An Interesting POR Case Study

A couple, The wife aged 41 years and the husband aged 43 years came to our hospital with a history of primary infertility for 9 years. Her cycles were regular. She underwent diagnostic Hysteroscopy and Laparoscopic Myomectomy in 2004. The Husband was a known case of type 2-Diabetes Mellitus for 3 years and was on medication. Following investigations were made during follow up.

Wife: Hemogram, OGCT, Prolactin hormones were normal. AMH was 0.9, TSH 1.51, D2: FSH 9.8, LH: 7.8, Baseline USG showed 4 follicles on the right side and two on the left side.

Husband: Semen analysis showed Asthenospermia with DFI 25%. Hemogram, OGCT, TSH was normal. The Couple were counselled in detail about poor ovarian reserve and the need for IVF treatment. The Wife was started on DHEA 75mg per day, 2 months before starting the IVF cycle. IVF stimulation was started using The antagonist protocol started with an injection of rFSH 187.5 IU and injection of HMG 75IU. Later total dose of GnRH increased to 325IU per day, a total of 14 days of stimulation was done. E2 response was adequate. Dual trigger using Inj HCG 5000IU & Injection of Lupride 1mg was given when follicles were more than 18mm. 3 oocytes were obtained. ICSI procedure was done, 1 good quality embryo was frozen. She has been prescribed transdermal testosterone gel 12.5 mg daily application to the upper arm and outer thighs for 3 weeks before starting the next IVF cycle. No systemic or local adverse effects were noted. During the 2nd IVF cycle, a mild stimulation protocol was used. Aromatase inhibitors dose of 2.5mg twice a day was given for 5 days from D2 to D6 along with rFSH 225IU per day, a total of 10 days of stimulation. Dual trigger using Injection of HCG 5000IU & Injection of Lupride 1mg was given when follicles were more than 18mm. E2 response was adequate. 9 oocytes were obtained. In that, 8 oocytes were mature( M2). ICSI procedure was done, five good quality embryos were frozen. After two months, frozen embryo transfer was done using HRT. Three good quality embryos were transferred and the patient conceived.

Rationale: Experimental studies have shown that treatment with testosterone increased FSH receptor expression in granulosa cells, promoting the initiation of primordial follicle growth, improving the number of growing preantral and antral follicles. Androgen treatment amplifies the effects of FSH on ovaries requiring less dose of FSH, shorter duration of treatment and better pregnancy rate. Aromatase inhibitors increase intraovarian androgen levels. Successful treatment for the poor ovarian responder remains a challenge. Still, good RCTs are required with an adequate sample number to provide information on the use of transdermal testosterone gel effectiveness in the poor responders.