Recombinant follicle-stimulating hormone (follitropin beta, Puregon) yields higher pregnancy rates in in vitro fertilization than urinary gonadotropins

A reappraisal of ovarian stimulation strategies used in assisted reproductive technology

Ovarian stimulation is a fundamental step in assisted reproductive technology (ART) with the intention of inducing ovarian follicle development prior to timed intercourse or intra-uterine insemination and facilitating the retrieval of multiple oocytes during a single in vitro fertilization (IVF) cycle. The basis of ovarian stimulation includes the administration of exogenous gonadotropins, with or without pre-treatment with oral hormonal therapy. Gonadotropin-releasing hormone agonist or antagonist is given in addition to the gonadotropins to prevent a premature rise of endogenous luteinizing hormone that would in turn lead to premature ovulation. With the advancement in technology, various stimulation protocols have been devised to cater for different patient needs. However, ovarian hyperstimulation syndrome and its serious complications may occur following ovarian stimulation. It is also evident that suboptimal ovarian stimulation strategies may have a negative impact on oogenesis, embryo quality, endometrial receptivity, and reproductive outcomes over recent years. This review describes the various forms of pre-treatment for ovarian stimulation and stimulation protocols, and aims to provide clinicians with the latest available evidence.

Effectiveness and safety of gonadotropins used in female infertility: a population-based study in the Lazio region, Italy

Purpose

Infertility is a topic of growing interest, and female infertility is often treated with gonadotropins. Evidence regarding comparative safety and efficacy of different gonadotropin formulations is available from clinical studies, while real-world data are missing. The present study aims to investigate effectiveness and safety of treatment with different gonadotropin formulations in women undergoing medically assisted procreation treatments in Latium, a region in central Italy, through a real-world data approach.

Methods

A retrospective population-based cohort study in women between the ages of 18 and 45 years who were prescribed with at least one gonadotropin between 2007 and 2019 was conducted. Women were enrolled from the regional drug dispense registry, and data on their clinical history, exposure to therapeutic cycles (based on recombinant “REC” or extractives “EXT” gonadotropin, or combined protocol “CMD” (REC + EXT)), and maternal/infantile outcomes were linked from the regional healthcare administrative databases. Multivariate logistic regression models were applied to estimate the association between exposure and outcomes.

Results

Overall, 90,292 therapeutic cycles prescribed to 35,899 women were linked to pregnancies. Overall, 15.8% of cycles successfully led to pregnancy. Compared to extractives, recombinant and combined treatments showed a stronger association with conception rate (RR_REC adj = 1.06, 95% CI: 1.01–1.12; RR_CBD adj = 1.17, 95% CI: 1.11–1.24). Maternal outcomes occurred in less than 5% of deliveries, and no significant differences between treatments were observed (REC vs EXT, pre-eclampsia: RR adj = 1.24, 95% CI: 0.86–1.79, ovarian hyperstimulation syndrome: RR adj = 1.25, 95% CI: 0.59–2.65, gestational diabetes: RR adj = 1.06, 95% CI: 0.84–1.35). Regarding infantile outcomes, similar results were obtained for different gonadotropin formulations (REC vs EXT: low birth weight: RR adj = 0.98, 95% CI: 0.83–1.26, multiple births: RR adj = 1.06, 95% CI: 0.92–1.23, preterm birth: RR adj = 1.03, 95% CI: 0.92–1.26).

Conclusions

Efficacy and safety profiles of REC proved to be similar to those of EXT. Regarding the efficacy in terms of conception rate and birth rate, protocols using the combined approach performed slightly better. Outcomes related to maternal and infantile safety were generally very rare, and safety features were overlapping between gonadotropin formulations.

Use of Follicle-Stimulating Hormone for the Treatment of Female Infertility – Current Concepts

Ovulatory dysfunction, which is common among women of reproductive age, often results in infertility. Over the last three decades, follicle-stimulating hormone (FSH), in the form of either urinary human menopausal gonadotropin or highly purified urinary FSH (uFSH), has been the mainstay in the treatment of women with ovulatory dysfunction. However, these preparations have several disadvantages, including variable composition, contamination with urinary proteins, and the limited availability of human menopausal urine from which uFSH is extracted. Recombinant human FSH (rhFSH) demonstrates higher purity and specific activity, and is suitable for subcutaneous administration. Additionally, rhFSH has facilitated the development of additional FSH products such as FSH-carboxy terminal peptide that possess different pharmacokinetic and pharmacodynamic properties and may provide more options in the treatment of ovulatory dysfunction and infertility. This article reviews the mechanism of action of FSH in folliculogenesis and ovulation, the current use of FSH in women for the medical management of infertility, and the published clinical experience to date with different rhFSH preparations.

WITHDRAWN: Gonadotrophin therapy for ovulation induction in subfertility associated with polycystic ovary syndrome

This review has been replaced by a review entitled 'Gonadotrophins for ovulation induction in women with polycystic ovarian syndrome'.

The editorial group responsible for this previously published document have withdrawn it from publication.

Efficacy of Highly Purified Urinary FSH versus Recombinant FSH in Chinese Women over 37 Years Undergoing Assisted Reproductive Techniques

BACKGROUND

Urine derived follicle-stimulating hormone (uFSH) contains a higher proportion of acidic isoforms, whereas recombinant FSH (rFSH) contains a higher proportion of less-acidic isoforms. Less-acidic isoforms have a faster clearance, and thus a shorter half-life than the acidic FSH isoforms. The slow clearance of the acidic isoforms has a longer half-life and higher biological activity. This study was designed to determine whether uFSH or rFSH is more effective in older Chinese women undergoing assisted reproductive techniques (ART).

MATERIALS AND METHODS

This is a prospective, randomized, controlled cohort study. A total of 508 Chinese women over 37 years were randomized into two following study groups for their in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) cycles: i. group A (n=254) were treated with rFSH, and ii. group B (n=254) were treated with uFSH. Both groups were suppressed with a gonadotropin-releasing hormone (GnRH) analogue using a long down-regulation protocol. The main outcomes for comparison were days of stimulation, estradiol (E2) on the day of human chorionic gonadotropin (hCG) administration, number of oocytes collected, amount of FSH used, quantity of FSH/oocyte, endometrial thickness at hCG day, M П oocyte rate, 2PN zygote rate, grade І embryo rate, number of embryos cryopreserved, pregnancy rate, implantation rate, abortion rate and the rate of no transferable embryos.

RESULTS

Twenty two cycles including 16 cycles with poor ovarian response and six cycles with ovarian hyperstimulation syndrome were cancelled. There were 243 cycles left in each group. The patients treated with uFSH had a significantly higher 2PN zygote rate (87.4 vs. 76.6%, p<0.001), grade І embryo rate (49.8 vs. 40.8%, p<0.001) and endometrial thickness on day of hCG (11.8 mm vs. 11.2 mm, respectively, p=0.006) and a lower rate of no transferable embryos (1.2 vs. 5.3%, p=0.019) than women treated with rFSH. The other measures evaluated showed no statistically significant differences between groups (p>0.05).

