Androgen Priming Research Articles

Андрогеновый прайминг при бедном ответе на овариальную стимуляцию

Андрогеновый прайминг при бедном ответе на овариальную стимуляцию

P-682 Androgen and Inhibin B levels during ovarian stimulation before and after eight weeks of low dose hCG priming in women with low ovarian reserve

Abstract Study question Does eight weeks of low dose human chorionic gonadotropin (hCG)-priming affect androgen or Inhibin B levels in serum and follicular fluid during IVF/ICSI treatment? Summary answer Inhibin B was reduced on stimulation day 1 in the IVF/ICSI cycle following hCG-priming. Androgen levels in serum and follicular fluid was not increased. What is known already In our recently published pilot study, eight weeks of low-dose hCG-priming was used to stimulate the intraovarian androgen synthesis in women with AMH <6.29 pmol/L. Priming resulted in more retrieved oocytes and more follicles sized 2-5 mm and less sized 6-10 mm at the start of stimulation. Stimulation time and FSH consumption was increased after priming. HCG priming potentially stimulate the intraovarian androgen synthesis causing upregulation of FSH receptors on granulosa cells, and therefore it was unexpected that the antral follicles were smaller and stimulation time longer following priming. This might indicate a different mechanism of action than previously thought. Study design, size, duration A prospective, paired, non-blinded, single-center study including 20 women conducted between January 2021 and July 2021 at a tertiary referral hospital. Participants underwent two identical IVF treatments: a Control cycle including elective freezing of all blastocysts and a Study cycle with fresh blastocyst transfer. The Control and Study cycles were separated by eight weeks (two menstrual cycles) of hCG-priming by daily injections of 260 IE hCG (details in our previously published paper). Participants/materials, setting, methods Women aged 18-40 years with cycle lengths of 23-35 days and AMH <6.29 pmol/L. Control and Study IVF cycles were performed in a fixed GnRH-antagonist protocol. Blood samples were taken on stimulation day 1, stimulation day 5-6, trigger day, day of oocyte pick up (OPU), and trigger day + 7 days in the Control and Study cycles. Follicular fluid was collected from the first aspirated follicle on both sides during OPU in both cycles. Main results and the role of chance Inhibin B serum levels were significantly lower on stimulation day 1 after hCG-priming, but no other significant differences in serum Inhibin B or androgen levels were seen. The concentrations of Inhibin B and androstenedione in the follicular fluid from the Study and Control cycle did not vary but testosterone was significantly lower in the Study cycle. A lower Inhibin B in the Study cycle corresponds with the antral follicles being significantly smaller after priming, and this probably led to a longer stimulation time in the Study cycle. This contradicts the theory that androgen priming causes more FSH receptors on developing (antral up to preovulatory) follicles. Instead, we hypothesize that androgen priming rescued some small antral follicles that would have otherwise undergone atresia by the end of the previous menstrual cycle. The mechanism of action was likely an increase in androgen levels and FSH receptor expression within these small follicles, however, not enough to elevate androgen levels in serum. We retrieved significantly more oocytes in the Study cycle and the production of estradiol per follicle ≥10 mm on trigger day was comparable in the Study and Control cycle, suggesting that the rescued follicles were competent in producing oocytes and steroid hormones. Limitations, reasons for caution The sample size was small, and androgen and Inhibin B levels were not the primary outcome. We have not demonstrated a higher androgen level or FSH receptor expression in small antral follicles following hCG-priming. Wider implications of the findings The results make us question the mechanism of action behind hCG-priming prior to IVF. It is important to design a study with retrieval of small antral follicles immediately after priming to investigate the proposed hypothesis and to confirm improved cycle outcomes i.e., more retrieved oocytes in a larger study population. Trial registration number NCT04643925

Eight weeks of androgen priming by daily low-dose hCG injections before ICSI treatment in women with low ovarian reserve.

