Effect of Three Androgen Indexes (FAI, FT, and TT) on Clinical, Biochemical, and Fertility Outcomes in Women with Polycystic Ovary Syndrome

The calculated and the rapid equilibrium dialyzed human serum free testosterone by LC-MS/MS and their performances in PCOS diagnosis

OBJECTIVE

To compare the calculated and the rapid equilibrium dialyzed (ED) human serum free testosterone (FT) by liquid chromatography-tandem mass spectrometry (LC-MS/MS) and to explore their performances in polycystic ovary syndrome (PCOS) diagnosis.

METHODS

A rapid ED LC-MS/MS method for serum FT was established and validated for linearity, lower limit of the measuring interval (LLMI), imprecision, trueness, stability, dilution, matrix specificity and carryover. The validated ED LC-MS/MS (ED-FT) was compared with calculated LC-MS/MS method from Vermeulen's formula (cFT) for FT measurement in 139 PCOS patients and 100 healthy controls. The performances of total testosterone (TT), ED-FT and cFT by LC-MS/MS in PCOS diagnosis were investigated with the same cohorts.

RESULTS

The linearity range of ED-FT was 1.74-890 pmol/L, with a LLMI at 1.74 pmol/L. The intra-assay and inter-assay imprecision were < 3.8 % and < 5.9 %. The trueness was acceptable with recoveries of 92.9 %-108.2 %. The equilibrium dialysis time was 4 h. The two FT methods displayed systematic and proportional differences and cFT showed significant positive deviations compared to ED-FT. Receiver operating characteristic curve analysis proved that ED-FT outperformanced in PCOS diagnosis with the an area under the curve at 0.973, sensitivity of 89.93 % and specificity of 96.00 %.

CONCLUSIONS

This study established a rapid, accurate and sensitive ED LC-MS/MS method for serum FT. ED-FT is optimal compared to TT and cFT by LC-MS/MS in PCOS diagnosis.

Free Androgen Index Might Not Be a Perfect Predictor of Infertility Outcomes in Patients with Polycystic Ovary Syndrome Undergoing Frozen Embryo Transfer:A Retrospective Cohort Study

Purpose

It is well known that androgen excess impairs oocyte quality, endometrial receptivity and even embryo invasion to some extent. Free androgen index (FAI) is strongly recommended to evaluate active androgen. Previous studies have showed conflicting conclusions on the effect of hyperandrogenism on the pregnancy outcomes in patients with polycystic ovary syndrome (PCOS). This study aims to analyze the influence of hyperandrogenemia based on FAI on frozen embryo transfer (FET) outcomes in patients with PCOS.

Patients and Methods

Patients diagnosed with PCOS who underwent their first FET between January 2017 and April 2022 were stratified into two cohorts using FAI, a highly recommended parameter: PCOS with hyperandrogenemia (n=73) and PCOS without hyperandrogenemia (n=255). Basic and infertility characteristics were analyzed using Student's t-test or chi-square (χ2) statistics. Logistic regression analysis was performed to verify whether FAI was helpful in predicting pregnancy outcomes in women with PCOS.

Results

Body mass index (BMI), total gonadotropin (Gn), basal serum follicle-stimulating hormone (bFSH), basal serum testosterone (bT), sex hormone binding globulin (SHBG), and FAI were significantly different between the two groups. (P=0.005, P<0.001, P<0.001, P<0.001, and P<0.001, respectively). However, clinical pregnancies, abortions, and live births did not differ significantly. Further regression analyses showed that FAI was not related to clinical pregnancy, abortion, or live birth rates (adjusted odds ratio (OR)=0.978, 95% confidence interval (CI)=0.911-1.050, P=0.539; adjusted OR=1.033, 95% CI=0.914-1.168, P=0.604; and adjusted OR=0.976, 95% CI=0.911-1.047, P=0.499, respectively).

Conclusion

FAI was not associated with pregnancy outcomes in patients with PCOS; that is, it did not reflect any negative effects of hyperandrogenemia on pregnancy outcomes in patients with PCOS and was not an informative clinical parameter. Therefore, more attention should be paid to the factors that influence the accuracy of FAI in reflecting androgen levels in vivo, and further discussion is needed.

Impact of dehydroepiandrosterone sulfate and free androgen index on pregnancy and neonatal outcomes in PCOS patients

BACKGROUND

Polycystic ovary syndrome (PCOS) is a prevalent endocrine disorder associated with infertility and pregnancy complications. The pathogenesis of PCOS and its impact on reproductive function may be influenced by the source of androgens, including testosterone, free androgen, dehydroepiandrosterone sulfate (DHEAS). However, the differential effects of these androgen on pregnancy and neonatal outcomes and the cut-off value of East Asian population with PCOS remain unclear.