CONCLUSION

This study showed that uFSH produced a significantly higher proportion of grade І embryos than rFSH in older Chinese women and there was a significantly lower chance of no transferable embryos in uFSH cycles. The clinical efficacy of the two gonadotropins was equivalent.

Sequential protocol with urinary-FSH/recombinant-FSH versus standard protocol with recombinant-FSH in women of advanced age undergoing IVF

A stimulation protocol mimicking the physiological pattern of FSH release may improve IVF outcome in women of advanced age. Urinary-FSH delivers a wider range of isoforms including the most acidic produced during the early follicular phase when oestradiol level is low, a common condition in women of advanced reproductive age. We hypothesized that a stimulation protocol using urinary-FSH during the early follicular phase and then shifting toward recombinant-FSH may improve oocyte quality and pregnancy rate in 35-40 years old patients in IVF program. A retrospective study was performed: after a standard down-regulation with GnRH-analogue, 115 women underwent stimulation with urinary-FSH for 6 days according to a step-down approach and then shifting to recombinant-FSH (group A), 115 women underwent a stimulation protocol with only recombinant-FSH (group B). Days of stimulation were lower in group A than in group B, a higher proportion of MII oocytes and of grade 1 embryos, higher implantation rate and pregnancy rate were observed in group A versus group B. We conclude that a sequential protocol using urinary-FSH in the early days of stimulation and subsequently recombinant-FSH may improve the IVF outcome in patients of advanced reproductive age.

Difference in mitochondrial gene expression in granulosa cells between recombinant FSH and hMG cycles under in vitro fertilization and transfer

Purpose

Examination of the mitochondrial mRNA expression in granulosa cells from an unspecified population of infertile patients to evaluate whether recombinant follicle stimulating hormone (recFSH) is more effective in producing higher quality embryo rates compared with human menopausal gonadotropin (hMG).

Method

Thirty-nine patients who underwent the in vitro fertilization and embryo transfer program were retrospectively examined. Patients were administered recFSH (n = 18) or hMG (n = 20) in a long protocol where GnRH agonist was used. Granulosa cells were obtained during oocyte retrieval and examined for mitochondria mRNA expression ratio against GAPDH. Expressions of mitochondria mRNA were evaluated by real-time PCR analysis.

Results

The high-quality embryo rate in the hMG cycle was higher than in the recFSH cycle, and the total dose of hMG showed a positive correlation with the expression level of mitochondrial genes in granulosa cells. Moreover, mitochondria mRNA expression was higher in the hMG cycle than in the recFSH cycle.

Conclusions

Compared with recFSH, hMG induces a higher mitochondrial gene expression ratio in granulosa cells at the time of oocyte retrieval and, therefore, may lead to higher quality embryo rates.

Use of follicle-stimulating hormone for the treatment of female infertility - current concepts

Ovulatory dysfunction, which is common among women of reproductive age, often results in infertility. Over the last three decades, follicle-stimulating hormone (FSH), in the form of either urinary human menopausal gonadotropin or highly purified urinary FSH (uFSH), has been the mainstay in the treatment of women with ovulatory dysfunction. However, these preparations have several disadvantages, including variable composition, contamination with urinary proteins, and the limited availability of human menopausal urine from which uFSH is extracted. Recombinant human FSH (rhFSH) demonstrates higher purity and specific activity, and is suitable for subcutaneous administration. Additionally, rhFSH has facilitated the development of additional FSH products such as FSH-carboxy terminal peptide that possess different pharmacokinetic and pharmacodynamic properties and may provide more options in the treatment of ovulatory dysfunction and infertility. This article reviews the mechanism of action of FSH in folliculogenesis and ovulation, the current use of FSH in women for the medical management of infertility, and the published clinical experience to date with different rhFSH preparations.

Comparison of the effect of two different doses of recombinant gonadotropin for ovarian stimulation on the outcome of intrauterine insemination

OBJECTIVE

The aim of this study was to identify an optimal stimulation protocol for intrauterine insemination (IUI) to obtain an acceptable pregnancy rate and low frequency of multiple pregnancies.

MATERIALS AND METHODS

In total, 340 patients, who received intrauterine insemination because of ovulation dysfunction, were enrolled in this study. Group I consisted of 203 patients who received recombinant FSH (r-FSH) 150U every other day as an ovulation induction agent. Group II consisted of 137 patients who received r-FSH 100U every other day as an ovulation induction agent. All patients in both groups also received clomiphene citrate 100 mg/day for consecutive five days from the fifth day of the cycle. Only patients with at least two follicles >18 mm on the human chorionic gonadotropin injection days were included in this study.

RESULTS

The clinical pregnancy rate was 14.8% (30/203) in Group I compared with 20.4% (28/137) in Group II, p > 0.05. The incidence of multiple pregnancy was 41.7% (10/24) in Group I compared with 12.5% (3/24) in Group II, p < 0.05.

CONCLUSIONS

The concurrent use of low-dose r-FSH and clomiphene citrate would seem not only to be cost-effective but also highly satisfactory in that it prevents high-order multiple pregnancies.

Human menopausal gonadotropin versus highly purified-hMG in controlled ovarian hyperstimulation for in-vitro fertilisation: does purity improve outcome?

OBJECTIVES

To examine and compare the effect of the two commercially available menotropins (highly purified-human menopausal gonadotropin (HP-hMG) and the traditional human menopausal gonadotropin (hMG)) on ovarian stimulation characteristics and in-vitro fertilisation (IVF) cycle outcome.

STUDY DESIGN

We studied 36 patients undergoing at least two controlled ovarian hyperstimulation cycles for IVF, with the same GnRH-analogue protocols, where one included HP-hMG and the other included hMG. Ovarian stimulation characteristics and outcome were compared between the two groups.

RESULTS

Patients in the HP-hMG group achieved significantly higher implantation (20.0% vs. 8.1%, p < 0.03; respectively) and pregnancy rates (47.2% vs. 19.4%, p < 0.009; respectively) compared to the hMG group. Although no in-between group difference was observed in the number of top-quality embryos per patient, the proportion of the total number of top-quality embryos per total number of generated embryos was significantly higher in the HP-hMG group (88/196 vs. 72/204, p < 0.049; respectively) as compared to the hMG group.

CONCLUSIONS

Patients undergoing controlled ovarian hyperstimulation for IVF that includes HP-hMG preparations produce significantly higher implantation and pregnancy rates, as compared to the traditional hMG.

Success of frozen embryo transfer: Does the type of gonadotropin influence the outcome?

OBJECTIVES

To determine whether there is a difference in outcome between different ovulation-induced cycles after frozen-thawed embryo transfer (FET).

METHODS

We searched the Cochrane Menstrual Disorders and Subfertility Group's trials register in May 2009, the Cochrane Central Register of Controlled Trials (Cochrane Library, Issue 1, 2008), ISI Web of Knowledge (1985 to August 2009), and reference lists of articles. Relevant conference proceedings were hand-searched and researchers in the field were contacted. Randomized controlled trials and retrospective studies were included, comparing the various cycle regimens and different methods during FET in assisted reproductive technology, ie, in vitro fertilization and intracytoplasmic sperm injection.