Does 8 weeks of continuous low-dose hCG administration increase the proportion of antral follicles that reach the preovulatory state during ovarian stimulation (OS) in women with low ovarian reserve? The proportion of antral follicles (2-10 mm) that reached the preovulatory state did not increase. The administration of androgens prior to OS might upregulate FSH receptor (FSHR) expression on granulosa cells, making follicles more responsive to exogenous FSH stimulation during OS. LH and hCG stimulate the local follicular androgen synthesis in theca cells and may be used as an endogenous androgen priming method. Exogenous priming by testosterone and dehydroepiandrosterone (DHEA) have been shown to increase the number of retrieved oocytes and live birth rate but the studies are small, and their use is associated with side effects. A prospective, paired, non-blinded single-center study including 20 women serving as their own controls conducted between January 2021 and July 2021 at The University Hospital Copenhagen Rigshospitalet, Denmark. Participants underwent two identical consecutive IVF/ICSI treatments, a Control cycle and a Study cycle, separated by ∼8 weeks (two menstrual cycles) of daily injections of 260 IU recombinant hCG (rhCG). A freeze-all strategy was applied in the Control cycle. Both IVF/ICSI cycles were performed in a fixed GnRH antagonist protocol using a daily dose of 300 IU recombinant FSH (rFSH) and GnRH antagonist 0.25 mg from stimulation days 5-6. Follicular output rate, defined as the number of follicles >16 mm on hCG trigger day divided by the antral follicle count (2-10 mm) at baseline, did not increase after 8 weeks of hCG priming (P = 0.8). The mean number of oocytes retrieved was significantly higher after the hCG priming being 4.7 (2.8) vs 3.2 (1.7) in the Study and Control cycle, respectively (P = 0.01). The duration of stimulation was longer in the Study versus the Control cycle (P = 0.05), despite the use of identical hCG trigger criterion and similar diameters of the three biggest follicles on hCG trigger day in the two cycles (P = 0.9). The sample size was small, and the number of oocytes retrieved was not the primary endpoint. Larger studies are needed to confirm this finding. Long-term, low-dose rhCG administration may increase the number of oocytes retrieved during IVF/ICSI in women with low ovarian reserve, but more research is needed before firm conclusions can be drawn. This study was funded by an unrestricted grant from Gedeon Richter. A.P. reports personal consulting fees from PregLem SA, Novo Nordisk A/S, Ferring Pharmaceuticals A/S, Gedeon Richter Nordics AB, Cryos International, and Merck A/S outside the submitted work and payment or honoraria for lectures from Gedeon Richter Nordics AB, Ferring Pharmaceuticals A/S, Merck A/S, and Theramex and Organon & Co. Grants to the institution have been provided by Gedeon Richter Nordics AB, Ferring Pharmaceuticals A/S, and Merck A/S and receipt of equipment by the institution from Gedeon Richter Nordics AB is reported. The remaining authors have no conflicts of interest to declare. ClinicalTrials.gov Identifier: NCT04643925.

P-626 Eight weeks of androgen priming by low dose hCG before IVF/ICSI in women with low ovarian reserve

Abstract Study question Does eight weeks of low dose hCG priming improve the outcome of ovarian stimulation for IVF/ICSI in women with low ovarian reserve. Summary answer Significantly more oocytes were retrieved following eight weeks of low dose hCG priming, when compared to an identical IVF/ICSI treatment immediately before the priming period. What is known already Administration of androgens prior to ovarian stimulation for IVF might upregulate the FSH receptor level on granulosa cells making the follicles more responsive to exogenous FSH. LH and hCG stimulate the follicular androgen synthesis, acting through LH receptors on the theca cells, enabling their use as an intra-ovarian androgen priming method. Exogenous testosterone and DHEA priming have been shown to increase the number of retrieved oocytes and the live birth rate, but systemic androgen administration is associated with side effects. Long term ‘intra-ovarian’ priming with hCG without systemic effects in women with low ovarian reserve has not previously been investigated. Study design, size, duration A prospective, paired, non-blinded study including 20 women serving as their own controls conducted between January 2021 and July 2021 at The University Hospital Copenhagen Rigshospitalet, Denmark. Participants underwent two identical consecutive IVF/ICSI treatments, a Control cycle including elective freezing of all blastocysts and a Study cycle with fresh blastocyst transfer. The Control and Study cycle were separated by approximately eight weeks (two menstrual cycles) of androgen priming by daily injections of 260 IE hCG. Participants/materials, setting, methods Inclusion criteria were age 18-40 years, regular menstrual cycle 23-35 days and AMH <6.29 pmol/L. Control and Study IVF/ICSI cycles were performed in a fixed GnRH-antagonist protocol using a daily dose of 300 IU rFSH and GnRH antagonist 0.25 mg from stimulation day 5-6. Primary endpoint was the follicular output rate defined as the pre-ovulatory follicle count (>16 mm) on hCG trigger day divided by the antral follicle count (2-10 mm) on cycle day 2-3. Main results and the role of chance 20 women with a mean (SD) age of 36.8 (3.2) years and an AMH level of 3.7 (1.5) pmol/L were included and completed the study. The number of oocytes retrieved was significantly higher in the Study compared to Control Cycle: 4.7 (2.8) vs. 3.2 (1.7), (P = 0.007), and the number of blastocysts was 1.2 (1.6) vs. 0.6 (0.7) in the Study compared to Control cycle, (P = 0.11). The follicular output rate was 0.4 (0.4) in the Study cycle initiated immediately after eight weeks of hCG priming, which was similar to the follicular output rate of 0.38 (0.2) in the Control cycle performed just before initiating the priming period (P = 0.81). The number of follicles above 10 mm on trigger day was 7.3 (5.0) in the Study and 5.3 (2.9) in the Control cycle (P = 0.018). Although the duration of stimulation seemed longer in the Study compared to Control cycle, 10.1 (1.5) and 8.9 (2.7) days respectively (P = 0.05), the same trigger criterion was defined and used in the two cycles confirmed by a similar mean diameter of the two biggest follicles on trigger day: 18.5 (1.1) vs. 18.3 (1.1) mm in the Study and Control cycle, respectively (P = 0.91). Limitations, reasons for caution The sample size calculation was based on the follicular output rate, and the study was not powered to look at oocyte retrieval rates. Bigger studies are needed to confirm this finding. Wider implications of the findings Although no increase in the follicular output rate was demonstrated, significantly more oocytes were retrieved after eight weeks of hCG priming, which is an important finding in a population of women with low ovarian reserve. Benefits of long term low dose hCG priming must be confirmed in a larger study. Trial registration number NCT04643925

