Individualization of Patient Treatment Sandro Esteves, M.D., Ph.D. Director, ANDROFERT Center for Male Reproduction & Infertility Campinas, BRAZIL Jordan, Lebanon, Kuwait, Qatar, Bahrain – Nov 2012
Center for Male Reproduction & Infertility Campinas, BRAZIL
Jordan, Lebanon, Kuwait, Qatar, Bahrain – Nov 2012
Esteves, 2
Use of Biomarkers to Individualize Ovarian Stimulation Protocols
Recent Advances in Injectable Gonadotropins Preparations Rec-FSH vs Urinary Products Agonist versus Antagonist GnRH To whom to give rec-hLH? Differences between rec-hLH and LH Activity in HMG Preparations?
Strategies to Improve Ovarian Stimulation Best Protocols to Minimize Risks and Reduce
Dropout Rates in IVF and IUI/OI
What is in it for me?
Presenter
Presentation Notes
These meta-analytic studies give us an overall idea but do not respond what we really want to know, that is,
Individualization of Patient Treatment Lecture Structure
Esteves, 3
Level Type of evidence 1a Obtained from meta-analysis of randomised trials 1b Obtained from at least one randomised trial 2a Obtained from one well-designed controlled study without
randomisation 2b Obtained from at least one other type of well-designed quasi-
experimental study 3 Obtained from well-designed non-experimental studies
(comparative and correlation studies, case series) 4 Obtained from expert committee reports or opinions or clinical
experience of respected authorities
Modified from Sackett et al. Oxford Centre for EBM Levels of Evidence (2009)
Level of evidence
Points I Consider Highly Relevant in Clinical Practice; Arguments Supported by Studies with High Level of Evidence.
Review this Lecture at: http://www.androfert.com.br/review
Individualization of Patient Treatment
Esteves, SC – Nov 2012
Esteves, 4
Esteves, 5
Use of Biomarkers to Individualize Ovarian Stimulation Protocols
Recent Advances in Gonadotropins Preparations Rec-FSH vs urinary products GnRH Agonist versus Antagonist To whom to give rec-hLH? Differences between rec-
hLH and LH activity in HMG preparations? Strategies to Improve Ovarian Stimulation Best Protocols to Minimize Risks and Reduce Dropout Rates in IVF
What is in it for me?
Presenter
Presentation Notes
Which are the useful biomarkers to individualize OS?
High-quality oocyte yield
Cycle cancellation, OHSS, multiple
pregnancy
Central Paradigm
Minimize complications
and risks
Maximize beneficial effects
of treatment
Fauser BC et al: Predictors of ovarian response: progress towards individualized treatment in ovulation induction and ovarian stimulation. Hum Reprod Update 2008;14:1-14. Esteves, 6
Presenter
Presentation Notes
Before answering this question I believe you agree with me that: First: Ovarian stimulation with gonadotropins have a key role in ART treatments. In fact, OS has been applied to compensate for inefficiencies in the IVF procedure by increasing the number of oocytes retrieved thus enabling the selection of the best quality embryos for transfer. And… Second: that today, the central paradigm of all ovarian stimulation protocols is to maximize the beneficial effects of treatment (relating to high-quality oocyte yield) while minimizing the potential risks associated with OHSS and multiple pregnancy.
Factors Determining Response to Ovarian Stimulation
Demographics and anthropometrics (Age, BMI, Race) Genetic profile Cause of Infertility Years of Infertility Health status Nutritional status
Esteves, 7
Presenter
Presentation Notes
However, variability in the subfertile patient population excludes the possibility of a single approach to controlled ovarian stimulation (COS). In fact, the patient is the main variable in ovarian stimulation response. There are multiple factors interacting mutually, such as demographics and anthropometrics, genetic profile, cause and duration of infertility, health and nutritional status.
Esteves, 8
Negative Predictors
Positive Predictor
van Loendersloot et al. Hum Reprod Update 2010; 16: 577–589.
Female Age Duration of infertility Basal FSH Type of infertility Indication Fertilization method Number of oocytes retrieved Number of embryos transferred Embryo quality
All reflecting ovarian reserve
Level 1a
Presenter
Presentation Notes
When we consider the most important predictive factors for success in IVF, as done in this meta-analysis of 14 studies, we learn that advanced female age, long duration of infertility and elevated basal levels of FSH are negative predictors while No. oocytes retrieved (up to a limit) is a positive predictor. Interestingly, all these significant factors are age related and reflect ovarian reserve, thus indicating that ovarian reserve is a major determinant of success. Therefore, determination of a given patient ovarian reserve prior to OS has a key role in the understanding of her chances of pregnancy. The summary OR for pregnancy and female age was 0.95 (95% CI:0.94–0.96) indicating that increasing female age was associated with lower pregnancy chances in IVF. Negative predictors: pregnancy and female age [OR: 0.95, 95% confidence interval (CI): 0.94–0.96], duration of subfertility (OR: 0.99, 95% CI: 0.98–1.00) and basal FSH (OR: 0.94, 95% CI: 0.88–1.00). A positive association was found for the number of oocytes (OR 1.04, 95% CI: 1.02–1.07). Better embryo quality was associated with higher pregnancy chances. .
●Genetic Biomarkers Single Nucleotide Polymorphisms for FSH-R/LH/LH-R/E2-R/AMH-R
Use of Markers to Determine Ovarian Reserve
Esteves, 9 Verberg M et al. Hum Reprod Update 2009;15:5-12
Pregnancy by number of oocytes retrieved after mild (♦ ) or conventional
(�) ovarian stimulation for IVF
⑤ ⑩
Level 1a
Presenter
Presentation Notes
Age and basal FSH levels remain the most commonly used single patient characteristics in clinical practice. These variables only provide a basic prognosis for success and indications for standard COS treatment based on gross patient categorization. In contrast, the anti-Müllerian hormone level appears to be an accurate predictor of ovarian reserve and response to COS, and could be used successfully to guide COS. The antral follicle count is a functional biomarker that could be useful in determining the dose of FSH necessary during stimulation. Meta-analysis of Verberg et al: Three randomized controlled trials comparing the efficacy of the mild ovarian stimulation regimen (involving midfollicular phase initiation of FSH and GnRH co-treatment) for IVF with a conventional long GnRH agonist co-treatment stimulation protocol could be identified by means of a systematic literature search.These studies comprised a total of 592 first treatment cycles. Individual patient data analysis showed that the mild stimulation protocol results in a significant reduction of retrieved oocytes compared with conventional ovarian stimulation (median 6 versus 9, respectively, P < 0.001). Optimal embryo implantation rates were observed with 5 oocytes retrieved following mild stimulation (31%) versus 10 oocytes following conventional stimulation (29%) (P = 0.045).