RESULTS

Using the agonist long protocol for downregulation, five trials provided extractable data for live-birth rates, ongoing pregnancy, and clinical pregnancy rates following FET. One trial provided extractable data for clinical pregnancy rate. There was no evidence of a significant difference in any outcome between the users of urinary gonadotropins versus recombinant follicle-stimulating hormone. Data on implantation and miscarriage rates following FET were not available for analysis.

CONCLUSIONS

It seems that clinical pregnancy rate after FET is not influenced by the type of gonadotropins used. Research should be directed towards improving freezing and thawing techniques.

Effect of urinary versus recombinant FSH on clinical outcomes after frozen-thawed embryo transfers: a systematic review

Recent randomized trials, systematic reviews and cost-effectiveness analyses have demonstrated the relative efficacy,and in some cases superiority, of urinary gonadotrophins (uFSH, human menopausal gonadotrophin) compared with recombinant FSH (rFSH). However, the effectiveness of frozen-embryo transfers (FET) following ovarian stimulation with uFSH versus rFSH in the fresh cycle has not been well investigated. The objective of this study was to determine whether there are differences in clinical outcomes in women undergoing FET according to the type of gonadotrophin used during ovarian stimulation. Following a meticulous search, all published comparative studies of FET using ovarian stimulation were reviewed. Data on clinical outcomes were extracted and systematically presented. Using the agonist long protocol for down-regulation, five trials provided extractable data for live-birth and ongoing pregnancy rates following FET, as well as the cumulative live-birth, ongoing pregnancy and clinical pregnancy rates following fresh-embryo transfer and FET from the same cycle. There was no evidence of significant effect difference between the uses of uFSH versus rFSH regarding any of the outcomes. In conclusion there is insufficient evidence to determine whether the use of a certain type of gonadotrophin during ovarian stimulation affects the clinical outcomes in subsequent FET.

Comparison of follitropin-beta administered by a pen device with conventional syringe in an ART programme - a retrospective study

OBJECTIVES

This study compares the efficacy and patient tolerance of follitropin-beta (recagon) administered using a pen device with conventional syringe in infertile couples undergoing in vitro fertilization/intracytoplasmic sperm injection treatment.

METHODS

Data for 481 patients were retrieved retrospectively for the analysis. Conventional syringe group constituted 204 patients with 217 cycles and 265 patients with 294 cycles in the pen-device group. Down-regulation was achieved with GnRH agonist.

RESULTS

Comparison of follitropin-beta administered with pen and syringe showed the following data, respectively. A total dose of 1909.38/2100.65 IU (P < 0.001), duration of stimulation, 9.70/10.47 days (P < 0.05), oestradiol levels on the day of human chorionic gonadotropin, 1488.34/1067.63 pg/ml, number of follicles reaching >16-mm size, 9.75/7.34 (P < 0.05), number of oocytes retrieved, 13.84/9.55 (P < 0.001) and number of embryos available for freezing, 4.56/1.30 (P < 0.05), the above data were observed in pen/conventional syringe groups, respectively. The live birth rates per cycle were 28.85% and 30.95% in the conventional syringe/pen-device groups, respectively. Patient tolerance with respect to pain at injection site was better with the pen device (P < 0.025).

CONCLUSION

The data show that follitropin-beta administered with pen device is well tolerated and more efficacious with respect to ovarian stimulation outcome compared with the conventional syringe.

Protein therapeutics: a summary and pharmacological classification

Once a rarely used subset of medical treatments, protein therapeutics have increased dramatically in number and frequency of use since the introduction of the first recombinant protein therapeutic--human insulin--25 years ago. Protein therapeutics already have a significant role in almost every field of medicine, but this role is still only in its infancy. This article overviews some of the key characteristics of protein therapeutics, summarizes the more than 130 protein therapeutics used currently and suggests a new classification of these proteins according to their pharmacological action.

Cost-effectiveness of recombinant follicle-stimulating hormone (FSH) versus human FSH in intrauterine insemination cycles: a statistical model-derived analysis

OBJECTIVE

Recently we proposed a randomized trial specifically designed to evaluate the cost-effectiveness of two different protocols of stimulation in intrauterine insemination (IUI) cycles. Computer-simulated clinical models have been developed to perform pharmacoeconomic studies, creating a decision tree in which the complex procedure is performed and repeated. The present study was designed to compare the cost-effectiveness of recombinant follicle-stimulating hormone (rFSH) and human-derived FSH (hFSH) in ovarian stimulation and to indicate which protocol should be used in IUI cycles.

STUDY DESIGN

Two computer-generated decision tree models were constructed to compare the clinical effects and costs of rFSH versus hFSH in IUI cycles. A first decision tree model was built according to the trial previously published. In a second model, 10 000 hypothetical infertile patients were entered in a computer-generated simulation and were stimulated with two different protocols for IUI. IUI was hypothetically performed in both groups of patients with a known pregnancy, cancellation, miscarriage and abandonment rate. The two protocols were compared using a cost-effective analysis: cost-effectiveness ratios (CE) and incremental cost-effectiveness ratios (ICER) were calculated. The cost-effectiveness acceptability curve (CEAC) was constructed.

RESULTS

The overall estimated costs with each ovarian stimulation strategy in the first model demonstrated that rFSH was a less cost-effective strategy, with an ICER of euro 13,727. The CEAC showed that at a level of euro 0 of willingness to pay, hFSH was cost-effective in 73% of the samples while rFSH was cost-effective in 27% only. Recombinant FSH would be more cost-effective than hFSH at an effectiveness threshold of 0.170 and at a cost per cycle of euro 235. This finding was also confirmed by the acceptability curve obtained with 10,000 Monte Carlo simulations, in which hFSH was cost-effective in about 96-98% of samples at any threshold of willingness to pay.

CONCLUSIONS

This study represents the first statistical model developed with a computer-generated clinical simulation with the intent to elaborate a pharmacoeconomic comparison between rFSH and hFSH in ovarian stimulation for IUI cycles. Results demonstrated that hFSH is more cost-effective than rFSH.

A comparison of the efficacy, tolerability, and convenience of two formulations of follitropin-alpha in Iranian woman undergoing intracytoplasmic sperm injection cycles

OBJECTIVE

To compare the efficacy, tolerability, and convenience of two formulations of the follitropin-alpha (Gonal-f) pen device versus the conventional form in Iranian women undergoing ovarian stimulation for intracytoplasmic sperm injection.

DESIGN

Randomized, single-center trial, parallel-group, single blind.

SETTING

Tertiary referral center, University Hospital.

PATIENT(S)

A total of 100 patients undergoing intracytoplasmic sperm injection.

INTERVENTION(S)

After down-regulation with busereline acetate, patients were randomized to receive the pen device or the conventional syringe of follitropin-alpha. A computer-generated randomization list was used to allocate the patients to one of these two groups.

MAIN OUTCOME MEASURE(S)

The primary outcomes were patients' satisfaction, convenience, occurrence of local tolerance symptoms, and pain. Total dose of follitropin-alpha, duration of follitropin-alpha treatment, number of oocyte retrieved, number of viable embryos, and clinical pregnancies were secondary outcome measures. Data collection was performed by means of a questionnaire designed for the purpose of this study. The pain scored according to the Visual Analogue Scale.

