Incidence and severity of ovarian hyperstimulation syndrome (OHSS) in high responders after gonadotropin-releasing hormone (GnRH) agonist trigger in "freeze-all" approach

OBJECTIVE

To determine the incidence and severity of ovarian hyperstimulation syndrome (OHSS) in high responders (25-35 follicles with a diameter of ≥12 mm on day of triggering) who received a gonadotropin-releasing hormone (GnRH) agonist to trigger final follicular maturation.

METHODS

We used individual data from women who participated in four different clinical trials and were high responders to ovarian stimulation in a GnRH antagonist protocol in this retrospective combined analysis. All women were evaluated for signs and symptoms of OHSS using identical criteria based on Golan's system (1989).

RESULTS

High responders (n = 77) were of different ethnicities. There were no differences in baseline characteristics between women with or without signs and symptoms of OHSS. Mean ± standard deviation baseline data were: age, 32.3 ± 3.5 years; anti-Müllerian hormone, 42.4 ± 20.7 pmol/L; antral follicle count, 21.5 ± 9.2. Before triggering, duration of stimulation was 9.5 ± 1.6 days and the mean number of follicles with a diameter of ≥12 mm and ≥17 mm was 26.5 ± 4.4 and 8.8 ± 4.7, respectively. Mean serum estradiol (17,159 pmol/l) and progesterone (5.1 nmol/l) levels were high at 36 h after triggering. Overall, 17/77 high responders (22%) developed signs and symptoms of mild OHSS which lasted 6-21 days. The most frequently prescribed medication was cabergoline to prevent worsening of OHSS. No severe OHSS occurred and no OHSS cases were reported as serious adverse events.

CONCLUSIONS

High responders receiving GnRH agonist for triggering should be informed that they may experience signs and symptoms of mild OHSS.

P-567 Recombinant hCG (choriogonadotropin beta, CG beta) exerts a positive dose-dependent effect on human follicular steroidogenesis during ovarian stimulation using a constant rFSH administration

Study question

How does increasing doses of CG beta augment follicular steroidogenesis and is it associated with gene expression in cumulus cells?

Summary answer

With the exception of progesterone, CG beta exerts dose-dependent effects on intrafollicular steroid hormone concentrations and CYP19a1 expression during constant rFSH administration.

What is known already

CG beta (FE 999302) is a newly developed rhCG, produced by a human cell line (PER.C6®). This variant contains the same amino acid sequence as the endogenous hCG but presents with a different glycosylation profile when compared to urinary hCG or rhCG derived from a CHO cell line. CG beta has also been shown to have a longer half-life and higher relative potency. It is well known that hCG like LH creates an intracellular response through the LHR expressed on theca cells and mature granulosa cells and hereby augment the production of androgens, progesterone, and oestrogen.

Study design, size, duration

This study is part of a randomised, double-blind, placebo-controlled trial to investigate the efficacy and safety of CG beta as an add-on treatment to rFSH in women undergoing ovarian stimulation during a long GnRH agonist protocol. The primary endpoint of this study was intrafollicular steroid levels in relation to CG beta administration. Secondary outcomes were gene expression of LHR, FSHR, CYP19a1, and androgen receptor (AR) and single nucleotide polymorphisms (SNPs) in LHR(312) and FSHR(307).

Participants/materials, setting, methods

619 women with AMH levels 5-35 pmol/L were randomized to receive either placebo or 1, 2, 4, 8, or 12 µg CG beta from day one of stimulation combined with a constant individualized dose of rFSH. Follicular fluid (FF) (n = 558), granulosa (n = 498) and cumulus cells (n = 368) were collected at oocyte retrieval. Steroid FF hormones were measured using ELISAs, gene expression was analysed in cumulus cells by qRT-PCR, and SNP analysis was performed in granulosa cells.

Main results and the role of chance

This study found that CG beta has a pronounced positive dose-dependent effect on intrafollicular concentrations of 17-OH-progesterone, androstenedione, testosterone, and oestradiol during constant rFSH administration. As compared to the placebo group without CG beta administration the concentrations of steroids were significantly dose-dependently increased (p-value<0.0001) reaching up to 10 times higher values in the highest dose group without a clear plateauing. However, for progesterone, there was no statistically significant difference between the CG beta dose groups and placebo. The gene expression level of CYP19a1 in the cumulus cells collected at oocyte retrieval increased significantly (p-value=0.0325) for the highest dose of CG beta. However, the gene expression level of FSHR, LHR, and AR in cumulus cells were not affected by CG beta administration, as no dose-response trend with increasing dose of CG beta was observed. Additionally, this study revealed that there was no overall clear difference in the number of oocytes retrieved between the different CG beta dose groups based on either the FSHR(307) or LHR(312) genotypes.

Limitations, reasons for caution

The gene expression was assessed in cumulus cells, but it would also have been interesting to evaluate the mural granulosa cells. Analysis of the gene expression of 3βHSD and other important steroidogenic enzymes in the mural granulosa cells could reveal further explanation to the effect of CG beta administration.

Wider implications of the findings

To our knowledge, this is the first study to show a clear dose-dependent effect of rhCG on human steroidogenesis during constant rFSH administration in preovulatory follicles. This reflects the importance of the combined effect of FSH and hCG/LH on granulosa cell activity, follicle health, and potentially oocyte quality.

Trial registration number

000289

P-568 The effect of recombinant hCG on FSH-induced ovarian stimulation in rats depends on the FSH dose and can be detrimental at high concentrations

Study question

What is the effect of choriogonadotropin beta (CG beta) on FSH-induced ovarian stimulation and multifollicular development in a rat model?

Summary answer

CG beta dose-dependently potentiates effects of low-to-mid FSH doses but has inhibitory effects at high concentrations: optimal CG beta/FSH ratio depends on the FSH dose.

What is known already

Similarly to follitropin delta (rFSH), CG beta (FE 999302) is a novel recombinant hCG purified from the human PER.C6®cell line. A recent placebo-controlled trial in women undergoing ovarian stimulation with follitropin delta demonstrated that the addition of 1 to 12 µg CG beta reduced the number of intermediate follicles and related hormones. This observation required further preclinical research to (1) evaluate whether the pharmacology of CG beta at LH/CGR was different than other hCG forms used in the clinic and/or (2) assess the effect of high concentrations of hCG and different hCG/FSH ratios on multiple follicular development and follicle atresia.

Study design, size, duration

Signaling properties of CG beta and other LH/hCG forms were compared at downstream pathways of LH/CGR in recombinant systems and human granulosa cells. To evaluate the effects of FSH±hCG in vivo, juvenile female rats were injected subcutaneously twice daily with follitropin delta ± CG beta/alfa for three days followed by an ovulatory dose of hCG. Oviducts were then collected for oocyte enumeration, ovaries and uteri were weighed, and ovaries were fixed for histological analysis.

Participants/materials, setting, methods

The pharmacology of CG beta and other LH/hCG forms was evaluated in a cAMP assay in human granulosa cells from follicular fluid from IVF patients and in recombinant systems, at the Gs, Gq and arrestin pathways. In the rat model, a dose response of follitropin delta (Rekovelle) was first evaluated, followed by evaluation of the dose-dependent effects of CG beta (0.00117-2.4 µg/kg), or CG alfa (Ovidrel/Ovitrelle), in combination with 1, 3 or 10 µg/kg rFSH.

Main results and the role of chance

The in vitro pharmacology (potency and efficacy) of CG beta was similar to recombinant LH, urinary hCG and recombinant hCG (CG alfa) tested at all proximal pathways evaluated downstream of LH/CGR as well as in human granulosa cells.

In vivo, treatment with follitropin delta induced a bell-shaped dose-response curve for oocyte release with a maximum response of 40-50 oocytes at 8-10 µg/kg follitropin delta dose.

