Abstract
Diminished ovarian reserve (DOR) is common in women with infertility and is associated with poorer in vitro fertilization (IVF) outcomes. Testosterone is widely used off-label in this patient group, although evidence for its efficacy and safety is limited. To address this, we conducted a triple-blind, placebo-controlled, randomized clinical trial evaluating whether transdermal testosterone gel prior to IVF improves clinical pregnancy rates in women with DOR. Females aged 18-43 with infertility and DOR according to the Bologna criteria were recruited at 10 fertility clinics in Europe between April 2015 and November 2022. Of 316 assessed for eligibility, 290 were enrolled and randomized. Two were excluded from the primary analysis as their treatment coincided with the onset of the COVID-19 pandemic, and they did not start ovarian stimulation, leaving 288 participants. Participants were randomized to 5.5 mg of transdermal testosterone or matching placebo once daily for ~9 weeks prior to ovarian stimulation. All participants received ovarian stimulation in a long GnRH-agonist cycle with 300IU/day of highly purified human menopausal gonadotropin; fresh embryo transfer was performed if an embryo was available. The primary outcome was clinical pregnancy rate following fresh embryo transfer, defined as an intrauterine gestational sac with an embryo demonstrating cardiac activity at ≥7 weeks’ gestation. Of the 288 participants, 134 were randomized to testosterone and 154 to placebo. Clinical pregnancy rates did not differ significantly, occurring in 21 women (15.7%) in the testosterone group and 23 (14.9%) in the placebo group (risk ratio (RR), 1.05; 95% confidence interval (CI) 0.61 to 1.81, p = 0.86). The study was terminated for futility at the prespecified interim analysis based on a conditional power calculation once 70% of the target sample size were randomized. In this study, transdermal testosterone did not improve clinical pregnancy rates compared with placebo in patients with infertility and DOR. Trial Registration: ClinicalTrials.gov: NCT02418572, EudraCT: 2014-001835-35
Similar content being viewed by others
Data availability
The data generated and analyzed during this study are not publicly available due to ethical and legal restrictions associated with participant consent and data protection regulations for this multicenter randomized clinical trial. De-identified data will be made available from the corresponding author upon request, subject to approval by the relevant ethics committees and data-sharing agreements.
References
World Health Organization. Infertility Prevalence Estimates, 1990–2021. (WHO, 2023).
Franasiak, J. M. et al. The nature of aneuploidy with increasing age of the female partner: a review of 15,169 consecutive trophectoderm biopsies evaluated with comprehensive chromosomal screening. Fertil. Steril. 101, 656–663.e1 (2014).
Centers for Disease Control and Prevention. 2021 National ART Summary. https://www.cdc.gov/art/reports/2021/summary.html (2023).
Drakopoulos, P. et al. Conventional ovarian stimulation and single embryo transfer for IVF/ICSI. How many oocytes do we need to maximize cumulative live birth rates after utilization of all fresh and frozen embryos? Hum. Reprod. 31, 370–376 (2016).
Devesa, M. et al. Cumulative live birth rates and number of oocytes retrieved in women of advanced age. A single centre analysis including 4500 women ≥38 years old. Hum. Reprod. 33, 2010–2017 (2018).
Neves, A. R., Montoya-Botero, P., Sachs-Guedj, N. & Polyzos, N. P. Association between the number of oocytes and cumulative live birth rate: a systematic review. Best. Pract. Res Clin. Obstet. Gynaecol. 87, 102307 (2023).
Polyzos, N. P. et al. Cumulative live birth rates according to the number of oocytes retrieved after the first ovarian stimulation for in vitro fertilization/intracytoplasmic sperm injection: a multicenter multinational analysis including ∼15,000 women. Fertil. Steril. 110, 661–670.e1 (2018).
Sunkara, S. K. et al. Association between the number of eggs and live birth in IVF treatment: an analysis of 400 135 treatment cycles. Hum. Reprod. 26, 1768–1774 (2011).
ESHRE Add-ons working group et al. Good practice recommendations on add-ons in reproductive medicine. Hum. Reprod. 38, 2062–2104 (2023).
Neves, A. R., Montoya-Botero, P. & Polyzos, N. P. Androgens and diminished ovarian reserve: the long road from basic science to clinical implementation. A comprehensive and systematic review with meta-analysis. Am. J. Obstet. Gynecol. 227, 401–413.e18 (2022).