RESULT(S)

Self-administration and patients' satisfaction were significantly higher in the pen device group than the conventional syringe group. Local reactions at injection sites and pain were significantly higher in the conventional syringe group than in the pen device group. There were no statistically differences in secondary outcome measures and convenience between two groups.

CONCLUSION(S)

Among the Iranian patients that we studied, the pen device of Gonal-f is safe, convenient, and less painful, with more patients' satisfaction than the conventional syringe form, but both forms have equal efficacy in intracytoplasmic sperm injection cycles.

WITHDRAWN: Recombinant versus urinary follicle stimulating hormone for ovarian stimulation in assisted reproduction cycles

BACKGROUND

Until recently, the main source of exogenous follicle stimulating hormone (FSH) for therapeutic use in infertility had been the urine of postmenopausal women. New developments have resulted in the production of FSH in vitro by recombinant DNA technology. The extremely high purity and batch-to-batch consistency of recombinant FSH (rFSH) make it an attractive alternative to urinary FSH (uFSH).

OBJECTIVES

To conduct a systematic review and meta-analysis of randomised trials comparing the effectiveness of rFSH with uFSH in ovarian stimulation protocols in in vitro fertilization (IVF) or intra-cytoplasmic sperm injection (ICSI) treatment cycles.

SEARCH STRATEGY

Search strategies included on-line searching of the MEDLINE and EMBASE databases from 1985 to 1999, hand searching of bibliographies of relevant publications and reviews and abstracts of scientific meetings, peer consultation and contacting the pharmaceutical companies that manufacture the gonadotropins under consideration.

SELECTION CRITERIA

Randomised trials comparing rFSH with uFSH for ovarian stimulation in IVF or ICSI treatment for infertility.

DATA COLLECTION AND ANALYSIS

The main outcome measure was clinical pregnancy per cycle started. Also considered were clinical pregnancy per cycle reaching oocyte retrieval and per cycle reaching embryo transfer (ET), ongoing pregnancy per cycle started, spontaneous abortion, multiple pregnancy, ovarian hyperstimulation syndrome (OHSS), number of follicles and serum estradiol level on the day of human chorionic gonadotropin administration day, total dose of FSH, and number of oocytes retrieved. Common odds ratios (OR) and risk differences for rFSH relative to uFSH were calculated after testing for homogeneity of treatment effect across all trials. The fixed effects model was used, unless significant heterogeneity was present, in which case the random effects model was used.

MAIN RESULTS

The overall odds ratio for clinical pregnancy per cycle started was 1.21 (95% confidence limits (CL) 1.04,1.42) for rFSH compared to uFSH. The risk difference was a 3.7% (0.8,6.7) absolute increase in clinical pregnancy rate with rFSH. The OR for ongoing pregnancy per cycle started was 1.29 (1.08,1.54). There was no significant difference between rFSH and uFSH in the rates of spontaneous abortion, multiple pregnancy or OHSS. The total dose of FSH was lower by 406 (185,627) IU with rFSH, but there was no significant difference in the number of follicles or serum estradiol on hCG day or in the number of oocytes retrieved.

AUTHORS' CONCLUSIONS

This review has demonstrated a statistically significant increase in clinical pregnancy rate with rFSH compared to uFSH, when used for ovarian stimulation in assisted reproduction. This benefit was observed only in standard IVF cycles and not in cycles in which ICSI was used.

A retrospective comparison of clinical outcomes and satisfaction using reconstituted recombinant gonadotropins (rFSH) or cartridge rFSH with a pen device in donor oocyte cycles

BACKGROUND

Use of recombinant follicle stimulating hormone (rFSH) in a cartridge pen device offers obvious benefits for donor oocyte cycles including the administration of fewer and more patient-friendly injectable medications.

METHODS

In a University-based IVF program, a total of 98 oocyte donor cycles using rFSH either reconstituted or as a pen device given to 118 recipients (eight split cycles) were retrospectively reviewed. Following discontinuation of oral contraceptive, controlled ovarian hyperstimulation was begun using either reconstituted rFSH (n = 19) or rFSH with a cartridge pen device (n = 79) (150-300 IU qd). GnRH-antagonists (Ganirelix, Organon) and an additional 75 IU of rFSH/day were begun when lead follicles were 13-14 mm in greatest diameter. The primary endpoints analyzed included cycle stimulation characteristics for each donor group and donor medication tolerance assessment with respect to each rFSH formulation, while secondary outcome measures included clinical pregnancy and implantation rates.

RESULTS

Oocyte donors using the pen required significantly less rFSH (2734 IU vs. 3276 IU, p < 0.05) and scored significantly higher medication tolerance scores (3.9 +/- 0.4 vs. 3.1 +/- 0.6, p < 0.05). No other differences in cycle stimulation for oocyte donors and clinical outcomes for recipients were seen including pregnancy rates (pen, 77% vs. reconstituted, 55%, p - NS) and clinical pregnancy rates (61% vs. 45%, p - NS). However, significantly greater implantation rates (57% vs. 31%, p < 0.01) occurred in the pen group.

CONCLUSION

Compared to reconstituted formulations, the pen device results in lower gonadotropin requirements and provides a simplified dosing method with better tolerance.

Comparison of different gonadotrophin preparations in intrauterine insemination cycles for the treatment of unexplained infertility: a prospective, randomized study

BACKGROUND

A comparison of the effectiveness of different gonadotrophin preparations in intrauterine insemination (IUI) cycles for patients with unexplained infertility was performed.

METHODS

Two hundred and forty-one patients were prospectively randomized using computer-generated random numbers into three groups: 81 in the Follitropin alpha (Group I), 80 in the urinary FSH (uFSH) (Group II) and 80 in the hMG (Group III). The primary outcome was clinical pregnancy rate with duration of stimulation, total gonadotrophin dose, number of dominant follicles, clinical pregnancy rate, multiple pregnancy, miscarriage rate and ovarian hyperstimulation syndrome (OHSS) rate being secondary outcomes.

RESULTS

Clinical pregnancy rate was significantly higher in the rFSH group (25.9% in Follitropin alpha, 13.8% in uFSH and 12.5% in HMG groups; P = 0.04). There was no significant difference in terms of duration of stimulation, but mean FSH dose consumed per cycle was significantly lower in the recombinant FSH (rFSH) group compared with others (825 IU in Follitropin alpha, 1107 IU in uFSH and 1197 IU in HMG groups; P = 0.001). The number of follicles > or =16 mm diameter was significantly higher in the rFSH group compared with the uFSH and HMG groups (2.6 in Follitropin alpha, 1.3 in uFSH and 1.4 in HMG groups; P = 0.001).

CONCLUSION

rFSH may result in a better outcome in IUI cycles for unexplained infertility.

Recombinant versus highly-purified, urinary follicle-stimulating hormone (r-FSH vs. HP-uFSH) in ovulation induction: a prospective, randomized study with cost-minimization analysis

BACKGROUND

Both recombinant FSH (r-FSH) and highly-purified, urinary FSH (HP-uFSH) are frequently used in ovulation induction associated with timed sexual intercourse. Their effectiveness is reported to be similar, and therefore the costs of treatment represent a major issue to be considered. Although several studies about costs in IVF have been published, data obtained in low-technology infertility treatments are still scarce.