O-128 Letrozole co-treatment during ovarian stimulation in antagonist cycles augments follicle growth and exerts pronounced effects on endocrinology: a randomized controlled trial

Abstract Study question What are the endocrine and paracrine effects of letrozole (LZ) co-treatment during ovarian stimulation (OS) and is follicle growth and recruitment affected? Summary answer Letrozole induces marked changes in the follicular and luteal phase endocrinology causing potentiation of follicle growth and corpus luteum function without affecting follicle recruitment. What is known already Letrozole is a 3rd generation aromatase inhibitor that is well-established as an effective ovulatory agent, while its possible benefits in standard in vitro fertilization (IVF) protocols are less thoroughly investigated. Study design, size, duration Double-blinded, placebo-controlled, randomized study with LZ or placebo intervention during OS for IVF treatment, a preceding baseline natural cycle, and a succeeding follow-up visit, in total three consecutive cycles. Participants were enrolled between August 2016 and November 2018. Participants/materials, setting, methods Thirty-one healthy, normo-responding women underwent a natural baseline cycle and an antagonist stimulation cycle with either LZ 5 mg/day (n = 16) or placebo (n = 15) during the follicular phase. Every third day, monitoring of follicle count and -growth and blood analyses of 12 endocrine and paracrine parameters were performed. Follicle recruitment was correlated to endocrine parameters, and differences in follicle recruitment, follicle growth and hormone parameters between groups were assessed. Main results and the role of chance In the LZ group, the number of follicles > 16 mm at oocyte pick up was increased (+2.0, 95% CI [0.1;3.8], p = 0.036), while the total number of follicles were the same (+0.2, 95% CI [-5.8;6.1], p = 0.958). The FSH concentration was increased in the LZ group at stimulation day 5 (p < 0.05), though the total FSH consumption during OS was similar (difference: -20 IU, 95% CI [-175;136], p= 0.794). Letrozole co-treatment suppressed oestradiol (E2) concentrations in the follicular phase (area under the curve (AUC) -62%, p < 0.001) and luteal phase (AUC -31%, p = 0.046). We found increased follicular phase LH (AUC +20.5%, p = 0.033), androstenedione (AUC +22%, p = 0.016), testosterone (AUC +33%, p = 0.013), and 17-OH-progesterone (+132%, p = 0.027). Interestingly, the corpus luteum (CL) output in the LZ group was increased with elevated luteal phase progesterone (AUC +35%, p = 0.043), Inhibin A (AUC +67%, p = 0.011), androstenedione (AUC +22%, p = 0.006), and testosterone (AUC +22%, p = 0.012). Hormone parameters were similar between groups at the follow-up visit. There was no effect of LZ co-treatment on recruitment of the next follicle cohort (p = 0.821). Limitations, reasons for caution This study included a relatively small, selected group of healthy women with an expected normal ovarian function and reserve, and the effects of LZ may therefore be different in other patient groups. Wider implications of the findings We confirm previous findings concerning increased follicle growth, increased endogenous FSH and androgen production, and support the rationale for use of LZ co-treatment as a form of endogenous androgen priming sensitizing the follicle to FSH. Letrozole appears to improve the luteal phase with better stimulation of CL and P4 secretion. Trial registration number NCT02939898

Effects of letrozole cotreatment on endocrinology and follicle development in women undergoing ovarian stimulation in an antagonist protocol.

