Letter
Impact of androgen supplementation on the follicular
endocrine milieu in women with hypoandrogenism
To the Editor
We read with great interest the study by von Wolff et al. (2017), in which
they investigated the follicular and serum levels of certain hor-
mones in women undergoing natural cycle IVF. For quite a number
of reasons, however, we have to disagree with the principal conclu-
sion they reached.
Serum and follicular fluids collected at the time of oocyte re-
trieval were assessed for luteinizing hormone (LH), total testosterone
(T), estradiol (E), dehydroepiandrosterone (DHEA) and anti-Müllerian
hormone (AMH) concentration. While within follicular fluids, T cor-
related with E (P < 0.001) and AMH (P < 0.01), and while follicular fluid
and serum LH, E and AMH correlated (P < 0.001), T did not.
From these findings, the authors concluded that the literature over
the last decade widely suggested that the impact of androgen supple-
mentation on the follicular endocrine milieu in hypoandrogenic women
(Prizant et al., 2014) must be questioned.
We disagree with this conclusion for the following reasons.
Firstly, on technical grounds, we consider as questionable how T
was assessed in their study. Because other testing platforms have
proven unreliable, leading endocrinology journals have mandated
that published androgen studies should utilize liquid chromatogra-
phy tandem mass spectrometry exclusively in assessing T and
most other androgens (Wartofsky and Handelsman, 2010). In this
study, an electro-chemiluminescence immunoassay was utilized,
raising technical questions about the validity of the T measure-
ments obtained.
Even assuming the reported T values to be correct, the authors
note that, while serum T declined with advancing female age as
expected (Gleicher et al., 2011), T in follicular fluid did not (their
Figure 1). Since follicular fluid is a serum transudate, this observa-
tion makes little sense physiologically, and T in follicular fluid
should in principle therefore demonstrate similar declines as in
serum. The only possible explanation for the results presented in
Figure 1, would be increased production of T in ovaries. That older
women’s ovaries produce more T than younger women’s is, however,
beyond unlikely.
https://doi.org/10.1016/j.rbmo.2018.03.004
1472-6483/© 2018 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.
T in follicular fluid does, indeed, decline with advancing female
age (Klein et al., 1996). The likelihood of increased androgen levels
with age is also contradicted by increases in ovarian aromatase ac-
tivity in follicular fluid as women age (Shaw et al., 2015), which
increases follicular estrogen levels (as, indeed, was reported in the
study) but which usually lowers androgen levels in follicular fluid.
By investigating androgen levels in follicular fluid at oocyte re-
trieval, von Wolff et al. also apparently misunderstood the biological
rationale for androgen supplementation. Androgen supplementa-
tion is recommended in patients with hypoandrogenic infertility because
small growing follicles (primary through to small antral follicles)
require adequate androgen levels for normal maturation. At those
stages, testosterone (via the androgen receptor on granulosa cells)
acts synergistically in enhancing granulosa cell sensitivity to follicle
stimulating hormone (FSH) (Gleicher et al., 2011; Prizant et al., 2014).
These small growing follicles, however, still require weeks to months
to reach gonadotropin dependency, when they become sensitive to
stimulation in IVF cycles. The testosterone level at oocyte retrieval,
therefore, has little, if any, relevance to the concept of androgen
supplementation at small growing follicle stages.
The authors also failed to consider the rather complex, though
now increasingly well understood, dynamics of ovarian androgen me-
tabolism that, based on a variety of genetic differences, affects
conversion rates of DHEA to T (reviewed by Shohat-Tal et al, 2015).
In addition, a very recent study also reported that the androgen re-
ceptor CAG repeat length affects T levels in follicular fluid, with long
CAG repeat lengths resulting in lower T than intermediate and short
repeat lengths (Borgbo et al., 2016).
Finally, multiple animal models (Prizant et al., 2014) and high-
dose T treatment of female transgender patients have established
clearly the effects androgens exert on ovaries (Loverro et al., 2016).
The conclusion reached by von Wollf et al that ‘it is questionable
whether supplementation with androgens could improve the endo-
crine milieu in follicles [of women with hypoandrogenism]’ is, therefore,
neither biologically nor clinically sustainable.