The addition of CG beta dose-dependently potentiated the effects at low-to-mid follitropin delta doses but had inhibitory effects on the number of ovulated oocytes at high CG beta concentrations. The lowest CG beta dose that clearly reduced the number of ovulated oocytes was 2.4, 0.6 and 0.3 µg/kg in combination with a fixed dose of 1, 3 and 10 µg/kg follitropin delta, respectively, which indicated that the optimal hCG/FSH ratio and corresponding hCG efficacious dose was inversely related to the FSH dose. There was no difference between CG beta and CG alfa for the dose effect on the number of ovulated oocytes or ovarian weight. Histology data indicated many cystic follicles following high CG beta exposure which may represent atretic follicles prior to triggering follicular maturation and ovulation.

Limitations, reasons for caution

This is the first study demonstrating that the FSH dose in combination with the hCG dose determines the effect on multiple follicle growth, ovulation, and atresia. These observations need to be confirmed in clinical research, as doses and ratios applied in the rat cannot be extrapolated to the clinical setting.

Wider implications of the findings

A better understanding of the effect of different FSH to hCG ratios will help to improve current mixed protocols and design future recombinant combination products providing the optimal treatment outcome for each individual patient.

Trial registration number

not applicable

P-755 Conventional outcome reporting per embryo-transfer cycle systematically underestimates the chance of success of women undergoing ART: a source of bias in registries, trials and guidelines

Study question

How should ART treatment success be estimated from data consisting of several treatment attempts per subject (e.g., fresh transfer followed by cryotransfer[s] and/or repetitive attempts)?

Summary answer

Live birth rate estimates per transfer cycle will be substantially higher when accounting for differences in the number of embryo transfers between subjects.

What is known already

Preconception counselling and expectation management is an integral part of fertility care. In the course of IVF-treatment, the majority of women undergo several embryo transfers (ET). The live birth rate per ET cycle may be severely underestimated since women with a poor prognosis will be overrepresented in the population compared to women with a good prognosis. This is because women achieving a live birth early will contribute few ETs, whereas women without live births will contribute several ETs to the pool of observations. This phenomenon does also add bias when comparing the live birth rates between fresh- transfers and cryo-transfers.

Study design, size, duration

The complete data set from the RAINBOW trial (NCT03564509) was applied to exemplify the underestimation of live birth chance of individual women in cryo-cycles. In total 557 women underwent treatment in a fixed, individualized daily- dose of follitropin delta in a long GnRH agonist protocol, IVF/ICSI and blastocyst transfer. Surplus blastocysts were cryopreserved on day 5/6 and subsequently used for cryo-transfers up to one year after start of the stimulation.

Participants/materials, setting, methods

Live birth rate was analyzed using a mixed effect logistic regression model where the log-odds of achieving a live birth was assumed to be normally distributed in the trial population. Type of transfer (fresh or cryo) was included as a factor in the model. The delta method was used to transform estimated mean log-odds from the model into estimated live birth rates per transfer, and to estimate the difference between fresh- and cryo-transfers.

Main results and the role of chance

Of the 619 women starting stimulation, 557 had at least one fresh- or cryo-transfer. A total of 927 embryo transfers were performed whereof 520 fresh- and 407 cryo-transfers. In total, 252 subjects had at least one cryotransfer, 102 had a second cryotransfer, 37 a third, 12 a fourth, three a fifth, and one had a sixth cryotransfer, respectively. Of the 520 fresh transfers, 212 (41%) resulted in a live birth, whereas for the 407 cryo-transfers 100 (25%) resulted in a live birth (unadjusted difference 16%). When using the mixed effect logistic regression model to adjust for repeated transfers in the same women, the live birth rates were estimated to be 41% for fresh transfers and 36% per transfer for cryo-transfers. The difference between rates for fresh transfer and per cryo-transfer was estimated to be 5.3% with 95% confidence interval ranging from -6.6% to 17.1% and with no statistically significant difference (p = 0.3827).

Limitations, reasons for caution

Comparison between live birth rate after fresh transfer and per cryotransfer in the same group of women will already be biased in favour of the fresh transfer. This is because the fresh transfer will normally use the embryo of highest quality, leaving embryos of lower quality for cryo-transfers.

Wider implications of the findings

Average chance of success reported per cycle or per embryo-transfer (e.g. registry reports) do not apply to individual couples, especially not at the outset of treatment. Live birth rates per transfer from datasets encompassing multiple transfers from single individuals can be more accurately reported using mixed effect logistic regression models.

Trial registration number

NCT03564509

P-134 The robustness of Gardner and Schoolcraft (GS) scoring prior vitrification for selecting a single vitrified blastocyst for transfer

Study question

Do changes in the GS score before vitrification and before transfer of a single vitrified-warmed blastocyst (SVBT) predict the chance of live birth?

Summary answer

There was no association between changes in GS score and the chance of live birth after SVBT.

What is known already

Morphological scoring of human blastocysts is commonly used for assessing the embryo potential for implantation and live birth. Blastocysts that are vitrified and subsequently warmed are usually observed for re-expansion, which is taken for the decision whether to transfer or if another blastocyst will be warmed. Re-scoring warmed embryos before SVBT may result in a lower, same or higher score and may be applied to select the embryo with the highest quality for transfer.

Study design, size, duration

The GS score was evaluated twice namely before vitrification and immediately before SVBT for 374 embryo transfers in 240 women participating in the RAINBOW trial (NCT03564509). Subjects were stimulated with a fixed individualized daily dose of follitropin delta in a long GnRH agonist protocol. Blastocyst transfer was performed on day 5; remaining blastocysts were cryopreserved on day 5/6.

Participants/materials, setting, methods

The association between changes in GS score from before vitrification to before SVBT was investigated using a mixed effect logistic regression model with factors for expansion and hatching status, inner cell mass, and trophectoderm (with decrease, no change, and increase as factor levels for each), and assuming that the log-odds of achieving a live birth was normally distributed in the trial population.

Main results and the role of chance

A total of 472 embryos were vitrified and scored with the GS grading system before vitrification and before SVBT. Of these 298 (63%) had identical scores before and after vitrification. Changes in expansion and hatching status were seen for 23%, inner cell mass for 21%, and trophectoderm for 21% of embryos. Of the 472 warmed embryos, 32 were discarded and 66 were used for double transfers. The remaining 374 blastocysts were used for single embryo transfers. Of these 374 embryos, 68% had identical GS scores at the two scorings, 12%/6% had increase/decrease in expansion and hatching score, 10%/6% had increase/decrease in inner cell mass grading, and 12%/4% had increase/decrease in trophectoderm grading. There was no statistically significant association between either of these changes and the chance of live birth (expansion and hatching: p = 0.94, inner cell mass: p = 0.71, trophectoderm: p = 0.60).

Limitations, reasons for caution

Only 68 (32%) of the 374 blastocysts had different scores before vitrification and before SVBT, indicating the consistency of the score regardless vitrification. Thus, there was only limited power to show an association with chance of live birth. Also, embryos with low quality after thawing were not used for transfer.

Wider implications of the findings

Selection of vitrified embryos for transfer can be based on the pre-vitrification score, as the post-vitrification quality correlates well with the pre-vitrification quality and potential changes may not affect the chance of live birth

Trial registration number

NCT03564509

O-013 The individualised dosing algorithm of follitropin delta, developed in a GnRH antagonist protocol, shows to be highly effective in a long GnRH agonist protocol

Study question

Is the individualised follitropin delta regimen based on serum anti-Müllerian hormone (AMH) concentration and body weight effective and safe in a long GnRH agonist protocol?

Summary answer

Per started stimulation, the live birth rate following fresh transfer was 43% and the cumulative live birth rate following fresh and frozen transfers was 58%.

