Chicago, Chicago, IL, 60612, USA
| | - Marc Foretz
- Université Paris Cité, Institut Cochin, CNRS, INSERM, F-75014, Paris, France
| | - Carlos Stocco
- Department of Physiology and Biophysics, University of Illinois at Chicago, Chicago, IL, 60612, USA.
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Lissaman AC, Girling JE, Cree LM, Campbell RE, Ponnampalam AP. Androgen signalling in the ovaries and endometrium. Mol Hum Reprod 2023; 29:gaad017. [PMID: 37171897 PMCID: PMC10663053 DOI: 10.1093/molehr/gaad017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 04/27/2023] [Indexed: 05/14/2023] Open
Abstract
Currently, our understanding of hormonal regulation within the female reproductive system is largely based on our knowledge of estrogen and progesterone signalling. However, while the important functions of androgens in male physiology are well known, it is also recognized that androgens play critical roles in the female reproductive system. Further, androgen signalling is altered in a variety of gynaecological conditions, including endometriosis and polycystic ovary syndrome, indicative of regulatory roles in endometrial and ovarian function. Co-regulatory mechanisms exist between different androgens, estrogens, and progesterone, resulting in a complex network of steroid hormone interactions. Evidence from animal knockout studies, in vitro experiments, and human data indicate that androgen receptor expression is cell-specific and menstrual cycle stage-dependent, with important regulatory roles in the menstrual cycle, endometrial biology, and follicular development in the ovaries. This review will discuss the expression and co-regulatory interactions of androgen receptors, highlighting the complexity of the androgen signalling pathway in the endometrium and ovaries, and the synthesis of androgens from additional alternative pathways previously disregarded as male-specific. Moreover, it will illustrate the challenges faced when studying androgens in female biology, and the need for a more in-depth, integrative view of androgen metabolism and signalling in the female reproductive system.
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Affiliation(s)
- Abbey C Lissaman
- Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Jane E Girling
- Department of Anatomy, School of Biomedical Sciences, University of Otago, Dunedin, New Zealand
| | - Lynsey M Cree
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
| | - Rebecca E Campbell
- Department of Physiology and Centre for Neuroendocrinology, University of Otago, Dunedin, New Zealand
| | - Anna P Ponnampalam
- Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Pūtahi Manawa-Healthy Hearts for Aotearoa New Zealand, Centre of Research Excellence, New Zealand
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Crespi BJ, Evans SF. Prenatal Origins of Endometriosis Pathology and Pain: Reviewing the Evidence of a Role for Low Testosterone. J Pain Res 2023; 16:307-316. [PMID: 36762368 PMCID: PMC9904225 DOI: 10.2147/jpr.s389166] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 01/04/2023] [Indexed: 02/05/2023] Open
Abstract
Endometriosis is a polygenic, estrogen-dependent, inflammatory disorder of uncertain aetiology associated with pain, infertility and reduced quality of life. While the positive association between endometriosis and estrogen is established, a suite of recent studies has demonstrated an inverse association between the presence of endometriosis lesions and levels of testosterone both prenatally and postnatally. The following narrative review provides new insights into the roles of testosterone in the aetiology, diagnosis, and management of endometriosis and associated symptoms, especially pain. A relatively short anogenital distance (AGD) is indicative of lower levels of testosterone during fetal development. A shorter AGD has recently been correlated with both a higher risk of developing endometriosis in adult life, and with known correlates of endometriosis including earlier onset of reproductive cycling, lower ovarian follicle number, lower postnatal testosterone, and premature ovarian insufficiency. During adult life, lower levels of testosterone are positively associated with key comorbidities of endometriosis, including days per month of pelvic pain and increased pain sensitivity. Biochemically, lower levels of testosterone are associated with higher levels of pro-inflammatory IL-1β and lower levels of β-endorphin. In rodents, prenatal administration of testosterone to females reduces their pain sensitivity in adulthood. The emerging convergent links of endometriosis with low prenatal and postnatal testosterone provide evidence of a centrally mediated effect beginning in early prenatal development, and persisting through adult life, with notable effects on pain sensitivity. They generate a novel conceptual framework for understanding, studying and treating this disorder, whereby endometriosis is mediated by a combination of high estrogen in endometrial tissue with low systemic and ovarian testosterone.
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Affiliation(s)
- Bernard J Crespi
- Department of Biological Sciences, Simon Fraser University, Burnaby, British Columbia, Canada,Correspondence: Bernard J Crespi, Email
| | - Susan F Evans
- Adelaide Medical School, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
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Higher live birth rate following transdermal testosterone pretreatment in poor responders: a systematic review and meta-analysis. Reprod Biomed Online 2023; 46:81-91. [PMID: 36369150 DOI: 10.1016/j.rbmo.2022.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 09/08/2022] [Accepted: 09/26/2022] [Indexed: 11/05/2022]
Abstract
A systematic review and meta-analysis was performed aiming to identify good-quality randomized controlled trials (RCT) evaluating testosterone pretreatment in poor responders. Eight RCTs were analysed, evaluating 797 women. Transdermal testosterone gel was used in all studies, with a dose ranging from 10 to 12.5 mg/day for 10-56 days. The main outcome measure was achievement of pregnancy, expressed as clinical pregnancy or live birth. Testosterone pretreatment was associated with a significantly higher live birth (risk ratio [RR] 2.07, 95% confidence interval [CI] 1.09-3.92) and clinical pregnancy rate (RR 2.25, 95% CI 1.54-3.30), as well as a significant increase in the number of cumulus-oocyte complexes retrieved. Significantly fewer days to complete ovarian stimulation, a lower total dose of gonadotrophins, a lower cancellation rate due to poor ovarian response and a thicker endometrium on the day of triggering of final oocyte maturation were observed. No significant differences were observed in oestradiol concentration, the numbers of follicles ≥17 mm, metaphase II oocytes, two-pronuclear oocytes and embryos transferred, and the proportion of patients with embryo transfer. The current study suggests that the probability of pregnancy is increased in poor responders pretreated with transdermal testosterone who are undergoing ovarian stimulation for IVF.
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Vitagliano A, Laganà AS, De Ziegler D, Cicinelli R, Santarsiero CM, Buzzaccarini G, Chiantera V, Cicinelli E, Marinaccio M. Chronic Endometritis in Infertile Women: Impact of Untreated Disease, Plasma Cell Count and Antibiotic Therapy on IVF Outcome-A Systematic Review and Meta-Analysis. Diagnostics (Basel) 2022; 12:diagnostics12092250. [PMID: 36140651 PMCID: PMC9498271 DOI: 10.3390/diagnostics12092250] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 09/13/2022] [Accepted: 09/14/2022] [Indexed: 01/10/2023] Open
Abstract
This systematic review and meta-analysis aims to evaluate the impact of chronic endometritis (CE) and its therapy on in vitro fertilization (IVF) outcome. Additionally, we aim to investigate whether various degrees of CE severity may exert a different effect on IVF outcome. Ongoing-pregnancy rate/live-birth-rate (OPR/LBR), clinical-pregnancy rate (CPR), and miscarriage rate (MR) were calculated. A total number of 4145 patients (from ten studies) were included. Women with CE had lower OPR/LBR (OR 1.97, p = 0.02) and CPR (OR 2.28, p = 0.002) compared to those without CE. CE cure increased OPR/LBR (OR 5.33, p < 0.0001) and CPR (OR 3.64, p = 0.0001). IVF outcome was comparable between women with cured CE and those without CE (OPR/LBR, CPR and MR: p = ns). Women with severe CE had lower OPR/LBR (OR 0.43, p = 0.003) and CPR (OR 0.40, p = 0.0007) compared to those mild CE. Mild CE showed no influence on the IVF outcome as compared to women without CE (OPR/LBR, CPR and MR: p = ns). Based on this data analysis, CE significantly reduces OPR/LBR and CPR in women undergoing IVF. Importantly, CE resolution after antibiotic therapy may improves IVF outcome, leading to similar OPR/LBR and CPR as compared to unaffected patients. The negative effects of CE on IVF outcome may be restricted to severe disease, whereas mild CE may have no influence on IVF success.