AMH = AFC >Inhibin B >FSH >Age
Esteves, 10 Broer et al. Fertil Steril 2009
Predictor of Pregnancy
In ART
Predictor of Excessive Response
Predictor of Poor
Response
Broer et al. Hum Reprod Update 2011
● AFC studies AMH Studies
● AFC studies AMH Studies
Level 1a
Presenter
Presentation Notes
pmol/l = x140/1000 = ng/mL (AMH = 140 Kda) Systematic reviews and meta-analysis of the existing literature have shown that AMH and AFC have similar power to predict both poor and excessive ovarian response to stimulation. AMH (82% and 76%, respectively) and AFC ( 82 and 80%, respectively). Comparison of the summary estimates and ROC curves for AMH and AFC showed no statistical difference (BroerSL et al, Hum Reprod Update 2011).
La Marca et al. Hum Reprod 2009
= remaining population of primordial and resting follicles
Esteves, 11
Anti-Mullerian Hormone levels
are correlated with the
number of follicles at
gonadotropin independent
stage.
Presenter
Presentation Notes
Ovarian reserve represents the remaining population of primordial and resting follicles. Importantly, FSH affects only antral follicles, in the last few weeks prior to ovulation. Specifically, primordial, primary, secondary and preantral follicles are unresponsible to both endogenous and exogenous gonadotropins. Anti-Mullerian Hormone, on the other hand, is a product of the granulosa cells, and it continues to be expressed until the antral stages. It correlates with the number of follicles at gonadotropin independent stage, and it is a potential better marker of ovarian reserve. If a stimulated follicle grows to a large antral stage, and receives an ovulatory signal, the chances are good that the oocyte within will appear normal and be at the correct stage of meiotic maturation. When stimulation fails, it is normally not because the follicles failed to respond to FSH, but because there were too few follicles present at the right stage to respond.
Antral Follicle Count (AFC)
Devroey et al. Hum Reprod Update 2009 Esteves, 12
= Number of antral follicles present in
the ovaries at a given time that can be stimulated into
dominant follicle growth by exogenous
gonadotropins
Level 1b
Eldar-Geva et al. Fertil Steril 2005
AFC alone on day 3 as a tool for predicting the number of retrieved
oocytes in COS
Presenter
Presentation Notes
A cohort of follicles measuring 2–5 mm is present very early in the follicular phase of the cycle. These follicles are in an early antral phase, and are easily detected by transvaginal ultrasound, as they contain a small amount of antral fluid. The number of small follicles at the beginning of the cycle may well represent the actual functional ovarian reserve. A gradual decrease with advancing age in the number of sonographically detectable antral follicles has been shown in many studies (Scheffer GJ et al., Hum Reprod 2003 , 18:700-706)., and these observations are in line with the contention that the number of visible antral follicles reflects the size of the remaining primordial pool in women with proven natural fertility. In recent years several papers have been published concerning the relation between the antral follicle count (AFC, defined as the total number of antral follicles, sized 2–5 or 2–10 mm, present in both ovaries) and the ovarian response in IVF, as well as the occurrence of the menopausal transition, indicating that this parameter relates strongly to the quantitative aspects of ovarian reserve. The high intercycle stability of AFC (Lass A et al., Hum Reprod 1997,12:294-297) and because it is much simpler and cheaper than measuring inhibin B or AMH are likely to make this test rather attractive for routine practice. A great advantage of AFC over any other test is its potential usefulness for its ability to concomitantly predict low and high responders. However, the criticisms on the usefulness of routine AFC to predict ovarian response to stimulation rely on the difficulties on test interpretation and standardization. The number of ovaries scanned, mean or total number of follicles counted, single or multiple ultrasound axes scanned, and the minimum/maximum follicle size included are potential source of errors. Eldar-Geva T, Hum Reprod 2005: avaluated 56 women, aged <38 years, with normal day 3 FSH levels, prospectvely. Serum estradiol, inhibin B and AMH were measured before and 24 h after administration of 300 IU of recombinant FSH on cycle day 3–4 and during the luteal phase. Ovarian volume and antral follicle count (AFC) were evaluated on cycle day 3–4. The predictive value of oocyte number and pregnancy were assessed. Poor responders (<6 oocytes) had significantly lower luteal AMH levels, while high responders (>20 oocytes) had significantly higher AFC, AMH and luteal stimulated inhibin B and estradiol than normal responders. They found correlation between AFC and inhibin B and AMH, especially in the early follicular phase. Multiple regression ANCOVA showed that the best model for predicting the number of oocytes included AFC alone (adjusted r2 = 0.657, P < 0.0001). Adding endocrine markers to the model did not improve its significance. When only endocrine parameters were entered into the model, the combination of follicular phase AMH (P < 0.05) and Δ inhibin B (P < 0.01) was selected (adjusted r2 = 0.624, P < 0.001). Para predizer gravidez, somente AMH teve valor, mas baixo. The probabilties of a pregnancy for women with serum AMH ≥18 pmol/l or <18 pmol/l are 67 and 39%, respectively. (p<0,02).
Alviggi et al, Reprod Biol Endocrinol 2012; Broer et al, Hum Reprod Update 2011; Broekmans et al, Fertil Steril 2009; Broer et al, Fertil Steril 2009; van Disseldorp et al, Hum Reprod 2010, La Marca
et al, Hum Reprod 2006; Hansen et al, Fertil Steril 2003; Elter et al, Gynecol Endocrinol 2005.
AMH and AFC
Esteves, 13
Anti-Mullerian Hormone (ng/mL)
Antral Follicle Count
Advantages Cycle independent test;
Intercycle stability Simple and inexpensive
Limitations
No international assay standards for
measurements (DSL & Immunotech-Beckman)
Variation in test interpretation and standardization;
Moderate intercycle and interobserver
variability
Presenter
Presentation Notes
At present there are two highly sensitive sandwich ELISA assays available: the Diagnostic Systems Laboratories (DSL) and the Immunotech-Beckman assay. The sensitivity of the DSL is reported to be 0.025 ng/ml compared with 0.07 ng/ml for the Immunotech- Beckman assay, although this difference was not confirmed in a recent clinical study (Taieb et al., 2008). The intra- and inter-assay variations of the two assays are similar (,7 and ,5%, respectively). The DSL assay is not species-specific, a feature which could be advantageous for research laboratories using rodent models. Initial studies comparing the two assays have shown that AMH levels appear to be 4–5-fold lower with the DSL assay compared with the Immunotech-Beckman assay (Bersinger et al., 2007; Freour et al., 2007). In their report, Bersinger et al. (2007) alluded to problems inherent to AMH measurements that stem from residual matrix effects and instabilities of certain antigenic determinants. However, although developed independently, these assays are now both produced by a single company (Beckman-Coulter), and cross- referencing has shown that the correlation between the two assays is . 0.9 ( personal communication from Beckman-Coulter representative). This is confirmed by recent studies that found similar AMH values with both the assays (Taieb et al., 2008; Streuli et al., 2009), therefore suggesting that the methodological problems mentioned by Bersinger et al. (2007) should have been addressed and solved by the assay manufacturer. Both kits are likely to remain in production over the next few years as approximately half of researchers are using the DSL assay and the other half the Immunotech-Beckman product. These assays have demonstrated a very good correlation, making it possible to translate results from one to the other within the same dataset. AMH is a cycle independent test (Cook et al., 2000; Hehenkamp et al., 2006; La Marca et al., 2006; Tsepelidis et al., 2007), so any measurement in the period before starting the ART cycle will be at the disposition of the clinician, making the test an ideal tool. For the AFC, standardization needs to be dealt with by the physician (Broekmans et al., 2009), implying choices on ultrasound equipment, dedicated personnel and a systematic visualization and counting process. The number of ovaries scanned, mean or total number of follicles counted, single or multiple ultrasound axes scanned, and the minimum/maximum follicle size included are potential source of errors. Moreover, (HANSEN, 2003) there is a moderate intercycle and interobserver variability in AFC . A possible explanation for the higher variability of AFC is the reproducibility and standardization of the AFC itself (Broekmans et al., 2009). But, since all AFC measurements were made by the same experienced observer on the same machine in both parts of the present study, observer variation in our data has thereby been minimized. With an expected increase in variation among different observers, the variation in the AFC may further increase (van disseldorp, 2005). AFC intercycle variability: The higher stability of AMH measurements may also be explained by assuming that AMH levels are also determined by a cohort of invisible pre-antral or small antral follicles, whereas the number of larger and visible antral follicles, expressed by the AFC, may be more prone to short-term variation. Possible explanations for a varying cohort of antral follicles might be cyclic differences in decay or growth rate which may depend on the presence of larger follicles in the early follicular phase (Grynberg et al., 2008; Hansen and Soules, 2008). AMH cost ~200 USD
Markers of Ovarian Response Antral Follicle Count (AFC)
Broekmans et al., Fertil Steril, 2010; 94(3):1044-51
Practical Recommendations for Better Standardization: ● Cycle day 2-4 ● Count all AF 2-10mm ● Real-time 2 dimension
image adequate ● Transvaginal probe 7Mhz
minimum
Esteves, 14
Use a systematic process for counting antral follicles:
