RBMOnline - Vol 11. No 5. 2005 570–580 Reproductive BioMedicine Online; www.rbmonline.

com/Article/1971 on web 3 October 2005

Symposium: Endocrinology in ovarian stimulation

Impact of androgens on fertility – physiological,
clinical and therapeutic aspects
Professor Jean-Noel Hugues trained in Endocrinology and Reproductive Medicine at Paris
University (France). After qualifying, he obtained his PhD in Biochemistry in 1987 and was
promoted to Professor of Reproductive Medicine in 1988. In 1995, he became the head
of the Reproductive Medicine Unit at Jean Verdier University Hospital in Paris. Research
interests include reproductive endocrinology, human infertility, developmental physiology
and clinical pharmacology. He is author of many published articles, reviews and chapters in
books in this field. He is a member of the French Societies of Endocrinology, Andrology and
Reproductive Medicine. He is also a member of the EHSRE, ASRM and SGI societies.

Dr J-N Hugues
J-N Hugues1, I Cédrin Durnerin
Reproductive Medicine Unit, Department of Gynaecology and Obstetrics, Jean Verdier Hospital, University Paris XIII,
France
1
Correspondence: e-mail: jean-noel.hugues@jvr.ap-hop-paris.fr

Abstract
Ovarian androgen synthesis and regulation are essential to ensure adequate steroidogenesis and folliculogenesis.
In primates, there is evidence for a direct impact on the number of small antral follicles and on the process of
chronic anovulation. Therefore, serum androgen should be more carefully assessed in infertile women.
Accurate measurements of serum androgen are required to better identify patients with androgen excess or
deficiency. Medical or surgical interventions are able to decrease ovarian androgen excess and to reduce the risk
of hyperstimulation. Conversely, androgen supplementation should be considered in women at risk of low ovarian
response to gonadotrophins, related to androgen deficiency. This review supports a specific and broad role of androgen
in reproductive physiology.

Keywords: androgen, androgen deficiency, folliculogenesis, PCOS, steroidogenesis

Introduction Ovarian androgen synthesis and

Androgens play a key role in the physiological
control of ovarian function, acting both as precursors for
oestrogen biosynthesis and directly via the ovarian androgen
receptor. Further to previous studies mainly performed in
rodents, it is widely believed that androgens have deleterious
effects on the follicular microenvironment and adversely
affect the chance of conception. Nevertheless, some studies
in primates have recently shown that androgens may in fact
have some synergistic effects with FSH on folliculogenesis.
This review will first consider some physiological aspects of
androgen secretion and actions at the ovarian level. In the
second part, two separate issues will be addressed: how to
control sex steroid secretion in patients with androgen excess,
and what could be the benefit of androgen supplementation in
infertile women with a low ovarian responsiveness to FSH?
570
actions
Biosynthesis of androgens
The normal ovary secretes three major C19 steroid androgens:
androstenedione, testosterone and dehydroepiandrosterone
(DHEA). However, the ovarian androgens are primarily
androstenedione and testosterone, secreted by the stroma
(interstitial tissue) and by the theca interna cells.
Figure 1 shows the biosynthetic pathways leading to
androgen synthesis. The common precursor is plasma
cholesterol, which is converted into pregnenolone. Next,
the conversion of pregnenolone to androstenedione, the
principal ovarian androgen, requires several specific and
identical enzymes [3β-hydroxysteroid-dehydrogenase and
an enzymatic complex cytochrome P450c17, including
17α-hydroxylase and C17–20 lyase activities] used sequentially
 Symposium - Impact of androgens on fertility - J-N Hugues & I Cédrin Durnerin
Figure 1. Different pathways of androgen biosynthesis.
throughout two parallel pathways (Ryan and Pedro, 1966), the
Δ4 pathway, leading to progesterone → 17α-OH-progesterone
→ androstenedione, and the Δ5 pathway, leading to 17α-OH-
pregnenolone → DHEA → androstenedione.
Finally, the conversion of androstenedione to testosterone
requires another specific enzyme, 17β-hydroxysteroid-
dehydrogenase.
There is a consensus that, in humans, the Δ5 pathway
predominates in the follicle for oestrogen synthesis, but that
the corpus luteum uses the Δ4 pathway for progesterone and
oestradiol synthesis (Ryan and Pedro, 1966). Moreover, the
possibility exists that humans have a Δ4 17,20-lyase distinct
from P450C17 (Lieberman et al., 1990)
Sources of androgens
It is well established that the ovarian contribution to the overall
androgen production in women is not predominant. Indeed,
DHEA is mainly produced by the zona reticularis of the adrenal
cortex. Moreover, a significant extra-glandular contribution to
the total androgen pool in the body results from the conversion
of precursor ‘pre-hormone’ steroids in tissues such as fat,
muscle, skin and brain.