What are the downstream endocrine and paracrine consequences of letrozole (LZ) cotreatment during ovarian stimulation and is follicle growth and recruitment affected? Letrozole cotreatment induces marked changes in both the follicular and luteal phase endocrinology causing potentiation of follicle diameter and an improved corpus luteum function without affecting the secondarily recruited follicle cohort. Letrozole is a third-generation aromatase inhibitor that is well-established as an effective ovulatory agent, while its possible benefits in standard in vitro fertilization protocols are less thoroughly investigated. This study included a double-blinded, placebo-controlled, randomized study with LZ or placebo intervention during ovarian stimulation for IVF treatment, an observational preceding baseline natural cycle and a succeeding follow-up visit. Participants were enrolled between August 2016 and November 2018. Data from the randomized, stimulated cycle were part of a larger RCT, which was previously published. The study was conducted at a public fertility clinic at Herlev Hospital, Denmark, including 31 healthy, normo-responding women eligible for IVF treatment. They underwent a natural baseline cycle and were subsequently randomized to receive either LZ 5 mg (n = 16) or placebo (n = 15) daily during ovarian stimulation from cycle day (CD) 2-3 until induction of ovulation. Throughout both cycles, monitoring was performed every third day with transvaginal ultrasound for assessment of follicle count and diameter, and blood analyses for the determination of twelve endocrine and paracrine parameters. A follow-up assessment was performed at CD2-3 in the succeeding cycle. In the randomized part of the study, we determined differences in blood parameters, follicle recruitment, and follicle diameter. In the observational part of the study, we assessed follicle recruitment in between cycles and its correlation to endocrine parameters. Letrozole cotreatment significantly suppressed oestradiol (E2) concentrations in the follicular phase (area under the curve (AUC) -58% (95% CI [-70%; -43%], P < 0.001)) and luteal phase (AUC -39% [-63%; -1%], P = 0.046). This had a marked effect on the endocrine and paracrine output with increased follicular phase luteinizing hormone (AUC +37% [3%; 82%], P = 0.033), androstenedione (AUC +36% [6%; 74%], P = 0.016), testosterone (AUC +37% [7%; 73%], P = 0.013) and 17-OH-progesterone (AUC +114% [10%; 318%], P = 0.027). Furthermore, follicle-stimulating hormone (FSH) was increased at stimulation day 5 in the LZ group (P < 0.05). In the luteal phase, increased corpus luteum output was reflected by elevated progesterone (AUC +44% [1%; 104%], P = 0.043), inhibin A (AUC +52% [11%; 108%], P = 0.011), androstenedione (AUC +31% [9%; 58%], P = 0.006) and testosterone (AUC +29% [6%; 57%], P = 0.012) in the LZ group. The altered balance between oestrogens and androgens was reflected in a markedly reduced SHBG concentration in the LZ group throughout the luteal phase (AUC -35% [-52%; -11%], P = 0.009). Endocrine and paracrine parameters were similar between groups at the follow-up visit. Letrozole cotreatment significantly increased the mean number of follicles >16 mm at oocyte retrieval (7.2 vs 5.2, difference: 2.0, 95% CI [0.1; 3.8], P = 0.036), while the mean total number of follicles at oocyte retrieval was the same (23.7 vs 23.5, difference: 0.2 [-5.8; 6.1], P = 0.958), and the mean FSH consumption during the stimulated cycle was similar (1500 vs 1520 IU, difference -20 IU [-175; 136], P = 0.794). Between cycles, the mean antral follicle count at CD2-3 was unchanged (natural cycle 19.0, stimulated cycle 20.9, follow-up cycle 19.7, P = 0.692) and there was no effect of LZ cotreatment on the recruitment of the next follicle cohort (test for interaction, P = 0.821). This study included a relatively small, selected group of healthy women with an expected normal ovarian function and reserve, and the effects of LZ may therefore be different in other patient groups. We confirm some previous findings concerning increased follicle growth and increased endogenous FSH and androgen production, which support the rationale for further studies on the use of LZ cotreatment, for example, as a form of endogenous androgen priming sensitizing the follicle to FSH. Letrozole appears to improve the luteal phase with better stimulation of corpus luteum and progesterone secretion. The authors declare no conflicts of interest relating to the present work. NCT02939898.

The Use of Androgen Priming in Women with Reduced Ovarian Reserve Undergoing Assisted Reproductive Technology.

Androgen priming with either dehydroepiandrosterone (DHEA) or testosterone has been suggested as an adjunct to improve in vitro fertilization (IVF) outcomes in women with diminished ovarian reserve (DOR). Numerous studies have investigated the effects of both DHEA and testosterone on IVF outcome. The results were inconsistent, and the quality of most studies is substandard. Meta-analyses have consistently reported that DHEA does appear to significantly improve IVF outcome in women with predicted or proven poor ovarian response (POR), but these have included some normal responders and/or nonrandomized studies. Our meta-analyses including randomized controlled trials (RCTs) incorporating only women with DOR or POR suggest that DHEA confers no benefit. While meta-analyses of RCTs on the use of testosterone in women with DOR or POR showed an improved IVF outcome, most studies included are of low quality with high risk of bias. When analysis of data from studies of only low-risk bias was performed, such a benefit with testosterone was not observed. Although recruitment may well be a challenge, a large, well-designed RCT is, however, still warranted to investigate whether or not androgen priming with either DHEA or testosterone should be recommended as an adjuvant treatment for women with DOR or POR undergoing IVF.

Biological and Clinical Rationale for Androgen Priming in Ovarian Stimulation.

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.