What is known already

Individualised follitropin delta treatment in a GnRH antagonist protocol reduces the incidence of OHSS and/or preventive interventions without compromising live birth rates. In a multinational, double-blind, randomised trial (RAINBOW, NCT03564509) exploring the efficacy and safety of choriogonadotropin beta in women undergoing ovarian stimulation in a long GnRH agonist protocol, the control group was treated with the same individualised follitropin delta regimen based on AMH (Elecsys AMH Plus Immunoassay) and body weight. Women had one stimulation cycle and were followed up to live birth following the fresh and all frozen blastocyst transfers performed within one year after start of stimulation.

Study design, size, duration

Analysis of fresh and cumulative live birth rates in 104 women (30–42 years, AMH 5-35 pmol/L) down-regulated with 0.1 mg/day triptorelin and stimulated in one cycle with a fixed individualised daily dose of follitropin delta. Triggering was performed when 3 follicles ≥17 mm. Oocytes were inseminated by ICSI; blastocyst transfer was on day 5 and remaining blastocysts were cryopreserved on day 5/6 and subsequently used for frozen transfers.

Participants/materials, setting, methods

Data collection included live birth and neonatal health follow-up for all transfers of fresh or frozen embryos performed within one year after the start of stimulation. The data presented are based on all women who were down-regulated and started stimulation. The cumulative live birth rate was calculated as the percentage of women starting stimulation that had at least one live born neonate.

Main results and the role of chance

Of 104 women starting stimulation, 101 had triggering. Two subjects were cancelled due to poor response and one due to adverse event. Nine subjects had transfer cancellations; six due to no day 5 blastocyst available, and one each due to risk of OHSS, adverse event, and other reason. The average daily dose of follitropin delta was 11.0±1.6 and the duration of stimulation was 10.3±1.6 days. The mean number of oocytes was 12.5±6.4; the mean number of blastocysts was 5.1±3.4; and 85% had at least one good-quality blastocyst. Following mostly single blastocyst transfer (95%), the ongoing pregnancy rate (10–11 weeks after transfer) was 43% per started stimulation. There were six cases of early OHSS (5.8%) graded as mild (3) and moderate (3) and six cases with late OHSS (5.8%) graded as moderate (3) and severe (3).

In total, 92% of women had at least one fresh or frozen transfer and 150 blastocyst transfers were performed (92 fresh and 58 frozen transfers). Per started stimulation, the live-birth rate following fresh transfer was 43% and the cumulative live-birth rate following fresh and all frozen transfers was 58%. There were three neonates with congenital anomalies following fresh transfer and none following frozen transfer.

Limitations, reasons for caution

This is the first clinical trial investigating the individualised follitropin delta regimen in a long GnRH agonist protocol. A final evaluation of this regimen requires comparative data. Accordingly, a randomised trial comparing follitropin delta in a long GnRH agonist protocol vs. in a GnRH antagonist protocol is currently ongoing (NCT03809429).

Wider implications of the findings

The use of individualised follitropin delta dosing based on AMH and body weight in a long GnRH agonist protocol resulted in high fresh and cumulative live birth rates, and with an incidence of OHSS similar to previously reported for other FSH products in long GnRH agonist protocols.

Trial registration number

NCT03564509

P–132 Centralized versus local embryologists scoring of blastocyst quality obtained in a large European multicenter clinical trial

Study question

Does blastocyst quality scoring by central assessment deviate from local assessment and potentially lead to the selection of a different single blastocyst for transfer?

Summary answer

Central and local assessment provided the same quality classification (poor / good / top) in 69% of all blastocysts and 63% of all transferred blastocysts.

What is known already

Blastocyst quality is scored most frequently by three morphological parameters, namely expansion and hatching (EH) status, inner cell mass (ICM) grading and trophectoderm (TE) grading. The score is used to define the quality classification (poor / good / top) which determines which embryo is to be transferred or cryopreserved. Blastocyst scoring and grading can be highly subjective, which does influence the choice for transfer and cryopreservation. Time-lapse imaging technology captures additional input about embryo development as well as enables centralized data storage and sharing for independent central assessments.

Study design, size, duration

Pooled embryo analysis from a prospective, randomized, multicenter trial (RAINBOW) of 619 women undergoing ovarian stimulation with an individualized dose of follitropin delta in a long GnRH agonist protocol between May 2018 and January 2020. Blastocysts were centrally assessed using time-lapse images by two independent assessors and one adjudicator . Selection of the blastocyst for transfer by local assessment was based on morphological scoring and not on morphokinetic time-lapse parameters.

Participants/materials, setting, methods

Oocytes were fertilized by ICSI and cultured in the Embryoscopeâ (Vitrolife) up to day 5 for transfer or day 5/6 for cryopreservation. Embryos were assessed as either non-blastocyst or blastocyst. Blastocysts were graded centrally and locally at 116 hrs of development, based on EH status (1–6), ICM (A-D) and TE grading (A-D). Central assessors were blinded to local assessment and embryo transfer selection.

Main results and the role of chance

In total 4282 embryos were assessed centrally, of which 2046 day 5 embryos (48%) were adjudicated due to a scoring difference of at least one parameter between the two central assessors. In total 38% of day 5 embryos were judged as non-blastocysts and 62% as blastocysts of which 61% (i.e. 38% of all embryos) were determined to be of good or top quality.

Identical results in terms of quality classification (poor / good / top) were obtained for 69% of blastocysts between local and central assessment and in 78%, between the two central assessors. Moreover, central and local scoring were identical in 62% for EH status, 53% for ICM grading and 57% for TE grading.

For all transferred blastocysts (n = 508), central and local quality assessment was aligned for 63%. The ongoing pregnancy rate following single blastocyst transfer (SBT) was 41% (202/489), and similar to when considering only the transfers for which the central assessment had the same or a higher classification than the local assessment (166/411=40%). In 16% of all SBT, central quality assessment gave a lower score for the transferred blastocyst than the central assessment. This discrepancy could potentially have led to transfer of a different blastocyst.

Limitations, reasons for caution

This trial included assessments made by embryologists from 20 IVF centres. Some centres has limited experience with time-lapse technology for morphological blastocyst scoring. Scoring could therefore have been affected by differences in focal planes, magnification and contrast compared to inverted microscopy, with potential influence on blastocyst scores and quality classification.

Wider implications of the findings: Local and central blastocyst quality classification based on morphology aligns well but remains subjective. Embryo assessment may benefit from using tools like artificial intelligence-based algorithms for a more objective analysis.

Trial registration number

NCT03564509

O-109 A first dose-response trial investigating the effects of adding choriogonadotropin beta to follitropin delta in women undergoing ovarian stimulation in a long GnRH agonist protocol

Study question

Does addition of choriogonadotropin beta (CG beta) to follitropin delta increase the number of good-quality blastocysts following ovarian stimulation in a long GnRH agonist protocol?

Summary answer

At the doses investigated, the addition of CG beta reduced the number of intermediate follicles and decreased the number of oocytes and blastocysts.

What is known already

CG beta is a new recombinant hCG (rhCG) molecule expressed by a human cell line (PER.C6â) with a different glycosylation profile compared to urinary hCG or rhCG derived from a Chinese Hamster Ovary (CHO) cell-line. In the first-in-human trial, the CG beta pharmacokinetics were similar between men and women. In women, the area under the curve (AUC) and the peak serum concentration (Cmax) increased dose proportionally following single and multiple daily doses. In men, a single dose of CG beta provided higher exposure with a longer half-life and proportionately higher testosterone production than rhCG derived from a CHO cell line.

Study design, size, duration

Placebo-controlled, double-blind, randomised trial (RAINBOW) to explore the efficacy and safety of CG beta as add-on treatment to follitropin delta in women undergoing COS in a long GnRH agonist protocol. The primary endpoint was the number of good-quality blastocysts (grade 3 BB or higher, Gardner and Schoolcraft, 1999). Subjects were randomised to receive either placebo or 1, 2, 4, 8, or 12 µg CG beta added to the daily individualised follitropin delta dose during COS.

