OPINIONs 008: November 17, 2014
We in this OPINION discuss the current skepticism, which still prevails within the field of reproductive endocrinology and infertility, about androgen supplementation of women with LFOR, even though such supplementation, especially with dehydroepiandrosterone (DHEA), is very rapidly becoming routine practice worldwide. The main argument of skeptics is absence of prospectively randomized clinical trials (RCTs) of adequate power. While this represents a valid criticism we support, it is also important to recognize that circumstances, sometimes, do not allow for conduct of RCTs. The investigation of women with LFOR may be such a situation since women with LFOR, rightly, are concerned about wasting 6 months of their short, remaining reproductive lifespan on, possibly, being assigned to placebo. In cases where RCTs are not possible, studies of other formats and with lower levels of evidence have to suffice to reach clinical conclusions, especially if supported by appropriate animal experiments. It is CHR’s conclusion, from review of the currently available literature that adequate RCTs of androgen supplementation, indeed, do not exist. Studies of clinically lower evidence levels in combination with animal studies, however, strongly support supplementation of women with LFOR with androgens in attempts to raise their intraovarian testosterone levels. They also establish a compelling physiologic model for why such supplementation should improve treatment outcomes. This CHROPINION should be reviewed in careful consideration of the Conflict Statement at the end.
Supplementation of androgens in women with LFOR has remained controversial, even though its use worldwide has very rapidly expanded. Very recently, an editorial in a prominent specialty journal in infertility, again, claimed absence of any supportive evidence for such treatment.1 Other prominent colleagues have at least partially concurred with this opinion.2 We, however, disagree, and this OPINION is meant to present what we consider strong supportive evidence that LFOR is a condition characterized by relative hypoandrogenemia, and, therefore, one that benefits from supplementation with androgens.
The above-mentioned recent editorial claims that only an empirical approach, rather than a biological hypothesis, is supporting current practice of androgen supplementation in women with LFOR. This claim can easily be disproven since, even when Casson et al for the first time proposed supplementation of women with LFOR with dehydroepiandrosterone (DHEA), they already pursued a biological hypothesis in suggesting that DHEA might work by increasing insulin-like growth factor 1 (IGF1) effects on granulosa cells at early follicle growth stages.3
Since then, our understanding of ovarian physiology has greatly advanced and, today, androgen supplementation of women with LFOR is, indeed, no longer based on hypotheses but on solid biological facts, presented in continuation.
To this date, three global female androgen receptor knock out (ARKO) mouse models4-6 and two granulosa cell ARKO mouse models7,8 have been established, which uniformly demonstrated that the knockout of androgen receptors (ARs) results in subfertility and development of primary ovarian insufficiency (POI). Studies in the granulosa cell-specific ARKO mouse model, in addition, established that androgen activities regulate follicle progression from pre-antral to antral stages. In absence of functional ARs, pre-antral follicles become artretic instead of developing into preovulatory follicles, capable of ovulation and corpus luteum development. Absence of functional ARs, thus, produces an almost classical LFOR ovarian phenotype.
Sen et al. also demonstrated that androgens not only stimulate follicular development but that androgen priming prior to super-ovulation of mice significantly increases the number of ovulated oocytes.7,9 In collaboration with this group of investigators from the University of Rochester School of Medicine and Dentistry, CHR investigators, in addition, have been able to demonstrate in the mouse model that DHEA supplementation, indeed, significantly increases the number of growing follicles in comparison to follicle stimulation hormone alone, and that AR inhibitor flutamide blocks this effect.10 Moreover, the molecular bases of some of the androgen actions in follicular development in mice,9 and of DHEA on cultured human granulosa cells from post-ovulatory follicles11 have also recently been demonstrated.
These and other studies, therefore, clearly establish the importance of adequate androgen levels (with testosterone being the primary functional androgen) at small growing follicle stages, where androgens, synergistically with follicle stimulating hormone (FSH), enhance the sensitivity of granulosa cells to FSH and, therefore, promote follicle growth and development. Absence of adequate androgen levels at these early follicle maturation stages results in increased follicle degeneration and apoptosis, poorer follicle and oocyte quality and, relevant to IVF, in fewer oocytes and poorer oocyte and embryo quality. Conversely, supplementation with androgens in women with a low peripheral androgen level improves follicle, oocyte and embryo numbers as well as quality.
We know this by now not only from above-noted and other (see below) animal models but also from human data. For example, it has become apparent that women with LFOR, whether due to advanced age or premature ovarian aging (POA), are relatively hypoandrogenic.12 Moreover, how well supplemented women convert DHEA to testosterone and by how much their testosterone levels increase after supplementation are predictive of subsequent in vitro fertilization (IVF) pregnancy rates.13,14
The recent editorial also raises a number of quite surprising questions since the answers are easily available from the published literature: For example, it asks why to treat with an “androgen precursor” (DHEA) rather than an androgen directly (likely referring to testosterone). DHEA is, in itself a mild androgen since it binds to AR, though with lower affinity than testosterone (it, of course, also binds to the estrogen receptor). And DHEA, indeed, does serve as substrate for other androgens, including testosterone (and estrogens). Since androgen levels vary in different organs, DHEA supplementation allows each organ, ovaries included, to draw organ-specific amounts of precursor to reach desirable testosterone levels. Direct administration of testosterone, necessary in some cases because ca. 15% of especially older women do not convert DHEA well to testosterone,14 in contrast, floods all organs with identical levels of testosterone, overexposing some and underexposing others. Side effects with direct testosterone administration, therefore, are more pronounced.