The effect of intra-ovarian androgen priming on ovarian reserve parameters in Bologna poor responders

What are the effects of long-term androgen priming in Bologna criteria poor ovarian reserve (POR) patients undergoing IVF? This open-label pilot study was conducted at IVFMD, My Duc Hospital, Ho Chi Minh City, Vietnam. It included consecutive patients aged 18-41 years who fulfilled Bologna criteria for POR undergoing intra-ovarian androgen priming and ultra-long down-regulation with a gonadotrophin-releasing hormone agonist (GnRHa), followed by stimulation with gonadotrophins and GnRH antagonist co-treatment for IVF (n = 30). Priming consisted of low-dose recombinant human chorionic gonadotrophin (rHCG) 260 IU every second day plus letrozole 2.5 mg/day, both for 8 weeks; priming stopped on the first day of ovarian stimulation. The primary endpoint was serum anti-Müllerian hormone (AMH) concentration 8 weeks after priming. Secondary endpoints included antral follicle count (AFC) (2-10 mm), serum human chorionic gonadotrophin (HCG), testosterone and progesterone levels. Circulating testosterone, progesterone, oestradiol and HCG levels remained unchanged during androgen priming; the mean AMH level decreased steadily from 0.49 ng/ml (baseline) to 0.33 ng/ml (8 weeks). AFC was 4-5 throughout the study. A mean of 1.1 ± 0.9 good transferable embryos were obtained; embryo transfer was performed in 15 patients; no ongoing pregnancies were obtained. Long-term intra-ovarian androgen priming in the current set-up had no significant effect on hormone levels, AFC and recruitable follicles after ovarian stimulation in Bologna POR patients undergoing IVF. Further studies are needed to explore other androgen priming protocols and the clinical value of priming regimens in IVF.

Administration of DHEA augments progesterone production in a woman with low ovarian reserve being transplanted with cryopreserved ovarian tissue

In recent years cryopreservation of ovarian tissue prior to potentially gonadotoxic treatment for malignant disease has proved to be an option for preservation of the reproductive function including fertility [1]. Following successful cancer treatment women have chosen to have transplantation of their frozen-thawed tissue if ovarian failure occurred as a consequence of cancer treatment. The autotransplanted tissue has in various centers resulted in the re-establishment of ovarian function leading to the return of fertility and the birth of healthy children [2, 3]. However, the ovarian reserve in the transplanted tissue typically is very low as currently only a limited number of follicles survive the entire procedure including freezing, thawing and transplantation [4]. This diminished reserve is reflected by persistent low levels of AMH [4], limiting the efficacy of controlled ovarian stimulation (COS) with exogenous FSH. In terms of fertility treatment, the women who have had frozen/thawed ovarian tissue transplanted often resemble poor responder patients and patients of advanced reproductive age. Attempts to augment the number of developing follicles by administration of oral DHEA for some months in the latter category of women have been reported [5–7], there being a growing literature describing a higher oocyte yield following COS and oocytes showing a better quality and thereby improving the reproductive outcome [5–7]. The particular mechanism by which DHEA may enhance follicle survival and growth has not yet been fully elucidated, but conversion of DHEA to androgens and an androgen priming effect on early stages of follicular development leading to an increased FSH receptor expression is one possible mechanism [8]. Although the vast majority of DHEA in the body is produced by the adrenals one obstacle in defining a more precise function of DHEA in improving follicle recruitment is the fact that the circulating DHEA is the sum of the local productions in the ovaries and those of adrenal glands [9]. In this study we observed the ovarian and endocrine events following DHEA administration in a woman, who had normal adrenal function but with very low ovarian reserve consequent to transplantation of frozen/thawed ovarian tissue, being postmenopausal at the time of transplantation. Only a fraction of frozen/thawed tissue from one ovary had been grafted with subsequent low ovarian reserve and evidenced by few follicles. This situation allowed a more direct evaluation of the endocrinological effect of DHEA administration on the synthesis of sex steroids.

Long-term androgen priming by use of dehydroepiandrosterone (DHEA) improves IVF outcome in poor-responder patients. A randomized controlled study

Abstract Introduction Success with COH depends on the ability to recruit adequate numbers of follicles. Unfortunately, some patients produce too few follicles with COH and are classified as poor responders. Over the years, numerous techniques and therapies have been developed in an effort to help the poor responder, but few have met with success. Recently attempts of ovarian androgen priming have been developed on the basis that temporary exposure of follicles to increased levels of androgens may augment their responsiveness to FSH. Long-term DHEA exposure can induce histological and sonographic changes in normal ovaries similar to PCOS. This effect is cumulative as more of the antral follicles become exposed to treatment. Objective The aim of this study was to compare the effect of DHEA supplementation on IVF treatment outcomes among a cohort of women with known decreased ovarian reserve using a short protocol. Design It is a randomized controlled study. Materials and methods Between July 2008 and April 2012, 133 patients with a prior poor response to ovarian stimulation in IVF were selected to undergo an IVF cycle. The cases were divided without prejudice into 2 groups; (1) study group (DHEA group); in which the patient began taking 25 mg of DHEA orally, three times a day, for at least 12 weeks before starting COH, (2) control group; in which the patient started COH without DHEA priming. Results The study group had statistically significant higher numbers of retrieved oocytes (5.9 ± 3.6) compared to the control group (3.5 ± 2.9) – P P P Conclusion According to our findings, long-term androgen priming by use of DHEA improves IVF outcome in poor responder patients. Additional, larger studies, using different protocols are needed to reinforce our findings.