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Affiliation(s)
- Amerigo Vitagliano
- Unit of Obstetrics and Gynecology, Department of Biomedical and Human Oncologic Science, University of Bari, 70100 Bari, Italy
| | - Antonio Simone Laganà
- Unit of Gynecologic Oncology, ARNAS “Civico-Di Cristina-Benfratelli”, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy
- Correspondence:
| | - Dominique De Ziegler
- Department of Obstetrics, Gynecology, and Reproductive Medicine, Hospital Foch, Faculté de Médecine Paris Ouest (UVSQ), 92150 Suresnes, France
| | - Rossana Cicinelli
- Unit of Obstetrics and Gynecology, Department of Biomedical and Human Oncologic Science, University of Bari, 70100 Bari, Italy
| | - Carla Mariaflavia Santarsiero
- Unit of Obstetrics and Gynecology, Department of Biomedical and Human Oncologic Science, University of Bari, 70100 Bari, Italy
| | - Giovanni Buzzaccarini
- Unit of Gynecology and Obstetrics, Department of Women and Children’s Health, University of Padua, 35128 Padua, Italy
| | - Vito Chiantera
- Unit of Gynecologic Oncology, ARNAS “Civico-Di Cristina-Benfratelli”, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy
| | - Ettore Cicinelli
- Unit of Obstetrics and Gynecology, Department of Biomedical and Human Oncologic Science, University of Bari, 70100 Bari, Italy
| | - Marco Marinaccio
- Unit of Obstetrics and Gynecology, Department of Biomedical and Human Oncologic Science, University of Bari, 70100 Bari, Italy
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La Marca A, Longo M. Extended LH administration as a strategy to increase the pool of recruitable antral follicles in hypothalamic amenorrhea: evidence from a case series. Hum Reprod 2022; 37:2655-2661. [DOI: 10.1093/humrep/deac195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 07/31/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
New evidence is indicating a growing role of LH in promoting ovarian follicular growth and maturation, even at the early stages. LH seems to enhance the transition of follicles to the antral stage hence leading to an increase in the so-called functional ovarian reserve (recruitable antral follicles). Hypogonadotropic hypogonadism is characterized by low, and sometimes undetectable, serum LH and FSH levels, which may indeed explain the low anti-Müllerian hormone (AMH) levels and antral follicle count (AFC) found in patients affected by this condition. We report here the cases of two young women affected by hypothalamic amenorrhea (HA) that presented for fertility treatment with very low functional ovarian reserve. The two patients were treated with exogenous LH for 1 and 2 months (extended LH administration: ELHA) at the dose of 187.5 IU LH every day and 150 IU LH every other day, respectively. In both the cases there was an increase in serum AMH levels and in the AFC. In one patient, the AMH and AFC increased from a baseline 1.3 ng/ml and 8 to 2.3 ng/ml and 14 at end of treatment, respectively. In the second case, serum AMH and AFC increased from 0.4 ng/ml and 6 to 1.6 ng/ml and 13, respectively. One patient underwent ovarian stimulation before and after ELHA, showing an increase in the number of mature oocytes recruited (3 versus 8 metaphase II (MII) oocytes before and after, respectively). The second patient underwent an IVF cycle after ELHA resulting in the retrieval of six MII oocytes and an ongoing pregnancy following transfer of a single blastocyst. Women with HA are characterized by chronic, low levels of gonadotrophins, which may impact not only on the cyclic recruitment of follicles but also the progression of small growing follicles through the first stages of folliculogenesis. Some women with HA may in fact show very low serum AMH and AFC. Our case series shows that the administration of LH at a dose of at least 150–187.5 IU every day or every other day may contribute to a clinically evident increase in the functional ovarian reserve (AFC), and probably accounts for a positive effect of LH on the progression of follicles throughout the early stages of folliculogenesis.
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Affiliation(s)
- Antonio La Marca
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia , Modena, Italy
- Clinica Eugin Modena , Modena, Italy
| | - Maria Longo
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia , Modena, Italy
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Galatis D, Kalopita K, Grypiotis I, Flessas I, Kiriakopoulos N, Micha G. Researching the Phenomenon of Poor Ovarian Responders and Management Strategies in IVF: A Narrative Review. Acta Med Acad 2022; 51:108-122. [PMID: 36318003 PMCID: PMC9982854 DOI: 10.5644/ama2006-124.379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 08/04/2022] [Indexed: 11/09/2022] Open
Abstract
This narrative review aims to summarize all the latest studies published between 2015-2021 concerning the management protocols adopted for poor ovarian response (POR) cases. Patients defined as "poor responders" show minimal response to controlled ovarian hyperstimulation, although there is no standard definition for POR. Although infertility specialists are endeavoring to improve cycle outcomes in poor responders by adopting multiple management strategies, still the estimated risk of cycle cancellation is about 20%. All the studies performed during this study period were evaluated and their results were recorded. The latest published protocols to improve oocyte retrieval in poor responders include: anti-Mϋllerian hormone, clomiphene citrate, co-enzyme Q10, corifollitropin, dehydroepiandrosterone, double stimulation, Follicle Stimulation Hormone, Growth Hormone, Gonadotropin-releasing hormone agonists, letrozole, human chorionic gonadotropin, Luteinizing Hormone, progesterone and testosterone. CONCLUSION: Although many strategies have been suggested to manage POR, none has been proven superior to the others. Further large-scale randomized studies are needed to validate experimental techniques leading towards successful individualized treatment regimens.
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Affiliation(s)
- Dionysios Galatis
- Department of Physiology, Medical School, National and Kapodistrian University of Athens, 75 Mikras Asias, 11527 Athens, Greece.
| | - Konstantina Kalopita
- Department of Anaesthesia, Helena Venizelou General and Maternity Hospital of Athens, Greece
| | - Ioannis Grypiotis
- Department of Anaesthesia, Helena Venizelou General and Maternity Hospital of Athens, Greece
| | - Ioannis Flessas
- Breast Center, Helena Venizelou General and Maternity Hospital of Athens, Greece
| | - Nikolaos Kiriakopoulos
- V' Department of Ob/Gyn, Helena Venizelou General and Maternity Hospital of Athens, Greece
| | - Georgia Micha
- Department of Anaesthesia, Helena Venizelou General and Maternity Hospital of Athens, Greece
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AOP key event relationship report: Linking decreased androgen receptor activation with decreased granulosa cell proliferation of gonadotropin-independent follicles. Reprod Toxicol 2022; 112:136-147. [PMID: 35868514 DOI: 10.1016/j.reprotox.2022.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/14/2022] [Accepted: 07/16/2022] [Indexed: 02/08/2023]
Abstract
We recently proposed to formally recognize Key Event Relationships (KERs) as building blocks of Adverse Outcome Pathways (AOPs) that can be independently developed and peer-reviewed. Here, we follow this approach and provide an independent KER from AOP345, which describes androgen receptor (AR) antagonism leading to decreased female fertility. This KER connects AR antagonism to reduced granulosa cell proliferation of gonadotropin-independent follicles (KER2273). We have developed both the KER and the two adjacent Key Events (KEs). A systematic approach was used to ensure that all relevant supporting evidence for KER2273 was retrieved. Supporting evidence for the KER highlights the importance of AR action during the early stages of follicular development. Both biological plausibility and empirical evidence are presented, with the latter also assessed for quality. We believe that tackling isolated KERs instead of whole AOPs will accelerate the AOP development. Faster AOP development will lead to the development of simple test methods that will aid screening of chemicals, endocrine disruptor identification, risk assessment, and subsequent regulation.