With regard to androstenedione, the respective contribution
of the ovary and the adrenal appears to vary with time of
day and phase of the menstrual cycle. The adrenal output of
androstenedione is responsive to ACTH stimulation, and exhibits
a diurnal rhythm coincident with that of cortisol. Therefore,
in the morning hours, adrenal secretion may account for over
80% of the total androstenedione production, with a substantial
reduction in the evening (Lachelin et al., 1979). Consequently,
the time of sampling should be considered in the interpretation
of the plasma value. Furthermore, in the early follicular phase,
the daily secretion of the adrenals (1.2 mg) exceeds that of both
ovaries (0.8 mg). Thereafter, as the developing follicle secretes
increasing amounts of androstenedione which is reflected by
an elevation of plasma concentrations, a 2-fold increase in the
daily production is usually observed near the mid-cycle (Baird,
1976). This increase is maintained during the luteal phase.
Testosterone is considered as the most potent of androgens,
acting directly or throughout conversion to dihydrotestosterone
(DHT). On the basis of hormonal measurement from ovarian
and adrenal venous blood, it has been shown (Kirschner et al.,
1976) that approximately 25% of total testosterone is produced
by the ovary, while 25% is of adrenal origin and the remaining
50% arises from peripheral (liver, fat, skin) metabolism of pre-
hormones, mainly androstenedione.
DHEA and its metabolite, DHEA-sulphate, are less active
biologically than the other androgens. Only 10% of the daily
production (8 mg) of DHEA can be accounted for by ovarian
secretion. Conversion of Δ5-steroids to Δ4-steroids also occurs
at extra-glandular sites, but in insignificant amounts.
Overall, these data show that the ovary only partly contributes
to androgen production. Within the ovary the stroma plays a
major role, but theca interna cells are also gradually involved in
the overall production as follicle proceeds to maturation.
Regulation of ovarian androgen
production
LH exerts a key role in the control of androgen secretion.
Indeed, LH acts on theca cells to stimulate the enzymatic
complex (cytochrome P450c17 including 17α-hydroxylase
and C17–20-lyase activity) which converts pregnenolone
and progesterone to androstenedione. LH increases cyclic
AMP (cAMP) production and cytochrome P450c17 synthesis
as a consequence of increased gene transcription, which is
dependent upon steroidogenic factor 1 (SF1) as well as other
transcription factors.
In normal ovaries, theca 17-OH-progesterone and androgens
rise in response to low doses of LH. Peak output is achieved
at moderate LH dosage and higher doses induce no further rise
(Gilling-Smith et al., 1994). According to comparative analysis
of androgen response to gonadotrophin-releasing hormone
(GnRH) agonist administration in men and women, it appears
that 17,20-lyase activity is much higher in Leydig cells than
in theca cells (Rosenfield et al., 1993).
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 Symposium - Impact of androgens on fertility - J-N Hugues & I Cédrin Durnerin
In contrast, little information has been provided so far on the
regulation of ovarian 17β-hydroxysteroid-dehydrogenase
activity, which ensures the conversion of androstenedione to
testosterone.
Besides the direct effect of LH on theca cells, there is also
some evidence in vitro that the granulosa cells participate in
local amplifying loops which regulate the inflow of androgens
from the theca cells. Indeed, inhibins, produced by granulosa
cells, act synergistically with LH in a paracrine fashion to
increase androgen production by the theca cells (Hsueh et al.;
1987; Hillier et al., 1991a; Nahum et al., 1995). Similarly,
IGF-1, expressed by granulosa cells, has been shown to
increase LH-induced androgen synthesis by the theca cells
synergistically with inhibins (Hillier et al., 1991a; Nahum et
al., 1995). In contrast, activin, although structurally related to
inhibin, antagonizes LH-induced androgen production by the
theca cells (Hsueh et al., 1987; Hillier et al., 1991b).
Metabolism of androgens within the
ovary
While androgens produced by the theca cells are partly
released into the blood to exert peripheral effects, a critical
role of androgens within the ovary results from the conversion
of androgens to oestrogens. Indeed, according to the two-
cell/two-gonadotrophin theory (Ryan et al., 1968), androgens
act as substrates for aromatase activity of granulosa cells,
where they are converted into oestrogens. This step is
essential because, to maintain optimal follicular growth
and development, both types of steroids must be present in
a delicate balance. Too low androgen concentrations will
impair oestrogen production. Conversely, high amounts of
androgens may exert negative effects on different processes
important for follicular growth (see below).
In normo-ovulatory cycles, the follicular fluid content of
steroids is closely related to follicular health and maturity.
Indeed, while high concentrations of oestradiol are associated
with healthy follicles containing oocytes capable of resuming
meiosis in vitro, high concentrations of androgens would
indicate atretic changes. Moreover, oocytes from androgenic
follicles are less prone to resume meiosis in vitro (Bomsel-
Helmreich et al., 1979; McNatty et al., 1979; Brailly et al.,
1981; Westergaard et al., 1986). The ratio of oestradiol to
androgen in follicular fluid obtained throughout the follicular
phase in women with normal menstrual cycles seems to be
one of the most precise parameters to distinguish whether
follicles with a diameter >6 mm are healthy or atretic
(Bomsel-Helmreich et al., 1979; McNatty et al., 1979, 1983;
Westergaard et al., 1986; Seibel et al., 1989).