Readers of this letter are advised to consult the list of compet-
ing interests given in the Declaration below.
720 REPRODUCTIVE BIOMEDICINE ONLINE 36 (2018) 719–720

Declaration: NG and DHB are co- during testosterone administration in young female-to-male
inventors on a number of pending and transsexuals. Taiwan. J. Obstet. Gynecol. 55, 686–691. doi:10.1016/
already awarded US patents claiming j.tjog.2016.03.004.
Prizant, H., Gleicher, N., Sen, A., 2014. Androgen actions in the ovary:
therapeutic benefits from androgen
Balance is key. J. Endocrinol. 222, 141–151. doi:10.1530/JOE-14-
supplementation in women with low
0296.
functional ovarian reserve (LFOR) and Shaw, N.D., Srouji, S.S., Welt, C.K., Cox, K.H., Fox, J.H., Adams, J.A.,
relating to the FMR1 gene in a Sluss, P.M., Hall, J.E., 2015. Compensatory increase in ovarian
diagnostic function in female fertility. aromatase in older regularly cycling women. J. Clin. Endocrinol.
Both receive royalties from Fertility Metab. 100, 3539–3547. doi:10.1210/JC.2015-2191.
Nutraceuticals, LLC, in which NG also Shohat-Tal, A., Sen, A., Barad, D.H., Kushnir, V., Gleicher, N., 2015.
Genetics of androgen metabolism in women with infertility and
holds shares. NG, DHB and VAK are
hypoandrogenism. Nat. Rev. Endocrinol. 11, 429–441. doi:10.1038/
also co-inventors on three pending nrendo.2015.64.
AMH-related patent applications. All von Wolff, M., Stute, P., Eisenhut, M., Marti, U., Bitterlich, N., Bersinger,
authors received research grants, N.A., 2017. Serum and follicular fluid testosterone concentrations do
travel funds and speaker honoraria not correlate, questioning the impact of androgen supplementation
from pharmaceutical companies, on the follicular endocrine milieu. Reprod. Biomed. Online 35,
616–623. doi:10.1016/j.rbmo.2017.07.012.
though none in any way relate to the
Wartofsky, L., Handelsman, D.J., 2010. Standardization of hormonal
materials presented here.
assays for the 21st century. J. Clin. Endocrinol. Metab. 95,
5141–5143. doi:10.1210/jc.2010-2369.
REFERENCES
Norbert Gleicher MD a,b,c,d,
Vitaly A. Kushnir MD David H. Barad MD, MS a,b
a,e

a
Borgbo, T., Macek, M., Sr., Chrudimska, J., Jeppesen, J.V., Hansen, L.L., The Center for Human Reproduction, New York, New York,
Andersen, C.Y., 2016. Size matters: Associations between the 10021, USA
androgen receptor CAG repeat length and the intrafollicular b
The Foundation for Reproductive Medicine, New York, New York
hormone milieu. Mol. Cell. Endocrinol. 5, 12–17. doi:10.1016/
10020, USA
j.mce.2015.09.015. c
Gleicher, N., Weghofer, A., Barad, D.H., 2011. The role of androgens in Stem Cell Biology and Molecular Embryology Laboratory,
follicle maturation and ovulation induction: friend or foe of infertility Rockefeller University, New York, New York
treatment? Reprod. Biol. Endocrinol. 17, 116. doi:10.1186/1477- 10016, USA
7827-9-116. d
Department of Obstetrics and Gynecology, Vienna University
Klein, N.A., Battaglia, D.E., Miller, P.B., Branigan, E.F., Giudice, L.C., School of Medicine, 1090 Vienna, Austria
Soules, M.R., 1996. Ovarian follicular development and the follicular e
Department of Obstetrics and Gynecology, Wake Forest University,
fluid hormones and growth factors in normal women of
Winston Salem VAK, North Carolina
advanced reproductive age. J. Clin. Endocrinol. Metab. 81,
1946–1951. 27101, USA
Loverro, G., Resta, L., Dellino, M., Edoardo, D.N., Cascarano, M.A., E-mail addresses: ngleicher@thechr.com,
Loverro, M., Mastrolia, S.A., 2016. Uterine and ovarian changes ngleicher@rockefeller.edu