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Battaglia R, Caponnetto A, Caringella AM, Cortone A, Ferrara C, Smirni S, Iannitti R, Purrello M, D’Amato G, Fioretti B, Di Pietro C. Resveratrol Treatment Induces Mito-miRNome Modification in Follicular Fluid from Aged Women with a Poor Prognosis for In Vitro Fertilization Cycles. Antioxidants (Basel) 2022; 11:antiox11051019. [PMID: 35624883 PMCID: PMC9137561 DOI: 10.3390/antiox11051019] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 05/16/2022] [Accepted: 05/18/2022] [Indexed: 12/13/2022] Open
Abstract
Advanced maternal age impairs reproductive performance, influencing the quantity and the quality of oocytes. Mitochondria dysfunction seems to play a decisive role in conditioning the quality of the female gamete. Different in vitro and in vivo studies, demonstrated the antioxidant and anti-inflammatory activities of Resveratrol and its ability to improve mitochondria function even if the exact mechanism of action has not yet been demonstrated in human oocytes. In this paper, by retrospective analysis, we evaluated follicular fluid (FF) miRNome modification in aged women with a poor ovarian reserve receiving a resveratrol-based supplement the three months before the in vitro Fertilization (IVF) cycle. We found 13 differentially expressed microRNAs (miRNAs) in women treated with resveratrol and specifically miR-125b-5p, miR-132-3p, miR-19a-3p, miR-30a-5p and miR-660-5p, regulating mitochondrial proteins, are able to control metabolism and mitochondrial biogenesis. MiRNA expression differences, observed after resveratrol treatment in FF from women with a poor prognosis for IVF, demonstrated that resveratrol may act on mitomiRNAs to improve follicular microenvironment by transcriptomic and proteomic modifications in granulosa cells.
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Affiliation(s)
- Rosalia Battaglia
- Department of Biomedical and Biotechnological Sciences, Section of Biology and Genetics “Giovanni Sichel”, University of Catania, 95123 Catania, CT, Italy; (R.B.); (A.C.); (C.F.); (S.S.); (M.P.)
| | - Angela Caponnetto
- Department of Biomedical and Biotechnological Sciences, Section of Biology and Genetics “Giovanni Sichel”, University of Catania, 95123 Catania, CT, Italy; (R.B.); (A.C.); (C.F.); (S.S.); (M.P.)
| | - Anna Maria Caringella
- Asl Bari, Reproductive and IVF Unit, PTA “F Jaia”, 70014 Conversano, BA, Italy; (A.M.C.); (A.C.); (G.D.)
| | - Anna Cortone
- Asl Bari, Reproductive and IVF Unit, PTA “F Jaia”, 70014 Conversano, BA, Italy; (A.M.C.); (A.C.); (G.D.)
| | - Carmen Ferrara
- Department of Biomedical and Biotechnological Sciences, Section of Biology and Genetics “Giovanni Sichel”, University of Catania, 95123 Catania, CT, Italy; (R.B.); (A.C.); (C.F.); (S.S.); (M.P.)
| | - Salvatore Smirni
- Department of Biomedical and Biotechnological Sciences, Section of Biology and Genetics “Giovanni Sichel”, University of Catania, 95123 Catania, CT, Italy; (R.B.); (A.C.); (C.F.); (S.S.); (M.P.)
| | | | - Michele Purrello
- Department of Biomedical and Biotechnological Sciences, Section of Biology and Genetics “Giovanni Sichel”, University of Catania, 95123 Catania, CT, Italy; (R.B.); (A.C.); (C.F.); (S.S.); (M.P.)
| | - Giuseppe D’Amato
- Asl Bari, Reproductive and IVF Unit, PTA “F Jaia”, 70014 Conversano, BA, Italy; (A.M.C.); (A.C.); (G.D.)
| | - Bernard Fioretti
- Department of Chemistry, Biology and Biotechnologies, University of Perugia, 06123 Perugia, PG, Italy;
| | - Cinzia Di Pietro
- Department of Biomedical and Biotechnological Sciences, Section of Biology and Genetics “Giovanni Sichel”, University of Catania, 95123 Catania, CT, Italy; (R.B.); (A.C.); (C.F.); (S.S.); (M.P.)
- Correspondence: ; Tel.: +39-0954781484
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Jirge PR, Patil MM, Gutgutia R, Shah J, Govindarajan M, Roy VS, Kaul-Mahajan N, Sharara FI. Ovarian Stimulation in Assisted Reproductive Technology Cycles for Varied Patient Profiles: An Indian Perspective. J Hum Reprod Sci 2022; 15:112-125. [PMID: 35928474 PMCID: PMC9345274 DOI: 10.4103/jhrs.jhrs_59_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 06/21/2022] [Accepted: 06/23/2022] [Indexed: 11/10/2022] Open
Abstract
Controlled ovarian stimulation has been an integral part of in vitro fertilisation (IVF) treatment cycles. Availability of different gonadotropins for ovarian stimulation and gonadotropin releasing hormone (GnRH) analogues for prevention of premature rise of leutinising hormone during follicular phase offer an opportunity to utilise them for a successful outcome in women with different subsets of ovarian response. Further, use of GnRH agonist as an alternative for human chorionic gonadotropin improves safety of ovarian stimulation in hyper-responders. Mild ovarian stimulation protocols have emerged as an alternative to conventional protocols in the recent years. Individualisation plays an important role in improving safety of IVF in hyper-responders while efforts continue to improve efficacy in poor responders. Some of the follicular and peri-ovulatory phase interventions may be associated with negative impact on the luteal phase and segmentalisation of the treatment with frozen embryo transfer may be an effective strategy in such a clinical scenario. This narrative review looks at the available evidence on various aspects of ovarian stimulation strategies and their consequences. In addition, it provides a concise summary of the evidence that has emerged from India on various aspects of ovarian stimulation.
