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This study was performed to investigate the effect of of transdermal testosterone gel TTG on controlled ovarian stimulation COS and IVF outcomes and ovarian morphology according to pretreatment duration in poor responders. A total of women were recruited for this pilot study.
They were randomized into control, 2 weeks, 3 weeks or 4 weeks TTG treatment groups. For three TTG treatment groups, Androgen leads follicular atresia in murine experimental models Fabregues et al. However, in primates, androgens had positive effects about follicular development and some synergistic effects with follicle stimulating hormone FSH.
Androgen supplementation such as testosterone or dihydrotestosterone recruited more growing follicles, and increased granulosa and theca cell proliferation Vendola et al. Furthermore, androgen makes follicular FSH receptor expression in granulosa cells Weil et al. These androgen actions showed some helpful outcomes during in vitro fertilization IVF treatment especially for poor ovarian responders Fabregues et al. Poor ovarian response to ovarian stimulation usually indicates a reduced follicular response during assisted reproduction.
According to a consensus developed by The European Society for Human Reproduction and Embryology, less than 3 oocytes could be retrieved with a conventional stimulation protocol in poor responders by definition Ferraretti et al. So a variety of stimulation protocols have been used, however none of them have been so effective for poor ovarian response. Androgen supplementation protocol is one of them Gonzalez-Comadran et al. In human data, there was controversy about androgen priming during assisted reproduction.
Transdermal testosterone pretreatment also showed increased ovarian sensitivity to gonadotropin Fabregues et al. However, Massin et al. They proposed several reasons about the absence of any beneficial effects of testosterone application, and timing and duration of androgen supplementation were thought to be critical in adequate follicle stimulation and total amount of androgen supplementation was also considered to be an important factor Massin et al.
Therefore we conducted a pilot study to investigate the effect of transdermal testosterone gel TTG among subgroups classified by use duration in patients who had experienced a poor ovarian response to prior IVF cycles. We observed and compared ovarian morphologies of each groups including antral follicle count, follicular diameter and intra-ovarian blood flow after TTG treatment.
The study population consisted of total women, and they had been showed poor ovarian responses during prior failed IVF cycles. All the patients were in good health within normal limits of thyroid, kidney and hepatic laboratory results, and they had regular menstruation period with duration days. None of them had ever taken any infertility medication over past 3 months. Our pilot study was performed at a university-based infertility clinic at the Asan Medical Center, Seoul, South Korea.
The sequence of allocation to the four groups was provided to the investigating physicians and randomization was performed as planned according to the randomization list order. The dose adjustment was based on an individual ovarian response assessed by serial transvaginal ultrasonography every 3 or 4 days.
Oocyte aspiration was performed under transvaginal ultrasound guidance hours after hCG injection, and up to four embryos per patients, after IVF or ICSI, were replaced on the third day after oocyte aspiration. Pregnancy diagnosis was made by rising serum b-hCG concentrations and ultrasonographic evidence of a gestational sac. For three TTG pretreatment subgroups, The dose of TTG, Once gel applied, patients were instructed to avoid washing the application sites, for 5 hours, but washed their hands thoroughly with soap and water.
The duration of TTG pretreatment was varied among the study subgroups, which were 2, 3 and 4 weeks respectively in prece-ding period of study stimulation cycle. Ovarian stimulation was started next day of last testosterone gel application.
The primary end point was the total number of mature retrieved oocytes. The secondary endpoints were the number of growing follicles, numbers of fertilized oocytes and good-quality embryos. We also evaluated and analyzed total dose and days of rhFSH administered, implantation rate, clinical pregnancy rate per cycle, and live birth rate per cycle.
Clinical pregnancy was indicated in case of the presence of a gestational sac by ultrasonography, and live birth was indicated in case of the delivery of a fetus with signs of life after 20 completed weeks of gestational age.
Miscarriage rate per clinical pregnancy was defined as the proportion of patients who failed to continue development before 20 weeks of gestation in all clinical pregnancies. Each three TTG pretreatment and control groups consisted of 30 cycles initiated, corresponding to 30 patients. There were no significant differences in clinical pregnancy rate CPR per cycle initiated and live birth rate between 3 weeks TTG treatment and control groups.
No local or systemic adverse effect according to TTG application was reported. This pilot study demonstrated the beneficial effect of transdermal testosterone gel treatment on COS and IVF in women with poor ovarian responses during prior failed IVF cycles. Indeed the testosterone effect was occurred at least 3 weeks after application of the gel. The TTG treated patients for 3 to 4 weeks responded to FSH more than control or 2 weeks treated patients with result of more numbers of growing follicles during stimulation and oocytes retrieved.