Participants/materials, setting, methods

In total 619 women (30-42 years) with AMH levels between 5 and 35 pmol/L were randomized in equal proportions to the six treatment groups. All subjects were treated with an individualised dose of follitropin delta determined based on AMH (Elecsys AMH Plus Immunoassay) and body weight. Triggering was performed when 3 follicles were ≥17 mm but no more than 25 follicles ≥12 mm were reached

Main results and the role of chance

The incidence of cycle cancellation (range 0%-2.9%), total follitropin delta dose (mean 112 µg) and duration of stimulation (mean 10 days) were similar across the groups. A reduced number of intermediate follicles (12 to 17 mm) and fewer oocytes (mean range 9.7 to 11.2) were observed for all doses of CG beta compared to the follitropin delta only group (mean 12.5). The mean number of goodquality blastocysts was 3.3 in the follitropin delta group and ranged between 2.1 and 3.0 across the CG beta groups. The incidence of transfer cancellation was higher in the 4, 8 and 12 µg group, mostly as no blastocyst was available for transfer. In the group receiving only follitropin delta, the ongoing pregnancy rate (10-11 weeks after transfer) was high i.e. 43% per started cycle vs 28-39% in CG beta groups and 49% per transfer vs 38-50% in the CG beta groups. In line with the number of collected oocytes, the OHSS incidence was overall lower following follitropin delta with CG beta than following follitropin delta only treatment. Regardless of the dose, CG beta was safe and well-tolerated with low risk of immunogenicity.

Limitations, reasons for caution

The effect of the unique glycosylation of CG beta and the associated potency implications in women were not known prior to this trial. Further studies will be needed to evaluate potentially lower doses of CG beta for this and/or different indications.

Wider implications of the findings

The high ongoing pregnancy rate in the follitropin delta group supports the use of individualised follitropin delta dosing in a long GnRH agonist protocol. The differential potency of CG beta may have impaired the growth of intermediate follicles with the investigated doses without affecting the ongoing pregnancy rates per transfer.

Trial registration number

NCT03564509

O-110 A randomised, controlled, assessor-blind trial assessing clinical outcomes of individualised dosing with follitropin delta in Asian IVF/ICSI patients

Study question

To evaluate the efficacy and safety of individualised dosing with follitropin delta versus conventional dosing with follitropin alfa in an Asian population undergoing ovarian stimulation.

Summary answer

Individualised dosing with follitropin delta results in significantly higher live birth rate and fewer early OHSS and/or preventive interventions compared to conventional follitropin alfa dosing.

What is known already

Previous randomised controlled trials conducted in Europe, North- and South America mainly including Caucasian IVF/ICSI patients as well as in Japan have demonstrated that ovarian stimulation with the individualised follitropin delta dosing regimen based on serum AMH level and body weight modulated the ovarian response and reduced the risk of OHSS without compromising pregnancy and live birth rates.

Study design, size, duration

Randomised, controlled, assessor-blind trial conducted in 1,009 Asian patients from mainland China, South Korea, Vietnam and Taiwan, undergoing their first IVF/ICSI cycle. Randomisation was stratified by age (<35, 35-37, 38-40 years). The primary endpoint was ongoing pregnancy assessed 10-11 weeks after transfer (non-inferiority limit -10.0%; analysis adjusted for age strata). Patients <35 years underwent single embryo transfer if a good-quality embryo was available, otherwise double embryo transfer. Patients ≥35 years underwent double embryo transfer.

Participants/materials, setting, methods

Follitropin delta (Rekovelle, Ferring Pharmaceuticals) daily treatment consisted of a fixed dose individualised according to each patient’s initial AMH level (<15 pmol/L: 12 μg; ≥15 pmol/L: 0.19 to 0.10 μg/kg; min-max 6-12 μg) and body weight. Follitropin alfa (Gonal-f, Merck Serono) dose was 150 IU/day for the first five days with subsequent potential dose adjustments according to individual response. A GnRH antagonist protocol was applied. OHSS was classified based on Golan’s system.

Main results and the role of chance

The ongoing pregnancy rate was 31.3% with follitropin delta and 25.7% with follitropin alfa (adjusted difference 5.4% [95% CI: -0.2%; 11.0%]). The live birth rate was significantly higher at 31.3% with follitropin delta compared to 24.7% with follitropin alfa (adjusted difference 6.4% [95% CI: 0.9%; 11.9%]; p < 0.05). Live birth rates per age stratum were as follows for follitropin delta and follitropin alfa; <35 years: 31.0% versus 25.0%, 3537 years: 35.3% versus 26.7%, 38-40 years: 20.0% versus 14.3%. Early OHSS risk, evaluated as the incidence of early OHSS and/or preventive interventions, was significantly (p < 0.01) reduced from 9.6% with follitropin alfa to 5.0% with follitropin delta. The number of oocytes was 10.0±6.1 with follitropin delta and 12.4±7.3 with follitropin alfa. Individualised follitropin delta dosing compared to conventional follitropin alfa dosing resulted in 2 more oocytes (9.6±5.3 versus 7.6±3.5) in potential low responders (AMH <15 pmol/L) and 3 fewer oocytes (10.1±6.3 versus 13.8±7.5) in potential high responders (AMH ≥15 pmol/L). Among patients with AMH ≥15 pmol/L, excessive response occurred less frequently with individualised than conventional dosing (≥15 oocytes: 20.2% versus 39.1%; ≥20 oocytes: 6.7% versus 18.5%). Total gonadotropin dose was reduced from 109.9±32.9 μg with follitropin alfa to 77.5±24.4 μg with follitropin delta.

Limitations, reasons for caution

The trial only covered the clinical outcome of one treatment cycle with fresh cleavage-stage embryo transfers.

Wider implications of the findings

The present trial implies that in addition to reducing the early OHSS risk, individualised dosing has the potential to improve the take-home baby rate in fresh cycles across all ages and with a lower gonadotropin consumption. The benefits in outcomes appear to be explained by the modulation of ovarian response.

Trial registration number

NCT03296527

Predictive factors of ovarian response and clinical outcome after IVF/ICSI following a rFSH/GnRH antagonist protocol with or without oral contraceptive pre-treatment

BACKGROUND

Prediction of ovarian response prior to the first controlled ovarian stimulation (COS) cycle is useful in determining the optimal starting dose of recombinant FSH (rFSH). However, potentially predictive factors may be subject to inter-cycle variability and many patients are pre-treated with oral contraceptives (OC) for scheduling purposes. Our objective was to determine predictive factors of ovarian response for patients undergoing COS with rFSH in a gonadotrophin-releasing hormone antagonist protocol and to determine the inter-cycle variability of these factors.

METHODS

In this multinational trial, 442 patients were randomized to receive either OC treatment or no treatment prior to their first COS cycle. For candidate predictive factors, patient characteristics were collected at screening, and endocrine and sonographic data were collected during the early follicular phase of the two subsequent cycles. A treatment regimen of 200 IU rFSH and 0.25 mg ganirelix was applied during the second cycle. Predictive factors of ovarian response and of too low (<6 oocytes) or too high (>18 oocytes) ovarian responses were determined using stepwise linear regression and stepwise logistic regression, respectively.

RESULTS

Anti-Müllerian hormone (AMH) and basal FSH were statistically significant predictors of the number of oocytes retrieved and of an excessive ovarian response. For low ovarian response, AMH was the only significant predictive factor. In the non-OC group, the predictive value was higher than in the OC group and higher at the early follicular phase of the stimulation cycle than of the previous cycle. The inter-cycle variation for AMH was low compared with the inter-cycle variation of other hormones. Between the two groups, there were no differences in the number or quality of embryos obtained or transferred, but the implantation rate was significantly lower in the OC group (24.1 versus 30.1%, P= 0.03), resulting in an ongoing pregnancy rate of 26.3% compared with 35.7% in the non-OC group (P= 0.05).