METHODS

Two hundred and sixty infertile women (184 with unexplained infertility, 76 with CC-resistant polycystic ovary syndrome) at their first treatment cycle were randomized and included in the study. Ovulation induction was accomplished by daily administration of rFSH or HP-uFSH according to a low-dose, step-up regimen aimed to obtain a monofollicular ovulation. A bi- or tri-follicular ovulation was anyway accepted, whereas hCG was withdrawn and the cycle cancelled when more than three follicles greater than or equal to 18 mm diameter were seen at ultrasound. The primary outcome measure was the cost of therapy per delivered baby, estimated according to a cost-minimization analysis. Secondary outcomes were the following: monofollicular ovulation rate, total FSH dose, cycle cancellation rate, length of the follicular phase, number of developing follicles (>12 mm diameter), endometrial thickness at hCG, incidence of twinning and ovarian hyperstimulation syndrome, delivery rate.

RESULTS

The overall FSH dose needed to achieve ovulation was significantly lower with r-FSH, whereas all the other studied variables did not significantly differ with either treatments. However, a trend toward a higher delivery rate with r-FSH was observed in the whole group and also when results were considered subgrouping patients according to the indication to treatment.

CONCLUSION

Considering the significantly lower number of vials/patient and the slight (although non-significant) increase in the delivery rate with r-FSH, the cost-minimization analysis showed a 9.4% reduction in the overall therapy cost per born baby in favor of r-FSH.

Urinary follicle-stimulating hormone (FSH) is more effective than recombinant FSH in older women in a controlled randomized study

OBJECTIVE

The following study was conducted to determine which FSH, recombinant or urinary, works better in older women.

DESIGN

We conducted a controlled randomized study in a single university IVF center.

SETTING

University IVF center.

PATIENT(S)

Women (N = 257) over 39 years old undergoing IVF.

INTERVENTION(S)

The patients were randomized into two study groups at their first IVF cycle: 121 patients were treated with recombinant FSH, and 120 patients were treated with urinary FSH. Both groups were suppressed with a long GnRH analog protocol.

MAIN OUTCOME MEASURE(S)

Days of stimulation, E2 at the day of hCG, total amount of FSH administered, number of oocytes collected, amount of FSH per oocyte, and number of embryos obtained.

RESULT(S)

Patients treated with urinary FSH required a significantly lower total amount of FSH, and a lower amount of FSH per oocyte than women treated with recombinant FSH. The other measures evaluated did not show any statistically significant differences.

CONCLUSION(S)

Our study showed that urinary FSH performed better in older women than recombinant FSH when associated with the long protocol.

Comparative assessment of the consistency and quality of a highly purified FSH extracted from human urine (urofollitropin) and a recombinant human FSH (follitropin α)

The revolutionary development of biotechnology-derived therapeutic proteins has provided the expected improvements in quality, purity and consistency, as demonstrated in recombinant human FSH (rhFSH). However, the development of urine-derived gonadotrophins has not always shown comparable improvements. More recently, highly purified urine-derived FSH (uFSH-HP) products have become widely available. The relative purity, level of urine-derived contaminants, and consistency of one such highly purified human uFSH (uhFSH) (urofollitropin) has been assessed and directly compared with rhFSH (follitropin alpha). It has been demonstrated that the highly purified urofollitropin contains variable levels of urine-derived contaminant proteins and demonstrates a variable level of FSH purity, FSH isoforms, and delivered dose. These variable factors may contribute to the control of ovarian stimulation. The relative purity, variable consistency and the presence of contaminants indicates that the urofollitropin is, at best, a partially purified uFSH that is not able to meet the quality attributes of follitropin alpha (rhFSH).

The role of aromatase inhibitors in ameliorating deleterious effects of ovarian stimulation on outcome of infertility treatment

Clinical utilization of ovulation stimulation to facilitate the ability of a couple to conceive has not only provided a valuable therapeutic approach, but has also yielded extensive information on the physiology of ovarian follicular recruitment, endometrial receptivity and early embryo competency. One of the consequences of the use of fertility enhancing agents for ovarian stimulation has been the creation of a hyperestrogenic state, which may influence each of these parameters. Use of aromatase inhibitors reduces hyperestrogenism inevitably attained during ovarian stimulation. In addition, the adjunct use of aromatase inhibitors during ovarian stimulation reduces amount of gonadotropins required for optimum stimulation. The unique approach of reducing hyperestrogenism, as well as lowering amount of gonadotropins without affecting the number of mature ovarian follicles is an exciting strategy that could result in improvement in the treatment outcome by ameliorating the deleterious effects of the ovarian stimulation on follicular development, endometrial receptivity, as well as oocyte and embryo quality.

Embryo quality based on ovulation induction: defining the differences

Patients undergoing IVF, with or without intracytoplasmic sperm injection, were treated with either recombinant human FSH or urine-derived FSH. Response to ovarian stimulation was monitored by ultrasound examinations and measurement of serum oestradiol concentrations. To define any differences in embryo quality and hence assisted reproductive technology success rates, a retrospective analysis of 811 recombinant FSH versus 555 urinary FSH cycles was undertaken. Embryo quality was assessed as embryo cell number and degree of fragmentation. Implantation and ongoing pregnancy rates were also compared. Use of recombinant FSH resulted in a higher percentage of mature oocytes, improved embryo cleavage, with more embryos available for freezing and higher implantation rates compared with urinary FSH. Oocyte and embryo quality were superior when recombinant FSH was used for ovarian stimulation compared with urinary FSH.

La fécondation in vitro en France. Approche économique et influence du choix des gonadotrophines (urinaires ou recombinantes) sur le coût

OBJECTIVES

The objective of the study was to make an economic evaluation of in vitro fertilization and to determine the impact of some factors on its cost, particularly the choice between recombinant follicle stimulating hormone (r-FSH) and urinary FSH (u-FSH) for ovarian stimulation.

PATIENTS AND METHODS

Costs were calculated in a Public Health view, by studying two phases: the stimulation cycle (including down-regulation) and the pregnancy (including the neonatal period). The calculation has included the side effects and the frozen embryos transfers. Economic data came from various sources: the French nomenclature on medical treatments (NGAP), the French drugs dictionary (Vidal) and the French Information system medical plan (PMSI). FSH costs were computed according to the currently marketed products, i.e., Fostimon (Laboratoires Genévrier, Sophia-Antipolis, France) for urinary FSH, and Gonal-F (Laboratoires Serono, Boulogne-Billancourt, France) and Puregon (Laboratoires Organon, Puteaux, France) for recombinant FSH. Two different ways of efficacy between u-FSH and r-FSH were considered for the calculations, those reported in Daya's meta-analysis (3.7% in favour of r-FSH for the clinical pregnancy rate per initiated cycle) and in the only double-blind study (Frydman et al., no difference).

