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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 1  |  Issue : 1  |  Page : 1-8

Effects of Dehydroepiandrosterone on Embryo Quality and Follicular Fluid Markers in Patients with Diminished Ovarian Reserves


1 Shanghai Ji Ai Genetics and IVF Institute, Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200011, China
2 Shi Men Second Road Community Health Service Center of Jingan District, Shanghai 200041, China
3 Shanghai Ji Ai Genetics and IVF Institute, Obstetrics and Gynecology Hospital, Fudan University; Key Laboratory of Female Reproductive Endocrine Related Diseases, Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200011, China

Date of Web Publication17-Jul-2017

Correspondence Address:
Xiao-Xi Sun
Obstetrics and Gynecology Hospital, Fudan University, No. 588 Fang Xie Road, Shanghai 200011
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2096-2924.210696

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  Abstract 


Background: To examine the effects of dehydroepiandrosterone (DHEA) on in vitro fertilization (IVF) intracytoplasmic sperm injection (ICSI) and the levels of follicular fluid (FF) markers, namely, anti-Müllerian hormone (AMH), insulin-like growth factor (IGF)-1, bone morphogenetic protein (BMP)-15, and growth differentiation factor (GDF)-9, in patients with diminished ovarian reserves (DORs).
Methods: 116 patients with DOR were randomized into two groups, DHEA group and control group. Each group contained 58 patients. The DHEA group received 75 mg/d of DHEA for 12 weeks prior to the start of IVF treatment, while the control group entered IVF treatment directly. All patients were treated with the same ovarian stimulation protocol. The primary outcome was high-quality embryo yield. Other IVF parameters, such as the clinical pregnancy rate, embryo survival rate, and intact blastomere rate, were compared between the two groups. FF samples from patients of both groups were collected to measure the levels of AMH, IGF-1, DHEA-sulfate, BMP-15, and GDF-9. Blood was also collected on day 3 of the menstrual cycle to define the baseline hormonal profile and to examine ovarian reserve markers.
Results: The high-quality embryo yield was higher in DHEA group than that in control group (P = 0.033). AMH and IGF-1 concentrations in FF were significantly higher in DHEA group than that in the control group (2.83 ± 1.14 ng/L vs. 1.37 ± 0.55 ng/L, P = 0.000; 94.02 ± 38.28 ng/L vs. 74.03 ± 25.46 ng/L, P = 0.004, respectively). The BMP-15 level was also higher in DHEA group (relative expression were 1.80 ± 0.41) than that in control group (relative expression were 0.79 ± 0.16, P < 0.0001); however, there was no difference in GDF-9 expression between the two groups (relative expression were 1.29 ± 0.54 and 1.16 ± 0.50 respectively, P > 0.05) and in the clinical pregnancy rate between the two groups (13.79% vs. 7.27%, respectively, P > 0.05).
Conclusions: In women with DOR undergoing IVF treatment, pretreatment with DHEA may increase the number of high-quality embryos, which may be due to increased levels of AMH, IGF-1, and BMP-15 in the FF.
Trial Registration: NCT02866253.

Keywords: Bone Morphogenetic Protein-15; Dehydroepiandrosterone; Diminished Ovarian Reserve; In vitro Fertilization


How to cite this article:
Fu J, Jiang HF, Li L, Xin AJ, Sun YJ, Sun XX. Effects of Dehydroepiandrosterone on Embryo Quality and Follicular Fluid Markers in Patients with Diminished Ovarian Reserves. Reprod Dev Med 2017;1:1-8

How to cite this URL:
Fu J, Jiang HF, Li L, Xin AJ, Sun YJ, Sun XX. Effects of Dehydroepiandrosterone on Embryo Quality and Follicular Fluid Markers in Patients with Diminished Ovarian Reserves. Reprod Dev Med [serial online] 2017 [cited 2020 Jul 16];1:1-8. Available from: http://www.repdevmed.org/text.asp?2017/1/1/1/210696




