5 Mar 2010
INTRODUCTION: Since the initial report of Casson et al in 2000, there has been an increasing interest in intracellular androgen modulation to improve follicular recruitment in older women with diminished ovarian reserve. We have previously reported that the use of supplemental dehydroepiandrosterone (DHEA) is associated with an improvement in pregnancy rate and a reduction in pregnancy loss in women over 35 yr (ASRM and CFAS 2009).
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, 215 patients 40 yr. and older were treated with 25 mg of pharmaceutical grade micronized DHEA 3 times daily for at least 3 months. Diminished ovarian reserve was evidenced by basal FSH level, AMH level and antral follicle count.
Of these 215 patients, 79 were lost to follow up, 2 stopped treatment due to side effects (acne; hair loss), and 134 continued with treatment. Of these 134, 32 patients 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 32 patients treated with DHEA and COH-IUI, 15 patients conceived (46,9%). The average patient age was 41.9 yr. The average time to conception was 2.2 cycles. The outcome in these 15 patients included 8 early losses (53.3%), and 7 singleton pregnancies. 4 pregnancies are delivered, 2 are ongoing and 1 was terminated due to trisomy 18.
CONCLUSION: 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.