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Affiliation(s)
- Padma Rekha Jirge
- Shreyas Hospital and Sushrut Assisted Conception Clinic, Kohlhapur, India
| | | | | | - Jatin Shah
- Mumbai Fertility Clinic & IVF Centre, Mumbai, India
| | | | | | | | - Faddy I Sharara
- Virginia Center for Reproductive Medicine, Reston; Department of O&G, George Washington University, Washington, DC, USA
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15
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Neves AR, Montoya-Botero P, Polyzos NP. Androgens and diminished ovarian reserve: the long road from basic science to clinical implementation. A comprehensive and systematic review with meta-analysis. Am J Obstet Gynecol 2022; 227:401-413.e18. [PMID: 35364061 DOI: 10.1016/j.ajog.2022.03.051] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 03/16/2022] [Accepted: 03/24/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE This study aimed to present a narrative review regarding androgen production, androgens' role in folliculogenesis, and the available therapeutic approaches for androgen supplementation, and to perform a systematic review and meta-analysis regarding the impact of androgens (dehydroepiandrosterone/testosterone) compared with placebo or no treatment on ovarian response and pregnancy outcomes in patients with diminished ovarian reserve and/or poor ovarian responders. DATA SOURCES An electronic search of MEDLINE, Embase, Cochrane Library, Cochrane Central Register of Controlled Trials, Scopus, ClinicalTrials.gov, the ISRCTN registry, and the World Health Organization International Clinical Trials Registry, was conducted for studies published until September 2021. STUDY ELIGIBILITY CRITERIA Randomized controlled trials that compared ovarian response and/or pregnancy outcomes between the different in vitro fertilization protocols using androgens (ie, dehydroepiandrosterone and testosterone) and conventional in vitro fertilization stimulation in patients with diminished ovarian reserve and/or poor ovarian responders were included. METHODS The quality of each study was evaluated with the revised Cochrane risk-of-bias tool for randomized trials (RoB 2). The meta-analysis used random-effects models. All results were interpreted on the basis of intention-to-treat analysis (defined as the inclusion of all randomized patients in the denominator). Risk ratios and 95% confidence intervals were used and combined for meta-analysis. RESULTS No significant differences were found regarding the number of oocytes retrieved (mean difference, 0.76; 95% confidence interval, -0.35 to 1.88), mature oocytes retrieved (mean difference, 0.25; 95% confidence interval, -0.27 to 0.76), clinical pregnancy rate (risk ratio, 1.17; 95% confidence interval, 0.87-1.57), live-birth rate (risk ratio, 0.97; 95% confidence interval, 0.47-2.01), or miscarriage rate (risk ratio, 0.80; 95% confidence interval, 0.29-2.22) when dehydroepiandrosterone priming was compared with placebo or no treatment. Testosterone pretreatment yielded a higher number of oocytes retrieved (mean difference, 0.94; 95% confidence interval, 0.46-1.42), a higher clinical pregnancy rate (risk ratio, 2.07; 95% confidence interval, 1.33-3.20), and higher live-birth rate (risk ratio, 2.09; 95% confidence interval, 1.11-3.95). CONCLUSION Although dehydroepiandrosterone did not present a clear effect on outcomes of assisted reproductive techniques, we found a potentially beneficial effect of testosterone priming on ovarian response and pregnancy outcomes. However, results should be interpreted with caution, taking into account the low to moderate quality of the available evidence.
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Affiliation(s)
- Ana Raquel Neves
- Department of Obstetrics, Gynecology and Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain; Autonomous University of Barcelona, Cerdanyola del Vallès, Spain
| | - Pedro Montoya-Botero
- Conceptum - Unidad de Fertilidad del Country, Bogotá, Colombia; Department of Epidemiology and Biostatistics, Fundación Universitaria de Ciencias de la Salud - FUCS, Bogotá, Colombia
| | - Nikolaos P Polyzos
- Department of Obstetrics, Gynecology and Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain; Faculty of Medicine and Health Sciences, Ghent University (UZ Gent), Ghent, Belgium.
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16
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Islam RM, Bell RJ, Skiba MA, Davis SR. Testosterone and androstenedione are positively associated with anti-Müllerian hormone in premenopausal women. Clin Endocrinol (Oxf) 2021; 95:752-759. [PMID: 34524701 DOI: 10.1111/cen.14592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 08/03/2021] [Accepted: 08/15/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To document associations between anti-Müllerian hormone (AMH) and circulating androgens in nonhealthcare-seeking premenopausal women. DESIGN Community-based, cross-sectional study. SETTING Eastern states of Australia. PARTICIPANTS Women aged 18-39 years not using systemic hormones, not pregnant or breastfeeding within 3 months, and not postmenopausal. MEASUREMENTS AMH, measured by the Beckman Access 2, 2 site immunometric assay from fresh samples, and testosterone, androstenedione, dehydroepiandrosterone (DHEA) and 11-oxygenated C19 steroids, measured by liquid chromatography-tandem mass spectrometry. RESULTS Data were available for 794 women, median age of 33 years (range: 18-39). 76.1% were of European ancestry and 48.2% were parous. Serum AMH was positively associated with testosterone (rho = .29, p < .001) androstenedione (rho = .39, p < .001) and DHEA (rho = .10, p = .005) but not 11-ketoandrostenedione or 11-ketotestosterone. When adjusted for age, body mass index and smoking, using quantile regression, independent positive associations remained between AMH and testosterone (β coefficient: 20.90, 95% confidence interval [CI]: 13.79-28.03; p < .001) and androstenedione (β coefficient: 5.90, 95% CI: 3.76-8.03; p < .001). The serum concentration of testosterone was greater at the top AMH quintile than other quintiles (0.56 nmol/L [range: 0.21-1.90] vs. 0.36 nmol/L [range: 0.13-0.87]; p = .001) in women with self-reported polycystic ovary syndrome. CONCLUSIONS The positive associations between serum testosterone and androstenedione and AMH in premenopausal women is consistent with androgens directly or indirectly influencing AMH production during follicular development. As the highest AMH concentrations are most likely to be seen in women with multifollicular ovaries, it would be expected that women with multifollicular ovaries would have higher serum testosterone. Therefore, whether hyperandrogenemia and multifollicular ovaries should be considered independent characteristics of polycystic ovary syndrome warrants review.
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Affiliation(s)
- Rakibul M Islam
- Department of Epidemiology and Preventative Medicine, Women's Health Research Program, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Robin J Bell
- Department of Epidemiology and Preventative Medicine, Women's Health Research Program, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Marina A Skiba
- Department of Epidemiology and Preventative Medicine, Women's Health Research Program, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Susan R Davis
- Department of Epidemiology and Preventative Medicine, Women's Health Research Program, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
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Marin L, Andrisani A, Bordin L, Dessole F, Noventa M, Vitagliano A, Capobianco G, Ambrosini G. Sildenafil Supplementation for Women Undergoing Infertility Treatments: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Clin Med 2021; 10:4346. [PMID: 34640363 PMCID: PMC8509188 DOI: 10.3390/jcm10194346] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/18/2021] [Accepted: 09/20/2021] [Indexed: 12/14/2022] Open
Abstract
The aim of this systematic review and meta-analysis is to summarize data on the effectiveness of Sildenafil supplementation for women undergoing assisted reproduction techniques. This meta-analysis of randomized controlled trials (RCTs) evaluates the effects of Sildenafil administration during infertility treatments compared with a control group in infertile women. Outcomes evaluated were endometrial thickness (ETh) and the clinical pregnancy rate (CPR). The chemical pregnancy rate (ChPR) was also evaluated. Pooled results were expressed as the risk ratio (RR) or mean differences (MD) with a 95% confidence interval (95% CI). Women undergoing ovulation induction who received Sildenafil showed higher ETh and a higher CPR in comparison to controls. In this group, both the ETh and ChPR resulted in significantly higher values only with delayed start administration. Women undergoing fresh or frozen embryo transfer who received Sildenafil showed no significant advantages regarding ETh and CPR in comparison to controls. In this group, we found a significantly higher ChPR in women receiving Sildenafil. A subgroup analysis revealed significant advantages regarding ETh with oral administration for women undergoing fresh or frozen embryo transfer. Sildenafil therapy appears to improve endometrial thickness and pregnancy rate in women undergoing timed intercourses but it resulted not effective in IUI and IVF treatments. Further RCTs with rigorous methodology are still mandatory.