  Introduction Top


The majority of women with diminished ovarian reserve (DOR) fail to adequately respond to ovarian hyperstimulatory drugs, leading to poor oocyte yields and low pregnancy rates of 2%–4%.[1] Casson et al.[2] reported that dehydroepiandrosterone (DHEA) could improve the ovarian response of poor responders, while other studies reported that it can improve oocyte and embryo yields, the embryo grade,[3] and the clinical pregnancy rate.[4],[5] DHEA may also improve the poor in vitro fertilization (IVF) outcomes,[6] as well as act as an antiaging agent.[2],[3] Despite the widespread use of DHEA as an adjuvant during IVF treatment in women with DOR, two major questions still remain unresolved.[7] The first question is whether DHEA is effective, because there are few large-scale, well-designed studies that support its ability to improve the ovarian response. The second question is how DHEA improves the ovarian response. Thus, further studies are needed to address these questions.

Follicles provide oocytes with a specialized microenvironment that promotes the developmental competence of embryos. Women with DOR usually lack high-quality oocytes and embryos, and a poor follicular microenvironment may be to blame.[8],[9] Previous studies reported associations among the growth factors,[10] proteins,[11] and metabolites [12] in the follicular fluid (FF) and oocyte quality, the fertilization rate, the embryonic developmental potential, and pregnancy outcome.[13] Anti-Müllerian hormone (AMH), which is secreted by granulosa cells from preantral and small antral follicles, has recently been shown to be a promising biomarker of follicle number in ovaries.[14] Recently, AMH was used to follow the progress of assisted reproductive technology. Lin et al.[15] showed that the AMH level correlated with high-quality embryos and blastocysts, but only the AMH level in FF associated with the live birth rate and clinical pregnancy rate. By contrast, Hattori et al.[16] reported that an elevated AMH level in either the serum or FF was a good predictor of clinical pregnancy.

Bone morphogenetic protein (BMP)-15 and growth differentiation factor (GDF)-9 are also crucial for follicular growth and female fertility. An elevated GDF-9 level in FF has been demonstrated to associate with high-quality oocytes, a high cleavage rate, and high-quality embryos.[17] Wu et al.[8] reported that BMP-15 in FF can predict IVF outcomes, and that poor responders aged 35 years or younger with an elevated BMP-15 in FF had the best implantation, pregnancy, and live birth rates, which were comparable with those of normal responders. Injecting a GDF-9 gene fragment into the ovaries of prepubertal gilts increased the primary follicle number, but decreased the primordial follicle number.[18] Furthermore, GDF-9 and BMP-15 is essential for ovarian follicular development in sheep.[19] Taken collectively, these results indicate that GDF-9 and BMP-15 play a critical role in regulating follicular development in these mammalian species.

Insulin-like growth factor (IGF)-1 is another regulator of follicle function in rodents and granulosa cell function in humans and rodents.[20],[21] Therefore, levels of AMH, BMP-15, GDF-9, and IGF-1 in FF constitute the microenvironment of oocytes, which influences embryo quality and IVF outcomes. However, it is unclear whether DHEA can improve follicular development and embryo quality through the growth-promoting and survival-enhancing effects of IGF-1. The roles of other proteins within paracrine and autocrine signaling pathways that control oogenesis and folliculogenesis are still unknown.

The aims of this study were (1) to compare the IVF parameters including oocyte retrievals, high-quality embryos, and clinical pregnancy rate between DHEA group and control group; (2) to examine the effects of DHEA on the levels of FF markers, namely, AMH, IGF-1, BMP-15, and GDF-9 during IVF; (3) to discuss the potential effect mechanism of DHEA in FF microenvironment.


