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R2014.01
DHEA- A review (2013) READ ON
In conclusion, our systematic review of the controlled studies on the effect of pre-treatment DHEA on IVF outcome in women with diminished ovarian reserve suggests that DHEA does not improve the quantitative ovarian response and pregnancy outcome.
 
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Background.
   
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Diminished ovarian response is the currently biggest challenge facing IVF clinics. This is mainly due to the increasing age of clients attending for fertility treatment. Since IVF works best when a reasonable number of oocytes are collected, poor ovarian response often results in decreased oocyte and embryo quality and choices, decreased pregnancy rates and increased miscarriage rates. Early in the growing phase, early follicles pass through an androgen dependency. It has been proposed that giving DHEA (an androgen) may recruit more follicles that may otherwise be lost, leading to increased oocyte recoveries and better outcomes.
 
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Possible actions of DHEA.
   
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While unclear of an action of DHEA, suggestions include influencing IGF-1 concentrations, FSH receptor and/or LH receptor activity. It may have a direct effect on the oocyte itself. There are suggestions up to 25% of clinics are using DHEA supplementation. Several small studies have suggested DHEA pre-treatment may increase oocyte numbers.
 
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Review of Meta Analyses.
   
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Two RTC studies failed to show an improved pregnancy rate, a decreased miscarriage rate, and increased oocyte recovery. Note though the P value of the clinical pregnancy rate was P=0.07 - suggesting that further studies may well find a significant difference in outcomes to exposure. It always remains a problem in client selection and definition as to who may benefit from DHEA pre-treatment.
 
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Interpretation.
   
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Part of the problem in the early stages of clinical management is the prior determination of who is a poor responder. Most age based outcome curves reveal the optimal age for IVF is late 20's-early 30's and with increasing age so comes poorer outcomes. Definition of a poor responder must therefore be age sensitive and poor response of a client in her mid forties is different to a client in her early thirties. There are also several tools available to clinicians to assist in their identification of a client who may respond poorly to a standard stimulation regimen. These include serum FSH or AMH or ultrasound scanning for early follicle numbers. In contrast, many clinics apply a standard stimulation regimen and if low egg numbers are collected, a definition of poor responder may be applied. Increasing the FSH stimulation in their next cycle sometimes improves outcome but continued increases in dose rarely is rewarding. So maybe the problem is that in some hands, DHEA is reported to be beneficial while in other studies it is not. There does not appear to be any negative aspects of DHEA administration.
 
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Should DHEA be used?
   
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Clinicians face considerable pressure from clients who fail to meet the clients expectations (usually raised by clinical advice) and using DHEA in future cycles is a good tool. However, it is unlikely to be a broad spectrum panacea for all poor responders of mature years. But like all treatment, most clients will need to try it, just to see if it works for them. Better aged based RCT need to be pursued to allow fine tuning of advice and to drown out the noise for indiscriminate and wide spread use.
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Reviewed on 27/10/2013 6:44:28 AM by Amarin Narkwichean
Review Groups: Stimulation / Age/Ovarian Reserve /
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