Total dose of consumed gonadotropin decreased, and there were no local or systemic adverse side effects. In this perspective, basal hormonal secretion should be more carefully assessed for poor ovarian responders and they could be affected by testosterone level more than who are not a poor responders during gonadotropin stimulation. Several strategies have not fulfilled to increase reproductive outcomes for these poor responders, and commonly used approach is to make a high androgen intra-ovarian environment.
So, dehydroepiandrosterone DHEA , transdermal testosterone, aromatase inhibitor or recombinant luteinizing hormone LH was commonly administered in clinical practice de los Santos et al. The roles of androgens in ovarian folliculogenesis have been proposed, and basically androgens are essential substrates for ovarian steroidogenesis according to 2-cell two- gonadotropin theory Ryan et al.
Granulosa and theca cell proliferation were significantly increased also in these follicles Vendola et al. They suggested androgens stimulate early, gonadotropin independent stages of follicular growth and enhance responsiveness to gonadotropin Vendola et al. In the study about human granulosa cells and follicular fluids of small antral follicles, significant correlative mRNA expression was observed between androgen receptor and FSH receptor.
Furthermore, follicular fluid testosterone levels were highly significantly correlated with FSH receptor mRNA expression Nielsen et al. There were a few studies about testosterone priming for COS, but the results were controversial and limited.
Fabregues et al reported increased ovarian follicular responses to gonadotropin stimulation in previous low responder IVF patients. They used transdermal testosterone patch with 2. However, there was no statistical difference about the numbers of retrieved oocytes and embryos, and the rate of clinical pregnancies Fabregues et al. Another prospective, randomized trial performed by Massin et al. They restricted the duration of application to prevent any side effects Massin et al.
The timing and duration of testosterone supplementation, and moreover the total amount of supplementation were presented as critical factors for absence of testosterone priming effect. In this point, our trial has some strengths and favorable results. Most of all, the study was designed to reveal testosterone effect according to the duration of application. The positive effects to ovarian stimulation were observed and moreover IVF outcomes were improved after 3 to 4 weeks of testosterone gel application.
CPR were significantly increased up to These results could be highlighted because the study population was poor responder. However, data on the dose-response effects of androgens are still limited. In primates study, the threshold effect of androgens on follicular function has been postulated. When high dose of androgens were used for 5 days before and continuing through out FSH and LH treatment, antagonistic actions to gonadotropin stimulation were observed Zeleznik et al.
Furthermore intra-ovarian bioavailability of androgens administered systemically at nonvilrilzing dose needs further investigation Fanchin et al. The proper duration of androgen pretreatment should be taken into consideration also. Ovarian morphology in circumstances of androgen excess is well known from patients of polycystic ovarian syndrome PCOS.
It is characterized by excessive AFCs, which have been positively correlated with circulating androgen concentrations Jonard et al. In case of congenital adrenal hyperplasia or some virilizing tumors, which exposed women to androgen for long duration, comparable ovarian morphologies in PCOS were observed Fanchin et al.
Because androgen promotes early stages of follicular growth, MFD had been thought to be decreased. The improvement of intra-ovarian blood flow was demonstrated also, and further investigations are required. National Center for Biotechnology Information , U. Journal List Dev Reprod v.
This article has been cited by other articles in PMC. Abstract This study was performed to investigate the effect of of transdermal testosterone gel TTG on controlled ovarian stimulation COS and IVF outcomes and ovarian morphology according to pretreatment duration in poor responders.
Patients The study population consisted of total women, and they had been showed poor ovarian responses during prior failed IVF cycles. Outcome measures The primary end point was the total number of mature retrieved oocytes. Control 2 wks treatment 3 wks treatment 4 wks treatment P No. Open in a separate window. Control 2 wks treatment 3 wks treatment 4 wks treatment No. Barad D, Gleicher N. Effect of dehydroepiandrosterone on oocyte and embryo yields, embryo grade and cell number in IVF.
Association of body mass index, age, and cigarette smoking with serum testosterone levels in cycling women undergoing in vitro fertilization. Dehydroepiandrosterone supplementation augments ovarian stimulation in poor responders: The follicular hormonal profile in low-responder patients undergoing unstimulated cycles: Transdermal testosterone may improve ovarian response to gonadotrophins in low-responder IVF patients: Androgens and poor responders: ESHRE consensus on the definition of 'poor response' to ovarian stimulation for in vitro fertilization: Effect of androgen levels on in vitro fertilization cycles.
Futterweit W, Deligdisch L. Histopathological effects of exogenously administered testosterone in 19 female to male transsexuals. J Clin Endocrinol Metab. Effects of transdermal testosterone in poor responders undergoing IVF: Ultrasound examination of polycystic ovaries: Effects of transdermal testosterone application on the ovarian response to FSH in poor responders undergoing assisted reproduction technique--a prospective, randomized, double-blind study.
Ovarian morphology in longterm androgen-treated female to male transsexuals.
Testosterone replacement therapy for male hypogonadism treatment
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