Therefore, these data show that the androgen/oestradiol ratio
in follicular fluid expresses a functional relationship between
theca cell-derived androgen synthesis and the ability of the
granulosa cells to aromatize androgens, which characterize
follicular health.
Actions of ovarian androgens
Specific androgen receptors that mediate the actions of these
572 steroids have been identified by immunohistochemistry in
human ovary. Several studies in human beings (Horie et al.,
1992; Suzuki et al., 1994) reported that staining intensity for
androgen receptors in the granulosa cells of dominant follicles
was much stronger than that of secondary follicles, which
suggests that androgen action, mediated by androgen receptors,
might play some role in the growth and maturation of dominant
follicles. However, Hillier et al. (1997), using a highly specific
androgen receptor antiserum in monkeys, showed that androgen
receptors are developmentally regulated with a progressive
disappearance as the follicle proceeds to the final stage of
maturation. The functional relevance of androgen receptor loss
in preovulatory follicles is still a matter of debate. It might
serve to diminish the potentially deleterious effects of androgen
on granulosa cell function, forming part of the intraovarian
mechanism that determines which follicles become dominant
and ovulate in primate ovarian cycles.
Two main actions of androgens within the ovary have been
demonstrated.
Effects of androgens on steroidogenesis
The identification of androgen receptors within the granulosa
cells led to the assumption that androgens might also exert a
paracrine effect on the regulation of steroidogenesis.
In-vitro studies have shown that androgens modulate the FSH-
stimulated aromatase activity of granulosa cells according to
the stage of follicular development. Indeed, while FSH-induced
aromatase activity in cells from small follicles is significantly
enhanced by the presence of testosterone, this steroid causes a
marked and significant suppression of FSH-induced aromatase
activity in cells from large follicles (Harlow et al., 1988).
A similar development-dependent change in the ability of
androgens (testosterone and DHT) to modulate LH/human
chorionic gonadotrophin (HCG)-stimulated aromatase activity
has also been demonstrated (Shaw et al., 1989).
These data on the modulation of FSH-dependent steroidogenesis
highlight the general paracrine role of androgens in the primate
ovarian function
Effects of androgens on folliculogenesis
(experimental–clinical models)
The role of androgens on the process of folliculogenesis is
still a matter of debate. One reason is related to the species-
dependent effects of androgens on follicular growth. Indeed, in
rodents, androgen excess has been shown to induce atresia of
developing follicles (Hillier and Ross, 1979; Billig et al., 1993).
In contrast, in primates, there is some evidence that androgens
may actually exert a synergistic effect with FSH to promote
follicular recruitment.
Indeed, a series of experiments have recently been performed
by Bondy and her collaborators in Bethesda to assess the effects
of administration of large androgen doses on folliculogenesis
in monkeys. These researchers first observed that a short-term
administration of high doses of androgens (4 mg/kg for 3
days or 0.4 mg/kg for 10 days) to monkeys induced dramatic
morphological changes of the ovaries, which actually gained
the appearance of polycystic ovaries (Vendola et al., 1998). In
 Symposium - Impact of androgens on fertility - J-N Hugues & I Cédrin Durnerin
fact, the ovaries of testosterone-treated animals were enlarged,
with increased antral follicle numbers compared with controls.
Furthermore, androgen administration induced more than a 2-
fold increase in capsular thickness. Most importantly, the total
number of growing pre-antral and small antral follicles was
actually increased by 2.5- to 4.5-fold, while the number of
large antral follicles remained unchanged. Other experiments
provided evidence for a positive effect of androgens on follicular
proliferation attested by expression of cell proliferation markers
(Ki67 antigen). Conversely, follicular atresia was not increased
and there were actually fewer apoptotic granulosa cells as
assessed by the TUNEL [TdT (terminal deoxynucleotidyl
transferase)-mediated dUDP nick-end labelling] system
(Vendola et al., 1998; Weil et al., 1998). In addition, androgen
receptor gene expression was positively related to follicular
growth and granulosa cell proliferation and negatively related
to follicular atresia and granulosa cell apoptosis. Therefore, it is
likely that, in primates, androgen receptors are involved in the
control of some stages of follicular growth. They also provide
evidence that a short-term administration of extra-physiological
doses of androgen might stimulate the pre-antral and small
antral stages of primate follicular growth.
In another set of experiments, the same group reported that
androgens are likely to act on folliculogenesis by increasing the
number of FSH receptors expressed in granulosa cells (Weil et
al., 1999). The mechanism whereby androgen administration
increases granulosa FSH-receptor gene expression is unclear.
This could be an indirect effect via increased IGF 1 and IGF1
receptor gene expression, which has also been shown in
androgen-treated monkeys. However, a recent study (Zeleznik
et al., 2004) using a more physiological model could not
demonstrate that androgens actually improve the ovarian
sensitivity to gonadotrophins. Indeed, in monkeys pretreated
with GnRH antagonist and DHT or testosterone, the ovarian
responsiveness to a pulsatile infusion of FSH and LH was not
increased. However, the limited number of tested animals and
the large variability in the ovarian response preclude any firm
conclusion from this study.