Patrizio, P. et al. How to define, diagnose and treat poor responders? Responses from a worldwide survey of IVF clinics. Reprod. BioMed. Online 30, 581–592 (2015).
Anderson, M. F. et al. P-780 Off-label use of androgens and letrozole in infertile women - a multinational survey in Europe and Australia. Hum. Reprod. 33, 499 (2018).
Massin, N. et al. Effects of transdermal testosterone application on the ovarian response to FSH in poor responders undergoing assisted reproduction technique—a prospective, randomized, double-blind study. Hum. Reprod. 21, 1204–1211 (2006).
Kim, C.-H., Howles, C. M. & Lee, H.-A. The effect of transdermal testosterone gel pretreatment on controlled ovarian stimulation and IVF outcome in low responders. Fertil. Steril. 95, 679–683 (2011).
Bosdou, J. K. et al. Transdermal testosterone pretreatment in poor responders undergoing ICSI: a randomized clinical trial. Hum. Reprod. 31, 977–985 (2016).
Doan, H. T., Quan, L. H. & Nguyen, T. T. The effectiveness of transdermal testosterone gel 1% (androgel) for poor responders undergoing in vitro fertilization. Gynecol. Endocrinol. 33, 977–979 (2017).
Al-Jeborry, M. M. Efficacy of transdermal testosterone in assisted reproduction outcome of poor responders. Ann. Trop. Med. Public Health 22, 210–218 (2019).
Hoang, Q. H. et al. Therapeutic effect of prolonged testosterone pretreatment in women with poor ovarian response: a randomized control trial. Reprod. Med. Biol. 20, 305–312 (2021).
Subirá, J. et al. Testosterone does not improve ovarian response in Bologna poor responders: a randomized controlled trial (TESTOPRIM). Reprod. Biomed. Online 43, 466–474 (2021).
Zhang, Y. et al. Adjuvant treatment strategies in ovarian stimulation for poor responders undergoing IVF: a systematic review and network meta-analysis. Hum. Reprod. Update 26, 247–263 (2020).
Nagels, H. E., Rishworth, J. R., Siristatidis, C. S. & Kroon, B. Androgens (dehydroepiandrosterone or testosterone) for women undergoing assisted reproduction. Cochrane Database Syst. Rev. https://doi.org/10.1002/14651858.cd009749.pub2 (2015).
Bosdou, J. K. et al. The use of androgens or androgen-modulating agents in poor responders undergoing in vitro fertilization: a systematic review and meta-analysis. Hum. Reprod. Update 18, 127–145 (2012).
Sunkara, S. K., Pundir, J. & Khalaf, Y. Effect of androgen supplementation or modulation on ovarian stimulation outcome in poor responders: a meta-analysis. Reprod. Biomed. Online 22, 545–555 (2011).
Noventa, M. et al. Testosterone therapy for women with poor ovarian response undergoing IVF: a meta-analysis of randomized controlled trials. J. Assist Reprod. Genet. 36, 673–683 (2019).
Polyzos, N. P. et al. Testosterone for poor ovarian responders: lessons from ovarian physiology. Reprod. Sci. 25, 980–982 (2018).
Neves, A. R., Montoya-Botero, P. & Polyzos, N. P. The role of androgen supplementation in women with diminished ovarian reserve: time to randomize, not meta-analyze. Front. Endocrinol. 12, 653857 (2021).
The ESHRE Guideline Group on Ovarian Stimulation et al. ESHRE guideline: ovarian stimulation for IVF/ICSI. Hum. Reprod. Open 2020, hoaa009 (2020).
Saville, B. R., Detry, M. A. & Viele, K. Conditional power: How likely is trial success? JAMA 329, 508 (2023).
Mehta, C. R. & Pocock, S. J. Adaptive increase in sample size when interim results are promising: a practical guide with examples. Stat. Med. 30, 3267–3284 (2011).
Yeung, T. W. Y. et al. A randomized, controlled, pilot trial on the effect of dehydroepiandrosterone on ovarian response markers, ovarian response, and in vitro fertilization outcomes in poor responders. Fertil. Steril. 102, 108–115.e1 (2014).