  Methods Top


Patients

This study was approved by the Ethics Committee of the Shanghai Ji Ai Genetics and IVF Institute (No. ShanghaiJiAi-05). Patients with primary or secondary infertility for DOR at the Shanghai Ji Ai Genetics and IVF Institute were recruited between December 2014 and February 2016. After a detailed explanation of the study and counseling, patients interested in participating provided written consent. This study was registered at ClinicalTrials.gov (No. NCT02866253).

The inclusion criteria were age ≤42 years and a diagnosis of poor ovarian reserve [22] defined as an antral follicle count (AFC) <5 or AMH <1.1 μg/L. Patients were excluded from the study if they had a history of endometriosis, received chemotherapy or pelvic irradiation, a history of ovarian surgery, or received DHEA for any indication at the time of recruitment. Using a computerized randomized list, patients were randomly assigned into two groups, DHEA group and control group.

After the determination of baseline values, patients in DHEA group received 25 mg of DHEA (Lab Hercules, USA) three times a day (i.e., 75 mg/d) for 12 weeks prior to IVF/ICSI treatment, while patients in control group entered IVF/ICSI treatment directly. Blood was collected on day 3 of the menstrual cycle to define the baseline hormonal profile.

Controlled ovarian stimulation protocol, oocyte retrieval, and IVF

All patients underwent mild controlled ovarian stimulation. To induce follicle growth, patients received 100 mg/d of clomiphene citrate (CC, Livzon, China) and 225 IU/d of human menopausal gonadotropin (hMG, Livzon, China) starting from day 3 of the menstrual cycle. When at least one dominant follicle (≥18 mm in diameter) was observed by ultrasound, 10,000 IU of human chorionic gonadotropin (hCG, Livzon, China) was administrated, followed by transvaginal oocyte retrieval 34–36 h later. Oocytes were fertilized using either conventional IVF or intracytoplasmic sperm injection with male factor and incubated in fertilization media (G-IVF, Vitrolife, Sweden) in a humidified atmosphere of 5% O2 and 6% CO2 at 37 °C. Normal fertilization was assessed and confirmed by the presence of two pronuclei and a second polar body at 16–18 h after insemination. The embryos were washed and cultured in cleavage medium (G1, Vitrolife, Sweden) for 48 h before assessing the embryo quality grade. Considering the antiestrogenic effects of CC on the endometrium,[23] we usually freeze all the available embryos on day 3 after insemination and use frozen-thawed embryo transfer (FET) for the patients who received CC plus hMG ovarian stimulation protocol.[24] Embryo quality was assessed by examining the number of blastomeres, the degree of fragmentation, and the uniformity of blastomeres. High-quality day 3 embryos were defined as Grades 1 and 2, according to Scott's criteria,[25] and with more than seven cells. Embryos with six or more cells were cryopreserved by vitrification as previously described.[26]

Transfer of frozen-thawed day 3 embryos

The endometrium was prepared for frozen-thawed embryo implantation and luteal phase support as previously described.[27] To prepare the endometrium for FET, all patients received hormone replacement treatment. On day 3 of the replacement cycle, patients started to receive estradiol valerate (E2, Progynova ®, Schering AG, Berlin, Germany) 2 mg/d, with increasing doses of up to 4 mg/d. When a thickness of the triple endometrial layers of at least 8 mm was observed, vaginal progesterone (Crinone, Merck-Serono, Switzerland) 90 mg/d was administered, whereupon embryos were thawed and transferred. One or two embryos were transferred. A clinical pregnancy was defined as a pregnancy with a beating heart after 6–8 weeks of gestation by ultrasound. Pregnant women continued to receive E2 and progesterone daily until 11 weeks of gestation.