1. Identify the ovary.
2. Explore the dimensions in two planes (perform a scout sweep). 3. Decide on the direction of the sweep to measure and count follicles. 4. Measure the largest follicle in two dimensions. A. If the largest follicle is ≤10 mm in diameter:
• Start to count from outer ovarian margin of the sweep to the opposite margin.
• Consider every round or oval transonic structure within the ovarian margins to be a follicle.
• Repeat the procedure with the contralateral ovary. • Combine the number of follicles in each ovary to obtain the AFC.
B. If the largest follicle is >10 mm in diameter:
• Further ascertain the size range of the follicles by measuring each sequentially smaller follicle, in turn, until a follicle with a diameter of %10 mm is found.
• Perform a total count (as described) regardless of follicle diameter.
• Subtract the number of follicles of >10 mm from the total follicle count.
Use of Biomarkers to Individualize Ovarian Stimulation Protocols
Esteves, 15
COS should maximize treatment beneficial effects (high-quality oocyte yield) and minimize risks (cancellation, OHSS, multiple pregnancy).
Significant predictive factors for pregnancy in IVF are related to ovarian reserve.
AMH levels and AFC accurately determine ovarian reserve. Results can be used to guide the choice of COS protocols.
Both AMH and AFC have similar high accuracy to predict which patients are at risk of excessive and poor response to OS but should not be used to predict the chances of pregnancy success.
Esteves, 16
Use of Biomarkers to Individualize Ovarian Stimulation Protocols
Recent Advances in Injectable Gonadotropins Preparations Rec-hFSH vs Urinary products GnRH Agonist versus Antagonist To whom to give rec-hLH? Differences between rec-hLH
and LH activity in HMG preparations? Strategies to Improve Ovarian Stimulation Best Protocols to Minimize Risks and Reduce Dropout Rates in IVF
What is in it for me?
64% • Incidence of Infertility (WHO II)
68% • Prevalence of Infertile Patients (WHO II) with PCO in Clinical Practice
Reproductive Hormones Report - GCC Countries (Feb 2011)
OI, IUI, IVF Clomiphene Citrate
1st line in up to 56% of cases Shift after an average of 3 cycles
Injectable Gonadotropins Esteves, 17
1930s 1950 1980 1995 2003
Pituitary FSH u-hMG
u-FSH
u-FSH HP r-hFSH
r-hFSH FbM
Intramuscular administration sc Injector pens
sc, subcutaneous; FbM, filled by Mass; HP, highly-purified
Safety, Quality, Consistency and Patient
Convenience
Esteves, 18
Long-acting
r-hFSH
2010
Puriity and
SpecificActivity
Adapted from Lunenfeld. Hum Reprod Update 2004;10:453–67
r-hFSH +r-hLH FbM
2007
Horse PMSG
Presenter
Presentation Notes
The therapeutic armamentarium for ovarian stimulation has increased over the last years and clinicians face the problem of which drug regimen to use. In clinical practice, the share is split in about 50% of doctors using urinary and recombinant products.
Meta-analyses of rec-hFSH vs HMG/HP-HMG/uFSH
Number of RCTs included
Number of
couples
Statistical significance
Clinical significance
Coomarasamy et al, 2008
7 2,159
LBR (RR = 1.18, 95% CI: 1.02 to 1.38, P<0.03) in favor of HMG
4% difference in LBR in favor of HMG (CI: 1%-?)