In summary, in addition to their role of precursors to oestrogen
biosynthesis, androgens seem to have positive trophic effects
upon follicle development in the monkey ovary.
Besides these experimental data, further evidence for any
positive effect of androgens on follicular proliferation and
growth in humans comes from pharmacological or pathological
models.
Firstly, frankly masculinizing plasma concentrations of
androgens are capable of inducing the histopathological
changes of polycystic ovarian syndrome (PCOS) in the ovary
and bringing about follicular maturation arrest. Indeed, long-
term exposure to large doses of exogenous testosterone in
female to male transsexuals has been associated with an
increased tunica albuginea depth and increased thickness of
the basal membrane (Amirikia et al., 1986). Additional studies
reported morphological features consistent with PCOS attested
by a significant increase in the number of small antral follicles
(Futterweit et al., 1986; Spinder et al., 1989, Pache et al.,
1991).
Secondly, polycystic-like ovaries have been described in women
with some non-ovarian causes of hyperandrogenism, such as
congenital adrenal hyperplasia (Lucis et al., 1966; Erickson et
al., 1989).
Finally, high androgen production may account for the antral
follicle excess usually observed in patients with PCOS
(De Leo et al., 1998). Indeed, a highly significant positive
correlation between the number of small follicles and androgen
concentrations has been reported (Jonard et al., 2003; Pigny et
al., 2003). Finally, as shown by Fauser and colleagues (Imani
et al., 2000), the ovarian response to FSH and the risk of
hyperstimulation are closely related to the concentrations of
serum androstenedione and free-androgen index.
While these data cannot exclude that androgen excess is the
consequence rather than the cause of the increased follicular
count observed in hyperandrogenic patients, data collected
from experiments with androgen administration in monkeys
and humans provide indirect evidence for a primary role of
androgens in the process of follicular excess. Furthermore,
they show that, in primates, androgens may play a critical role
in the control of follicular development and in the follicular
sensitivity to FSH.
Clinical and therapeutic aspects
In a clinical workup, assessment of androgen production is usually
performed at the beginning of the cycle by the measurement of
serum androgens. However, as discussed below, several pitfalls
still exist in the methodology of the androgen assay. This may
lead to misdiagnosis of some pathological conditions. Two
situations are commonly observed in clinical practice. The
first deals with androgen excess. The most common feature
is related to PCOS where both excess of follicles and chronic
anovulation have been mainly attributed to hyperandrogenism.
One challenge for clinicians involved in reproductive medicine
is to control hyperandrogenism. The effectiveness of therapeutic
agents to reduce androgen hypersecretion and further restore
ovulation will be considered. The second situation is related
to androgen insufficiency. An age-related decline in ovarian
androgen secretion has been demonstrated as well as a decreased
responsiveness to LH stimulation during the late 30s (Piltonen
et al., 2003). With respect to the potential beneficial effects of
androgens on folliculogenesis, this paper will challenge the
issue of androgen supplementation for some women in order to
improve the ovarian responsiveness to FSH.
Measurement of serum androgens
Androgens are routinely measured as part of a clinical work-
up, particularly in women with hyperandrogenism and
oligomenorrhoea. Therefore, it is essential to have a closer look
at the main problems inherent in the measurement of androgens
in women.
Firstly, the measurements of androgens (e.g. testosterone,
free testosterone and androstenedione) in blood is notoriously
inexact. Indeed, the small size and significant similarity of
many of these molecules, including oestradiol, explains why,
to be exact, this assay requires a purification step with serum
extraction and chromatography of the blood sample. However,
most laboratories currently use commercial kits that measure 573
 Symposium - Impact of androgens on fertility - J-N Hugues & I Cédrin Durnerin
androgens in unextracted serum. This is likely to explain
between kit variability which has been reported to be highly
significant in women with low androgen values (Boots et al.,
1998). Furthermore, free testosterone represents only 2% of total
testosterone but, so far, commercial kits are unable to directly
measure this bio-active part of testosterone (Azziz, 2003). The
calculation of the free androgen index (FAI) (total testosterone/
sex hormone-binding globulin; SHBG) can indirectly but not
accurately reflect the circulating free fraction of testosterone.
Indeed, while SHBG is a major determinant of the bioavailability
of sex steroids, variations in plasma concentrations of
SHBG impact significantly on the amount of free androgens.
Furthermore, SHBG has different binding affinities for sex
steroids (DHT > testosterone > androstenedione) and weakly
binds DHEA. Therefore, improvement in kit reliability is
clearly needed.
Secondly, the normal range of serum androgen concentrations is
particularly large and estimated to be 0.05–0.97 ng/ml in a recent
study (Barbieri et al., 2005). This range is usually calculated
by kit manufacturers by measuring blood concentrations of the
hormone in a small number of unselected women. As some of
them might have a degree of hyperandrogenism, it has been
assumed that the upper limit of this assay might have been
overestimated (Carmina et al., 1999).
Thirdly, as previously mentioned, serum androgen concentrations
show some circadian and cycle variations. Therefore, samples
should be performed under very strict conditions to provide
consistent information.