Sample collection and test

FF was obtained by transvaginal ultrasound-guided puncture and aspiration of follicles 18–20 mm in diameter. FF (4–6 mL) was collected from the first aspirated follicle of each patient and centrifuged at 250 g for 10 min. The supernatant was stored at −80 °C until the levels of AMH, DHEA-sulfate (DHEA-S), IGF-1, BMP-15, and GDF-9 were measured. The levels of AMH (AMH Gen II ELISA, Beckman Coulter, Fullerton, CA, USA), DHEA-S (DHEA-S ELISA, Abnova, Taiwan, China), and IGF-1 (Quantikine Human IGF-1 ELISA, R&D Systems, Minneapolis, MN, USA) in the FF and AMH in the serum were determined by ELISA. BMP-15 and GDF-9 levels in the FF were quantified by Western blotting analysis. In brief, FF was diluted five times in deionized water, 100 μg of protein was separated by 10% SDS-PAGE, and proteins were transferred to Immobilon-P membranes (Millipore, USA). The membranes were blocked with 5% nonfat milk for 1 h at room temperature in 10 mmol/L Tris, 150 mmol/L NaCl, pH 7.6, containing 0.05% Tween-20 (TBST), and then probed with anti-BMP-15 (1:2,000, Abcam, Cambridge Science Park, Cambridge, UK) and anti-GDF-9 (1:200, Abcam, Cambridge Science Park, Cambridge, UK) primary antibodies overnight at 4 °C. After washing three times in TBST, the membranes were incubated with secondary antibodies (1:3,000, CWBIO, Beijing, China) for 1.5 h at room temperature. After washing, immunoreactive proteins were detected by Western Bright TMECL (Com Win Biotech Co., Ltd., Beijing, China). Each sample was screened in triplicate. Serum E2, P, T, and LH levels were measured by specific radioimmunoassays (Beckman Coulter, USA).

Statistical analysis

This was a randomized controlled study. The number of high-quality embryos was used as the primary outcome of the study. According to our results, the mean number of high-quality embryos was 1.32, with a standard deviation (SD) of 1.24 (1.32 ± 1.24) (data not shown). Assuming that the number of high-quality embryos obtained was two to be clinically significant, 53 patients in each arm would be required to achieve a significance of 0.05 and a power of 0.8. Considering possible dropouts, we aimed to recruit 60 patients in each arm (i.e., a total of 120 patients).

SPSS software 17.0 version (SPSS Inc., Chicago, IL, USA) was used for data analysis. Quantitative variables were analyzed by Student's t-test and presented as the mean ± SD. Qualitative variables were analyzed by Chi-square test and Fisher's exact test and presented as percentages. Statistical significance was set at P < 0.05.


  Results Top


Patient enrollment

A total of 157 patients with primary or secondary infertility due to DOR were screened at the Shanghai Ji Ai Genetics and IVF Institute. A total of 118 out of 157 patients met the criteria of the trial; they were recruited and randomized into two groups, namely DHEA group (n = 60) and control group (n = 58). Two patients were subsequently excluded from the DHEA group, including one patient who entered IVF treatment in another center and one patient who became pregnant after taking DHEA for 1 month. Thus, a total of 116 patients were included in this study [Figure 1].
Figure 1: A flow diagram of enrollment. One hundred and eighteen patients who met the criterion of the trial were recruited, randomized, and divided into two groups. There were 60 patients in the DHEA group and 58 patients in the control group. Two patients were excluded from the DHEA group, including one patient entered IVF cycle in another center and one patient got pregnant after taking DHEA for 1 month. At last, totally 116 patients including 58 patients in DHEA group and 58 patients in control group were observed during the whole trial. DHEA: Dehydroepiandrosterone; IVF: In vitro fertilization.

