22 Sep 2017
INTRODUCTION: DHEA is an androgen precursor, and it is believed that intraovarianandrogen levels can positively influence ovarian follicular growth (recruitment of pre antral resting follicles 0.2-0.4 mm into the 3-5 mm range, when FSH receptors are acquired), which might lead to improvement on oocyte recruitment. The exact mechanism is not well known, but likely involves insulin like growth factor1increased sensitivity. Some trials have found that the use of supplemental DHEA in women with poor ovarian reserve improves embryo quality(2), implantation rate(3), pregnancy rate(3-8) and areduced pregnancy loss rate(4,11,12). However, others have found no beneficial effect when compared to standard treatment(2,12-16). Therefore, its recommendation is still controversial. Our objective is to report our clinic’s pregnancy rate per embryo transfer (PR/ET), clinical pregnancy rate per ET (CPR/ET) and live birth rate (LBR) in women with DOR undergoing IVF treatment with DHEA supplementation.
MATERIALS AND METHODS: In a retrospective study (February 2006-February 2017), we collected information on DHEA-supplemented IVF cycles in women with DOR who had failed to get pregnant on oral (femara) or injectable fertility medication (COS with IUI). IVF cycles were D3 transfers as all patients had DOR and if left for D5 transfer, they might not have had any embryos to transfer based on our own experience. We excluded cycles in women ≥44 years old, frozen , and donor cycles. We divided the cycles by age groups: <35yo, 35-39yo, and 40-≤43yo. PR/ET included chemical pregnancies. CPR/ET was defined as an intra uterine pregnancy on ultrasound at 4 weeks post ET. Statistical analyses were performed using STATA version 11.1.
RESULTS: A total of 176 DHEA-supplemented IVF cycles were included, 28 cycles in women <35yo, 69 cycles in women 35-39yo, and 79 cycles in women 40-≤43yo. Average number of embryos transfer red was 3.1 +/- 1.4 (SD). For the three different age groups, the cancellation rate was 17.9% (n=5), 20.3% (n=14), and 26.6% (n=21). Even though the PR/ET was not statistically significant amongst the age groups, 39.1% (n=9), 50.9% (n=28), and 31.0% (n=18), p=0.10, we did see a higher PR/ET in the 35-39yo group. The CPR/ET was 26.1% (n=6), 47.3% (n=26), and 29.3% (n=17), p=0.08. The LBR/ET was 21.7% (n=5), 36.4% (n=20), 20.7% (n=12), p=0.14. From the 49 clinical pregnancies, 13 were multiple pregnancies (26.5%), and 36 were single pregnancies (73.5%).
CONCLUSION: The use of DHEA supplementation in our 11-year practice experience in women with DOR undergoing IVF treatment had no statistical significance on PR/ET, CPR/ET and LBR between this notoriously poor prognosis groups. Note has to be made of the very poor prognosis of women under 35yrs with D.O.R. No doubt some of this group likely had fragile X syndrome or more likely gene abnormalities on other autosomes as has been published over the most recent years(17-20). Our under 35yrs women with DOR had basically the same results as our over 40 yrsgroup. However, the LBR/ET was higher in our clinic than in the reported CARTR Plus 2015 registry for women with DOR (35-39yo [30%], and >40yo [10%]). However, our clinical pregnancy rate for multiple pregnancy (26.5%) is more than double of the rate reported in CARTR Plus, 2015 (12.2%), therefore we will be using a one single embryo transfer even in women with DOR age over 38yrs to decrease our multiple pregnancy rate.Overall, the use of DHEA in women with DOR undergoing IVF treatment should not be dismissed and should be investigated in randomized well controlled trials.
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