METHODS

A retrospective cohort study was conducted at the Reproductive Medicine Center of the First Affiliated Hospital of Sun Yat-sen University from January 2015 to November 2022, involving 636 cycles of in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI). Subgroup analyses were performed using cut-off values of 6.4 for free androgen index (FAI), 9.5 µmol/L for DHEAS. Pregnancy and neonatal outcomes were compared between groups. Restricted cubic spline (RCS) was used to identify significant cut-off values affecting pregnancy.

RESULTS

Higher FAI levels (> 6.4) were associated with decrease in clinical pregnancy rate (PR) (50.61% vs. 41.66%, p = 0.024), live birth rate (LBR) (42.42% vs. 32.35%, p = 0.011). When DHEAS levels exceeded 9.5 µmol/L, there was a significant decrease in clinical PR (51.27% vs. 42.73%, P = 0.039), LBR (42.73% vs. 32.73%, P = 0.012). Negative correlations were also observed between DHEAS levels and cumulative pregnancy rate (70.57% vs 56.62% p = 0.002) and cumulative live birth rate (CLBR) (59.35% vs 43.37%, p = 0.0007). Both FAI and DHEAS elevated is associated with the lowest clinical pregnancy rate (37.84%). Conversely, when solely FAI is elevated, the pregnancy rate increases to 52.38%, while an elevation in DHEAS alone is associated with a pregnancy rate of, both of which are lower than when neither FAI nor DHEAS are elevated (60.68%). The live birth rates exhibit a similar trend (30.00% vs 40.00% vs 41.83% vs 44.48%). RCS revealed a significant decrease in CPR and CLBR when DHEA levels exceeded 7.69 umol/L, while the cut-off value of FAI was 6.36 for CPR and CLBR.

CONCLUSION

In conclusion, PCOS patients with biochemical hyperandrogenism show unsatisfactory clinical PR and CLBR when undergoing assisted reproductive technology (ART). This may be attributed to the influence of both adrenal-derived DHEAS and ovarian-derived FAI on the unfavorable pregnancy outcomes.

Metabolic Syndrome Rather Than Other Phenotypes in PCOS as a Predictive Indicator for Clinical Outcomes in IVF: Comprehensive Phenotypic Assessment across All PCOS Classifications

Polycystic ovary syndrome (PCOS) is a well-recognized, multi-system metabolic disorder affecting fertility. Although various classification methods have been proposed to assess the phenotypic heterogeneity of PCOS, there is currently no reliable phenotype for predicting clinical IVF outcomes. This retrospective study, as a comprehensive phenotypic assessment across all PCOS classifications, aimed to identify dependable phenotypes that can serve as predictors for IVF and pregnancy outcomes. The study included 1313 PCOS patients who received their initial IVF treatment between January 2019 and December 2021. The phenotypes reflect the diverse metabolic and hormonal characteristics in this study. Phenotype A, within the Rotterdam criteria classification, exhibited the highest anti-Müllerian hormone levels (AMH), while phenotype D displayed the lowest Homeostasis Model Assessment of Insulin Resistance (HOMA-IR) values. Both the hyperandrogenism (HA) phenotype within HA-based classification and the overweight phenotype within the body-mass-index-based classification showed increased HOMA-IR and metabolic syndrome (MetS). The MetS phenotype had higher free androgen index and a lower AMH. Notably, the MetS-based classification system demonstrated an independent association of MetS with cumulative live birth, preterm birth, and gestational diabetes mellitus as a contributing risk factor for PCOS patients undergoing IVF (p < 0.05). These findings carry noteworthy implications for advancing clinical management strategies for PCOS.

Predictive Factors of Menstrual Recovery After Laparoscopic Sleeve Gastrectomy in Polycystic Ovary Syndrome Women with Obesity

Objective

To explore the predictors of menstrual recovery in polycystic ovary syndrome (PCOS) women with obesity following laparoscopic sleeve gastrectomy (LSG).

Methods

A total of 88 PCOS patients with obesity and 76 control patients with obesity aged 18-45 years were enrolled between May 2013 and December 2020. PCOS was diagnosed using the Rotterdam diagnostic criteria (2003). Anthropometric measurements, biochemical parameters, sex hormones, and circulating fibrinogen-like protein 1 (FGL-1) levels were collected before and six-month after LSG. The data on postoperative menstrual status, body weight, and fertility were obtained through telephone follow-ups for all individuals with PCOS.