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Patient baseline characteristics and IVF

Patients of DHEA and control groups were aged 37.4 ± 3.6 and 36.8 ± 4.3 years, respectively. The baseline characteristics of patients in both groups were similar [Table 1]; there were no significant differences between the groups in terms of age, body mass index (BMI), the duration of infertility, the number of IVF cycle, and primary or secondary infertility (all P > 0.05). There were no differences in the levels of AFC, serum AMH, FSH, E2, LH, P, and T between groups, indicating that patients exhibited a comparable ovarian reserve (all with P > 0.05).
Table 1: Baseline characteristics of the DHEA group pretreatment and control group

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The number of retrieved oocytes, MII oocytes, fertilized embryos, cleaved embryos, available embryos, and high-quality embryos were compared between the two groups [Table 2]. As shown in [Table 2], the number of available embryos (2.02 ± 1.28 vs. 1.44 ± 1.20, respectively, P = 0.018) and the number of high-quality embryos (1.43 ± 1.08 vs. 1.02 ± 0.98, respectively, P = 0.033) were significantly higher in DHEA group than those in control group. There was no difference in the number of retrieved oocytes and mature oocytes between the two groups (P = 0.056 and P = 0.240, respectively). Fresh cycles without any oocyte retrieved or available embryos for cryopreservation and FET cycles without any available embryos for transfer were defined as cancel cycles. The number of cancel cycles was significantly lower in DHEA group than that in control group (8.93% vs. 27.27%, respectively, P = 0.014). After thawing, there was no significant difference in embryo survival rate in the two groups (P = 0.370). However, the intact blastomere rates were higher in the DHEA group than that in control group (P = 0.003). Among the patients of the DHEA group, 8 out of 58 patients conceived after IVF, with a pregnancy rate of 13.79%. In control group, 4 out of 58 patients conceived after IVF, with a pregnancy rate of 7.27%. However, there was no significant difference in clinical pregnancy rate (P = 0.223) between the two groups.
Table 2: The IVF parameters of DHEA group and control group

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FF test outcomes

After ovarian stimulation, 48 and 43 FF specimens were collected from patients of DHEA (after three IVF cycles) and control (after five IVF cycles) groups, respectively. A total of seven and ten FF specimens from patients of DHEA and control groups, respectively, were discarded due to blood contamination. A total of 91 FF specimens were analyzed.

The characteristics of patients in both groups are presented in [Table 3]. There were no significant differences between the two groups in terms of age, BMI, the duration of infertility, the number of IVF cycle, the cause of infertility, AFC, AMH, and FSH levels in serum (all P > 0.05). AMH, DHEA-S, and IGF-1 levels in the FF were significantly higher in DHEA group than those in control group.
Table 3: The baseline characteristics and FF hormone profile of DHEA group and control group

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Western blotting analysis showed a single immunoreactive protein of about 45,000, corresponding to BMP-15, in all 91 specimens. GAPDH (36,000) served as the internal reference protein [Figure 2]a. The gray intensity of BMP-15 level was higher in DHEA group (1.80 ± 0.41) than those in control group (0.79 ± 0.16) (P < 0.0001) [Figure 2]b. Western blotting analysis also showed a single immunoreactive protein of ~ 51 kDa, corresponding to GDF-9, in all 91 specimens. The gray intensity of GDF-9 level was 1.29 ± 0.54 in DHEA group and 1.16 ± 0.50 in control group (normalized to the standard specimen). There was no significant difference in GDF-9 level in FF between the two groups (P > 0.05) [Figure 2]c.
Figure 2: BMP-15 and GDF-9 expression in the follicular fluid of the two groups. (a) Western blot results of BMP-15 and GDF-9 in the FF of two groups. Totally, 91 FF samples from the two groups were tested for the Western blot assay. Among them, 48 samples belonged to the DHEA group and 43 samples to the control group. This figure only showed the result of eight samples. N9, N10, N8, and N7 were FF samples from the control group, while D59, D87, D2, and D13 were FF samples from the DHEA group. It showed significantly higher expression of BMP-15 in the DHEA pretreatment group than that in control, but there was no significant difference found in the expression of GDF-9 in FF. (b and c) The relative intensity of BMP-15 and GDF-9 tested by Western blot assay in control group (n = 43) and DHEA Group (n = 48). Note: **P < 0.01. BMP-15: Bone morphogenetic protein-15; GDF-9: Growth differentiation factor-9; DHEA: Dehydroepiandrosterone.

