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\begin{document}

\title{RE: Dehydroepiandrosterone supplementation has no added benefit on live
birth rate in poor ovarian responders}



\author[1]{Ankita Sethi }%
\author[1]{Neeta Singh}%
\author[1]{Garima Patel}%
\affil[1]{All India Institute of Medical Sciences}%


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  \date{May 25, 2024}


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\textbf{TYPE OF ARTICLE: LETTER TO EDITOR}

\textbf{RE: Dehydroepiandrosterone supplementation has no added benefit
on live birth rate in poor ovarian responders}

We read the recently published article in your journal with great
interest(1). Due to paucity of literature, the routine use of
dehydroepiandrosterone(DHEA) prior to In-vitro fertilisation cycle (IVF)
was inconclusive. But this study succeeds in highlighting similar effect
of DHEA as compared to a placebo, thus concluding no beneficial effect
of DHEA on the live birth rate.

Although the study provides concrete evidence, thus refuting the use of
DHEA in IVF cycle, however we as readers would like to enquire the
authors about some concerns that can help in better understanding of
this randomised trial.

\begin{itemize}
\tightlist
\item
  The study participants were defined according to Bologna criteria,
  which is now obsolete for defining poor ovarian response. POSEIDON is
  a more validated criteria for defining poor ovarian response and
  should be utilised as the inclusion criteria(2). Though the study
  mentions that a stratified analysis by age (\textless{}35 years and
  [?]35 years) based on the POSEIDON criteria was done, but the detailed
  result of this analysis is not presented in the study.
\item
  All participants underwent ovarian stimulation using short GnRH
  agonist protocol but GnRH antagonist is equally good in this group of
  patients thus requiring less dose of gonadotropins for stimulation(3).
\item
  Though table 2 mentions five different stimulation protocols, but in
  methodology text only short agonist protocol is mentioned as only the
  IVF protocol.
\item
  The recommended starting dose of gonadotropins should be 300 rFSH and
  150 HMG, but the starting dose was 150-225 IU Menotropins was used,
  how was the dose titrated and any adjuvants used (2).
\item
  DHEA was administered for a very broad flexible and variable time
  period i.e. 4-12 weeks in the study. As it is already mentioned that
  at least three month of DHEA administration is required for maximal
  effect, therefore only those completing 12 weeks course should have
  been included in the study.
\item
  It is mentioned that in five participants, three embryos were
  transferred. But as per ESHRE recommendation, a maximum of two embryos
  should be transferred in a women of advanced age, thus reducing the
  risk of multiple gestation (4).
\item
  Standard terminologies for various clinical rate should be used, thus
  refraining from terminologies like conception and continuing pregnancy
  as mentioned in table 3.
\end{itemize}

Disclosure of interests: No conflicts to declare.

REFERENCES

1. Wang Z, Yang A, Bao H, Wang A, Deng X, Xue D, et al. Effect of
dehydroepiandrosterone administration before in vitro fertilization on
the live birth rate in poor ovarian responders according to the Bologna
criteria: A randomised controlled trial. BJOG. 2021 Dec
29;1471-0528.17045.

2. Alviggi C, Andersen CY, Buehler K, Conforti A, De Placido G, Esteves
SC, et al. A new more detailed stratification of low responders to
ovarian stimulation: from a poor ovarian response to a low prognosis
concept. Fertility and Sterility. 2016 Jun;105(6):1452--3.

3. The ESHRE Guideline Group on Ovarian Stimulation, Bosch E, Broer S,
Griesinger G, Grynberg M, Humaidan P, et al. ESHRE guideline: ovarian
stimulation for IVF/ICSI+. Human Reproduction Open. 2020 Feb
1;2020(2):hoaa009.

4. Guidelines for the number of embryos to transfer following in vitro
fertilization: No. 182, September 2006. International Journal of
Gynecology \& Obstetrics. 2008 Aug;102(2):203--16.

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