RESULTS

The annual cost of ART reaches approximately 130 million Euros in France, for the cycles only, and 170 million Euros when including the pregnancy costs. Urinary FSH is much cheaper than recombinant FSH. Whereas the number of administered FSH units was higher in u-FSH, this results in a mean lower cost of 500 Euros per cycle (2422 Euros for u-FSH and 2959 Euros for r-FSH). For one complete year, in France, the potential over cost of recombinant products reaches 24 million Euros when considering only the cycles (128.4 vs. 104.0 million Euros) and 24-31 million Euros when pregnancies and babies (neonatal period) are considered (171.4 vs 140.7 and 147.0 million Euros, respectively). The IVF per baby cost can be estimated at 16 463 Euros for r-FSH and at 14 116 Euros (in case of equivalence between the two drugs) to 15 805 Euros (in case of a difference of 3.7% pregnancy per oocyte recovery) for u-FSH.

CONCLUSION

This gives Public Health lighting to the choices in the matter of ovulation stimulation. It shows the economic impact of the choice in the FSH type.

Recombinant FSH and pregnancy-associated plasma protein

OBJECTIVES

To evaluate the effect of rec-FSH on the ovarian follicular environment in controlled ovarian hyperstimulation (COH) cycle, we compared the expression of the markers that have been reported to reflect the follicle health.

STUDY DESIGN

A total of 31 women (<35 years) with normal ovarian function were allocated to three different COH protocols (urinary FSH (u-FSH)+hMG, rec-FSH only, or u-FSH only). E2, P4, leptin and IGF-I levels in serum or follicular fluid (FF) were measured with radioimmunoassay; cyclin D2, EGF receptor (EGF-R), and inhibin-alpha mRNA levels in luteinized granulosa cells were measured with RT-PCR; and IGFBP-4 and PAPP-A levels in FF were measured with Western blot analysis.

RESULTS

There were no significant differences in serum E2, P4 and leptin levels and follicular leptin and IGF-I levels. Cyclin D2, EGF-R, and inhibin-alpha mRNA expression in luteinized granulosa cells were not different among three groups. However, follicular IGFBP-4 and PAPP-A levels in rec-FSH group were significantly higher than other groups (P<0.05).

CONCLUSIONS

The use of rec-FSH increases the expression of follicular PAPP-A reflecting IGFBP-4 proteolytic activity and it may influence positively the follicular environment.

A prospective randomized clinical trial comparing 150 IU and 225 IU of recombinant follicle-stimulating hormone (Gonal-F*) in a fixed-dose regimen for controlled ovarian stimulation in in vitro fertilization treatment

OBJECTIVE

To compare fixed daily doses of the recombinant FSH (rFSH) Gonal-F (150 IU vs. 225 IU) for ovarian stimulation in IVF-ET.

DESIGN

Single-center prospective, randomized study. Assisted conception unit of a university hospital. One hundred twenty-four women aged 23-41 years participated in the study. Exclusion criteria were as follows: FSH of >10 IU/L, polycystic ovarian syndrome, one ovary or previous ovarian surgery, previous poor response to ovarian stimulation, or ovarian hyperstimulation syndrome (OHSS).

INTERVENTION(S)

Randomized to commence 150 IU or 225 IU of Gonal-F per day without dose alterations during treatment.

MAIN OUTCOME MEASURE(S)

Number of oocytes retrieved and total rFSH dose.

RESULT(S)

More oocytes were retrieved in women aged <or=32 years in the 225-IU compared with the 150-IU group (11.8 +/- 8.0 vs. 7.0 +/- 5.8). In older women (>or=33 years), the number of oocytes retrieved in the two groups were similar. No significant differences were found for fertilization rate, number of embryos formed and cryopreserved, and pregnancy rates between the two groups. The total rFSH dose used was higher in the 225-IU group (2,595.0 +/- 510.0 vs. 1,897.5 +/- 457.5 IU). The cancellation rate due to insufficient ovarian response was higher in the 150-IU group (15.0% vs. 3.3%). All cases of ovarian hyperstimulation syndrome (n = 4) occurred in the 225-IU group.

CONCLUSION(S)

Two hundred twenty-five IU is more effective than 150 IU in younger women but requires a higher total dose of Gonal-F. The use of 225 IU in older women did not result in a higher oocyte yield, suggesting that 225 IU of rFSH does not compensate for the age-related decline in the number of follicles available for stimulation.

Recombinant human follicle-stimulating hormone: a scientific step to clinical improvement

Urinary-derived follicle-stimulating hormone (FSH) preparations have been used clinically for many years. Although effective, these have a number of disadvantages, not least of which is their variable composition. The availability of recombinant human FSH (r-hFSH), produced from CHO cells, with its constant composition and exceptionally high purity, has, therefore, aroused great interest. This review focuses on the use of r-hFSH for ovarian stimulation in assisted reproduction technology protocols and the treatment of World Health Organization Group I and II anovulation. The use of r-hFSH has been shown to lead to improvements in efficacy over urinary-derived preparations, particularly in assisted reproductive treatment, and a recent meta-analysis has shown higher ongoing pregnancy rates with the recombinant product. Although the two available recombinant products from CHO cells (follitropin alpha [Gonal-F((R))] and beta [Puregon((R))]) are similar from a physicochemical perspective, some minor advantages have been reported for follitropin alpha in relation to pregnancy rates and better local tolerance to injections. The apparent higher bioactivity of r-hFSH has led to reduced total FSH consumption over shorter treatment periods compared with conventional preparations, thus reducing overall exposure for patients. This is likely to confer not only safety benefits, but also cost-effectiveness as demonstrated through pharmaco-economic modelling.

Follitropin-beta administered by pen device has superior local tolerance compared with follitropin-alpha administered by conventional syringe

A receiver- and assessor-blind, randomized, single-centre, crossover study was performed in 60 healthy women volunteers, to compare the local tolerance of two recombinant FSH preparations administered by a pen device (delivering 150 IU follitropin-beta) or by conventional syringe (delivering 150 IU follitropin-alpha). Volunteers were randomized to one of two treatment sequences: pen device followed by conventional syringe, or the reverse. Each preparation was injected once, subcutaneously in the umbilical region and local tolerance reactions were assessed within 5 min, at 1 and 24 h after each administration. In addition, subjects were asked to rate the pain experienced during a period of 24 h after each injection by means of a visual analogue scale (VAS). At administration (within 5 min), severe to moderate pain was experienced in 70.0% of subjects injected by the conventional syringe, whereas only 21.7% of subjects treated with the pen device experienced pain. This difference was highly significant (P </= 0.001). The overall pain score (VAS) was low but significantly lower in subjects treated with the pen device (P </= 0.01). In this study, follitropin-beta administered by the pen device was far less painful than follitropin-alpha administered by conventional syringe. The pen device is the first multiple-use device available for the self-administration of recombinant FSH (rFSH) during ovarian stimulation for assisted reproduction.

Administration of recombinant human FSH (solution in cartridge) with a pen device in women undergoing ovarian stimulation

This study evaluated the first multiple-use pen device for the self-administration of recombinant FSH. The pen device is used for the subcutaneous injection of a pre-mixed ready-to-use solution of follitropin beta from a multiple-dose cartridge, and has flexible dosing capabilities. In the ease-of-use questionnaire, 90% of subjects rated the overall experience of self-injecting follitropin beta using the pen device as 'very good' (on day 6). The comprehension questionnaire revealed that prior to the first injection and during the second injection, the follitropin beta cartridge was properly loaded into the pen device by 96.7 and 100% of the subjects respectively. The questionnaire also showed that the correct dose was selected and self-administered by 98.3 and 100% of the subjects respectively. Biochemical and ongoing pregnancy rates per attempt were 56.7 and 45.0% respectively. The pen device is safe, effective, and easy to use for self-administering recombinant FSH during ovarian stimulation.