Al Inany et al, 2009 6 2,371
Insufficient evidence of a difference in odds of pregnancy or live birth
None
Van Wely et al, 2011
28 7,339 Insufficient evidence of a difference in odds of live birth Subgroup analysis of r-hFSH vs HMG in favor of HMG (OR 0.84, 95% CI 0.72 TO 0.99; N=3,197)
None
For a LBR of 25%, use of rFSH rather than hMG would result in a LBR
19%-25%
Coomarasamy et al, Hum Reprod. 2008;23:310-5; Al Inany et al, Gynecol Endocrinol. 2009; 25:372-8; Van Wely et al. Cochrane Database Syst Rev. 2011; 2:CD005354 Esteves, 19
Level 1a
Presenter
Presentation Notes
A number of meta-analyses have compared the efficacy of different gonadotropin products. These meta-analyses have a number of limitations. There are various differences between the studies, such as the type of down-regulation protocol, inclusion and exclusion criteria, and gonadotropin product used. Coomarasamy et al., including seven randomized trial (2159 women) comparing hMG versus rFSH following a long down-regulation protocol in IVF-ICSI cycles, have showed a significant increase with hMG in clinical pregnancy (RR = 1.17, 95% CI = 1.03 to 1.34) and live birth rate (RR = 1.18, 95% CI: 1.02 to 1.38, P < 0.03). No significant differences were noted for gonadotrophin use, spontaneous abortion, multiple pregnancy, cancellation and ovarian hyperstimulation syndrome rates. The observed difference was a 4% increase in live birth rate with hMG when compared with rFSH. However, the lower limit of the confidence interval was 1%, and thus the finding of this meta-analysis should not be over-interpreted (10). In 2009, Al-Inany et al, in another meta-analysis, with six randomized trials included (2371 participants), comparing HP-hMG vs. rFSH, have showed no diference in clinical pregnancy or ongoing pregnancy/live-birth. Separing only IVF cycles (not ICSI), it was demonstrated a better ongoing pregnancy/live-birth rate in favour of HP-hMG (O.R = 1.31, 95% CI = 1.02 to 1.68) (11). The most recent meta-analysis, published by Van Wely et al (Cochrane Database), in 2011, has compared rFSH to urinary gonadotropins (hMG, HP-hMG, FSH-P, FSH-HP) in IVF/ICSI cycles, including 28 trials (7339 couples), and have showed no diference in live birth or OHSS rate. Comparing only hMG/HP-hMG to rec-hFSH, they have showed significantly fewer clinical pregnancies after rFSH as compared to HMG (OR 0.85, 95% CI 0.74 to 0.99; I2 of 0%; 12 trials, N=3775) and fewer live birth (or ongoing pregnancy) (OR 0.84, 95% CI 0.72 TO 0.99; I2 OF 0%; 11 trials, N=3197). the majority of the included trials were industry sponsored and this may have introduced a bias in favour of the gonadotrophin produced by the sponsor. The subgroup analyses in which we grouped the primary outcomes for pharmaceutical sponsoring suggest that live birth and clinical pregnancy rate were lower for rFSH compared to urinary FSH in the Ferring sponsored trials. However, further analysis of the Ferring sponsored trials and the non-sponsored trials that compared HMG/HP-HMG with rFSH showed comparable summary OR and confidence intervals that overlapped. Hence, though they couldn’t rule out that a sponsor effect was involved in this finding the potential effect of this sponsor bias appears to be limited. The conclusion was that it appears that all available gonadotrophins are equally effective and safe (12). For a live birth rate of 25%, use of rFSH rather than hMG would result in a live birth rate between 19 and 25% (a). Another bias in the comparisons of hMG/HP-hMG and rec-hFSH is that rec-hFSH shows only FSH activicty, while the first have 1:1 FSH:LH ratio (1). This differrence can interfere in the results of specific groups of patients that could be beneficiated by LH activity.
Bassett et al. Reprod Biomed Online 2005;10:169–177.
Purity (FSH
content)
Mean specific activity
(IU/mg protein)
LH activity
(IU/vial)
Injected protein
per 75 IU (mcg)
hMG < 5% ~100 75 ~750
hMG-HP < 70% 2,000–2,500 75 ~33 rec-hFSH
Follitropin beta
–
7,000–10,000
0
8.1
Follitropin alfa
> 99% 13,645 0 6.1
Esteves, 20
Presenter
Presentation Notes
However, this does not mean that urinary and recombinant drugs are the same. The higher the product purity, the less material has to be injected and the lower the likelihood that injection-site tolerability issues will arise. Gonadotropins are much purer when recombinant technology is used. To administer the same amount of FSH, more protein must be injected when using urinary products compared with r-hFSH. The enhanced purity and increased specific activity allow SC delivery in very small volumes.
Bassett et al. Reprod Biomed Online 2005;10:169–177; Driebergen et al. Curr Med Res Opin 2003;19:41–46.
Vitual elimination of batch-to-batch variation. The enhanced purity and increased specific activity allow SC delivery in very small volumes. A further improvement towards quality and patient convenience came with the development of an innovative method for measuring the gonadotropin content that comes in each vial. The conventional method to quantify the activity of gonadotropin products is the Steelman–Pohley assay, which is an in vivo rat bioassay. As well as being costly and subject to ethical concerns related to the use of animals, this technique has an inherent variability of up to 20%. In 2003, a novel physiochemical method was developed for measuring FSH content (by protein mass), that improved batch-to-batch consistency of r-hFSH (follitropin alfa) in terms of specific activity, isoform pattern and sialylation profile. Following this, These advances led to the development of GONAL-f® FbM, which is formulated based on r-hFSH protein content. Driebergen et al. Curr Med Res Opin 2003;19:41–46 Bassett et al. Reprod Biomed Online 2005;10:169–177
Number of Retrieved Oocytes by the Same Dose of rec-hFSH vs HP-HMG
↑ 1.5 oocytes (GnRH antagonist cycles) Devroey et al., 2012
↑ 3.1 oocytes (GnRH antagonist cycles) Bosch et al., 2008
↑ 1.8 oocytes MERIT Study, 2006
↑ 2.8 oocytes (GnRH agonist cycles) Hompes et al., 2008
Esteves, 22
Level 1b
Devroey P et al, Fertil Steril. 2012;97:561-71; Bosch E et al, Hum Reprod. 2008;23:2346-51; Nyboe Andersen A, et al. Hum Reprod. 2006;21:3217–3227; Hompes PG et al, Fertil Steril. 2008;89:1685-93 ;
Presenter
Presentation Notes
In fact, there is clinical evidence that recFSH is more potent than urinary gonadotropins as showed in large studies. The scientific truth that recFSH is purer since it is not extracted from urine and uses recombinant technology.
Esteves, 23
Reproductive Biology and Endocrinology 2009; 7:111. To
tal D
ose p
er L
ive B
irth
(IU)*
0
3,000
7,000
10,000
21.6%
rec-hFSH HP-hMG
6,324* 7,739
hMG
9,690 52.2%
*Mean total dose per cycle/Live birth rate (≤35 years)
To achieve a live birth, 21-52%
more HP-hMG and hMG was
required compared with
rec-hFSH
Level 2a
Presenter
Presentation Notes
In which we examined the clinical efficacy of different gonadotropin products used for ovarian stimulation in our clinical practice. We compared the efficacy of rec-hFSH (n=236), hMG (n=299) and HP-hMG (n=330) in a subset of normogonadotropic down-regulated women undergoing IVF/ICSI. UI (19). This difference in favour of r-hFSH was reflected for the amount of gonadotropin used per live birth. To achieve a live birth significantly less r-hFSH was required than hMG (52% reduction) and HP-hMG (21% reduction). One practical implication of this observation is that this marked difference neutralizes part of the cost difference between r-hFSH and hMG preparations. We observed that it was far more common to step the rec-hFSH dose down during ovarian stimulation as compared to hMG. We discovered that in our practice, it was far more common to step the rec-hFSH dose down during ovarian stimulation as compared to hMG. The clinicians stated that they felt comfortable with the pen device that allow small dose reductions of 37.5UI , after perceiving a better response with rec-hFSH compared to u-HMG using the same starting doses. The clinicians involved in this study stated that they felt comfortable with the pen device, which allowed more precise small dose reductions of 37.5 UI rather the 75UI reductions in the HMG preparations.
Rec-hFSH vs Urinary products
Esteves, 24
Overall, recombinant and urinary gonadotropins have comparable clinical efficacy, but this does not mean drugs are the same.