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Finally, no major adverse events were reported during this study. Only one patient complained of poor appetite and two patients complained of acne.


  Discussion Top


This study is firstly to measure AMH, IGF-1, BMP-15, and GDF-9 levels in the follicular microenvironment after DHEA treatment of patients with DOR prior to IVF. These markers were indicators of embryo quality and IVF outcomes in previous studies.[8],[15],[28] We found a statistically significant increase in AMH and IGF-1 levels in FF and confirmed an increase in the BMP-15 level and no effect on the GDF-9 level after DHEA treatment before IVF as reported by a previous study.[9] The results of this study confirm the beneficial effects of DHEA in previous studies,[4],[29],[30] which reported that women with DOR had improved embryo quality and yields. However, there was no significant difference in the oocyte yield and clinical pregnancy rate. The mechanism of action of DHEA on the ovary remains elusive. The improvement of reproductive parameters after DHEA administration in poor responders may be induced by the pro-hormone in follicular microenvironment.[30] Our results showed that DHEA administration before IVF increased the number of high-quality embryos and available embryos. This may be in association with the constitution of AMH, BMP-15, and IGF-1 in the FF. In the follicular microenvironment, oocyte developmental competence is a very complex process involving many factors, some of which are unknown. Some researchers have focused on the FF microenvironment and the regulation by cytokines, such as members of the transforming growth factor-β (TGF-β) superfamily, which include AMH, BMP-15, and GDF-9.[17],[31],[32] AMH, a dimeric glycoprotein belonging to the TGF-β family, is secreted by follicular granulosa cells from preantral and small antral follicles. As we observed in DHEA group (n = 48) and control group (n = 43), they had the similar serum AMH level. However, the AMH level in FF was significantly higher in DHEA group than that in control group, in which patients entered the IVF cycle directly. Although we only tested the AMH in the first dominant FF, we still observed the increase of AMH level in DHEA group. This may be due to the effect of DHEA on the whole ovarian follicles and granulosa cells, which increased AMH baseline levels. However, the AMH level in FF and serum may be slightly different in the same patient, which explains why patients of the same control group had different levels of AMH in FF and serum. These results indicate that an elevated BMP-15 level in FF is associated with the high quality of oocytes and embryos.[33] The higher level of BMP-15 observed in DHEA group associated with a better ovarian reserve and high embryo quality. The other possible mechanisms of BMP-15 action could include the regulation of AMH, as it has been confirmed that BMP-15 enhances AMH and AMH-specific receptor 2 expressions in human granulosa cells, whereas GDF-9 had no effect.[33] This is in line with the findings of the current study where higher levels of AMH and BMP-15 were noted in the FF of patients pretreated with DHEA, but no significant changes of GDF-9 were observed. There are also data showing a negative correlation between FSH and BMP-15 in that high levels of FSH suppressed BMP-15 expression.[31] It may be inferred that there exists a feedback loop between BMP-15 and FSH. However, a similar relationship with GDF-9 expression was not detected, which implied that GDF-9 may exert its action through a different signaling pathway. Thus, through the different pathways, GDF-9 and BMP-15 work in synergistic ways to regulate the follicle and oocyte growing.

