2. The Story of the Index Patient
• 43 year old infertile women DESPERATELY
searches the literature for remedies to
avoid using an egg donor
3. Dehydroepiandrosterone supplementation augments ovarian
stimulation in poor responders: a case series
P.R. Casson1, M.S. Lindsay,M.D. Pisarska, S.A. Carson and J.E. Buster
Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and
Gynecology, Baylor College of Medicine,6550 Fannin, Suite 801, Houston, Texas 77030,
USA
Received February 8, 1999.
Accepted June 7, 2000.
4.
5. OVERVIEW
• How Does Age affect Fertility?
• How can the Ovarian reserve be Assessed?
• How does DHEA improve Ovarian reserve?
6. YES!!
15 - 20% of all couples will experience difficulties with
conception, but this increases up to 50% at age 35 – 40.
Is Infertility Affected by Age?
7. The Age Factor
• A woman's fertility naturally
starts to decline in her late
20's.
• After age 35 a woman's
fertility decreases rapidly.
• A woman is born with all the
eggs she'll have, and with
time, the supply diminishes.
9. • Decline in AFC
• Reduced cohort size
• Decreased oocyte quality &
potential fertility
• Altered feedback
– Reduced inhibin B
– Steady rise in FSH
– Gradually declining AMH
Miscarriages due to Aneuploidy
F. J. Broekmans et al., 2009
Aging & Fertility
10. Outcome of IVF in Women 45Years Older
• 30% Cancellation Rate
• Overall PR 21.1% Per Retrieval
• 85.3% Experienced a Pregnancy Loss
• Overall Delivery Rate Was 3.1%
Steven D. Spandorfer, Zev Rosenwaks, Jan 2007
15. Day 3 FSH level FSH interpretation
<10 Normal FSH level. Expect a good response to ovarian stimulation.
10 - 12 Borderline FSH. Response to stimulation is somewhat reduced.
13- 15 Elevated FSH. Reduced ovarian reserve. Reduced response to stimulation.
16 - 20 Markedly elevated FSH. Marked reduction in response to stimulation
> 20 Very poor (or no) response to stimulation.
Follicle Stimulating Hormone (FSH)
16. Anti-Mullerian Hormone (AMH)
• AMH is a glycoprotein
• Appears in females at puberty
• Produced by granulosa cells of
pre-antral and small antral follicles
• Not cycle dependant-can be measured
any day
• Less cycle to cycle variation than FSH
• Nor effected by GnRH agonists- can
measure during downregulation
• BUT expensive
17. AMH Level ng/ml Interpretation Expected
Response to FSH
Anticipated
Cancellation Rate
with IVF
Anticipated
Pregnancy Rate
with IVF
>3.0 High, often
PCOS
Very High Low Normal
1.0-3.0 Normal Good Low Normal
0.4-0.9 Low Reduced Increased Reduced
<0.4 Very Low Very Poor Very High Very Low
AMH and Ovarian Aging
18. AGE SPECIFIC FSH and AMH LEVELS
Age FSH AMH
< 33 Years < 7.0 mIU/mL 2.1 ng/mL
33-37 Years < 7.9 mIU/mL 1.7 ng/mL
38-40 Years < 8.4 mIU/mL 1.1 ng/mL
= 41 Years < 8.5 mIU/mL 0.5 ng/mL
19. Antral Follicle Count (AFC)
• Follicles 2 to 5mm on Day 1 or 2
• Inter-observer variation
• If AFC < 5- significantly worse outcome
20. Antral Follicle
Count
Interpretation Expected Response
to FSH
Anticipated
Cancellation with
IVF
Anticipated
Pregnancy Rate
with IVF
<4 Very low Very poor Very high Very low
4-6 Low Poor High Low
7-10 Reduced Reduced Increased Decreased
11-30 Normal Good Low Excellent
>30 Above
Normal(PCOS)
Increased risk of
hyperstimulation
Low Good
Antral Follicle Count (AFC)
25. Studies on DHEA
Fertil Steril 2005;84(3):756.
This was the first case report on the effects of DHEA on oocyte
production. Describing the stunning increase in oocyte production
after supplementation with DHEA in a 42-year-old patient with
severe DOR, the report (correctly, as it turned out,) speculated that
"ovarian function may be salvaged, even in women of advanced
reproductive age."
Hum Reprod 2006;21(11):2845-9.
In this case-control study, 25 patients underwent IVF cycles both before
and after supplementation with DHEA. After DHEA treatment, patients
had more oocytes that fertilized and more normal embryos on day-3.
More embryos were transferred, and average embryo grade were
significantly higher (better), confirming the earlier hypothesis that
DHEA supplementation may have beneficial effects on the ovarian
functions of women with DOR.
J Assist Reprod Genet 2007;24(12):629-34.
In this case-control study, 190 women with DOR were divided into
DHEA-supplemented group and control group. Women who received
DHEA supplementation had more than double the pregnancy rates
of women without DHEA (28.4%, compared to 11.9%).
CHR's Published Research on DHEA and Ovarian Reserve
26. Reprod Biol Endocrinol 2011;17(9):67.
An extensive and detailed review of current best available evidence in
this study confirmed that DHEA improves ovarian function, increases
pregnancy chances and, by reducing aneuploidy, lowers miscarriage
rates. Based on the improvement of oocyte/embryo quality after DHEA,
this study introduced a new concept of ovarian aging, where
ovarian environments, but not oocytes themselves, age. The study
also suggested that DHEA may be the first pharmacological agent
that beneficially affects aging ovarian environments.
Reprod Biol Endocrinol 2011;9(1):116.