The editorial further asks why 75 mg of DHEA per day are administered, when there are no dose-determining studies. For this answer, we refer him to Casson’s original study,3 which presents a logical rationale based on daily adrenal production rates of DHEA, and to the results obtained by our first DHEA patient, who drew her dosaging from Casson’s paper.15
Next, the editorial asks why 4 months duration of supplementation if there are no time studies. Observational studies, of course, demonstrated that the effects of DHEA supplementation continue to increase for approximately 4-5 months before plateauing.16 Secondly, our initial recommendation was at least 6 weeks of pretreatment with DHEA since statistically significant outcome differences in clinical pregnancy rates became apparent starting at the 6-week point. More recently published DHEA literature, however, suggests that IVF treatment start is no longer determined by length of prior DHEA supplementation but by when appropriate testosterone levels are reached.13,14
The editorial is, however, absolutely correct when asking why so many small studies have been performed but no adequately sized prospectively randomized clinical trials (RCTs). Indeed, this is exactly the point CHR has been making in counter-arguing the so widely supported cliché that clinical evidence of treatment efficacy canonly be established via RCTs.16 CHR, indeed, failed twice in establishing RCTs of DHEA supplementation in women with LFOR, once at CHR-New York and a second time in collaboration with European colleagues, who were convinced they would succeed where CHR had failed, in recruiting enough women with LFOR, who were willing to be randomized to six months of placebo.
Our European colleagues very quickly found out that they, too, had misjudged their abilities. Like U.S. women, recognizing the limited time available to them to conceive, most European women with LFOR also refused to lose valuable six months of their reproductive life to placebo. Like CHR before, our European colleagues, therefore, also had to abandon the trial for lack of recruitable patients.
Four RCTs on DHEA have, nevertheless, been published to date.17-20 They, however, do not contribute significantly to the literature because all four are grossly underpowered. Underpowered RCTs are, of course, highly misleading because, as RCTs, they are erroneously viewed by many as at the highest evidence levels, while in reality they are practically worthless in establishing evidence, especially when claiming lack of therapeutic benefits in presence of typical type 2 errors. These four studies are, thus, excellent examples of why, at times, other study formats of lower evidence level may offer more clinical value.
The small study sizes of the above-noted RCTs can also be viewed as further confirmation of how difficult it is to conduct RCTs in women with LFOR. In clinical situations like this, the scientific community, therefore, faces obvious choices: either we accept human studies of lower evidence levels, supported by appropriately designed animal experiments, as adequate to introduce new therapeutic modalities or we simply do nothing, and continue preaching about the necessity of unlikely ever to be performed RCTs.
We previously pointed out that, had our research community, indeed, done nothing in absence of RCTs when IVF was evolving, IVF, as we know it today after the delivery of over 5 million babies worldwide, would not exist, and Robert G. Edwards, PhD, would never have been awarded the Nobel.16
The editorial cites another prominent voice in our professional community in support of its position.2 Yet, in his position as Editor-in-Chief, Evers recently published in Human Reproduction likely the so far most elegant large-animal model describing DHEA supplementation effects on ovaries. Not only did this study practically confirm all observations CHR and other investigators have made and reported based on clinical experience with DHEA supplementation in women with low FOR, but the authors concluded that DHEA might be (after all) a useful therapy to delay the effects of ovarian aging and, therefore, may have a role in improving ovarian response in women with LFOR.21
While Evers has recently refused acceptance of clinical DHEA studies other than RCTs in Human Reproduction(even if approved by the journal’s reviewers; Gleicher N, personal communication), with the argument that whatever such lower evidence studies can offer has already been published and only RCTs can further enhance evidence, by accepting this British sheep study for publication, he did acknowledge the value of animal studies, which allow for extrapolation to the human experience.
CHR’s Drs. Gleicher and Barad are co-inventors and co-owners with CHR of a number of U.S. patents, claiming clinical benefits from androgen (including DHEA) supplementation of women with LFOR. These patents have been licensed to Fertility Nutraceuticals, LLC, and both physicians receive royalties from this company. Dr. Gleicher also owns shares in this company.