Results

Patients with PCOS were followed up for at least six months after surgery, and the mean follow-up time was 3.23 years. At 6 months after LSG, circulating total testosterone (TT), calculated free testosterone (cFT), and FGL-1 levels declined significantly. The mean percent excess weight loss (%EWL) and percent total weight loss (%TWL) in PCOS patients at the final follow-up was 97.52% ± 33.90% and 31.65% ± 10.31%, respectively. The proportion of regular menstruation in PCOS patients significantly increased within six months (75.86% vs 0.03% at baseline). In the logistic regression analysis, time from PCOS diagnosis (P=0.007), body mass index (BMI) (P=0.007), TT (P=0.038) at baseline were demonstrated to be independent predictive factors for the regular menstruation in women with PCOS and obesity within 6 months after LSG.

Conclusion

In PCOS patients with obesity, time from PCOS diagnosis, BMI, and TT levels at baseline were independently and negatively associated with menstrual recovery within 6 months after LSG, which could be applied in preoperative evaluation.

Role of sex hormone-binding globulin in the free hormone hypothesis and the relevance of free testosterone in androgen physiology

According to the free hormone hypothesis, biological activity of a certain hormone is best reflected by free rather than total hormone concentrations. A crucial element in this theory is the presence of binding proteins, which function as gatekeepers for steroid action. For testosterone, tissue exposure is governed by a delicate equilibrium between free and total testosterone which is determined through interaction with the binding proteins sex hormone-binding globulin and albumin. Ageing, genetics and various pathological conditions influence this equilibrium, hereby possibly modulating hormonal exposure to the target tissues. Despite ongoing controversy on the subject, strong evidence from recent in vitro, in vivo and human experiments emphasizes the relevance of free testosterone. Currently, however, clinical possibilities for free hormone diagnostics are limited. Direct immunoassays are inaccurate, while gold standard liquid chromatography with tandem mass spectrometry (LC-MS/MS) coupled equilibrium dialysis is not available for clinical routine. Calculation models for free testosterone, despite intrinsic limitations, provide a suitable alternative, of which the Vermeulen calculator is currently the preferred method. Calculated free testosterone is indeed associated with bone health, frailty and other clinical endpoints. Moreover, the added value of free testosterone in the clinical diagnosis of male hypogonadism is clearly evident. In suspected hypogonadal men in whom borderline low total testosterone and/or altered sex hormone-binding globulin levels are detected, the determination of free testosterone avoids under- and overdiagnosis, facilitating adequate prescription of hormonal replacement therapy. As such, free testosterone should be integrated as a standard biochemical parameter, on top of total testosterone, in the diagnostic workflow of male hypogonadism.

Sexual Function in Chinese Women with Polycystic Ovary Syndrome and Correlation with Clinical and Biochemical Characteristics

To investigate sexual function in Chinese women with polycystic ovary syndrome (PCOS) and to explore the correlation with clinical and biochemical characteristics. A cross-sectional study was designed in 1000 PCOS women, aged 18–45 years, via the Chinese version of Female Sexual Function Index (FSFI) evaluating sexual function, with additional questions possibly related to sexual life. Clinical and biochemical characteristics likely to affect sexual function were determined, including anthropometric indicators, serum levels of hormones, luteinizing hormone to follicle-stimulating hormone ratio (LH/FSH ratio), prolactin (PRL), total testosterone (TT), free androgen index (FAI), sex-hormone-binding globulin (SHBG), glucose, and lipid metabolism indicators. Nine hundred ten PCOS women participated in the study, 685 patients were included after screening, and 211 were suitable to detect correlations of clinical and biochemical characteristics with sex function parameters. The mean total FSFI score was 24.19 ± 2.8; 79.56% of the women were at risk of female sexual dysfunction (FSD). Women doing regular aerobic exercise and use of contraception had higher FSFI scores, while those with a desire to conceive and clinical signs of hyperandrogenism had lower FSFI scores. There were negative associations of FSFI scores with age and body fat distribution. No significant associations between FSFI scores and hormonal factors (surprisingly including SHBG) were found, except for total testosterone and satisfaction (OR = 0.976, p = 0.002). HOMA-IR was significantly related to reduced desire score (OR = 0.914, p = 0.004) and lubrication score (OR = 0.964, p = 0.044). PCOS was associated with a high risk of FSD (defined according to FSFI) in about 80% of the women in our study, and clinical characteristics play a more important role.