Finally, serum testosterone values should be interpreted
according to some clinical parameters. Indeed, it has been shown
that, in cycling infertile women, high BMI (>26) and cigarette
smoking are associated with increased serum testosterone and
FAI (Barbieri et al., 2005). Conversely, advancing age is usually
associated with decreased serum testosterone concentrations.
Therefore, serum androgen measurements should be cautiously
interpreted. These pitfalls in androgen measurement and
interpretation could explain why some patients with PCOS might
be classified as ‘normal’ as regards androgen concentrations
(Azziz, 2003). They also emphasize how difficult the diagnosis
of androgen deficiency could be when using the usual kits
provided for measurement of serum androgens.
Hyperandrogenism
In women facing clinical hyperandrogenism, determination
of serum androgens (testosterone, androstenedione, 17-OH-
progesterone, DHEA-S) is helpful in separating patients
according to the presumed ovarian, adrenal or idiopathic origin
of the clinical symptoms.
Idiopathic hyperandrogenism in young adolescents without
menstrual dysfunction and infertility has been attributed to
hypersensitivity of peripheral tissues to androgens without any
excess in androgen production (Serafini and Lobo, 1985). In
this situation, the reason for consultation is mostly cosmetic
and anti-androgen agents are indicated.
574 In other cases, a late onset 21-hydroxylase deficiency is
suspected on the basis of a baseline or post-ACTH increase in
serum 17-OH-progesterone and androstenedione concentrations.
The adrenal origin of the androgen excess in those patients
justifies the prescription of glucocorticoids to suppress the
corticotrophin axis.
Finally, PCOS appears to be the most common situation of
hyperandrogenism and is commonly associated with anovulatory
infertility. Further to in-vitro studies, steroidogenic properties
of both compartments within the follicle from PCOS patients
are modified. On the one hand, theca cell steroidogenesis is
dramatically stimulated as demonstrated by a 20-fold increase
in androstenedione secretion and a 10-fold increase in 17-OH-
progesterone production, regardless of menstrual cycle history.
On the other hand, granulosa cells remain steroidogenically
competent, attesting that follicles are not atretic in anovulatory
patients whose oestradiol production is significantly enhanced.
In this context, ovarian androgen hypersecretion is likely to
account for anovulation. However, the mechanism leading
to the arrest in follicular growth remains unclear. One of the
most convincing explanations for anovulation in PCOS women
came from in-vitro studies providing evidence for premature
activation of LH effects in antral follicles of anovulatory PCOS
women (Willis et al., 1998). In normal ovaries, granulosa cells
usually respond to LH when the follicle has reached 9–10 mm
in diameter. In contrast, LH induces secretion of oestradiol
and progesterone by granulosa cells from follicles as small as
4 mm, derived from anovulatory women with PCOS (Willis
et al., 1998). This ‘premature response to LH’ is associated
with accumulation of cAMP which should be responsible
for follicular development arrest. This prematurely advanced
stage of development is likely to be the result of the effects of
hyperandrogenism in association with high concentrations of
LH and hyperinsulinism.
Overall, these data provide some evidence for a critical
role of androgen excess in the process of PCOS. However,
as demonstrated in adolescents who displayed precocious
pubarche, the development of ovarian hyperandrogenism
is also dependent on genetic factors. Variation in androgen
receptor receptivity with shorter androgen receptor gene
CAG repeat number has been shown to account for increased
androgen sensitivity (Ibanez et al., 2003). Furthermore, insulin
and several growth factors contribute to the development of
ovarian hyperandrogenism with individual variations linked to
polymorphism related to insulin transcription levels (Ibanez et
al., 2001).
In addition, other negative effects of androgen excess on
reproductive function have been demonstrated in cycles
stimulated for assisted reproductive technologies. Indeed, studies
comparing the concentrations of total and free biologically active
androgens and oestrogens in conception and non-conception
cycles have shown that androgen concentrations throughout
the follicular phase were significantly lower in conception
cycles (Yding Anderson and Ziebe, 1992). In another study,
Yding Anderson (1993) showed that the oestradiol to androgen
ratio should express the oocyte quality and may be related to
the pregnancy potential. Therefore, androgen hypersecretion,
especially free biologically active androgen, seems to affect
conception negatively. Furthermore, it has been assumed that
the deleterious effect of androgen excess on fertility should also
 Symposium - Impact of androgens on fertility - J-N Hugues & I Cédrin Durnerin
be exerted through a negative effect on endometrium receptivity
where androgen receptors have been identified (Horie et al.,
1992).
Whatever the mechanism involved in the infertility process
related to ovarian hyperandrogenism, the next issue to be
addressed is the management of ovarian androgen excess in
order to restore ovarian function and fertility.
As shown in Figure 2, many therapeutic tools have been
proposed to control ovarian androgen secretion.