- Garcia-Velasco JA. Poor responders and androgen adjuvant treatment: “Still haven’t found what I’m looking for…” Reprod Biomed Online 2014; 28:661-662
- Evers JLH. The wobbly evidence base of reproductive medicine. Reprod Biomed Online 2013; 27:742-746
- Casson PR, Lindsay MS, Pisarska MD, Carson SA, Buster JE. Dehydroepiandrosterone supplementation augments ovarian stimulation in poor responders: a case series. Hum Reprod 2010;15:2129-2132
- Hu YC, Wang PH, Yeh S, Wang RS, Xie C, Xu Q, Zhou X, Chao HT, Tsai MY, Chang C. Subfertility and defective folliculogenesis in female mice lacking androgen receptor. Proc Natl Acad Sci USA 2004;101:11209-11214
- Shiina H, Matsumoto T, Sato T, Igarashi K, Miyamoto J, Takemasa S, Sakari M, Takada I, Nakamura T, Metzger D, Chambon P, Kanno J, Yoshikawa H, Kato S. Premature ovarian failure in androgen receptor-deficient mice. Proc Natl Acad Sci USA 2006;103:224-229
- Walters KA, Allan CM, Jimenez M, Lim PR, Davey RA, Zajac JD, Illingworth P, Handelsman DJ. Female mice haploidinsufficient for an inactivated androgen receptor (AR) exhibit age-dependent defects that resemble the AR null phenotype of dysfunctional late follicle development, ovulation, and fertility. Endocrinology 2007;148:3674-3684
- Sen A, Hammes SR. Granulosa cell-specific receptors are critical regulators of ovarian development and function. Mol Endocriol 2010; 24:1393-1403
- Walters KA, Middleton LJ, Joseph SR, Hazra R, Jimenez M, Simanainen U, Allan CM, Handelsman DJ. Targeted loss of androgen receptor signaling in murine granulosa cells of preantral and antral follicles causes female subfertility. Biol Reprod 2012; 87:151
- Sen A, Prizant H, Light A, Biswas A, Hayes E, Lee H-J, Barad D, Gleicher N, Hammes SR. Androgens regulate ovarian follicular development by increasing follicle stimulating hormone receptor and microRNA-124b expression. Proc Natl Acad Sci USA 2014;111;3008-3013
- Kushnir VA, Sen A, Hammes SR, Barad DH, Lazzaroni-Tealdi E, Wu Y-G, Lee J-J, Gleicher N. Proof of concept in a mouse model for beneficial effects of dehydroepiandrosterone (DHEA) on small growing follicles. 16th International Congress of Endocrinology (ICE), Chicago, June 21-24, 2014 (abstract)
- Wu Y-G, Lee H-J, Barad DH, Kushnir VA, Lazzaroni-Tealdi E, Gleicher N. Dehydroepiandrosterone (DHEA) stimulates aromatase and FSH receptor expression in cultured human primary granulosa cells. Annual Meeting of the Society for the Study of Reproduction, Grand Rapids, Michigan, July 19-23, 2014 (abstract)
- Gleicher N, Kim A, Weghofer A, Kushnir VA, Shohat-Tal A, Lazzaroni E, Lee HJ, Barad DH. Hypoandrogenism in association with diminished functional ovarian reserve. Hum Reprod 2013;28:1084-1091
- Weghofer A, Kim A, Barad DH, Gleicher N. The impact of androgen metabolism and FMR1 genotypes on pregnancy potential in women with dehydroepiandrosterone (DHEA) supplementation. Hum Reprod 2012;27:3287-3293
- Gleicher N, Kim A, Weghofer A, Shohat-Tal A, Lazzaroni E, Lee HJ, Barad DH. Starting and resulting testosterone levels after androgen supplementation determine at all ages in vitro fertilization (IVF) pregnancy rates in women with diminished ovarian reserve (DOR). J Assist Reprod Genet 2103;30;49-62
- Barad DH, Gleicher N. Increased oocyte production after treatment with dehydroepiandrosterone. Fertil Steril 2005;84:756
- Gleicher N, Barad DH. Misplaced obsession with prospectively randomized studies. Reprod Biomed Online 2010;21:440-443
- Wiser A, Gonen O, Ghetler Y, Shavit T, Berkowitz A, Shulman A. Addition of dehydroepiandrosterone (DHEA) for poor responder patients before and during IVF treatment improves the pregnancy rate: a randomized prospective study. Hum Reprod 2010;25:2496-2500
- Artini PG, Simi G, Ruggiero M, Pinelli S, Di Berardino OM, Papini F, Papini S Monteleone P, Cela V. DHEA supplementation improves follicular microenvironment in poor responder patients. Gynecol Endocrinol 2012;28:669-673
- Yeung TW, Li RH, Lee VC, Ho PC, Ng EH. A randomized double-blinded placebo-controlled trial on the effect of dehydroepiandrosterone for 16 weeks on ovarian response markers in women with primary ovarian insufficiency. J Clin Endocinol Metab 2013; 98:380-388
- Yeung TW, Chai J, Li RH, Lee VC, Ho PC, Ng EH. A randomized, controlled pilot trial on effect of dehydroepiandrosterone on ovarian response markers, ovarian response, and in vitro fertilization outcomes in poor responders. Fertil Steril fertnstert. 2014.03. 044. [Epub ahead of print]
- Narwichean A, Jayaprakasan K, Maalouf WE, Hernandez-Medrano JH, Pincott-Allen C, Campbell BK. Effects of dehydroepiandrosterone on in vivo ovine follicular development. Hum Reprod 2014;29:146-154