Assessment of theca cell function: a prerequisite to androgen or luteinizing hormone supplementation in poor responders

Poor responders are a heterogeneous population, with some patients displaying a diminished ovarian reserve and others a poor ovarian reserve with preserved granulosa cell function. Androgen and LH/hCG supplementation has been advocated for poor responders, mainly those >40 years old. Although androgens synergistically act with FSH to support folliculogenesis, and ovarian androgen secretion declines with age, there is still no evidence that androgen therapy is actually effective to improve ovarian FSH sensitivity. The main reason seems to be that theca cell function has not been appropriately assessed in patients at risk of poor response. The definition of theca insufficiency is hampered by methodologic shortcomings in routine bioassays. Provocative tests for theca cells might help to identify those patients who could benefit from androgen supplementation. The lack of data regarding theca cells in these patients might contribute to explaining the absence of evidence for a positive effect of androgen therapy.

The follicular hormonal profile in low-responder patients undergoing unstimulated cycles: is it hypoandrogenic?

What is the final hormonal milieu of pre-ovulatory follicles of low-responder (LR) patients undergoing unstimulated cycles? Neither androgen secretion nor LH was impaired in pre-ovulatory follicles of LR women. Therapies currently used to improve ovarian response in LR women have an impact on the final hormonal follicular milieu, and these changes are believed to be partially responsible for determining the success rate in these women. Surprisingly, as far as we know, there is no report of the final hormonal profile of LR women undergoing unstimulated cycles or evidence that follicular androgen secretion in LR women is impaired. A prospective case-control study including 94 women, 36 normal controls and 58 LR patients (19 Young ≤ 35 years LR and 39 Aged >35 years LR) from 2009 to 2011. Fifty-eight LR women were divided into two groups: Young LR (age ≤ 35; n = 19) and Aged LR (ALR; age >35; n = 39). The control group (group C) comprised 36 egg donors undergoing an unstimulated cycle in our IVF unit. Serum and follicular fluid hormonal concentrations for estradiol (E₂), progesterone, testosterone and androstendione were measured. The spindle parameters of metaphase II oocytes generated from these groups were also analysed. Pre-ovulatory follicles from LR patients had similar androgenic and LH concentrations to those observed in the control group. However, higher intrafollicular concentrations of FSH and progesterone were observed in ALR. Moreover, no differences were found for the spindle evaluation of oocytes between groups by the Oosight technology. The controls were younger and had a lower BMI than the LR women. The sample size available restricted statistical power. This study suggests that the problem with LR women is not the final pre-ovulatory follicular androgen concentration since this is similar to normal responders, but in the ability to respond to controlled ovarian stimulation protocols. Therefore, efforts should be focused on long-interval androgen priming to potentially increase the recruitment of small antral follicles rather than increasing the intraovarian androgen levels within the current cycle. The present project has been supported by the R+D programme from the Generalitat Valenciana (Regional Valencian Government) IMPIVA MIDTF/2010/95. The authors have no conflict of interest to declare.

Reply: Androgen priming before ovarian stimulation for IVF

Reply: Androgen priming before ovarian stimulation for IVF

Rapid Testosterone Cycling and Chemotherapy for Prostate Cancer: A Way Forward or Return to the Past?