Recombinant preparations have 3 major differences compared to urinary products: Higher purity and specific activity (SC delivery in
very small volumes)) Higher dose precision (FbM) Higher potency (more oocytes retrieved)
Agonist administration
Gonadotropin administration Long GnRH
agonist protocol
Antagonist administration
Gonadotropin administration
GnRH antagonist protocol
Longer treatment
Can exclude early
pregnancy
Can be integrated in spontaneous and OI cycles
Pre-treatment cycle Treatment cycle
Flare up effect
Pituitary suppression
No hormonal withdrawal
No flare effect with
possible cyst formation
Shorter duration of stimulation
Prevent OHSS by GnRH-a
Esteves, 25
Presenter
Presentation Notes
The are several advantages in using GnRH antagonists associated to ovarian stimulation: No flare effect with possible cyst formation No hormonal withdrawal symptoms (since pituitary suppression is achieved after ovarian stimulation has been started and not before) The antagonist cannot be given in early pregnancy, since this can be excluded by a pregnancy test Initiation of the IVF treatment cycle in a normal menstrual cycle with an undisturbed early fodllicular phase recruitment of a cohort of follicles. This enables the endogenous inter-cycle FSH rise to be utilized rather than suppressed. Therefore, cyclic follicle recruitment and initial stages of gonadotropin-dependent growth of the recruited cohort of follicles can proceed undisturbed. By postponing the initiation of OS to the mid-follicular phase, kexogenous FSH may only stimulate the most mature foillicles to ongoing development to the Graffian stage giving rise to the best quality oocyte. As such: Less gonadotropins necessary Shorter treatment duration More physiologic, since it can be integrated in the spontaneous menstrual cycle The GnRH antagonist is another step towards individualized approach.
pyro (Glu) – His – Trp – Ser – Tyr – Gly – Leu – Arg – Pro – Gly – NH2
Activation of the GnRH receptor
Regulation of receptor affinity
Regulation of receptor biological activity
Antagonistic effect
1 3 2
Esteves, 26
GnRH Antagonists Mode of Action
Presenter
Presentation Notes
Compared to GnRH agonists, there are more changes necessary in the structure of the natural GnRH molecule, to achieve antagonistic properties. These antagonistic properties mean absence of intrinsic effect and competitive action. As you can see an antagonist is structurely very similar to the GnRH so it binds in a competitive fashion causing immediate decline in FSH and LH levels, therefore no flare effect is observed. This suppression occurs within hours and is sustained as long as levels of GnRH antagonist are sufficient to occupy the GnRH receptors thereby preventing native GnRH from binding to its receptor and exerting its biological actions.
Esteves, 27
Why introduction of antagonists in clinical practice has been slow?
Experience with Agonists Why change if it is working
Clinicians’ concerns: Lower pregnancy rates Not been able to program
aspirations on weekdays LH surge (more monitoring) Difficult to use
Presenter
Presentation Notes
In fact, there is clinical evidence that recFSH is more potent than urinary gonadotropins as showed in large studies. The scientific truth that recFSH is purer since it is not extracted from urine and uses recombinant technology.
Esteves, 28
N studies 45 22
Included IUI cycles
Yes No
N patients 7511 3176
Primary outcome OPR or LBR LBR
Odds-ratio 0.86 (95% CI: 0.69-1.08)
0.86 (95% CI: 0.72-1.02)
1. Al-Inany et al. Cochrane Database Syst Rev. 2011; 5:CD001750. 2. Kolibianakis et al. Hum Reprod Update. 2006;12:651.
Probability of Live Birth
Level 1a
Esteves, 29
Pre-treatment with OCP 4 RCT; 847 patients Days of stimulation +1.41 (+1.13; +1.68) Gonadotropin consumption (UI) +542 (+127; +956) No. oocytes retrieved 1.63 (-0.34; 3.61)
Kolibianakis EM, et al. Fertil Steril. 2011; 95:558-62
9.7
29.7
12.0 24.7
9.9
29.2
10.3 23.3
Days ofstimulation
Dosegonadotropin
(x75UI)
No. Oocytes Pregnancy (%)
Flexible* (N=68) Fixed on Day 6 (N=72)
*LH >10 IU/L, and/or mean follicle >12 mm, and/or serum E2 >150 pg/mL; No LH surge reported
P>0.05
Level 1b
Presenter
Presentation Notes
Flexible vs. fixed administration of cetrorelix in patients undergoing ICSI In all the traditional parameters used to evaluate outcomes, the flexible dose did not differ significantly from the fixed protocol. However, significantly less cetrorelix was utilized.
Esteves, 30
RCT normogonadotropic women <40 yrs. on antagonist COH
Kyrou D et al. Fertil Steril. 2011; 96(5):1112-5. Kyrou D et al. Fertil Steril. 2011; 96(5):1112-5.
Level 1b
Presenter
Presentation Notes
Significant differences were observed between the early-hCG and the late-hCG group regarding E2 (1,388 931 [mean SD] vs. 2,040 1,231 pg/mL, respectively) and P (0.8 0.3 vs. 1.1 0.5 ng/mL, respectively) levels on the day of hCG administration and the number of metaphase II oocytes (9.2 7.1 vs. 6.1 4.9, respectively). No significant differences were observed between the early-hCG and the late-hCG group regarding positive hCG (46.2% vs. 50%, respectively) and ongoing pregnancy rates (34.6% vs. 40.7%, respectively). Conclusion(s): The current study provides evidence that earlier administration of hCG is not associated with the probability of pregnancy in cycles stimulated with recombinant FSH and GnRH antagonists. (Fertil Steril 2011;96:1112–5.2011)
Recent Advances in Gonadotropins Preparations
GnRH Agonist versus Antagonist
Esteves, 31
Clinical Outcomes Evidence No difference in probability of live birth (overall and subgroups) compared to agonists
1a
No difference in flexible or fixed GnRH antagonist protocols
1b
OCP programming not detrimental 1b
Delaying hCG by 1 day not detrimental 1b
Esteves, 32
• ~80% normogonadotropic women (WHO II) undergoing Ovarian Stimulation1-3
Nor
mal
• 15-20% of NG women have less sensitive ovaries • Older patients (≥35 years)4
1. Alviggi et al. Reprod Biomed Online 2006;12:221; 2. Tarlatzis et al. Hum Reprod 2006;21:90; 3. Esteves et al. Reprod Biol Endocrinol 2009;7:111; 4. Marrs et al. Reprod Biomed Online 2004;8:175;5. Mochtar MH, Cochrane Database, 2007; 6. Alviggi, et al.
