Published Research > E.A.J. Ryan, S. Blanco Mejia, E.A. Claessens. Improving fertility in patients with diminished ovarian reserve undergoing controlled ovarian hyperstimulation with intra uterine insemination. Meeting of the Canadian Fertility and Andrology Society, Vancouver, Canada. September 2013.


27 Sep 2013

INTRODUCTION: Women with diminished ovarian reserve (DOR) or premature ovarian insufficiency (POI) have a poor fertility prognosis1-7. Dehydroepiandrosterone (DHEA) and Coenzyme-Q10 (CoQ10) have been found to improve pregnancy rate and to decrease pregnancy loss rate. The aim of the study was to analyze the difference in pregnancy rates in women 35-39 years old with DOR/POI treated with DHEA or DHEA+CoQ10 undergoing COH with intra uterine insemination (IUI).

METHODS: We conducted a historical and prospective cohort study. We included women between 35-39 years old who had a diagnosis of DOR/POI as per the Bologna criteria, who had not got pregnant either spontaneously or with aromatase inhibitors. COH/IUI cycles were performed using day 3 agonist flare protocol, a dose of 75 to 450 IU FSH per day and 10.000 IU of HCG was given once the lead follicle was 1.8-2.2 cm. Patients were taking either DHEA alone, or DHEA+CoQ10 for an average of 3 months before the treatment cycle. Pregnancy rate per IUI (PR/IUI) and pregnancy loss rate (PLR) per IUI (PLR/IUI) excluded chemical pregnancies. Live birth rate (LBR) per intra-uterine insemination (LBR/IUI) was the main outcome. 
 
RESULTS: We included 114 women (81 on DHEA alone and 33 on DHEA+CoQ10) that underwent a total of 241 COH/IUI cycles (Average 2.1 cycles per patient). There was no statistical difference for LBR/IUI, PR/IUI or PLR (Table 1). 
 
  
 
 
 
 
CONCLUSION: The addition of CoQ10 to DHEA does not seem to add a statistically significant beneficial effect in women with DOR/POI undergoing COH/IUI treatment. A definite trend to a higher LBR/IUI is noted in the DHEA+ CoQ10 group and will require  larger full scale studies to prove statistical significance.
The mainstay for achieving a pregnancy for almost 50 yrs was COH/IUI8. The problem is, the pregnancy rate, and especially the multiple pregnancy rates with its attendant high cost to Global health care, were so varied from study to study that concerns are being raised about the use of COH/IUI at al.9-11. Very few of the published studies to date have been done on documented patients with DOR/POI and on the costs of IUI cycles versus IVF7, 12-14 and when one should switch from a planned COH/IUI cycle to IVF15, 16 or vice-versa. Our results here show a good LBR /cycle in this worst scenario type of patient and yet a very low multiple pregnancy rate confirming our underlying diagnosis of DOR/POI in our study group. An ideal study would be an RCT based on strict definition of DOR/POI as per Bologna criteria with a sample size of approx  160 patients in each arm of the study,17. This planned ideal study seems unlikely now,  due to the widespread evidence especially from IVF results18 worldwide, with over 30% of IVF centers now using exogenous Androgens to  improved embryo numbers and  quality and reduce pregnancy loss rates19. The work of Bentov et al.20, 21  has opened the door further to “micromanipulation “ of intracellular biology for the betterment of oocyte function in older women who already have DOR/POI. The future looks much better for older women who want a pregnancy without resorting to a donor egg solution22.
 

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