We also showed that the IGF-1 level in FF was higher in DHEA group than that in control group. Casson et al.[2] first reported the beneficial effects of DHEA on ovaries with diminished reserve and they demonstrated a transient increase in serum IGF-1 in patients undergoing exogenous gonadotropin ovulation induction after pretreatment for only 8 weeks of DHEA.[34] Such a transient increase in IGF-1 may due to the decrease of IGF-1-binding hormone. They hypothesized that the beneficial effects of DHEA may have been mediated by an increase in the IGF-1 level.[2],[34] In this study, we also confirmed the effects of the increased IGF-1 level on the number of available embryos and the yield of high-quality embryo in DHEA group. However, we did not observe a significant difference in the number of retrieved oocytes (P = 0.056). It might be due to the mild ovarian stimulation protocol which employed CC and hMG. As the P value was very close to 0.05, the difference may be detected between the two groups by increasing the samples. These findings indicated that oocyte yields and embryo quality may be improved by an elevated IGF-1 level. IGF-1 plays a role as an autocrine and paracrine modulator of ovarian function and its level is reduced in poor responders.[35] Few studies have reported a major role of IGF-1 in the regulation of human follicular and embryonic development through regulation of the cell cycle.[35],[36] It has also been implicated in mediating aromatase activity and estrogen production by developing follicles.[35] IGF-1 can also act locally in primordial and late-stage follicles. Therefore, it is possible that DHEA can induce the synthesis of androstenedione to the theca cells of the remaining follicles, and thus increase estradiol production by the granulosa cells. This mechanism may improve follicle growth and responsiveness.

Since it takes more than 120 days for the primordial follicles passing through the primary follicle stage and reaching preantral stage, we chose 12 weeks for the duration of DHEA treatment. Furthermore, it takes 65 days for the preantral follicle developing into the antral follicle. A longer duration of DHEA may confer additional benefits for increasing folliculogenesis. However, whether a longer duration and/or higher dose of DHEA could recruit more of the remaining follicles and build a greater pool still requires further investigation.

Strengths and limitations

There were several strengths in this study. First, it attempted to elucidate the mechanism for how DHEA improves IVF parameters in the DOR population on a molecular level, although the benefits of DHEA are still somewhat controversial in literature. Second, it was a randomized prospective study, which minimized potential bias during the research.

There were also several limitations in this study. First, the sample size was small, and it was not a placebo-controlled trial for the DOR patients who were eager to receive treatment other than by taking placebo pills because of the limited time to fertility. Second, because of the study design, the patients randomized in DHEA group could not enter the IVF cycle directly to measure the baseline levels of AMH, IGF-1, BMP-15, and GDF-9 in FF. However, the ovarian reserve markers and serum hormone were similar between patients of the DHEA and control groups. Third, the live birth rate should be the ideal outcome measure in clinical trials that assess IVF outcomes. The primary aim of our study was to assess whether DHEA would improve the embryo quality and generate enough embryos for transfer. Therefore, we chose high-quality embryo yield as the surrogate primary outcome. If significant improvement was observed, a large sample of randomized controlled trials could be performed using the live birth rate as the primary outcome. Fourth, the majority of the published studies used DHEA at 75 mg/d for 5–16 weeks.[6],[29] In our present study, we prescribed a 12-week pretreatment based on our clinical experience, although there are no dose-finding studies to confirm the optimal dose and duration for DHEA. It is possible that DHEA pretreatment at the present dose and duration may not be adequate to achieve the optimal follicular microenvironment in all women to improve the outcomes. Further studies should focus on the dose and duration of DHEA used before IVF treatment.

In conclusion, in women with DOR undergoing IVF, pretreatment with DHEA for at least 12 weeks was associated with a higher number of high-quality embryos. The effects of DHEA may be due to the increased AMH, IGF-1, and BMP-15 expression in the follicular microenvironment. Taken together, these findings suggest the need for further large-scale studies on the effects of DHEA on IVF outcomes, as currently there is a lack of a true consensus regarding this issue. Despite a relatively small sample size, significant findings were noted including the increased number of high-quality embryos and a lower transfer cycle cancelation rate, as well as changes in the FF microenvironment that have previously been associated with improved IVF outcomes. Further studies on the effects of DHEA on granulosa cells are needed.

Acknowledgments

The authors thank the patients who volunteered to participate in this study and Dr. Laurence Udoff for his helpful suggestions.

Financial support and sponsorship

This work was supported by the Shanghai Municipal Commission of Health and Family Planning (No. 20134Y096) and the Shanghai Hospital Development Center (No. SHDC12014131).

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

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