CONCLUSIONS

The best predictive model of ovarian response was in the non-OC group and included both AMH and basal FSH determined at the early follicular phase of the stimulation cycle. In the proceeding cycle, AMH alone had sufficient predictive value since it was not affected by inter-cycle variability or OC pretreatment.

Treatment with the GnRH antagonist ganirelix prevents premature LH rises and luteinization in stimulated intrauterine insemination: results of a double-blind, placebo-controlled, multicentre trial*

BACKGROUND

This study was designed to assess whether the use of ganirelix in women undergoing stimulated IUI could prevent the occurrence of premature LH rises and luteinization (LH+progesterone rises).

METHODS

Women of infertile couples, diagnosed with unexplained or male factor infertility, were randomized to receive either ganirelix (n=103) or placebo (n=100) in a double-blind design. All women were treated with an individualized, low-dose rFSH regimen started on day 2-3 of cycle. Ganirelix (0.25 mg/day) was started if one or more follicles>or=14 mm were visualized. Ovulation was triggered by HCG injection when at least one follicle>or=18 mm was observed and a single IUI was performed 34-42 h later. The primary efficacy outcome was the incidence of premature LH rises (+/-progesterone rise).

RESULTS

In the ganirelix group, four subjects had a premature LH rise (value>or=10 IU/l), one LH rise prior to the start of ganirelix and three LH rises during ganirelix treatment, whereas in the placebo group 28 subjects had a premature LH rise, six subjects prior to the start of placebo and 22 subjects during placebo treatment. The incidence of LH rises was significantly lower in ganirelix cycles compared to placebo cycles (3.9 versus 28.0%; P=0.003 for ITT analysis). When excluding subjects with an LH value>or=10 IU/l before the start of ganirelix/placebo the incidence of LH rises was also significantly lower in ganirelix cycles compared to placebo cycles (2.9 versus 23.4%; P=0.003 for ITT analysis). Premature luteinization (LH rise with concomitant progesterone rise>or=1 ng/ml) was observed in one subject in the ganirelix group and in 17 subjects in the placebo group of which three subjects had a premature spontaneous ovulation. Ongoing pregnancy rates per attempt were 12.6 and 12.0% for the ganirelix and placebo groups respectively.

CONCLUSIONS

Treatment with ganirelix effectively prevents premature LH rises, luteinization in subjects undergoing stimulated IUI. Low-dose rFSH regimen combined with a GnRH antagonist may be an alternative treatment option for subjects with previous proven luteinization or in subjects who would otherwise require insemination when staff are not working.

Similar endometrial development in oocyte donors treated with either high- or standard-dose GnRH antagonist compared to treatment with a GnRH agonist or in natural cycles

BACKGROUND

This descriptive study evaluates the impact on endometrial development of standard and high doses of a GnRH antagonist in stimulated cycles compared with GnRH agonist and natural cycles.

METHODS

Thirty-one oocyte donors were treated with a combination of rFSH and 0.25 mg/day ganirelix (standard dose), 2 mg/day ganirelix (high dose) or 0.6 mg/day buserelin (long protocol). Vaginal progesterone (200 mg/day) was administered in the luteal phase. Endometrial biopsies were performed 2 and 7 days after HCG administration. Additional biopsies were carried out in a subset of 12 subjects, 2 and 7 days following the LH peak of their previous natural cycle. Biopsies were evaluated histologically and by scanning electron microscopy. Gene expression profiles were also studied.

RESULTS

At HCG +2, all the parameters studied were similar in all the groups and comparable to those observed in the natural cycle. At HCG +7, endometrial dating, steroid receptors and the presence of pinopodes were comparable in both GnRH antagonist groups and in the natural cycle. In buserelin group, endometrial dating and pinopode expression suggested an arrested endometrial development. For window of implantation genes, expression patterns were closer to those in the natural cycle following standard- or high-dose ganirelix than after buserelin administration.

CONCLUSION

No relevant alteration was observed in the endometrial development in the early and mid-luteal phases in women undergoing controlled ovarian stimulation for oocyte donation following daily treatment with a standard- or high-dose GnRH antagonist. In addition, the endometrial development after GnRH antagonist mimics the natural endometrium more closely than after GnRH agonist.

Perinatal outcome of pregnancy after GnRH antagonist (ganirelix) treatment during ovarian stimulation for conventional IVF or ICSI: a preliminary report

BACKGROUND

Gonadotrophin-releasing hormone (GnRH) antagonists have been proven safe and effective, with no adverse effects on offspring in animal studies. Careful study of pregnancy outcome in humans is mandatory.

METHODS AND RESULTS

This preliminary report includes follow-up data of patients treated with the GnRH antagonist, ganirelix, during ovarian stimulation for IVF or ICSI. In total, 333 patients were randomized in a multicentre, double-blind, dose-finding study of ganirelix, at six different doses ranging from 0.0625 to 2 mg. In total, 68 vital intrauterine pregnancies were established that resulted in the birth of 46 singletons, 12 twins and one triplet. Follow-up of the 67 pregnant patients (one subject was lost to follow-up) revealed six miscarriages (9%). Of the 61 subjects with an ongoing pregnancy, two with a singleton pregnancy did not give birth to a live-born infant (one spontaneous abortion in week 19, and one intrauterine death in week 27). The mean gestational age was 39.4 weeks for singleton pregnancies, and 36.6 weeks for multiple pregnancies. In total, 73 infants (33 boys, 40 girls) were born. A birth weight <2500 g was reported for 8.7% and 54.2% of the infants resulting from singleton and twins delivery respectively. One major congenital malformation was diagnosed; a boy with Beckwith-Wiedemann syndrome (exomphalos and macroglossia). Seven minor malformations were reported among five infants.

CONCLUSIONS

In this first follow-up study, the incidence of adverse obstetrical and neonatal outcome was comparable with reported incidences for IVF-embryo transfer pregnancies.

Embryo implantation and GnRH antagonists: GnRH antagonists do not activate the GnRH receptor

Recent suggestions that gonadotrophin-releasing hormone (GnRH) antagonists activate the GnRH receptor are discussed. Most of the studies cited in support of this suggestion are in-vitro studies, testing supra-pharmacological doses of GnRH analogues in cancer cell lines, whereas GnRH antagonists, e.g. ganirelix or cetrorelix, do not affect the steroidogenesis of human granulosa cells in vitro. In patients treated with GnRH antagonists prior to IVF or intracytoplasmic sperm injection (ICSI), oocyte maturity and fertilization rates are equal to those achieved following a long protocol of GnRH agonists. Although there is a tendency towards a lower pregnancy rate (not statistically significant) in the initial trials using GnRH antagonist with either recombinant FSH or human menopausal gonadotrophin (HMG) for ovarian stimulation, this new treatment option of GnRH antagonists facilitates short and simple treatment and improves the convenience and safety for the patient. As with GnRH agonists in the past, the clinical outcome of GnRH antagonist treatment will improve with time as more clinical experience is gained (learning curve) and the treatment protocol is optimized. Moreover, a GnRH agonist instead of human chorionic gonadotrophin (HCG) may be used for triggering ovulation and will decrease the cancellation rate and minimize the risk for developing ovarian hyperstimulation syndrome (OHSS).

