7 May 2010
OBJECTIVE: The aim of this study was to determine the efficacy of DHEA in a subset of women 40 years and older with diminished ovarian reserve who were treated with controlled ovarian hyperstimulation and intrauterine insemination (COH-IUI).
METHODS: A retrospective cohort study was conducted in a private, university affiliated fertility center. Between February 2006 and September 2009, 214 patients 40 years and older were treated with 25mg of pharmaceutical grade micronized DHEA 3 times daily for at least 3 months. Diminished ovarian reserve was evidenced by basal FSH level, AMH level, antral follicle counts or previous low response to ovarian stimulation. Of these 214 patients, 79 were lost to follow up, 2 stopped treatment due to side effects (acne; hair loss), and 133 continued with treatment. Of these 133, 29 patients who did not get pregnant on DHEA alone or both DHEA and aromatase inhibitors were treated with COH-IUI. This consisted of an age appropriate dose of HMG starting on cycle day 3, midcycle HCG, 2 consecutive inseminations and luteal phase progesterone support.
RESULTS: In the 29 patients treated with DHEA and COH-IUI, 14 patients conceived (48%), pregnancy rate per cycle 18.6%. Excluding the 2 patients with the most cycles without achieving a pregnancy (7 and 11 cycles), the pregnancy rate per cycle is 24.4%. The average patient age was 41.7 years. The average time to conception was 2.6 cycles. The outcome in these 14 patients included 8 early losses (57%), and 6 (43%) singleton pregnancies, that resulted in 4(67%) full term deliveries and 2(33%) pregnancies still ongoing.
CONCLUSION: Casson et al. (2000) reported a beneficial effect of exogenously administered androgens in 5 patients resulting in improved fertility in older women. Since 2005 Gleicher et al. have reported similar results in older women doing IVF. Our center has been using DHEA since February 2006 and now has over 140 pregnancies from DHEA alone or DHEA combined with aromatase inhibitors, or COH-IUI or IVF. Pretreatment with DHEA followed by COH-IUI in our study resulted in an excellent pregnancy rate in an otherwise poor prognosis group of patients. This study failed to demonstrate the reduction in pregnancy loss with DHEA that we had previously reported in all age groups. However, we propose that COH-IUI remains an efficient and affordable therapeutic modality for older women who have taken DHEA for at least 3 months.