Wang, Z. 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 129, 1030–1038 (2022).
Walters, K. A. Role of androgens in normal and pathological ovarian function. Reproduction 149, R193–R218 (2015).
Fooladi, E., Reuter, S. E., Bell, R. J., Robinson, P. J. & Davis, S. R. Pharmacokinetics of a transdermal testosterone cream in healthy postmenopausal women. Menopause 22, 44–49 (2015).
Hirschberg, A. L. et al. Effects of moderately increased testosterone concentration on physical performance in young women: a double blind, randomised, placebo controlled study. Br. J. Sports Med. 54, 599–604 (2020).
Ferraretti, A. P. et al. ESHRE consensus on the definition of ‘poor response’ to ovarian stimulation for in vitro fertilization: the Bologna criteria. Hum. Reprod. 26, 1616–1624 (2011).
Roche Diagnostics. Elecsys Testosterone II Data Sheet. https://elabdoc-prod.roche.com/eLD/web/global/en/products/CPS_000519 (2024).
Acknowledgements
The study was supported by unrestricted grants and support to N.P.P. from Besins Healthcare, Roche Diagnostics and Ferring Pharmaceuticals, who had no access to participant data and had no role in the interpretation of the data, nor in the writing or approval of the final manuscript. The study medication and placebo were provided by Besins Healthcare. The researchers were independent of the funders, and all authors had full access to all of the dat×°a in the study and take responsibility for the integrity of the data and accuracy of the data analysis. S.L. is supported by the Jean Murray Jones Scholarship of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists.
Author information
Authors and Affiliations
Contributions
N.P.P. designed and was the lead investigator of the study and is the guarantor of the content. S.L. and N.P.P. interpreted the data and wrote the first draft of the report. N.P.P., F.M., C.B., A.G., L.D., A.P., F.F., D.S., C.D. and P.H. recruited participants. I.R. performed the statistical analysis. S.D. contributed to the study design. All authors contributed to reviewing and editing the final report. All authors had full access to all data in the study and had final responsibility for the decision to submit for publication. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.
Corresponding author
Ethics declarations
Competing interests
All authors have completed the ICMJE uniform disclosure form at http://www.icmje.org/disclosure-of-interest/ and declare the following competing interests. NPP has received grants from Merck Serono, Ferring Pharmaceuticals, Theramex, Organon and Besins Healthcare, consulting fees from Merck Serono, Besins Healthcare, Organon and IBSA, honoraria from Merck Serono, Theramex, IBSA, Ferring Pharmaceuticals, Organon, Roche Diagnostics and Besins Healthcare, and is a shareholder in Alife Fertility and FertilAI. SL has received honoraria from Merck, Organon and Hologic, and educational support from Merck, Organon, Besins Healthcare and Ferring Pharmaceuticals. FM has received educational support from Ferring Pharmaceuticals. CB has received consulting fees and honoraria from IBSA, Ferring Pharmaceuticals, Gedeon Richter, Organon, Merck A/S and Abbott. AP has received grants from Gedeon Richter, Ferring Pharmaceuticals, Merck A/S and Cryos, consulting fees and honoraria from IBS, Ferring Pharmaceuticals, Gedeon Richter, Cryos, Merck A/S and Organon, and educational support from Gedeon Richter. FF has received honoraria from IBSA. SD has received grants from NHMRC Australia, MRFF Australia and the Australian Heart Foundation, and honoraria from Mayne Pharma, Abbott Laboratories, Healthed and Besins Healthcare. PH has received honoraria from Merck, IBSA, Gedeon Richter and Besins Healthcare. AG, LD, DS, IR and CD have no interests to declare.
Peer review
Peer review information
Nature Communications thanks Micah Hill, Amanda Adeleye, Mary Putt and the other, anonymous, reviewer(s) for their contribution to the peer review of this work. A peer review file is available.
Additional information
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Supplementary information
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
About this article
Cite this article
Polyzos, N.P., Leathersich, S.J., Martínez, F. et al. Transdermal testosterone gel vs placebo in women with diminished ovarian reserve prior to in vitro fertilization: a randomized, clinical trial. Nat Commun (2026). https://doi.org/10.1038/s41467-026-69557-z
Received:
Accepted:
Published:
DOI: https://doi.org/10.1038/s41467-026-69557-z