Androgen deprivation therapy is the mainstay of treatment for metastatic prostate cancer. Among men with overt metastatic disease, androgen deprivation therapy by either bilateral orchiectomies or chronic treatment with a gonadotropin-releasing hormone agonist achieves responses in the vast majority, with a median response duration is approximately 1 to 2 years. Only rarely does androgen deprivation therapy result in prolonged remission or cure. Docetaxel is the standard first-line chemotherapy for men who develop disease progression despite androgen deprivation therapy. In two randomized controlled trials in men with castrate-resistant prostate cancer, docetaxel improved overall survival compared with treatment with mitoxantrone. For men with castrate-resistant disease, the current standard of care is to continue androgen deprivation therapy indefinitely, based on concerns that testosterone recovery might accelerate disease progression. The strategy of continuous androgen deprivation therapy and the addition of chemotherapy after emergence of hormone-resistant disease contrasts with the current paradigm of sequential hormone therapy and chemotherapy in breast cancer. In metastatic breast cancer, attempts to improve efficacy by combining hormone therapy and chemotherapy began decades ago. Several randomized controlled trials have compared hormone therapy to hormone therapy plus chemotherapy. Most studies report higher response rates for combination therapy; none report a significant improvement in survival. Other randomized controlled trials have compared chemotherapy alone to chemotherapy plus hormone therapy. Most of those studies reported significantly higher response rates for combination therapy but did not carefully evaluate the cumulative response rates for subjects who received sequential chemotherapy followed by hormone therapy at disease progression. None of the studies have reported a significant improvement in overall survival. An Australian study carefully evaluated concurrent and sequential chemotherapy and hormone therapy for metastatic breast cancer. In that study, 339 women with metastatic breast cancer were assigned randomly to one of three groups: tamoxifen, cyclophosphamide and doxorubicin (CA), or concurrent tamoxifen and CA. Women assigned to tamoxifen were treated with salvage chemotherapy at disease progression. The initial response rates to either CA (45%) or concurrent tamoxifen and CA (50%) were significantly higher than tamoxifen alone (22%). With salvage chemotherapy, however, the cumulative response rates were similar for each of the arms. Overall survival was also similar for each of the regimens. The North American Intergroup designed a study (Intergroup 0100/Southwest Oncology Group 8814) in the late 1980s to address the sequencing of hormone therapy and chemotherapy in the adjuvant setting. A total of 1,477 postmenopausal women with estrogen receptor–positive or progesterone receptor–positive nodepositive breast cancer were randomly assigned to tamoxifen alone, tamoxifen plus concurrent cyclophosphamide, doxorubicin, and fluorouracil (CAF), or CAF followed by tamoxifen. The combination of tamoxifen and CAF was superior to tamoxifen alone. Sequential CAF followed by tamoxifen, however, reduced the incidence of recurrence or death by approximately 50% compared with concurrent therapy. Based on these findings, most clinicians have adopted the strategy of administering chemotherapy followed by hormone therapy for the adjuvant treatment of estrogen receptor–positive breast cancer. Notably, other studies in both premenopausal and postmenopausal women have reported no difference between concurrent and sequential tamoxifen and chemotherapy in the adjuvant setting. In preclinical models of breast cancer, estrogens recruit dormant breast cancer cells into the cell cycle. In phase II studies of women with locally advanced or metastatic breast cancer, short-term pretreatment with estrogen before chemotherapy was associated with relatively high response rates. In one study, for example, estrogen priming and chemotherapy were also associated with comparatively long response duration and survival. A randomized controlled trial from the Netherlands, however, demonstrated no benefit from estrogen priming before chemotherapy. In that study, 318 women with stage II/IIIA breast cancer were assigned randomly to fluorouracil, doxorubicin, and cyclophosphamide with or without pretreatment with ethinyl estradiol. After a median follow-up of 6.8 years, there were no significant differences in relapse-free and overall survival between the groups. Similar results were observed in multivariate analyses that adjusted for subject and disease characteristics. The slow growth rate of prostate cancer may partially explain its limited sensitivity to chemotherapy. In the Dunning rat model of prostate cancer, androgen priming induces cell proliferation and increases sensitivity to chemotherapy compared with chemotherapy alone. The strategy of androgen priming to increase the efficacy of chemotherapy in men with prostate cancer was first evaluated more than two decades ago. In 1988, Manni et al reported the results of a small randomized controlled trial of men with castrate-resistant metastatic prostate cancer. A total of 85 men with disease progression despite bilateral orchiectomies were randomly assigned to monthly chemotherapy (CAF) or monthly chemotherapy preceded by three JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 26 NUMBER 18 JUNE 2

Short-term androgen priming by use of aromatase inhibitor and hCG before controlled ovarian stimulation for IVF. A randomized controlled trial

Temporary exposure of follicles to increased levels of androgens may augment follicular responsiveness. The present study tested whether short-term androgen priming by aromatase inhibitor and human chorionic gonadotrophin (hCG) before controlled ovarian stimulation (COS) increases the number of top-quality embryos after IVF/ICSI. Patients were randomized to androgen priming (n = 53): anastrozole 1 mg cycle day (c.d.) 2, 3 and 4, hCG 1250 IU and cetrorelix 3 mg on c.d. 2, rFSH 150 IU from c.d. 5 following a flexible antagonist protocol; or control (n = 50): flexible antagonist protocol. The mean (confidence interval) number of top-quality embryos was 1.08 (0.83,1.40) and 1.43 (1.12,1.81) in the priming and control group, respectively, being 32% (-7%, 89%) higher in the control compared to priming group (P = 0.120). Stimulation duration was longer in the priming group (P < 0.001). On the day of hCG administration, the proportion of c.d. 2 antral follicles reaching >or=14 mm was higher in the priming group (P = 0.014), as were serum estradiol (E(2)) (P < 0.001) and E(2) per follicle >or=14 mm (P = 0.005). Pre-ovulatory follicular fluid levels of E(2) (P = 0.007) and testosterone (P = 0.014) were higher in the priming group. The number of oocytes retrieved was similar. The fertilization rate was lower in the priming group (P = 0.007). Ongoing pregnancy rates in priming and control group were 30 and 36% (P = 0.531). Administration of aromatase inhibitor and hCG before COS for IVF/ICSI failed to improve the number of top-quality embryos.