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Affiliation(s)
- Loris Marin
- Department of Women’s and Children’s Health, University of Padua, 35128 Padua, Italy; (L.M.); (A.A.); (A.V.); (G.A.)
| | - Alessandra Andrisani
- Department of Women’s and Children’s Health, University of Padua, 35128 Padua, Italy; (L.M.); (A.A.); (A.V.); (G.A.)
| | - Luciana Bordin
- Department of Molecular Medicine-Biological Chemistry, University of Padova, 35131 Padova, Italy;
| | - Francesco Dessole
- Department of Surgical, Microsurgical and Medical Sciences, Gynecologic and Obstetric Clinic, University of Sassari, 07100 Sassari, Italy; (F.D.); (G.C.)
| | - Marco Noventa
- Department of Women’s and Children’s Health, University of Padua, 35128 Padua, Italy; (L.M.); (A.A.); (A.V.); (G.A.)
| | - Amerigo Vitagliano
- Department of Women’s and Children’s Health, University of Padua, 35128 Padua, Italy; (L.M.); (A.A.); (A.V.); (G.A.)
| | - Giampiero Capobianco
- Department of Surgical, Microsurgical and Medical Sciences, Gynecologic and Obstetric Clinic, University of Sassari, 07100 Sassari, Italy; (F.D.); (G.C.)
| | - Guido Ambrosini
- Department of Women’s and Children’s Health, University of Padua, 35128 Padua, Italy; (L.M.); (A.A.); (A.V.); (G.A.)
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18
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Hoang QH, Ho HS, Do HT, Nguyen TV, Nguyen HP, Le MT. Therapeutic effect of prolonged testosterone pretreatment in women with poor ovarian response: A randomized control trial. Reprod Med Biol 2021; 20:305-312. [PMID: 34262398 PMCID: PMC8254170 DOI: 10.1002/rmb2.12383] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 02/17/2021] [Accepted: 03/01/2021] [Indexed: 01/30/2023] Open
Abstract
PURPOSE This study compared the therapeutic effects of transdermal testosterone gel (TTG) application at 4 and 6 weeks before controlled ovarian hyperstimulation (COH) in women with poor ovarian response (POR). METHODS In this randomized control trial, infertile women with POR who underwent in vitro fertilization (IVF) were recruited and randomly classified into 4 week (n = 42) and 6 week (n = 38) TTG treatment groups and control group (n = 42). The primary outcome was total number of retrieved mature oocytes. The secondary outcomes were the biochemical pregnancy rate, clinical pregnancy rate, and ongoing pregnancy rate. RESULTS No significant differences were observed in the number of oocytes retrieved, mature oocytes and embryos between all groups. Human chorionic gonadotropin (hCG) positive, clinical, and ongoing pregnancy rates were significantly higher in the TTG pretreatment groups than in the control group but no differences were observed between the 4- and 6 week groups. CONCLUSIONS Applying TTG in infertile women with POR may ameliorate the outcomes of IVF. The extended application of TTG to 6 weeks did not improve the response to ovarian stimulation regarding the number of retrieved oocytes nor pregnancy outcomes compared to the 4 week pretreatment.
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Affiliation(s)
- Quoc Huy Hoang
- Department of Obstetrics and GynecologyThai Nguyen University of Medicine and PharmacyThai Nguyen UniversityThai NguyenVietnam
| | - Hung Sy Ho
- Department of Obstetrics and GynecologyHanoi Medical UniversityHanoiVietnam
- National Assisted Reproductive Technology CentreNational Hospital of Obstetrics and GynecologyHanoiVietnam
| | - Huong Thuy Do
- Department of Histology and EmbryologyHanoi Medical UniversityHanoiVietnam
| | - Tien Viet Nguyen
- Department of Obstetrics and GynecologyHanoi Medical UniversityHanoiVietnam
- National Assisted Reproductive Technology CentreNational Hospital of Obstetrics and GynecologyHanoiVietnam
| | - Hong Phuong Nguyen
- Department for Science Technology and International CooperationThai Nguyen University of Medicine and PharmacyThai Nguyen UniversityThai NguyenVietnam
- International Food Policy Research InstituteHanoiVietnam
| | - Minh Tam Le
- Department of Obstetrics and GynecologyHue University of Medicine and PharmacyHue UniversityHueVietnam
- Hue Center for Reproductive Endocrinology and InfertilityHue University HospitalHueVietnam
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Dinsdale NL, Crespi BJ. Endometriosis and polycystic ovary syndrome are diametric disorders. Evol Appl 2021; 14:1693-1715. [PMID: 34295358 PMCID: PMC8288001 DOI: 10.1111/eva.13244] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/09/2021] [Accepted: 04/10/2021] [Indexed: 12/15/2022] Open
Abstract
Evolutionary and comparative approaches can yield novel insights into human adaptation and disease. Endometriosis and polycystic ovary syndrome (PCOS) each affect up to 10% of women and significantly reduce the health, fertility, and quality of life of those affected. PCOS and endometriosis have yet to be considered as related to one another, although both conditions involve alterations to prenatal testosterone levels and atypical functioning of the hypothalamic-pituitary-gonadal (HPG) axis. Here, we propose and evaluate the novel hypothesis that endometriosis and PCOS represent extreme and diametric (opposite) outcomes of variation in HPG axis development and activity, with endometriosis mediated in notable part by low prenatal and postnatal testosterone, while PCOS is mediated by high prenatal testosterone. This diametric disorder hypothesis predicts that, for characteristics shaped by the HPG axis, including hormonal profiles, reproductive physiology, life-history traits, and body morphology, women with PCOS and women with endometriosis will manifest opposite phenotypes. To evaluate these predictions, we review and synthesize existing evidence from developmental biology, endocrinology, physiology, life history, and epidemiology. The hypothesis of diametric phenotypes between endometriosis and PCOS is strongly supported across these diverse fields of research. Furthermore, the contrasts between endometriosis and PCOS in humans parallel differences among nonhuman animals in effects of low versus high prenatal testosterone on female reproductive traits. These findings suggest that PCOS and endometriosis represent maladaptive extremes of both female life-history variation and expression of sexually dimorphic female reproductive traits. The diametric disorder hypothesis for endometriosis and PCOS provides novel, unifying, proximate, and evolutionary explanations for endometriosis risk, synthesizes diverse lines of research concerning the two most common female reproductive disorders, and generates future avenues of research for improving the quality of life and health of women.