Broadening the scope beyond human fertility and into published animal
data, this extensive review of literature theorized that androgens,
including DHEA, may play an essential role in the maturation of oocyte-
containing follicles. At certain therapeutic concentrations, DHEA and
other androgens may be capable of improving the early stages of
folliculogenesis. The study presented the possibility that androgens
like DHEA may be forerunners of a completely new class of
ovulation-inducing medications that affect much earlier stages of
follicle maturation than gonadotropins.
Hum Reprod 2011;26(7):1905-9.
This study, published with Dr. Weghofer, CHR's affiliate in Austria, as
lead author, showed that DHEA-supplemented women can conceive
at reasonable rates even with the most severe forms of DOR,
including undetectable levels of anti-Müllerian hormone (AMH).
Similarly, moderate but still reasonable live birth rates were possible with
DHEA supplementation.
Studies on DHEA
27. Tel Aviv Study 2010
• A study conducted by Adrian Shulman, MD and co-
workers of Tel Aviv University in Tel Aviv, Israel
• 33 women, 17 on DHEA and 16 controls
• Represents the first prospectively randomized study
of DHEA in infertility.
• "In the DHEA group, there was a 23% live birth rate as
opposed to a 4% rate in the control group
28. Beneficial Effects of DHEA
• increased egg and embryo counts and quality
• increased chromosomally normal embryos
• Increased number of embryos for transfer in IVF treatments
• Accelerated time to pregnancy in fertility treatment
• Increased spontaneously conceived pregnancies
29. How DHEA Acts?
Growth Phase
Gonadotrophin
dependent phase of
growth
• Act before , during or after the recruitment phase
32. EVIDENCE BASED STUDIES
• Improve oocytes yields via IGF-1
• They promote preantral follicle growth by Granulosa
cell - specific androgen receptors
• Preventing follicular atresia
• Synergistic effect between DHEA and gonadotropins
33. “Rejuvenate” Ovarian Environment
Ovarian environments, but not resting oocytes, that age
as women grow older
DHEA, and other pharmaceuticals rejuvenate ovarian
environments, in normally fertile, older women
Dehydroepiandrosterone (DHEA) supplementation in diminished ovarian reserve (DOR)
Norbert Gleicher and David H Barad Gleicher and Barad
Reproductive Biology and Endocrinology 2011, 9:67
34. • Like supplementation with folic acid to prevent neural
tube defects
• Supplementation with DHEA may achieve favourable
public health consequences by potentially reducing
aneuploidy and spontaneous pregnancy losses in a
general population.
36. Indications – Since Jan 2007
• All women above age 40 have been offered routine
supplementation
• Younger women, under age 40, are continuing to be
only selectively supplemented
1. if demonstrating elevated age-specific baseline
follicle stimulating hormone (FSH) levels
2. Inappropriately low oocyte yield in at least one IVF
cycle
CENTER OF HUMAN REPRODUCTION
37. Clinical Application
• DHEA effects occur relatively quickly
(apparently within 2 months)
• Peak only after 4-5 months of DHEA supplementation
• The beneficial effects of DHEA increased with length of
DHEA supplementation
38. Dosage
• Oral, pharmaceutical grade micronized medication at a
dosage of 25 mg, three times daily (TID)
• Patients receive at least two months of DHEA
supplementation prior to oocyte retrieval
• DHEA is maintained until pregnancy, and is
discontinued with second positive pregnancy test.
39. Safety and Toxicity
• Despite being a steroid hormone, DHEA appears to be
relatively safe if given at normal physiological doses
• Few side effects noted
- breast tenderness,
- reversible hirsutism in women
- mild to moderate acne due to sebaceous secretion
40. Side Benefits
• Improved overall feeling
• Feeling of being physically stronger
• Improved sex drive
• Feeling of being mentally sharper
• Feeling of better memory
41. OUR EXPERIENCE
• 2012
• Selected patients – DOR and POA
• Minimum of 2 months before IUI or IVF
• One patient conceived spontaneously while being worked up or
IVF
• AMH has improved in 2 patients
42. Conclusions
• Age is the main determinant of success of infertility
treatments
• AMH is the most promising method of assessing
ovarian reserve
• DHEA acts by Rejuvenating Ovarian Environment in
women with DOR and POA
• It significantly improves pregnancy rates in IVF
• It decreases miscarriages and pregnancy losses
43. • One third of all IVF centre around the world are using
DHEA in their IVF protocols
• It should be used discriminately in carefully
selected patients --- DOR AND POA
44.
45. ADDRESS
35 , Defence Enclave, Opp. Preet Vihar Petrol Pump,
Metro pillar no. 88, Vikas Marg , Delhi – 110092
CONTACT US
011-22414049, 42401339
WEBSITE :
www.lifecarecentre.in
www.drshardajain.com
www.lifecareivf.com
E-MAIL ID
Sharda.lifecare@gmail.com
Lifecarecentre21@gmail.com
info@lifecareivf.com
&
Notes de l'éditeur
After about age 32, a woman's fertility potential gradually declines. Infertility in older women may be due to a higher rate of chromosomal abnormalities that occur in the eggs as they age. Older women are also more likely to have health problems that may interfere with fertility. The risk of miscarriage also increases with a woman's age. A gradual decline in fertility is possible in men older than 35. The reason is straightforward. A woman is born with all the eggs she'll have. And with time, the supply diminishes. The remaining eggs also age along with the rest of the body.
FIG. 10. Schematic representation of the changes in average early follicular levels of endocrine and ovarian ultrasound markers for ovarian aging according to the STRAW phases of reproductive aging. Note the late decrease in estradiol and inhibin A levels, the gradual decrease in AMH across the subsequent stages, and the abrupt decrease in inhibin B in the menopausal transition. Drawing is based on several sources (46, 66, 95, 109, 122, 124, 155, 329).