Impact of urinary FSH price: a cost-effectiveness analysis of recombinant and urinary FSH in assisted reproduction techniques in the USA

This study compares the cost-effectiveness of recombinant human FSH (r(h)FSH, Gonal-F) and urinary FSH (uFSH) in assisted reproduction techniques in the USA, using several hypothetical prices for uFSH. A specifically designed Markov model and Monte-Carlo simulation techniques were used to model the possible outcomes during three treatment cycles. Data included in the model were derived from randomized clinical trials and databases. An expert panel determined probability distributions for each decision point throughout each virtual treatment cycle. The assumed unit cost of r(h)FSH was $58.52 (based on the average retail cost) and three unit prices ($49, $45, $40) were used for uFSH. A total of 5000 simulations was performed on a virtual cohort of 100,000 patients. The mean number of assisted reproduction treatment cycles/success (ongoing pregnancy at 12 weeks) was 4.34 with r(h)FSH and 4.75 with uFSH. The total number of pregnancies achieved was 40,665 and 37,890, respectively. The mean cost per successful pregnancy with r(h)FSH was $40 688. For uFSH at unit costs of $40, $45 and $49, the mean costs per successful pregnancy were $43,500, $44,400 and $45,000, respectively (each P < 0.0001 versus r(h)FSH). Thus, despite its greater cost per unit dose, r(h)FSH is more cost-effective than uFSH over a wide range of uFSH prices, reflecting the greater clinical efficacy of r(h)FSH.

A group-comparative, randomized, double-blind comparison of the efficacy and efficiency of two fixed daily dose regimens (100- and 200-IU) of recombinant follicle stimulating hormone (rFSH, Puregon) in Asian women undergoing ovarian stimulation for IVF/ICSI

PURPOSE

To compare the efficacy, efficacy and safety of a fixed daily dose of recombinant FSH (Puregon) of a 100- and 200-IU regimen in Asian women undergoing ovarian stimulation for IVF/ICSI.

METHODS

This was a prospective, randomized, double-blind, multicenter (n = 9) study. Prior to the start of rFSH, all women were pretreated with a gonadotropin releasing hormone agonist (GnRH-a) for pituitary downregulation.

RESULTS

A total of 330 women were treated with rFSH: 163 subjects with 100 IU and 167 subjects with 200 IU. In the 200 IU treatment group, significantly more oocytes were retrieved compared to the 100 IU group (9.6 vs. 5.0 oocytes, p < 0.001). The total dose rFSH needed to develop at least three follicles with a diameter of >17 mm was significantly lower in the 100 IU treatment group (1,194 vs. 2,034 IU, p < 0.001). Although more cycle cancellations were seen in the 100 IU group (24 vs. 13%), the ongoing pregnancy rate per started cycle was comparable between both groups (16.6% in the 100 IU group vs. 15.0% in the 200 IU group).

CONCLUSIONS

The use of a 100 IU fixed dose is less effective in terms of the number of oocytes retrieved and the higher cancellation rate, but more efficient as indicated by a lower total recombinant FSH dose needed.

The conflict between effective and affordable health care--a perspective from the developing world

The recent introduction of recombinant FSH into the clinical management of patients suffering from infertility appears to be associated with several treatment benefits when compared with urinary human menopausal gonadotrophin. However, from the perspective of the developing world the associated increase in cost is a cause for concern--particularly if the "cheaper" urinary gonadotrophins are no longer marketed. The need for infertility care in Africa is significant, but health resources are very limited. The commonest cause of infertility in Africa is tubal disease, so that assisted reproductive techniques, and therefore exogenous gonadotrophins, are central to effective management. The conflict between affordable and effective health care is addressed.

Analysis of the cost effectiveness of recombinant versus urinary follicle-stimulating hormone in in vitro fertilization/intracytoplasmic sperm injection programs in the United States

OBJECTIVE

To compare the cost effectiveness of recombinant human FSH (Gonal-F; Serono, Inc., Randolph, MA) and urinary FSH (Fertinex; Serono, Inc.) for ovarian stimulation during IVF with or without intracytoplasmic sperm injection for the treatment of infertility.

DESIGN

Clinical decision analysis techniques (the Markov model) were used to model the direct medical costs per patient during assisted reproductive technology.

MAIN OUTCOME MEASURE(S)

Clinical and economic outcomes of two different ovarian stimulation protocols (recombinant human FSH or urinary FSH) during three treatment cycles were considered.

RESULT(S)

More ongoing pregnancies were achieved, with fewer stimulation cycles, after recombinant human FSH (Gonal-F) than after urinary FSH (Fertinex) (40,665 versus 37,890). In addition, recombinant human FSH was also found to be more cost effective per ongoing pregnancy. From a societal perspective, the mean cost per pregnancy was $40,688 for recombinant human FSH versus $47,096 for urinary FSH. From the insurers' perspective, the mean cost/pregnancy for recombinant human FSH was $28,481 versus $32,967 for urinary FSH.

CONCLUSION(S)

Recombinant human FSH (Gonal-F) is not only more efficient clinically than urinary FSH (Fertinex), but also more cost effective. This analysis illustrates the point that the economic effectiveness of a drug depends less on its acquisition costs and rather more on the clinical outcomes associated with its use.

Cost-effectiveness modelling of recombinant FSH versus urinary FSH in assisted reproduction techniques in the UK

BACKGROUND

The purpose of this study was to undertake an economic evaluation to compare the cost-effectiveness of recombinant (r)FSH with urinary (u)FSH for attaining clinical pregnancy with assisted reproduction.

METHODS

Mathematical modelling was utilized incorporating a Markovian decision framework and a Monte Carlo simulation. Statistical representations of recurrent events over time were incorporated into a decision analysis involving fresh and frozen cycles in any sequence (after the first fresh embryo transfer cycle) over three successive assisted reproduction attempts. The mean values of transition probabilities were derived from randomized controlled clinical trials and published reports. The distributions of these transition probabilities were agreed upon by a panel of experts. Cost data for procedures and drugs were derived and validated according to the perspectives of the National Health Service and private clinics in the UK.

RESULTS

The study involved 5000 Monte-Carlo simulations of treatment on a Markov cohort of 100 000 patients. The total number of pregnancies attained was significantly higher in the rFSH (40 575) compared with the uFSH (37 358) group. The cost per successful pregnancy was significantly lower for rFSH (5906 pounds sterling) compared with uFSH (6060 pounds sterling) and overall, fewer cycles of treatment were required with rFSH to achieve an ongoing pregnancy. The incremental cost-effectiveness ratio is 4148 pounds sterling for each additional clinical pregnancy with rFSH.

CONCLUSIONS

In addition to the increased effectiveness of rFSH in ART, this study demonstrated that it is more cost-effective and more efficient than uFSH in attaining an ongoing pregnancy.