RBMOnline 2009; 7. De Placido et al. Clin Endocrinol (Oxf) 2004;60:637;
Presenter
Presentation Notes
Approximately 45% of pts. seen in our clinical practice have 35 years or above. The general consensus regarding LH is that most women have sufficient levels of endogenous LH and do not require supplementation. However, certain subgroups with low levels of LH may benefit from additional LH. Early studies identified a subgroup of normogonadotrophic patients who have normal estimated ovarian reserves but suboptimal responses to FSH stimulation (De Placido et al., 2001, 2004, 2005; Mochtar et al., 2007). Such women express ovarian resistance to FSH but seem to be distinct from classical poor responders because some investigators suggest that luteinizing hormone (LH) supplementation improves their ART treatment outcomes (Alviggi et al., 2006). The subgroups which may benefit from LH supplementation include women over the age of 35 years, those with a poor response to ovarian stimulation or women with highly suppressed levels of endogenous LH. The general consensus regarding LH is that most women have sufficient levels of endogenous LH and do not require supplementation, although certain subgroups with low levels of LH may benefit from additional LH (Alviggi et al. Reprod Biomed Online 2006;12:221–233; Tarlatzis et al. Hum Reprod 2006;21:90–94; Esteves et al. Reprod Biol Endocrinol 2009;7:111; Marrs et al. Reprod Biomed Online 2004;8:175–182). The subgroups which may benefit from LH supplementation include women over the age of 35 years, those with a poor response to ovarian stimulation or women with highly suppressed levels of endogenous. It has been suggested that a subgroup of women with adequate AFC and FSH levels with hypo-response to ovarian stimulation may also benefit from LH supplementation (Alviggi, et al. RBMOnline 2009). These patients harbor single nucleotide polymorphisms of FSH and LH receptors. After pituitary suppression, residual circulating levels of endogenous LH are usually adequate to support multiple follicular growth and oocyte development, also even when drugs containing FSH with low or absent LH activity are administered (Loumaye et al., 1997; Sills et al., 1999). It has been demonstrated that only 1% of LH receptors need to be occupied to drive adequate ovarian steroidogenesis for reproduction. Nevertheless, in a subset of normogonadotrophic patients, the ovarian response to this association is suboptimal. It has been suggested that this may be due to a profound suppression of endogenous LH in some women whose activity may fall below an hypothetical threshold value. Thus, it could be hypothesized that those subjects may benefit from the use of LH-containing gonadotrophin preparations (Laml et al., 1999; Fleming et al., 2000; Levy et al., 2000; Westergaard et al., 2000; De Placido et al., 2001). Nagawa, 2008: pts with very low LH levels after down-regulation had lower pregnancy and implantaion rates. A possible mechanism behind the beneficial effect of exogenous LH supplementation in older women may relate to decreasing numbers of functional LH receptors with increasing age (Vihko et al. 1996). It suggests that younger women, due to a higher number of LH receptors, do not require exogenous LH, while supplementation with exogenous LH in the older woman secures a sufficient LH-induced response. In addition, Piltonen et al. (2003) found that ovarian androgen secretion, i.e. oestrogen precursor secretion capacity, starts to decline as early as before the age of 30 years, again suggesting a diminished capacity of the ovary to respond to LH stimulus with age. Another subgroup of women that seems to benefit from exogenous LH supplementation is the group of women with high endogenous LH concentrations on day 8 of stimulation (i.e. >1.99 IU/l). r-hLH supplementation in this subgroup resulted in a significantly higher implantation rate and a marginally higher pregnancy rate (P = 0.07) as compared with the non-supplemented subgroup. This is an interesting and surprising finding. A possible explanation for this phenomenon could be a desensitization of the ovarian LH receptor due to high concentrations of circulating endogenous LH, leading to receptor down-regulation (Zor et al., 1976; Amsterdam et al.. 2002). LH receptor polymorphism also seems to play a role. In summary: less LH receptors, less sensitive LH receptors, Low LH levels.
Increase in FSH drive FSH
• Theca cells
• Granulosa
cells
LH
LH
Increase in LH drive
Esteves, 33
Pregnancy rates
% Cycle cancellation
Number oocytes retrieved
Increasing the Stimulation Dose of
FSH…
…is not associated with better IVF outcome
Manzi et al, 1994 Klinkert et al, 2004
Berkkanoglu & Ozgur, 2010
Level 1b
Presenter
Presentation Notes
In the ovary, granulosa cells are the only target cells of FSH action, whereas both theca and late-stage (In the ovary, granulosa cells are the only target cells of FSH action, whereas both theca and late-stage (luteinizing) granulosa cells contain LH receptors. Increased FSH drive has been shown to be of only limited value in the less gonadotrophin-sensitive ovary, and there is a potential need for LH activity to be part of an individualized treatment regimen tailored for the biologically older ovary. LH half-life: 20 minutes; hCG: 24 hours
Esteves, 34
• Older patients (≥35 years)
• Poor responders
• Slow/Hypo-responders
• Deeply suppressed endogenous LH (endometriosis)
Less
Sen
sitiv
e O
varie
s
Marrs et al. Reprod Biomed Online 2004;8:175 De Placido et al. Clin Endocrinol (Oxf) 2004;60:637; Ferraretti et al. Fertil Steril. 2004; 82:1521-6;
Mochtar MH, Cochrane Database, 2007; Alviggi, et al. RBMOnline 2012
Poor Responders* At least 2 of the following: Advanced maternal age (≥40 years) Previous POR (≤3 oocytes with a conventional stimulation protocol) Abnormal ovarian reserve test (AFC<5; AMH <1.1) Or: 2 episodes of POR after maximal stimulation
Hypo/Slow Responders Normal markers of ovarian reserve Hypo-responders: d1-d7: normal initial follicullar recruitment using fixed starting dose of FSH; d7- d10: plateau on follicullar growth despite continuing same FSH dosage Slow responders: High doses of FSH (>3,000UI) to promote follicular growth; May indicate genetic polymorphisms of LH and/or FSH receptor
Up to 45% Infertility Patients
aged 35 or above
Presenter
Presentation Notes
In the ovary, granulosa cells are the only target cells of FSH action, whereas both theca and late-stage (In the ovary, granulosa cells are the only target cells of FSH action, whereas both theca and late-stage (luteinizing) granulosa cells contain LH receptors. Increased FSH drive has been shown to be of only limited value in the less gonadotrophin-sensitive ovary, and there is a potential need for LH activity to be part of an individualized treatment regimen tailored for the biologically older ovary. LH half-life: 20 minutes; hCG: 24 hours
LH Supplementation in Poor Responders…
Regimen Outcome Effect on Pregnancy
Mochtar et al, 2007 3 RCT (N=310) Poor responders
r-hFSH+rLH vs. r-hFSH alone* OPR OR 1.85
(95% CI: 1.10; 3.11)
Bosdou et al, 2012 7 RCT (N= 603) Poor responders
r-hFSH+rLH vs. r-hFSH alone*
CPR
LBR (only 1 RCT)
RD: +6%, (95% CI: -0.3; +13.0)
RD: +19%
(95% CI: +1.0; +36.0%)
Hill et al, 2012 7 RCT (N=902) Women advanced age ≥35 yrs.