Some agents act on gonadotrophin secretion, assuming that
adequate control of LH secretion should restore a normal
ovarian responsiveness to FSH. For that purpose, contraceptive
pills or GnRH analogues have been proposed as a pretreatment
before FSH therapy. There is so far no convincing evidence for
a clear benefit of short-term pretreatment because the risk of
hyperstimulation under FSH treatment remains high. Indeed, the
FSH threshold for follicular development does not seem to be
modified. However, long-term suppression of the gonadotroph
axis with an oral contraceptive regimen is likely to be more
effective. Moreover, it has been shown that dual suppression with
oral contraceptives and GnRH agonists is effective in reducing
the risk of hyperstimulation (Damario et al., 1997). Therefore,
both duration and intensity of pituitary suppression seem to
Figure 2. Different impacts of medications used to reduce androgen secretion and/or peripheral androgenic effects. GnRH =
gonadotrophin-releasing hormone, DHT = dihydrotestesterone.
be critical for restoring ovarian sensitivity to FSH. The use of
cyproterone acetate, which acts simultaneously on pituitary LH
secretion and on peripheral sensitivity to androgen, has not been
proved to be effective in restoring fertility, but could be of interest
as a pretreatment prior to FSH stimulation (Hwang et al., 2004).
Other interventions may be effective by acting directly on ovarian
androgen hypersecretion and may contribute to the restoration of
normal menstrual cyclicity.
Laparoscopic ovarian drilling proved to be quite effective.
Indeed, this surgical procedure is able to significantly reduce
ovarian androgen secretion and to further restore spontaneous
cycles (Bayram et al., 2004).
Several medical interventions have also been proposed to control
hyperandrogenism, but these therapeutic agents do not display
a selective action on the ovary. This is the case for insulin
sensitizers, mainly metformin. This medication primarily acts on
insulin sensitivity and reduces circulating insulin concentrations.
As insulin has been shown to stimulate both LH and androgen
theca cell secretions, metformin may indirectly contribute to
reduce plasma androgens in PCOS women (Norman, 2004).
Moreover, it has been shown that metformin may also decrease
androgen secretion through a direct effect on ovarian 17α−
hydroxylase (Mansfield et al., 2003). As recently reported
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 Symposium - Impact of androgens on fertility - J-N Hugues & I Cédrin Durnerin
(Palomba et al., 2004), metformin administration in PCOS
patients is as efficacious as laparoscopic ovarian drilling in
restoring ovulation, and is more cost-effective. A direct and even
stronger anti-androgenic effect at the ovarian level has also been
shown with the new class of thiazolidinediones (Arltt et al., 2001),
which might be promising in the management of infertility in
hyperandrogenic women. Nevertheless, it should be emphasized
that weight reduction and lifestyle modification is the first line
therapy in overweight PCOS women in order to improve insulin
sensitivity and to restore ovulation (Norman, 2004).
Other therapeutic agents acting as anti-androgens on
peripheral tissues and currently used in women with idiopathic
hyperandrogenism also exert a direct effect on ovarian androgen
secretion.
Flutamide, a non-steroidal anti-androgen, acts by blocking
androgen receptors, but also reduces androgen synthesis and/
or increases its metabolism to inactive androgen (Brochu et
al., 1987). In that way, flutamide is able to restore ovulation
in anovulatory PCOS patients (De Leo et al., 1998). However,
there is still concern about the use of flutamide in women with
infertility because the risk of teratogenic side effects has not been
definitely excluded.
Spironolactone competes with androgens (testosterone and DHT)
on their respective receptors but is also effective in inhibiting
17α-hydroxylase and C17–20-lyase activities (Boisselle and
Tremblay, 1979). However, this medication is usually associated
with menstrual dysfunctions and prolonged infertility.
In contrast, finasteride, a member of the azasteroid family,
only inhibits 5α-reductase activity and consequently blocks
the conversion of testosterone into dihydrotestosterone in
periperal tissues. However, it does not interfere with ovarian and
gonadotrophin secretion and is meaningless for the treatment of
ovulatory disorders in PCOS patients (Fruzzeti et al., 1994).
Another issue to be addressed as regards the control of
hyperandrogenism is related to the specific role of the adrenals.
While there is some evidence that in PCOS women, adrenals may
contribute to hyperandrogenism in terms of an excessive androgen
response to ACTH due to greater Δ5 17α-hydroxylase activity
(Moran et al., 2004), the administration of dexamethasone has not
proved to be effective in restoring ovulation. Similarly, in women
with idiopathic hirsutism who usually have normal menstrual
cycles, there is no reason to recommend such medication in
clinical practice. In contrast, dexamethasone is usually effective
in controlling the concentrations of androgen secretion in patients
with late onset 21-hydroxylase deficiency.
In summary, ovarian hyperandrogenism is likely to contribute
to both an excess antral follicle count and anovulation. The
major objective of any clinical interventions should be to control
ovarian androgen secretion adequately. However, there is so far
no clear evidence that, among the pharmaceutical arsenal, one
specific medication might meet this expectation. Nevertheless,
according to a recent report (Palomba et al., 2004), medical or
surgical interventions acting directly on the ovaries seem to be
effective and should be considered as a first line therapy rather
than therapeutic agents interfering at the pituitary level with
gonadotroph secretion.