Subcutaneously administered Repronex in oligoovulatory female patients undergoing ovulation induction is as effective and well tolerated as intramuscular human menopausal gonadotropin treatment

OBJECTIVE

To determine the efficacy and safety of Repronex SC as compared with Repronex IM and Pergonal IM in patients undergoing ovulation induction.

DESIGN

Randomized, open-label, multicenter, parallel group study.

SETTING

Ten academic and private fertility clinics with expertise in ovualtion induction.

PATIENT(S)

Premenopausal anovulatory and oligoovulatory females (n = 115) undergoing ovulation induction.

INTERVENTION(S)

Down-regulation with leuprolide acetate followed by up to 12 days of treatment with gonadotropins and hCG administration and luteal phase progesterone support.

MAIN OUTCOME MEASURE(S)

Percentage of patients ovulating; percentage of cycles with follicular development meeting criteria for hCG administration; number of follicles recruited per cycle meeting hCG criteria; peak serum E(2) levels; rates of chemical, clinical and ongoing pregnancies; adverse events; injection-site pain scores.

RESULT(S)

There was no statistically significant difference in the percentage of women who ovulated among the treatment groups. However, Repronex SC was significantly more effective than Pergonal IM in producing follicular development in patients who met hCG criteria. There were no significant differences in clinical, ongoing, or continuing pregnancy rates or in multiple pregnancies among the treatment groups. No differences were found in the safety assessments, proportions or seriousness of adverse events or treatment discontinuations. Also, there were no differences between the three treatment groups in patient-recorded scores of injection-site pain or injection-site reactions.

CONCLUSION(S)

Repronex SC is as efficacious and well tolerated as Repronex IM or Pergonal IM in ovulation induction. Self-administration of Repronex SC provides a convenient treatment alternative to daily IM injections.

Comparison of recombinant and urinary follicle-stimulating hormone preparations in short-term gonadotropin releasing hormone agonist protocol for in vitro fertilization-embryo transfer

PURPOSE

To compare the efficiency and efficacy of two recombinant human FSH (r-FSH) and urinary (u-FSH) preparations in patients undergoing superovulation for IVF-ET using a short-term gonadotropin releasing hormone agonist (GnRH-a) (Triptorelin) protocol.

METHODS

A total of 88 women undergoing IVF-ET were included in this prospective study. They were randomized to receive u-FSH (150 IU/d), follitropin-alpha (100 IU/d), or follitropin-beta (100 IU/d) for 2 days, and dosages were subsequently adjusted according to the ovarian response.

RESULTS

The FSH dose required for the overall stimulation was significantly lower in patients treated with r-FSH than in those treated with u-FSH while serum FSH values were higher in the latter group. There were no statistically significant differences in ovarian response and IVF outcome between r-FSH preparations.

CONCLUSIONS

Recombinant FSH preparations have a higher efficiency than urinary ones in patients undergoing IVF-ET using a short-term GnRH-a protocol. In this situation, the two recombinant follitropins have comparable effectiveness.

Role of periovulatory luteinizing hormone concentrations during assisted reproductive technology cycles stimulated exclusively with recombinant follicle-stimulating hormone

OBJECTIVE

To study the effect of endogenous luteinizing hormone (LH) concentration on fertilization, pregnancy, and early pregnancy loss rates.

DESIGN

Retrospective cohort study.

SETTING

Tertiary-care university center.

PATIENT(S)

One hundred sixty-six normogonadotropic patients undergoing IVF.

INTERVENTION(S)

Luteal phase pituitary down-regulation and recombinant FSH (Gonal-F) were used for ovarian stimulation. The mean of 4-5 serum LH concentrations, from stimulation days 5-12, was computed for analysis.

MAIN OUTCOME MEASURE(S)

Fertilization, pregnancy, and early pregnancy loss rates according to periovulatory levels of LH.

RESULT(S)

Data were analyzed by stratifying patients according to a mean periovulatory LH value of 3 mIU/mL. After controlling for confounding variables with logistic regression, results showed that the fertilization rate was significantly lower in patients with a periovulatory LH <3 mIU/mL versus > or = 3 mIU/mL (52% and 58%, respectively; P=.03). Pregnancy rates and spontaneous abortion rates were similar in both groups. There were seven biochemical pregnancies, all in patients with an LH <3 mIU/mL (P=.07).

CONCLUSION(S)

Low endogenous LH concentrations (<3 mIU/mL) in the late follicular phase of an IVF cycle are associated with significantly lower fertilization rates and a trend toward higher biochemical pregnancy rates. It may be of clinical benefit, when exclusively using r-hFSH in ART cycles, to add LH in the late follicular phase or to further reduce the dose of GnRH agonist.

Reflections on the cost-effectiveness of recombinant FSH in assisted reproduction. The clinician's perspective

PURPOSE

To analyze the relative cost-effectiveness of recombinant FSH (rFSH) and urinary FSH (uFSH) in assisted reproduction techniques (ART).

METHODS

Calculation of the average cost-effectiveness ratio and the incremental cost-effectiveness ratio to compare costs and effects (pregnancy rates) of the two therapeutic options (rFSH and uFSH).

RESULTS

Assuming that the cost of the procedure per ART cycle is between 100,000 pesetas (601 euro) and 150,000 pesetas (901.52 euro), and pricing the GnRH analogues used for pituitary suppression at 35,000 pesetas (210.3 euro), the cost-effectiveness ratio is better for rFSH than for uFSH, implying that the cost per pregnancy is lower when the recombinant preparation is used.

CONCLUSIONS

In ART, the use of rFSH is more cost-effective than uFSH.

A prospective, randomized, controlled clinical study of a new subcutaneous, purified, urinary FSH preparation for controlled ovarian hyperstimulation in in vitro fertilization

The aim of this study was to evaluate the clinical efficacy and safety of a new urinary follicle stimulating hormone (FSH) preparation (Fostimon) in patients undergoing in vitro fertilization-embryo transfer or intracytoplasmic sperm injection. Metrodin HP was adopted as a reference drug, as its purity and therapeutic efficacy are well known. Sixty normo-ovulatory patients aged 18-38 years with normal basal FSH and body mass index < 25 kg/m2 were selected for the study. After gonadotropin releasing hormone analogue pituitary desensitization, patients were randomized to receive either Fostimon or Metrodin HP at the initial dosage of 225 IU for 6 days. Thereafter, the dosage was tailored according to the ovarian response. Both drugs were administered by the subcutaneous route. The primary end-points were: number of follicles larger than 15 mm, levels of 17 beta-estradiol on the day of human chorionic gonadotropin (hCG) injection and number of oocytes recovered. The secondary end-points were: number of FSH ampules used, day of hCG injection and pregnancy rate. FSH kinetic curves were calculated during the treatment period with both products. Safety was evaluated by pre- and post-treatment blood biochemistry and hematology, and recording all side-effects. Local tolerance was investigated at each visit. None of the parameters evaluated showed a statistically significant difference between the two groups. Local tolerance was always recorded as good/excellent by both the patients and the physician. In conclusion, Fostimon proved to be an effective and safe drug for assisted reproductive cycles.