Mochtar MH et al. Cochrane Database Syst Rev. 2007;2:CD005070; Bosdou JK et al, Hum Reprod Update 2012; 8(2):127-45. Hill MJ et al. Fertil Steril 2012; 97:1108-4. Esteves, 35
Level 1a
Presenter
Presentation Notes
It has been shown, in retrospective studies, that low concentrations of circulating follicular phase LH in women undergoing GnRH-agonist long-protocol cycles might be associated with impaired oestradiol synthesis and/or a low oocyte yield as well as low fertilization rates, low pregnancy rates and high miscarriage rates (Westergaard et al., 2000; Esposito et al., 2001; Humaidan et al., 2002). The beneficial effect of LH supplementation in down-regulated poor responders undergoing COH with rFSH has been demonstrated in this meta-analysis. The potential benefit of LH administration for older patients could be explained by two different mechanisms. On the one hand, the endocrine changes occurring with ovarian aging include an increase of the serum FSH levels in the early follicular phase, which are not accompanied by an LH increase but by a progressive decrease of the basal androgen levels. Moreover, the follicular capability for inducing androstenedione synthesis after rFSH administration is significantly impaired in older patients compared with younger reproductive-aged patients, whereas E2 secretion is preserved by increased aromatase function. Action of LH at the follicular level that increases androgen production for its later aromatization to estrogens in a dose dependent manner may restore the follicular milieu in these patients to recover oocyte quality and, therefore, embryo quality and implantation rates. Follicle-stimulating hormone acts on granulosa cells to promote the conversion of cholesterol into P, which is passed to the thecal cells to be converted into androgens under the influence of LH, therefore reducing circulating P. All in all, this could explain why stimulation with rFSH alone can produce poorer outcomes in older and low-responding patients because they usually receive higher FSH doses for COS, they show higher P levels at the end of stimulation, and, subsequently, their endometrium receptivity diminishes.
De Placido et al. studied the effects of LH supplementation in women showing a poor response to ovarian stimulation. ‘Poor responders’ were defined as those who had serum oestradiol levels below 180 pg/ml and no follicles over 10 mm on day 8. These women were randomized to a daily dose of either 75 IU or 150 IU r-hLH. Women classified as ‘good responders’ received no additional r-hLH (control group). They found that the high dose of r-hLH was significantly more effective in terms of oocyte development and maturation than the increasing FSH drive. Furthermore, there was no significant difference between the high-dose group and controls in terms of these outcomes.
To Whom to give LH Supplementation in OI and IUI
LH levels 1.2 UI/L (WHO group I) Higher follicular development pts. receiving LH (67% vs 20%; p=0.02): Shoham, 2008.
Similar follicular development HMG vs FSH+rLH; higher cumulative PR after 3 cycles in FSH+LH (56% vs 23%; p=0.01): Carone, 2012.
Level 1b
Esteves, 37
WHO group II Clomiphene-resistant: fewer intermediate-sized follicles and OHSS in
LH-supl. vs FSH group; similar ovulation rate (Plateau, 2006); Previous over-response: higher monofollicular development in LH group
(32% vs 13%; p=0.04): Hughes, 2005; IUI: higher monofollicular development in LH group without
intermediate-size (42% vs 11%; p=0.03); lower cycle cancellation due to risk OHSS (-7% difference): Segnella 2011.
Presenter
Presentation Notes
Hypogonadotrophic hypogonadism Management options include exogenous replacement of gonadotropins and pulsatile GnRH agonist administration. In women with intact pituitary function, pulsatile gonadotropin releasing hormone (GnRH) therapy can be used. Exogenous gonadotropins administration is the alternative therapeutic option in hypothalamic dysfunction and the first line treatment if the defect is primary pituitary failure. Currently available evidence indicates that rFSH alone may not be sufficient to promote optimum follicular growth in severely gonadotropin deficient women. It has been suggested that a minimum threshold of serum LH is required to re-establish meiosis and final stages of growth of antral follicles. The European Recombinant Human LH Study Group, 1998: A dose finding trial included 38 WHO type I anovulatory patients, who were randomly assigned to receive either 0, 25, 75, or 225 IU rLH once daily in addition to 150 IU follitropin alpha once daily. None of the 8 patients who received follitropin alpha alone ovulated in the absence of rLH. Fourteen percent of patients who received follitropin alpha and 25 IU/L rLH ovulated compared to 66% and 80% of those who received 75 IU/L and 225 IU/L, respectively. Significant dose dependent increases in the rate of optimal follicular growth were observed in women receiving follitropin alpha with different doses of rLH varying from 0 to 225 IU/day. Shoham et al, 2008: Double-blind, randomized, placebo-controlled trial conducted in 25 medical centres in four countries. Thirty-nine patients with LH < 1.2 IU/l and FSH < 5.0 IU/l were treated with concomitant 75 IU lutropin alfa and 150 IU follitropin alfa or concomitant placebo and 150 IU follitropin alfa. With LHr: 66.7% achieved follicular development compared with 20.0% of patients receiving placebo (P = 0.023). Burgues et al, 2001: A case series from Spain included 38 hypogonadotrophic anovulatory (WHO group I) women undergoing 84 ovulation induction cycles where patients received 150 IU/day rFSH and 75 IU/day rLH. Sufficient follicular growth was observed in 79 (94%) out of 84 initiated cycles. The cumulative pregnancy rate following three cycles of stimulation with follitropin alpha and lutropin alpha was 39.5%. Kaufman et al, 2007: An open-label, noncomparative study with 31 hypogonadotrophic hypogonadal women. They receive Lutropin alfa 75 IU and follitropin alfa (75-225 IU). In a total of 54 cycles, 27 of 31 (87.1%) achieved follicular development within three cycles. Twenty of 27 patients (74.1%) who achieved follicular development and received hCG became pregnant; 16 (59.3%) continued to clinical pregnancy. Carone et al, 2012: Two-arm randomized open-label study, 35 women with hypogonadotropic hypogonadism, comparing: r-hFSH + r-hLH (2:1) X hMG-HP in women with. Following a total of 70 cycles, 70% of r-hFSH/r-hLH treated patients ovulated vs. 88% in hMG-HP group (p=0.11). However, PR in r-hFSH/rhLH group was 55.6% compared to 23.3% in hMG-HP group (p=0.01). OI in WHO group II anovulation The large majority of women with PCOS would have excess elevated LH concentrations when measured at the appropriate time. This may justify the potential advantages in preparations devoid of LH activity as follitropin alpha. Currently, there is no role of lutropin alpha in the management of women with PCOS. (conclusao de uma revisao de gibreel et al, 2009). Mas ha 2 estudos com inducao de ovulacao neste tipo de pacientes: Plateau et al, 2006: A randomized, open-label, assessor-blind, multinational study. Women with anovulatory infertility WHO Group II and resistant to clomiphene citrate were randomized to stimulation with HP-HMG (n=91) or rFSH (n=93) using a low-dose step-up protocol. The ovulation rate was 85.7% with HP-HMG and 85.5% with rFSH (per-protocol population), and non-inferiority was demonstrated. Significantly fewer intermediate-sized follicles were observed in the HP-HMG group (P<0.05). The singleton