Use of a single bolus of GnRH agonist triptorelin to trigger ovulation after GnRH antagonist ganirelix treatment in women undergoing ovarian stimulation for assisted reproduction, with special reference to the prevention of ovarian hyperstimulation syndrome: preliminary report: short communication

A new treatment option for patients undergoing ovarian stimulation is the gonadotrophin-releasing hormone (GnRH) antagonist protocol, with the possibility to trigger a mid-cycle LH surge using a single bolus of GnRH agonist, reducing the risk of developing ovarian hyperstimulation syndrome (OHSS) in high responders and the chance of cycle cancellation. This report describes the use of 0.2 mg triptorelin (Decapeptyl) to trigger ovulation in eight patients who underwent controlled ovarian hyperstimulation with recombinant FSH (rFSH, Puregon) and concomitant treatment with the GnRH antagonist ganirelix (Orgalutran) for the prevention of premature LH surges. All patients were considered to have an increased risk for developing OHSS (at least 20 follicles > or =11 mm and/or serum oestradiol at least 3000 pg/ml). On the day of triggering the LH surge, the mean number of follicles > or =11 mm was 25.1 +/- 4.5 and the median serum oestradiol concentration was 3675 (range 2980-7670) pg/ml. After GnRH agonist injection, endogenous serum LH and FSH surges were observed with median peak values of 219 and 19 IU/l respectively, measured 4 h after injection. The mean number of oocytes obtained was 23.4 +/- 15.4, of which 83% were mature (metaphase II). None of the patients developed any signs or symptoms of OHSS. So far, four clinical pregnancies have been achieved from the embryos obtained during these cycles, including the first birth following this approach. It is concluded that GnRH agonist effectively triggers an endogenous LH surge for final oocyte maturation after ganirelix treatment in stimulated cycles. Our preliminary results suggest that this regimen may prove effective in triggering ovulation and could be said to prevent OHSS in high responders. The efficacy and safety of such new treatment regimen needs to be established in comparative randomized studies.

Treatment with the gonadotrophin-releasing hormone antagonist ganirelix in women undergoing ovarian stimulation with recombinant follicle stimulating hormone is effective, safe and convenient: results of a controlled, randomized, multicentre trial. The European Orgalutran Study Group

A multicentre, open-label, randomized study of the gonadotrophin-releasing hormone (GnRH) antagonist ganirelix (Orgalutran((R))/Antagon((TM))) was performed in women undergoing ovarian stimulation with recombinant FSH (rFSH: Puregon((R))). The study was designed as a non-inferiority study using a long protocol of buserelin (intranasal) and rFSH as a reference treatment. A total of 730 subjects was randomized in a treatment ratio of 2:1 (ganirelix:buserelin) using an interactive voice response system which stratified for age, type of infertility and planned fertilization procedure [IVF or intracytoplasmic sperm injection (ICSI)]. The median duration of GnRH analogue treatment was 5 days in the ganirelix group and 26 days in the buserelin group, whereas the median total rFSH dose was 1500 IU and 1800 IU respectively. In addition, in the ganirelix group the mean duration of stimulation was 1 day shorter. During ganirelix treatment the incidence of LH rises (LH >/=10 IU/l) was 2.8% versus 1.3% during rFSH stimulation in the buserelin group. On the day of triggering ovulation by human chorionic gonadotrophin (HCG), the mean number of follicles >/=11 mm diameter was 10.7 and 11.8, and the median serum oestradiol concentrations were 1190 pg/ml and 1700 pg/ml in the ganirelix and buserelin groups respectively. The mean number of oocytes per retrieval was 9.1 and 10.4 respectively, whereas the mean number of good quality embryos was 3.3 and 3.5 respectively. The fertilization rate was equal in both groups (62.1%), and the same mean number of embryos (2.2) was replaced. The mean implantation rates were 15.7% and 21.8%, and the ongoing pregnancy rates per attempt were 20.3% and 25.7% in the ganirelix and buserelin groups respectively. Evaluation of all safety data indicated that the ganirelix regimen was safe and well tolerated. The overall incidence of ovarian hyperstimulation syndrome was 2.4% in the ganirelix group and 5.9% in the reference group. The results of this study support a safe, short and convenient treatment regimen of ganirelix, resulting in a good clinical outcome for patients undergoing ovarian stimulation for IVF or ICSI.

Local tolerance, pharmacokinetics, and dynamics of ganirelix (Orgalutran) administration by Medi-Jector compared to conventional needle injections

The feasibility of administering a relatively high dose of the gonadotrophin-releasing hormone (GnRH) antagonist ganirelix by means of a needle-free injection device, which could be useful in the long-term treatment of sex-steroid-dependent disorders, was evaluated in a randomized, crossover study in 16 healthy females. Local tolerance and pharmacokinetics of ganirelix administered by MediJector versus conventional needle injections were compared. Additionally, the pharmacodynamic effect was evaluated. Two milligrams of ganirelix was administered s.c. once daily for 7 days by Medi-Jector or conventional needle in a randomized sequence, without a washout period. No apparent differences in local tolerance were observed. Most injections (87.5%) gave either no or only a mild reaction. Of the moderate reactions, swelling and redness were reported most frequently (overall 4.9 and 8.5% per injection, respectively). Administration by Medi-Jector was bioequivalent to conventional needle injection with respect to the peak concentration and area under the curve. A profound suppression of luteinizing hormone and follicle stimulating hormone was observed. Serum oestradiol and progesterone concentrations were relatively low prior to treatment and remained low during the entire study period. In conclusion, administration of a relatively high dose of ganirelix by Medi-Jector might be useful for long-term treatment of sex-steroid dependent disorders.

High doses of gonadotrophin-releasing hormone antagonist in in-vitro fertilization cycles do not adversely affect the outcome of subsequent freeze-thaw cycles

The clinical application of gonadotrophin-releasing hormone (GnRH) antagonists instead of GnRH agonists, to prevent spontaneous premature luteinizing hormone surge during ovarian stimulation for assisted reproduction treatment has been advocated. A recent, double-blind, dose-finding study, including six dosages of the GnRH antagonist ganirelix, in women undergoing ovarian stimulation with recombinant follicle stimulating hormone (FSH), has indicated that high doses of GnRH antagonist (1 or 2 mg once daily) are associated with a low implantation rate. This follow-up study reports on the pregnancy rate after replacement of cryopreserved embryos obtained in stimulation cycles of the above-mentioned trial. Ovarian stimulation was initiated on day 2 of the cycle, with daily injections of 150 IU recombinant FSH. Ganirelix (0.0625, 0.125, 0.25, 0.5, 1.0 or 2.0 mg) was administered once daily from stimulation day 6 onwards, up to and including the day of human chorionic gonadotrophin. Retrieved oocytes were fertilized by in-vitro fertilization (IVF) or intracytoplasmic sperm injection and a maximum of three fresh embryos was transferred. Excess embryos were frozen, and subsequently used in either natural or programmed cycles. Until June 1998, 11 ongoing pregnancies (12-16 weeks after embryo transfer) were achieved from 46 cycles in which embryos had been first frozen (23.9% per transfer). Six of these 11 patients had been treated with a high dose of ganirelix (1.0 or 2.0 mg) during the IVF cycles in which the embryos were obtained. In conclusion, our data suggest that high dosages of ganirelix do not adversely affect the potential of embryos to establish clinical pregnancy in freeze-thaw cycles.

First established pregnancy after controlled ovarian hyperstimulation with recombinant follicle stimulating hormone and the gonadotrophin-releasing hormone antagonist ganirelix (Org 37462)

This case report describes the first established pregnancy after the use of gonadotrophin-releasing hormone (GnRH) antagonist, ganirelix (Org 37462; Organon), to prevent a premature luteinizing hormone surge during ovarian hyperstimulation with recombinant human follicle stimulating hormone (rhFSH). The pregnancy progressed normally and ended with the birth of a healthy boy and a girl after an elective Caesarean section at gestational age of 37 weeks. This case illustrates, for the first time, the use of a GnRH antagonist in combination with a pure FSH preparation for ovarian stimulation.

Serum hormone concentrations during treatment with multiple rising doses of recombinant follicle stimulating hormone (Puregon) in men with hypogonadotropic hypogonadism

OBJECTIVE

To study increases of serum FSH and gonadal response in gonadotropin-deficient men treated with recombinant FSH (Puregon; NV Organon, Oss, The Netherlands).