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Affiliation(s)
| | - Bernard J. Crespi
- Department of Biological SciencesSimon Fraser UniversityBurnabyBCCanada
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20
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Testosterone does not improve ovarian response in Bologna poor responders: a randomized controlled trial (TESTOPRIM). Reprod Biomed Online 2021; 43:466-474. [PMID: 34312088 DOI: 10.1016/j.rbmo.2021.05.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/28/2021] [Accepted: 05/24/2021] [Indexed: 11/23/2022]
Abstract
RESEARCH QUESTION Does testosterone, either in a long or short course, before IVF increase the number of mature oocytes retrieved in poor ovarian response? DESIGN Single-centre, single-blinded, randomized controlled trial. Poor ovarian response is defined according to Bologna criteria. Sixty-three participants were included and assigned to three arms: group 1 (long testosterone [n = 17]) 12.5 mg/day testosterone gel for 56 days before ovarian stimulation; group 2 (short testosterone [n = 16]) 12.5 mg/day testosterone gel for 10 days before ovarian stimulation; and group 3 (control, no intervention). Primary outcome was number of mature oocytes retrieved. Secondary outcomes included other cycle parameters (duration of stimulation, antral follicle count, number of follicles >16 mm, total oocytes retrieved and testosterone levels). RESULTS The number of mature oocytes retrieved did not differ between the three groups (2.16, 2.71 and 2.91, P = 0.719, groups 1, 2 and 3, respectively). No other significant differences were found in the remaining cycle parameters, except for testosterone levels at the beginning of ovarian stimulation, which were higher in both testosterone groups and relatively higher in group 2 (1.67 and 3.03, respectively versus 0.14 control group, P = 0.01). A Poisson regression model showed no significant differences for the primary outcome (group 3 versus group 2: 0.925, 95% CI 0.572 to 1.508, P = 0.753; group 3 versus group 1: 0.873, 95% CI 0.534 to 1.426, P = 0.587). CONCLUSIONS The use of testosterone, even when applied for a prolonged period, does not improve the number of mature oocytes in poor ovarian response.
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21
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Serum testosterone levels are positively associated with serum anti-mullerian hormone levels in infertile women. Sci Rep 2021; 11:6336. [PMID: 33737663 PMCID: PMC7973568 DOI: 10.1038/s41598-021-85915-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 03/05/2021] [Indexed: 11/09/2022] Open
Abstract
Anti-Mullerian hormone (AMH) and testosterone (T) both play distinct roles in the early stages of folliculogenesis. However, the relationship between serum T and AMH levels is poorly understood. This study aimed to investigate the association between serum T and AMH levels in infertile women. A total of 1935 infertile women aged 20-46 years were included in the cross-sectional study and divided into four quartile groups (Q1 to Q4) based on serum T levels. Compared to the subjects in the highest T quartile (Q4), those in the lowest T quartile (Q1) showed significantly lower AMH levels. After adjustment for age, body weight, body mass index and FSH, increasing T quartile categories were associated with higher AMH levels. Binary logistic regression analyses revealed that the odds for the risk of diminished ovarian reserve (DOR) were 11.44-fold higher in Q1 than in Q4 and the odds for the risk of excess ovarian reserve (EOR) were 10.41-fold higher in Q4 than in Q1. Our data show that serum T levels are positively associated with serum AMH levels and suggest that androgen insufficiency may be a potential risk factor for DOR; androgen excess may lead to EOR in infertile women.
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Neves AR, Montoya-Botero P, Polyzos NP. The Role of Androgen Supplementation in Women With Diminished Ovarian Reserve: Time to Randomize, Not Meta-Analyze. Front Endocrinol (Lausanne) 2021; 12:653857. [PMID: 34079524 PMCID: PMC8165260 DOI: 10.3389/fendo.2021.653857] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 04/23/2021] [Indexed: 11/24/2022] Open
Abstract
The management of patients with diminished ovarian reserve (DOR) remains one of the most challenging tasks in IVF clinical practice. Despite the promising results obtained from animal studies regarding the importance of androgens on folliculogenesis, the evidence obtained from clinical studies remains inconclusive. This is mainly due to the lack of an evidence-based methodology applied in the available trials and to the heterogeneity in the inclusion criteria and IVF treatment protocols. In this review, we analyze the available evidence obtained from animal studies and highlight the pitfalls from the clinical studies that prevent us from closing the chapter of this line of research.
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Affiliation(s)
- Ana Raquel Neves
- Department of Obstetrics, Gynecology and Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain
- Faculty of Medicine, Autonomous University of Barcelona, Cerdanyola del Vallès, Spain
| | - Pedro Montoya-Botero
- Department of Reproductive Medicine, Conceptum – Unidad de Fertilidad del Country, Bogotá, Colombia
| | - Nikolaos P. Polyzos
- Department of Obstetrics, Gynecology and Reproductive Medicine, Dexeus University Hospital, Barcelona, Spain
- Faculty of Medicine and Health Sciences, Ghent University (UZ Gent), Gent, Belgium
- *Correspondence: Nikolaos P. Polyzos,
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The Benefits of Testosterone Therapy in Poor Ovarian Responders Undergoing In Vitro Fertilisation (IVF). EUROPEAN MEDICAL JOURNAL 2020. [DOI: 10.33590/emj/20-00095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Introduction: Poor ovarian responders are the most challenging patients in reproductive medicine and no successful treatment has been proposed. Androgens are thought to play an important role during early folliculogenesis and diminished levels are associated with decreased ovarian sensitivity to follicle-stimulating hormone. This study aimed to determine whether pretreatment with testosterone improves the results in poor responders undergoing in vitro fertilisation (IVF). Materials and methods: This observational pilot study enrolled 33 poor responders undergoing IVF. Eleven patients were pretreated with 250 mg intramuscular testosterone and compared to a control group of 22 patients. The participants were tested for free testosterone, dehydroepiandrosterone sulfate, sex hormone binding globulin, and anti-mullerian hormone (AMH). Results: The two groups had similar baseline characteristics. Significant improvement was reached in the hormones free testosterone, dehydroepiandrosterone sulfate, and sex hormone binding globulin in the testosterone-pretreatment group. No difference was detected in antral follicle count (5.06 versus 4.24); AMH (0.51 versus 0.53), mature oocytes (2.2 versus 2.32), and the number of embryos (1.2 versus 1.33) between the study and control groups, respectively. There was a slow improvement in fertilisation rate but without any significance (62.97% versus 57.61%). However, the cancellation rate of the ovarian stimulation was much greater in the control group (18.18%) in comparison with the study group (0.0%). Pregnancy rate (PR) in the testosterone group was higher than controls (PR per cycle: 27.3% versus 4.6; p=0.09). Conclusion: Based on the limited number of patients studied, pretreatment with testosterone seems to improve PR and cancellation rate in poor responders but failed to affect antral follicle count, AMH, and the number of mature oocytes and embryos. Given these results, further research would provide more certainty.
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The Conundrum of Poor Ovarian Response: From Diagnosis to Treatment. Diagnostics (Basel) 2020; 10:diagnostics10090687. [PMID: 32932955 PMCID: PMC7555981 DOI: 10.3390/diagnostics10090687] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/27/2020] [Accepted: 09/09/2020] [Indexed: 12/11/2022] Open
Abstract
Despite recent striking advances in assisted reproductive technology (ART), poor ovarian response (POR) diagnosis and treatment is still considered challenging. Poor responders constitute a heterogeneous cohort with the common denominator of under-responding to controlled ovarian stimulation. Inevitably, respective success rates are significantly compromised. As POR pathophysiology entails the elusive factor of compromised ovarian function, both diagnosis and management fuel an ongoing heated debate depicted in the literature. From the criteria employed for diagnosis to the plethora of strategies and adjuvant therapies proposed, the conundrum of POR still puzzles the practitioner. What is more, novel treatment approaches from stem cell therapy and platelet-rich plasma intra-ovarian infusion to mitochondrial replacement therapy have emerged, albeit not claiming clinical routine status yet. The complex and time sensitive nature of this subgroup of infertile patients indicates the demand for a consensus on a horizontally accepted definition, diagnosis and subsequent effective treating strategy. This critical review analyzes the standing criteria employed in order to diagnose and aptly categorize POR patients, while it proceeds to critically evaluate current and novel strategies regarding their management. Discrepancies in diagnosis and respective implications are discussed, while the existing diversity in management options highlights the need for individualized management.