576
Androgen deficiency and supplementation
It has been previously reported that plasma androgen
concentrations decrease in elderly women (Piltonen et al., 2003).
Indeed, there is some evidence that the ageing ovary is no more an
androgen-producing gland (Couzinet et al., 2001). This could be
partly related to the decreased responsiveness to LH stimulation
reported during the late 30s (Piltonen et al., 2003). Furthermore,
during the menopausal transition, the ovarian sensitivity to FSH
is reduced and the success of IVF procedures is usually low. In
clinical practice, the ovarian reserve is commonly assessed by
measurement of hormonal parameters such as FSH, oestradiol and
inhibin B, which only reflect granulosa cell healthy condition.
Until recently, little attention had been paid to the assessment
of the theca cell function in women to predict the ovarian
responsiveness to gonadotrophins. Recently, Frattarelli and
Peterson (2004) reported interesting data on the predictive value
of serum androgen concentrations in 43 normo-ovulatory women
enrolled in an IVF programme. The purpose of their study was
to investigate whether serum testosterone concentrations are
related to IVF outcomes. While serum androgen concentrations
were not related to the ovarian volume or the number of antral
follicles, a negative correlation was observed between serum
androgen concentrations and the total dose of FSH or the days of
stimulation. More importantly, they reported that a low baseline
testosterone value was predictive for a poor cycle outcome
with a threshold estimated at <0.2 ng/ml. Indeed, women with
baseline testosterone values lower than 0.2 ng/ml were 5 times
less likely to achieve pregnancy. The ability of serum androgen
concentrations to predict ovarian response in assisted reproduction
cycles was confirmed in another study by Barbieri et al. (2005).
Indeed, they observed a positive correlation between baseline
plasma testosterone or FAI and the number of retrieved oocytes
in regularly cycling infertile women undergoing their first IVF
cycle.
Therefore, these data show that assessment of theca cell function
is valuable in predicting the ovarian responsiveness to FSH.
In conjunction with experimental data which demonstrate
the potential positive role of androgens on folliculogenesis, it
has been assumed that administration of androgens could be
beneficial in women with a low response to FSH. However,
studies performed so far in human beings and using physiological
androgen supplementation are still scarce.
Casson et al. (2000) assessed the effects of dehydroepiandrosterone
(DHEA), a steroid precursor, on the ovarian responsiveness to
FSH. For that purpose, DHEA (80 mg/day) was administered 2
months prior to ovarian stimulation and intrauterine insemination
to patients who had previously experienced a poor response
to gonadotrophins. In those patients whose baseline serum
DHEA-S concentrations were relatively low, the authors in fact
observed an increase in testosterone serum concentrations and an
improvement in the hormonal response to gonadotrophins. While
the small number of patients enrolled in this study, as well as
the absence of randomization and a placebo controlled group,
preclude any firm conclusion, this study was the first to address
the issue of the potential benefit of androgen supplementation on
the ovarian sensitivity to FSH in 35- to 40-year-old women with
a low sensitivity to FSH.
 Symposium - Impact of androgens on fertility - J-N Hugues & I Cédrin Durnerin
In a recently reported study (Hugues et al., 2004), it was assumed
that androgen supplementation during the early phase of follicular
recruitment might improve the number of small antral follicles
as well as ovarian sensitivity to FSH. To test this hypothesis,
a double-blind, placebo-controlled, prospective, randomized
study was set up to assess the effects of testosterone application
on the ovarian response to FSH in a subgroup of patients who
had previously experienced a poor ovarian response to ovarian
stimulation (oestradiol value <1200 pg/ml at day HCG and
number of total retrieved oocytes ≤5) together with a low ovarian
reserve.
The design was set up to perform a paired comparison of the
ovarian parameters recorded in two consecutive cycles, each
woman being used as her own control. The first cycle allowed
selection of patients according to the inclusion criteria while
the second cycle was performed after application of a gel filled
with testosterone or placebo. The protocol used for ovarian
stimulation was comparable in the two consecutive cycles with
similar GnRH analogue protocol as well as identical starting
dose of recombinant FSH. A gel containing 1% testosterone or
placebo was applied once daily (the test gel containing 10 mg of
testosterone) on the external face of the thigh in order to achieve
a plasma testosterone concentration within the upper part of the
normal range for women. (Slater et al., 2001). Either testosterone
gel or placebo gel was applied for 15–20 days in the period
preceding the second stimulation for IVF or ICSI, i.e. during the
period of pituitary desensitization in women treated with a long
GnRH agonist protocol or during pill administration in women
treated with another analogue protocol.
The primary end-point was the number of total retrieved oocytes.
Twenty-five placebo-treated and 24 testosterone-treated patients
actually completed the study and participated in the final analysis.
Mean plasma testosterone values significantly increased from
0.58 ± 0.03 to 1.55 ± 0.18 ng/ml (P < 0.0001) in testosterone
treated women. However, the count of small antral follicles (3–9
mm in diameter) before FSH stimulation as well as plasma anti-
Müllerian hormone concentrations were not significantly affected
by either testosterone nor placebo gel administration.