DESIGN

An open, prospective, multiple rising dose study in which volunteers received single daily IM doses of recombinant FSH for 3 weeks. The dose administered was increased at weekly intervals: the first 7 days, 75 IU/d; the subsequent 7 days, 150 IU/d; and the last 7 days, 225 IU/d.

PARTICIPANTS

Nine men suffering from isolated gonadotropin deficiency or panhypopituitarism.

MAIN OUTCOME MEASUREMENTS

Immunoreactive FSH, LH, inhibin, T, and androstenedione.

RESULTS

Serum immunoreactive FSH (median) rose in accordance with the recombinant FSH doses administered from 0.5 mIU/mL (range < 0.05 to 1.9 mIU/mL) at baseline to 4.3 mIU/mL (range 2.0 to 8.5 mIU/mL), 8.4 mIU/mL (range 4.9 to 17.8 mIU/mL), and 13.6 mIU/mL (5.6 to 28.4 mIU/mL) after 1, 2, and 3 weeks of medication, respectively. The elimination half-life of recombinant FSH was 48 +/- 5 hours (mean +/- SD), which was slightly longer than that reported after single dose administration of recombinant FSH (32 +/- 12 hours). The bioactivity of recombinant FSH was reflected by serum inhibin levels, which rose from 116 U/L (range 34 to 356 U/L) at baseline to 350 U/L (range 63 to 1,109 U/L) at day 22. However, serum FSH and inhibin levels did not correlate when compared after 1, 2, and 3 weeks of recombinant FSH administration. Serum immunoreactive LH, T, androstenedione, and E2 were 0.2 mIU/mL (range < 0.05 to 0.7 mIU/mL [conversion factor to SI unit, 1.0]), 58 ng/dL (range < 12 to 222 ng/dL [conversion factor to SI unit, 0.0347]), 14 ng/dL (range 6 to 115 ng/dL [conversion factor to SI unit, 0.0349]), and 14 pg/mL (range < 14 to 16 pg/mL [conversion factor to SI unit, 3.67]), respectively, at baseline and remained unchanged during the entire treatment period.

CONCLUSION

These data indicate that recombinant FSH treatment increases serum FSH in a dose-proportional fashion, increases inhibin secretion, and lacks intrinsic LH activity.

A randomized, assessor-blind, group-comparative efficacy study to compare the effects of Normegon and Metrodin in infertile female patients undergoing in-vitro fertilization

A randomized, assessor-blind, group-comparative study was performed to compare the efficacy of Normegon [75 IU follicle stimulating hormone (FSH) and 25 IU luteinizing hormone (LH) and Metrodin (75 IU FSH and < 1.25 IU LH) in infertile women undergoing in-vitro fertilization (IVF) and embryo transfer. None of the patients were pituitary-suppressed by means of gonadotrophin-releasing hormone (GnRH)-agonist treatment. They were randomized in blocks of five with a ratio between treatment with Normegon and with Metrodin of 3:2. A total of 158 patients started hormonal treatment, i.e. 93 patients with Normegon and 65 patients with Metrodin and a total of 248 cycles were performed. Evaluation of first treatment cycles included statistical analysis of the total number of ampoules, number of follicles (> or = 14 mm), serum oestradiol concentrations on the day of HCG (10,000 IU) administration, the number of oocytes retrieved and the ongoing pregnancy rate per attempt and per transfer. For none of these parameters were significant differences revealed. In both groups the median duration of stimulation was 7 days and the median number of ampoules used was 21. Overall, the duration of treatment was short in order to prevent as much as possible endogenous LH rises. The overall ongoing pregnancy rate per transfer of all cycles was 21% in the Normegon group and 19% in the Metrodin group. Analysis of completed treatment cycles (n = 90) with premature rises of LH > 10.0 IU/l and/or progesterone > 1.0 ng/l revealed a relatively high incidence (23%) of fertilization failure and poor embryo quality, but the ongoing pregnancy rate per transfer was still 22%.(ABSTRACT TRUNCATED AT 250 WORDS)

Folliculogenesis in hypophysectomized rats after treatment with recombinant human follicle-stimulating hormone

To examine the role of FSH and LH in follicular growth and atresia, immature hypophysectomized (hypox) rats were treated twice daily for four days with a total dose either of 2.5 to 40 IU recombinant human FSH (recFSH; Org 32489) or of 8 IU recFSH supplemented with 0.2 to 5 IU hCG. RecFSH alone caused dose-dependent increases in ovarian weight and intraovarian estradiol (E2) but was unable to elevate circulating E2 levels. The number of antral follicles was also increased in a recFSH dose-dependent manner, and a gradual shift of small antral follicles to large preovulatory follicles was noted. The latter ovulated after a single bolus injection of 10 IU hCG. In comparison with follicles from hypox vehicle-treated animals, these follicles showed a diminished incidence of atresia, especially in the smallest size class of antral follicles. A total dose of > or = 10 IU recFSH increased uterine weight accompanied by endometrium proliferation. When 8 IU recFSH was supplemented with 0.2 to 5 IU hCG, ovarian weight was augmented in an hCG dose-dependent fashion, but no further increases in total number of antral follicles were noted except with the highest hCG dose given. Nevertheless, addition of relatively low doses of hCG caused considerable shifts of small follicles to large, preovulatory follicles. Furthermore, supplementation with hCG, especially low dosages of hCG (0.2 and 0.5 IU), reduced the incidence of atresia in antral follicles of all size classes. These data suggest that in the complete absence of LH activity, recFSH induces follicular growth up to the stage of mature preovulatory follicles and induces ovarian estradiol production and endometrium proliferation. The addition of small amounts of LH activity increases the percentage of healthy follicles.

Clinical outcome of a pilot efficacy study on recombinant human follicle-stimulating hormone (Org 32489) combined with various gonadotrophin-releasing hormone agonist regimens

In total, 50 couples participated in a pilot study evaluating the efficacy of various regimens of gonadotrophin-releasing hormone agonist (GnRHa) in association with recombinant human follicle-stimulating hormone (recFSH) in women undergoing in-vitro fertilization (IVF) and embryo transfer. The women were treated with recFSH alone (group I), or with recFSH in conjunction with pituitary desensitization using a buserelin intranasal spray, 4 x 150 micrograms per day, in a short protocol (group II) or in a long protocol (group III), or using triptorelin in a long protocol, giving a single dose of 3.75 mg i.m. (group IV) or daily s.c. injections of 200 micrograms (group V). In all women, treatment with recFSH resulted in multiple follicular growth and rises of serum inhibin and oestradiol. The latter indicates that the amount of remaining luteinizing hormone (LH) was sufficient to support FSH-induced oestrogen biosynthesis. On the day of human chorionic gonadotrophin (HCG) administration, endogenous LH was most profoundly suppressed in subjects treated with triptorelin. The median number of ampoules and treatment days required in the various treatment groups varied from 21 to 36 ampoules and from 7 to 14 days, respectively. The median number of oocytes per group ranged from 9 to 11 and all cumulus-corona-oocyte complexes, with the exception of two, were classified as mature. The median fertilization and cleavage rates ranged between the treatment groups from 40 to 73% and from 73 to 100%, respectively. Fertilization failure of retrieved oocytes occurred in six couples with andrological or unexplained infertility. One patient had no transfer because of insufficient embryo quality.(ABSTRACT TRUNCATED AT 250 WORDS)

Circulating bioactive and immunoreactive recombinant human follicle stimulating hormone (Org 32489) after administration to gonadotropin-deficient subjects

OBJECTIVE

To study the bioactivity of recombinant and urinary human FSH after single IM injection into gonadotropin-deficient subjects.

DESIGN

Serum FSH levels were measured by immature rat granulosa cell bioassay and immuno-fluorometric assay. The isohormone distributions of injected FSH materials were analyzed by chromatofocusing. Serum samples were collected before, and 6, 24, and 72 hours after 300 IU of recombinant or urinary FSH.