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Cozzolino M, Cecchino GN, Troiano G, Romanelli C. Growth hormone cotreatment for poor responders undergoing in vitro fertilization cycles: a systematic review and meta-analysis. Fertil Steril 2020; 114:97-109. [PMID: 32553470 DOI: 10.1016/j.fertnstert.2020.03.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 03/04/2020] [Accepted: 03/04/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of growth hormone (GH) supplementation in improving the in vitro fertilization (IVF) outcomes of poor responders. DESIGN Systematic review and meta-analysis. SETTING Not applicable. PATIENT(S) Poor ovarian responders undergoing conventional IVF or intracytoplasmic sperm injection (ICSI). INTERVENTION(S) Randomized controlled trials (RCTs) of poor ovarian responders undergoing a single IVF/ICSI cycle with GH supplementation versus conventional controlled ovarian stimulation. This review was registered in the PROSPERO database before starting data extraction (CRD42020151681). MAIN OUTCOME MEASURE(S) Primary outcome was live birth rate. Clinical pregnancy rate, miscarriage rate, ongoing pregnancy rate, number of oocytes, number of mature (metaphase II [MII]) oocytes and the number of embryos available to transfer were considered as secondary outcomes. RESULT(S) Twelve RCTs were included; 586 women were assigned to the intervention group and 553 to the control group. The analysis revealed that patients receiving GH supplementation did not show an increased live birth rate, miscarriage rate, or ongoing pregnancy rate. However, GH supplementation in poor responders increased clinical pregnancy rate, number of oocytes retrieved (mean difference 1.62), number of MII oocytes (mean difference 2.06), and number of embryos available to transfer (mean difference 0.76). Sensitivity and subgroup analyses did not provide statistical changes to pooled results. CONCLUSION(S) The present meta-analysis provides evidence that GH supplementation may improve some reproductive outcomes in poor responders, but not live birth rates.
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Affiliation(s)
- Mauro Cozzolino
- IVIRMA, IVI Foundation, Health Research Institute La Fe, Valencia, Spain; Universidad Rey Juan Carlos, Móstoles, Madrid, Spain; Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut.
| | - Gustavo N Cecchino
- Universidad Rey Juan Carlos, Móstoles, Madrid, Spain; Department of Gynecology, Federal University of São Paulo, São Paulo, Brazil; Department of Reproductive Medicine, Mater Prime, São Paulo, Brazil
| | | | - Chiara Romanelli
- Department of Clinical and Experimental Biomedical Sciences, University of Florence, Florence, Italy
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Improvement of Pregnancy Rate and Live Birth Rate in Poor Ovarian Responders by Intraovarian Administration of Autologous Menstrual Blood Derived- Mesenchymal Stromal Cells: Phase I/II Clinical Trial. Stem Cell Rev Rep 2020; 16:755-763. [DOI: 10.1007/s12015-020-09969-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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27
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Wang ET, Diamond MP, Alvero R, Casson P, Christman GM, Coutifaris C, Hansen KR, Sun F, Legro RS, Robinson RD, Usadi RS, Pisarska MD, Santoro NF, Zhang H. Androgenicity and fertility treatment in women with unexplained infertility. Fertil Steril 2020; 113:636-641. [PMID: 32192596 PMCID: PMC7088440 DOI: 10.1016/j.fertnstert.2019.10.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 10/11/2019] [Accepted: 10/25/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine whether biochemical or clinical markers of androgenic activity predict live birth rate with ovarian stimulation in the unexplained infertility population. DESIGN Secondary analysis of the Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation (AMIGOS) clinical trial. SETTING Multicenter university-based clinical practices. PATIENT(S) Nine hundred couples with unexplained infertility were included. Women were 18-40 years old with regular menses, a normal uterine cavity, at least one patent fallopian tube, and a male partner with ≥5 million motile sperm. Women were randomized to receive gonadotropin, clomiphene, or letrozole with IUI for four or fewer four treatment cycles. Women were evaluated for biochemical (total testosterone, DHEAS, and free androgen index) and clinical markers of androgenic activity (sebum, acne, and hirsutism). Multivariable logistic regression models adjusting for treatment group, maternal age, and body mass index were performed. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) The primary outcome was live birth. Secondary outcomes included conception, clinical pregnancy, and pregnancy loss. RESULT(S) When comparing 900 women in the AMIGOS trial based on quartiles of serum TT, women were of younger age, higher body mass index, and higher waist circumference with increasing TT. Increasing quartiles of TT also showed increasing DHEAS and free androgen index values. Serum androgens were not associated with outcomes of live birth, conception, clinical pregnancy, or pregnancy loss. Clinical androgen markers were not associated with pregnancy outcomes. CONCLUSION(S) In a randomized cohort of women with unexplained infertility, biochemical and clinical measures of androgens did not predict live birth rate after ovarian stimulation treatment. CLINICAL TRIAL REGISTRATION NUMBER NCT 01044862.
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Affiliation(s)
- Erica T Wang
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California.
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Ruben Alvero
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado
| | - Peter Casson
- Department of Obstetrics and Gynecology, University of Vermont, Burlington, Vermont
| | - Gregory M Christman
- Department of Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville, Florida
| | - Christos Coutifaris
- Department of Obstetrics and Gynecology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Karl R Hansen
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - Fangbai Sun
- Department of Biostatistics, Yale University School of Public Health, New Haven, Connecticut
| | - Richard S Legro
- Department of Obstetrics and Gynecology, Penn State College of Medicine, Hershey, Pennsylvania
| | - Randal D Robinson
- Department of Obstetrics and Gynecology, University of Texas Health San Antonio Long School of Medicine, San Antonio, Texas
| | - Rebecca S Usadi
- Department of Obstetrics and Gynecology, Atrium Health, Charlotte, North Carolina
| | - Margareta D Pisarska
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Nanette F Santoro
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado
| | - Heping Zhang
- Department of Biostatistics, Yale University School of Public Health, New Haven, Connecticut
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28
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Blumenfeld Z. What Is the Best Regimen for Ovarian Stimulation of Poor Responders in ART/IVF? Front Endocrinol (Lausanne) 2020; 11:192. [PMID: 32362870 PMCID: PMC7180183 DOI: 10.3389/fendo.2020.00192] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 03/18/2020] [Indexed: 12/12/2022] Open
Abstract
The infertile patients with aging ovaries-also sometimes referred to as impending premature ovarian insufficiency (POI), impending premature ovarian failure (POF), or poor ovarian responders (POR), constitute a significant and increasing bulk of the patients appealing to IVF/ART. Different causes have been cited in the literature, among the identified etiologies, including chromosomal and genetic etiology, metabolic, enzymatic, iatrogenic, toxic, autoimmune, and infectious causes. Although the most successful and ultimate treatment of POI/POF/POR patients is egg donation (ED), many, if not most, of these infertile women are reluctant to consent to ED upon the initial diagnostic interview, requesting alternative solutions despite the low odds for success. Despite anecdotal case reports, no unequivocal treatment proved to be successful for these patients in prospective randomized controlled trials. Nevertheless, the addition of growth hormone (GH) to ovarian stimulation in POR with GH deficiency may improve the results of controlled ovarian hyperstimulation (COH) and the IVF success. In patients with autoimmune etiology for POR/POI, the combination of glucocorticosteroids, pituitary-ovarian suppression, and COH may be successful in achieving the desired conception.