Figure 3. The effects of testosterone or placebo gel administration on the ovarian response to FSH stimulation. Different graphs
indicate the number of follicles according to their size. Results are expressed as means ± SEM. S = stimulation day, HCG = human
chorionic gonadotrophin.
Furthermore, as shown in Figure 3, the comparative analysis
of the number of follicles at day 1, day 8 and day of HCG of
the FSH stimulation did not show any significant difference
between both treated groups. Criteria for HCG administration
were met and oocyte retrievals were performed in 16 women
treated with testosterone (67%) and in 20 women treated with
placebo (80%).
The total dose of FSH used during ovarian stimulation, as
well as plasma oestradiol values at the time of HCG, were
similar in the two groups. Finally, the comparison between the
number of follicles, oocytes and embryos observed in placebo
and testosterone-treated patients did not show any significant
difference (Figure 4).
In conclusion, this prospective, randomized, double-blind,
placebo-controlled study was not able to demonstrate any
beneficial effect of testosterone application on the ovarian
responsiveness to FSH in women who had previously
experienced a poor ovarian response. These data also show
that androgen supplementation does not exert any detrimental
effects on the ovarian response to FSH and provides indirect
evidence that androgens have no atretogenic action on follicular
growth in humans.
The absence of any beneficial effects of testosterone application
observed in this study may be due to several reasons. Firstly, the
androgen secretion of women enrolled in the IVF programme
was presumably normal. Indeed, their basal plasma androgen
concentrations were within the normal range. Therefore, it may
be assumed that androgen supplementation may be effective
only in patients with a decreased androgen production. If
this hypothesis is valid, this would imply that basal androgen
secretion should be more carefully assessed in patients at
risk for a poor ovarian response. Further studies are required
to investigate whether dynamic tests of theca cell stimulation
could be helpful in predicting the ovarian sensitivity to FSH.
Secondly, the timing and the duration of androgen
supplementation could be critical to adequately stimulate
577
 Symposium - Impact of androgens on fertility - J-N Hugues & I Cédrin Durnerin

Figure 4. IVF outcomes in the control cycle (CC) and the treated cycle (TC). Results are expressed as means ± SEM in both
placebo group (dark grey and white bars) and testosterone group (light grey and black bars). Asterisks indicate significant statistical
differences in paired comparison between CC and TC within each placebo or testosterone group. No statistical difference was observed
between patients treated with testosterone or placebo gels. SHCG = day of human chorionic gonadotrophin administration.

follicular growth. In this study, testosterone was only
administered prior to FSH administration and the application
was restricted to 2 weeks to prevent any side effects. However,
as suggested by data reported by Casson et al. (2000), a longer
duration of androgen application before and during FSH
stimulation might be required to improve follicular growth
effectively.
Thirdly, the total amount of androgen supplementation may
also be a major determining factor of success. In this study,
the daily dose and the route of administration were chosen
to get steady supra-physiological concentrations of serum
testosterone. Such a design largely differs from those reported
in monkey experiments or in studies performed in female to
male transsexuals. Up to now, data on the dose dependent
effects of androgen have not been available and further clinical
studies are clearly needed.
Finally, to validate the concept of the androgen control of
follicular growth, a systemic administration of androgens might
not have been optimal. Indeed, in-situ androgen concentration is
likely to be critical for achieving a paracrine stimulatory effect
on follicles. In that respect, an alternative to systemic androgen
administration could be the administration of exogenous LH- or
578 LH-like activity to stimulate in-situ production of androgens.
Indeed, a recent report suggests that LH supplementation may
be beneficial for women with low ovarian response to FSH (De
Placido et al., 2005).
Therefore, while the data were not able to demonstrate a
beneficial effect of androgen supplementation in patients with
a decreased ovarian reserve, it is still unclear whether androgen
supplementation might be useful to improve the ovarian
sensitivity to gonadotrophins in a subgroup of women with low
serum androgen concentrations but without ovarian deficiency.
Further studies are required to validate the concept of androgen
related control of follicular growth.
Conclusion
Altogether, these data emphasize the importance of androgen
assessment in infertile women. However, there is still room
for improvement in the measurement of serum androgens by
using commercial kits with higher sensitivity and reliability.
Androgen ovarian excess which largely contributes to
both enhanced number of small antral follicles and chronic
anovulation in PCOS patients remains imperfectly controlled
and new medications such as insulin-sensitizing drugs seem to
be promising for reducing androgen secretion. Conversely, as
 Symposium - Impact of androgens on fertility - J-N Hugues & I Cédrin Durnerin
androgens seem to have a positive impact on folliculogenesis
in human beings, androgen deficiency should be more carefully
assessed in clinical practice. Indeed, androgen supplementation
could be beneficial for a subgroup of women with a low response
to FSH. However, additional studies are required to validate
this concept and to better identify the subgroup of patients who
should benefit from androgen supplementation.
This review supports a specific and broad role of androgen in
reproductive physiology. In clinical practice, more attention
should be paid to androgen assessment and additional
randomized clinical trials are needed to better elucidate their
impact on infertility.
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