VOLUNTEERS

Fifteen gonadotropin-deficient subjects (8 women and 7 men) received recombinant FSH and 8 of them (4 women and 4 men) received an equal dose of urinary FSH.

RESULTS

No significant differences were apparent between the bioactive FSH levels after recombinant and urinary FSH treatments (n = 8). The immunoreactive FSH levels at 72 hours after urinary FSH were significantly higher than after recombinant FSH injection with values (median and range) of 3.80 (2.76 to 5.75) IU/L (IRP 78/549) and 3.10 (1.78 to 4.95) IU/L, respectively. There were no significant changes in the bioactive to immunoreactive ratios of FSH within time and between sexes after either recombinant FSH (n = 15) or urinary FSH (n = 8). However, the bioactive to immunoreactive ratio of the FSH material injected and of the post-treatment serum samples were both higher after recombinant FSH than after urinary FSH injection. Chromatofocusing revealed that injected recombinant FSH contained more activity in the basic fractions than urinary FSH.

CONCLUSION

Recombinant human FSH maintains its biological activity when injected into gonadotropin-deficient subjects. The bioactive to immunoreactive ratio of recombinant FSH was higher than that of urinary FSH indicating that recombinant FSH contains relatively more basic isohormones, and this finding was strengthened by chromatofocusing.

Effects of recombinant human follicle stimulating hormone on cultured human granulosa cells: comparison with urinary gonadotrophins and actions in preovulatory follicles

The effects of recombinant human follicle stimulating hormone (rFSH; Org 32489) have been examined in human granulosa cells from ovaries obtained from women with spontaneous menses. In the first series of experiments the actions of rFSH on production of oestradiol and progesterone were compared with those of urinary-derived gonadotrophins. Recombinant FSH induced dose-dependent increases in production of both oestradiol and progesterone which were similar to the effects of 'pure' FSH (Metrodin) and the International Standard IS 71/223. In further studies, the actions of rFSH on oestradiol production by individual preovulatory follicles were investigated; rFSH increased oestradiol accumulation from cells obtained from follicles before the luteinizing hormone (LH) surge. In contrast, rFSH inhibited oestradiol production by granulosa cells derived from a follicle after the onset of the LH surge, whereas the gonadotrophic action of growth hormone was maintained. Following preliminary reports of the in-vivo effects of rFSH in women, these findings provide further validation of the efficacy of rFSH in the human ovary. The results of studies of the preovulatory follicle illustrate the experimental importance of the availability of recombinant preparations of pure gonadotrophins, produced by recombinant technology, in the understanding of human ovarian function.

First established pregnancy and birth after ovarian stimulation with recombinant human follicle stimulating hormone (Org 32489)

This case report describes the first established pregnancy and birth after ovarian stimulation with Org 32489, pure recombinant human follicle stimulating hormone (recFSH, Organon International). A patient with tubal infertility participated in an open efficacy study of recFSH evaluating the efficacy of combined gonadotrophin-releasing hormone (GnRH)-agonist/recFSH treatment in women undergoing in-vitro fertilization (IVF) and embryo transfer. Ovarian stimulation was induced by recFSH in association with buserelin (Suprecur, 4 x 150 micrograms/day) using a short protocol. After 9 days of recFSH treatment (75 IU/day), six pre-ovulatory follicles (> or = 15 mm) were observed and 10,000 IU human chorionic gonadotrophin were administered. Nine mature oocytes were retrieved by oocyte puncture and after IVF, three embryos were replaced in the uterus. A viable singleton intra-uterine pregnancy was revealed at a gestational age of 7 weeks. The pregnancy progressed normally and ended with a vaginal delivery at a gestational age of 39.5 weeks. A healthy girl was born and paediatric examination did not demonstrate any abnormality.

Induction of follicular growth using recombinant human follicle-stimulating hormone in two volunteer women with hypogonadotropic hypogonadism

OBJECTIVE

To examine the safety, tolerance, pharmacokinetics, follicular growth, and steroidogenesis after the administration of recombinant human FSH (Org 32489; Organon International, Oss, The Netherlands) in women with isolated hypogonadotropic hypogonadism.

DESIGN

An open phase I multiple rising dose study with recombinant FSH in two hypogonadotropic but otherwise healthy women. The drug was administered intramuscularly one time per day for a maximum of 21 days, i.e., 75 IU for the first 7 days, 150 IU for the next 7 days, and 225 IU during the last 7 days. Treatment was discontinued if serum E2 was > or = 1,100 pmol/L and/or one or more growing follicle > 14 mm in diameter was observed. After the last recombinant FSH injection, subjects were monitored for another 3 weeks.

SETTING

Specialist Reproductive Endocrinology and Infertility Unit.

VOLUNTEERS

Two women with isolated hypogonadotropic hypogonadism who did not want to get pregnant anymore.

MAIN OUTCOME MEASURES

Serum FSH, androstenedione (A), T, P, LH, follicular growth, and endometrial thickness. Safety parameters: blood pressure, heart rate, urinalysis, hematology, blood biochemistry, and antirecombinant FSH antibodies.

RESULTS

Treatment with recombinant FSH resulted in dose-related increases of serum FSH. Both women showed follicular growth (diameter, 17 mm), whereas serum A concentrations were very low, and serum E2 concentrations rose to only 76.7 and 139.5 pmol/L, respectively. No antirecombinant FSH antibody formation or changes of safety variables were noted.

CONCLUSION

This study in two women with hypogonadotropic hypogonadism is consistent with the two-cell theory that FSH alone can induce follicular growth. The low concentrations of A and E2 indicate the need for LH to induce appropriate steroidogenesis. It was also found that recombinant FSH is well absorbed, safe, and well tolerated after daily treatment for up to 21 days.

Single-dose pharmacokinetics and pharmacodynamics of recombinant human follicle-stimulating hormone (Org 32489*) in gonadotropin-deficient volunteers

OBJECTIVE

To assess safety, pharmacokinetic, and pharmacodynamic properties of recombinant human follicle-stimulating hormone (FSH; Org 32489, Organon International, Oss, The Netherlands) after a single intramuscular injection in the buttock.

DESIGN

In a prospective study, safety variables, serum FSH, luteinizing hormone, inhibin, estradiol (females only), and testosterone (males only) were evaluated up to a maximum of 11 days after injection of 300 IU recombinant FSH.

SETTING

Four specialist Reproductive Endocrinology and Infertility units.

VOLUNTEERS

Fifteen men and women exhibiting all pituitary gonadotropin deficiency.

RESULTS

A single bolus of 300 IU recombinant FSH was well tolerated, and no drug-related adverse effects were noted. Comparison of before and after treatment safety variables, including serum antirecombinant FSH antibodies, showed no changes of clinical relevance. Analysis of serum FSH levels revealed comparable elimination half-lives of 44 +/- 14 (mean +/- SD) and 32 +/- 12 hours in women and men volunteers, respectively. In contrast, peak FSH concentrations were significantly lower in women than in men volunteers (4.3 +/- 1.7 versus 7.4 +/- 2.8 IU/L), and the time required to reach peak levels of FSH was significantly longer in women than in men (27 +/- 5 versus 14 +/- 8 hours). The area under the serum level versus time curve tended to be smaller in women than in men volunteers (339 +/- 105 versus 452 +/- 183 IU/L x hours), but the difference did not reach statistical significance. Together these data suggest that recombinant FSH is absorbed from its intramuscular depot to a lower rate and extent in women than in men. In both sexes a relationship between serum FSH levels and body weight was apparent. During the experimental period, other hormones remained low at baseline levels or were only slightly increased.

CONCLUSION

Our findings indicate that recombinant FSH is well tolerated and that it is absorbed from its intramuscular depot to a higher rate and extent in men than in women. After intramuscular administration, its half-life is in good agreement with that previously reported for natural FSH.