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Løssl K, Freiesleben NLC, Wissing ML, Birch Petersen K, Holt MD, Mamsen LS, Anderson RA, Andersen CY. Biological and Clinical Rationale for Androgen Priming in Ovarian Stimulation. Front Endocrinol (Lausanne) 2020; 11:627. [PMID: 33013703 PMCID: PMC7498541 DOI: 10.3389/fendo.2020.00627] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/31/2020] [Indexed: 12/24/2022] Open
Abstract
Androgen receptors are expressed by all stages of growing follicles, and follicular fluid androgen levels are positively correlated to granulosa cell androgen receptor and follicle-stimulating hormone (FSH) receptor expression. Thus, androgens may promote follicular growth, accumulation and/or responsiveness to gonadotropins. This is explored therapeutically in the concept of androgen priming, to improve the ovarian response to stimulation in assisted reproduction. Androgen effects may be achieved in two different ways, either directly by providing exogenous androgen or by providing luteinizing hormone (LH) activity [i.e., LH or human chorionic gonadotropin (hCG)] to stimulate local ovarian production of androgen. The androgen concentrations in follicular fluid by far exceed the levels in female circulation and it has recently been shown that there was no correlation between serum testosterone levels and follicular fluid androgen levels. There is some evidence that administration of exogenous dehydroepiandrosterone or testosterone increases live birth rates, but an optimal protocol has not been established and such adjuvant treatment should be considered experimental. Furthermore, studies exploring long-term administration of LH activity, achieving LH levels comparable to those seen in women with polycystic ovary syndrome, are awaited. The aim of the present review is to discuss critically the most suitable approach for androgen priming from a biological and clinical standpoint, and to evaluate current approaches and results obtained in clinical trials.
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Affiliation(s)
- Kristine Løssl
- The Fertility Clinic, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | | | | | | | - Linn Salto Mamsen
- Laboratory of Reproductive Biology, The Juliane Marie Centre for Women, Children and Reproduction, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Richard A. Anderson
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, United Kingdom
| | - Claus Yding Andersen
- Laboratory of Reproductive Biology, The Juliane Marie Centre for Women, Children and Reproduction, University Hospital of Copenhagen, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- *Correspondence: Claus Yding Andersen
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30
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Bovbjerg ML. Current Resources for Evidence-Based Practice, January 2020. J Obstet Gynecol Neonatal Nurs 2020; 49:116-124. [DOI: 10.1016/j.jogn.2019.11.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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31
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Cozzolino M, Franasiak J, Andrisani A, Ambrosini G, Vitagliano A. "Delayed start" gonadotropin-releasing hormone antagonist protocol in Bologna poor-responders: A systematic review and meta-analysis of randomized controlled trials. Eur J Obstet Gynecol Reprod Biol 2019; 244:154-162. [PMID: 31786492 DOI: 10.1016/j.ejogrb.2019.11.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 10/15/2019] [Accepted: 11/22/2019] [Indexed: 01/29/2023]
Abstract
To evaluate the effectiveness of delay start protocol in improving the success of in vitro fertilization (IVF) in poor responders according to Bologna's criteria. Only randomized controlled trial (RCT) of infertile women undergoing a single IVF/ICSI cycle with ovarian stimulation protocol based on daily injections with delay start protocol or a conventional antagonist protocol were included in this systematic review and meta-analysis. The review protocol was registered in PROSPERO before starting the data extraction (CRD42019128284). Primary outcome was clinical pregnancy rate. Ongoing pregnancy rate, miscarriage rate, number of oocytes, number of MII oocytes, stimulation length, gonadotropin amount and cancellation rate were considered as secondary outcomes. Four randomized controlled trials were included with a total number of 380 participants. 189 patients were included in the delayed start protocol and 191 were allocated to the comparison group. The results showed a significant higher clinical pregnancy rate (CPR) in patients allocated to the intervention. Data from all studies failed to detect a statistical difference between groups in terms of ongoing pregnancy rate (OPR), miscarriage rate (MR), Total-Oocyte, MII-Oocyte and Total-Embryos. Gonadotropin amount (GA) was significantly lower in the intervention group in comparison to controls, with no difference in stimulation length (SL) and cancelled cycle (CC). Delayed start GnRH-antagonist protocol may reduce GA and improve CPR in poor ovarian responder according to Bologna criteria.
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Affiliation(s)
- Mauro Cozzolino
- IVIRMA, IVI Foundation, Health Research Institute La Fe, Avenida Fernando Abril Martorell, 106 - Torre A, Planta 1ª, 46026, Valencia, Spain; Universidad Rey Juan Carlos, Calle Tulipán, 28933, Móstoles, Madrid, Spain; Department of Obstetrics, Gynaecology and Reproductive Sciences, Yale School of Medicine, 310 Cedar St, 06510, New Haven, CT, USA.
| | | | - Alessandra Andrisani
- Department of Women and Children's Health, Unit of Gynecology and Obstetrics, University of Padua, Padua, Italy
| | - Guido Ambrosini
- Department of Women and Children's Health, Unit of Gynecology and Obstetrics, University of Padua, Padua, Italy
| | - Amerigo Vitagliano
- Department of Women and Children's Health, Unit of Gynecology and Obstetrics, University of Padua, Padua, Italy
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32
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Cozzolino M, Marin D, Sisti G. New Frontiers in IVF: mtDNA and autologous germline mitochondrial energy transfer. Reprod Biol Endocrinol 2019; 17:55. [PMID: 31299996 PMCID: PMC6626406 DOI: 10.1186/s12958-019-0501-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 07/08/2019] [Indexed: 01/01/2023] Open
Abstract
Many infertility specialists support the existence of a relationship between the levels of mitochondrial DNA and the quality of the blastocysts. Despite the extensive use of pre-implantation genetic testing for aneuploidy, a significant percentage of euploid embryos do not implant even though the endometrium is normal. Mitochondrial DNA may be used as a new test in evaluating embryonic vitality.Ovarian aging leads to a decrease in the quantity and quality of oocytes and aged oocytes have a reduced number of mitochondria. Mitochondria are the energy factories of the cells and their lacked could leads to lower fertilization rates and poor embryonic development. Various strategies have been tested to increase the mitochondria quantity and thus improve the quality of oocytes used in in vitro fertilization. Results of ovarian rejuvenation techniques such as autologous mitochondrial transplantation have been controversial. In this review, we describe the state of the art concerning the use of mitochondrial DNA and autologous mitochondrial transplantation as new possibilities to increase success in vitro fertilization.
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Affiliation(s)
- Mauro Cozzolino
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA.
- Universidad Rey Juan Carlos, Madrid, Spain.
- IVIRMA, Fundación Instituto Valenciano de Infertilidad, Avda/Fernando Abril Martorell, n° 106, Valencia, Madrid, Spain.
| | - Diego Marin
- IVIRMA New Jersey, Basking Ridge, NJ, 07920, USA
| | - Giovanni Sisti
- Department of Obstetrics and Gynecology, Lincoln Medical and Mental Health Center, Bronx, New York, USA
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