Increased intrafollicular androgen levels affect human granulosa cell secretion of anti-müllerian hormone and inhibin-B

To evaluate whether the follicular fluid concentrations of anti-müllerian hormone (AMH), inhibin-B, and P become affected by androgen priming before controlled ovarian hyperstimulation and IVF/intracytoplasmic sperm injection (ICSI) treatment, extending our previous study. Prospective nonrandomized clinical study. University hospital. Patients (N = 45) undergoing IVF/ICSI treatment received androgen priming before controlled ovarian hyperstimulation. All patients received cetrorelix, 3 mg SC, on cycle day 2 and 5. Group I (n = 15) received no other pretreatment. Group II (n = 15) received 2.5 mg once daily of letrozole from cycle day 2 through 8. Group III (n = 15) received letrozole as group II plus 1,250 IU hCG on cycle day 2. Follicular fluid concentrations of AMH, inhibin-B, and steroids. Follicular fluid concentrations of AMH were significantly higher in group III than in groups I and II (2.6 +/- 0.3 vs. 1.6 +/- 0.2 and 1.5 +/- 0.4 ng/mL. Concentrations of inhibin-B were significantly lower in group II and III as compared with group I (27 +/- 4, 27 +/- 3 versus 46 +/- 6 ng/mL, respectively). Follicular fluid P concentrations remained similar in all groups. Granulosa cell production of AMH was significantly augmented and inhibin-B production was significantly reduced by a highly specific pharmacologically induced increase in the intrafollicular androgen levels, suggesting a dual action of androgen on follicular growth and development.

Hormone‐refractory prostate cancer: what have we learned?

The current EAU guidelines recommend continued androgen suppression in patients not treated by orchidectony and with HRPC, although few studies have addressed the benefits of this approach. The EAU recommendation was based primarily on evidence reported by Manni et al. [4], who conducted a small randomized trial to determine whether androgen priming potentiates the cytotoxic effects of chemotherapy. In all, 85 men with disease progression despite orchidectomy were randomly selected to receive androgen priming or chemotherapy alone. The median survival of men who received androgen priming (10 months) was significantly worse than that of men who did not (15 months; P = 0.005), a result indicating that continuous androgen blockade might be beneficial in men with HRPC.

Androgen priming using aromatase inhibitor and hCG during early-follicular-phase GnRH antagonist down-regulation in modified antagonist protocols

Temporary exposure of follicles to increased levels of androgens may enhance their sensitivity to FSH. The aim of this study was to increase the intraovarian androgen level using aromatase inhibitors and hCG before controlled ovarian stimulation (COH) and to test this concept clinically. In a prospective, non-randomized study, 45 patients were treated in modified antagonist protocols including early-follicular-phase down-regulation and androgen priming before COH. All patients received cetrorelix, 3 mg s.c., on cycle days 2 and 5. Group I (n=15) received no other pretreatment. Group II (n=15) received 1 daily tablet of aromatase inhibitor, letrozole 2.5 mg, from cycle days 2 to 8. Group III (n=15) received letrozole as Group II and 1250 IU of hCG s.c. on cycle day 2. From cycle day 8, all patients were stimulated with highly purified menotrophin in a flexible antagonist protocol. Aromatase inhibitor increased the level of testosterone in follicular fluid (P<0.002), but not in plasma. Androgen priming with aromatase inhibitor and hCG increased the number of good-quality embryos (P=0.015) but did not increase the implantation rate. The use of aromatase inhibitor before COH significantly influences the local endocrine environment before and during stimulation. Androgen priming with both aromatase inhibitor and hCG may result in more good-quality embryos.

Testosterone Replacement Therapy Induces Spermatogenesis and Partially Restores Fertility in Luteinizing Hormone Receptor Knockout Mice

Testosterone (T) is essential for spermatogenesis, fertility, and maintenance of the male phenotype. We analyzed in hypogonadal LH receptor knockout (LuRKO) male mice whether T treatment can restore their phenotype, spermatogenesis, and fertility. In LuRKO mice, spermatogenesis is arrested at round spermatids, adult-type Leydig cells are absent, T production is dramatically decreased, the animals are cryptorchid, and their accessory sex organs are atrophic. T replacement therapy from 21 d of life for 60 or 120 d in LuRKO mice induced a male phenotype macroscopically indistinguishable from that of wild-type littermates as well as full spermatogenesis and testicular descent. Thus, the absence of LH-dependent prepubertal androgen priming is not necessary for subsequent maturation of the male phenotype. Conspicuously, some abnormalities remained in epididymal histology after T treatment despite normal expression of several epididymis-specific genes in caput epididymis. The mice displayed normal mating behavior, although at lower frequency than wild-type controls. The spermatozoa were able to fertilize oocytes, but their impaired passage from epididymis to uterus was apparent. The mice remained subfertile, because only 9% of all breedings resulted in pregnancy, and only two of 13 mice (15%) were fertile. Moreover, inflammation in epididymides and prostate was found in many T-treated LuRKO mice, which probably impaired sperm transport and contributed to their high rate of subfertility. In conclusion, T replacement initiated prepubertally only partially restores the fertility of LuRKO mice, even though most features of the male phenotype recover. Full fertility may require higher and/or earlier postnatal T exposure or production of other Leydig cell factors lacking in this model.