live birth rate was comparable between the two groups. The frequency of ovarian hyperstimulation syndrome and/or cancellation due to excessive response was 2.2% with HP-HMG and 9.8% with rFSH (P=0.058). Hugues et al, 2005: 153 wHO group ii anovulation women that during ovulation induction had over-response (at least 3 follicles 11-15mm and no one >15) were randomized to receive, in addition to 37.5IU recombinant human FSH (rFSH), either placebo or different doses of rLH (6.8, 13.6, 30 or 60mg) daily for a maximum of 7 days. The proportion of patients with exactly one follicle ≥ 16mm ranged from 13.3% in the placebo group to 32.1% in the 30 mg rLH group (P =0.048). The pregnancy rate ranged from 10.3% in the 60 mg group to 28.6% in the 30 mg rLH group. Adverse events were similar between groups. CONCLUSIONS: In patients over-respond- ing to FSH during ovulation induction, doses of up to 30 mg rLH/day appear to increase the proportion of patients developing a single dominant follicle (≥ 16mm). Our data support the ‘LH ceiling’ concept whereby addition of rLH is able to control development of the follicular cohort. IIU 1 RCT comparing HP-hmg com FSHr Segnella et al, 2011: 523 patients with unexplained infertility or mild male infertility undergoing controlled ovarian hyperstimulation for IUI. Patients were randomized for treatment with rFSH (262 patients) or HP-hMG (261 patients). Insemination was performed 34-36 hours after hCG injection. The primary outcome was clinical pregnancy rate (PR). The secondary outcome was the number of interrupted cycles for high risk of ovarian hyperstimulation syndrome (OHSS) and multiple pregnancy. -Regarding follicular development, there was a significantly lower average number of intermediate-size follicles (14–16 mm) at the end of stimulation in the HP-hMG group (0.73 ± 1.00 in HP-hMG and 1.96 ± 1.54 in rFSH; P=0.001); - furthermore, the number of follicles ≥17 mm was significantly higher in rFSH cycles (1.27 ± 0.45 in HP-hMG and 1.69 ± 0.84 in rFSH; P1⁄=0.03; -Development of one dominant follicle (≥17 mm) without intermediate-size follicles was achieved for 42.3% in the HP-hMG cycles versus 11.5% in the rFSH cycles (P1⁄=0.03). -On the hCG day, E2 levels were significantly higher in the rFSH group compared with HP-hMG (833.19 ± 385.80 pg/mL and 551.75 ± 240.06 pg/mL, respectively; P1⁄=0.004). -No significant difference in endometrial thickness were observed. -Higher P levels were observed in the rFSH cycles (37.77 ± 26.22 ng/mL in rFSH and 23.52 ± 13.39 ng/mL in HP-hMG; P=0.02) The clinical PR was 19.7% (95% confidence interval [CI] 15.3%-25.1%) in the HP-hMG group and 21.4% (95% CI 16.9%-26.8%) in the rFSH group [absolute difference -1.7% (95% CI -8.6% to 5.2%)]; The number of interrupted cycles for OHSS risk and multiple pregnancy was significantly higher in the rFSH group, 8.4% (95% CI 5.6%-12.4%) than in the HP-hMG group 1.2% (95% CI 0.4%-3.3%) [absolute difference -7.27% (95% CI -11.3 to -3.7)]. CONCLUSION(S): HP-hMG is not inferior compared with rFSH regarding clinical PR. Comments: Bi/multifollicular development was significantly higher in the rFSH cycles, contributing to the significantly higher estradiol concentration compared with HP-hMG cycles. In contrast, the develop- ment of a single dominant follicle without intermediate-size follicles was significantly higher in the HP-hMG cycles. The lower number of follicles obtained in HP-hMG cycles could reflect an LH effect during the follicular phase; the gonadotropin might induce follicular atresia. In the present study, despite significant differences between the two treatment groups regarding number of dominant follicles and hormonal environment, the endometrial thickness and the clinical pregnancy rate were similar between the two groups. We could hypothesize that exogenous LH/hCG activity might positively influence oocyte quality and development. This observation could explain the benefit regarding PR for those normo-ovulatory women with unexplained infertility who achieved pregnancy even though they developed a monofollicular response. Interesting data in the present study concern the different mean age of pregnant patients. Mean age of pregnant patients was higher in the HP-hMG group compared with the rFSH group. This observation led us to hypothesize that, in older women, the addition of LH/hCG activity could positively affect oocyte quality and steroidogenesis. This hy-pothesis is supported by data demonstrating that in poor responders, superimposing rLH on rFSH improves outcome data. Finally, because one of the main challenges for clinicians in- volved in ovulation induction is controlled ovarian hyperstimulation cycle cancellation, another end point of our work was to evaluate the frequency of interrupted cycles for high risk of OHSS and multiple pregnancy. We observed that the number of interrupted cycles was higher in the rFSH group; therefore, HP-hMG treatment might besafer in women who tend to a multifollicular response. References: The European Recombinant Human LH Study Group. Recombinant human luteinizing hormone (LH) to support recombinant human follicle-stimulating hormone (FSH)-induced follicular development in LH- and FSH-deficient anovulatory women: a dose-finding study. J Clin Endocrinol Metab. 1998 May;83(5):1507-14. ShohamZ,SmithH,YekoT,O’BrienF,HemseyG,O’DeaL.Recombinant LH (lutropin alfa) for the treatment of hypogonadotrophic women with profound LH deficiency: a randomized, double-blind, placebo-controlled, proof-of-efficacy study. Clin Endocrinol (Oxf). 2008;69(3):471–478. Burgues S. Spanish Collaborative Group on Female Hypogonadotrophic Hypogonadism. The effectiveness and safety of recombinant human LH to support follicular development induced by recombinant human FSH in WHO group I anovulation: evidence from a multicentre study in Spain. Hum Reprod. 2001;16(12):2525–2532. Kaufmann R, Dunn R, Vaughn T, et al. Recombinant human luteinizing hormone, lutropin alfa, for the induction of follicular development and pregnancy in profoundly gonadotrophin-deficient women. Clin Endocrinol (Oxf). 2007;67(4):563–569. Carone D, Caropreso C, Vitti A, Chiappetta R. Efficacy of different gonadotropin combinations to support ovulation induction in WHO type I anovulation infertility: clinical evidences of human recombinant FSH/human recombinant LH in a 2:1 ratio and highly purified human menopausal gonadotrophin stimulation protocols. J Endocrinol Invest. 2012 Oct 22. Platteau P, Andersen AN, Balen A, et al. Ovulation Induction (MOI) Study Group. Similar ovulation rates, but different follicular develop- ment with highly purified menotrophin compared with recombinant FSH in WHO Group II anovulatory infertility: a randomized controlled study. Hum Reprod. 2006;21(7):1798–1804. Recombinant LH Study Group. Does the addition of recombinant LH in WHO group II anovulatory women over-responding to FSH treatment reduce the number of developing follicles? A dose-finding study. Hum Reprod. 2005;20(3):629–635. Sagnella F, Moro F, Lanzone A, Tropea A, Martinez D, Capalbo A, Gangale MF, Spadoni V, Morciano A, Apa R. A prospective randomized noninferiority study comparing recombinant FSH and highly purified menotropin in intrauterine insemination cycles in couples with unexplained infertility and/or mild-moderate male factor. Fertil Steril. 2011 Feb;95(2):689-94. Epub 2010 Sep 25.
Esteves, 38
What is the optimal LH supplementation protocol? Existing studies give us some clues but the
optimal LH protocol has yet to be established How much LH should be used? Should the dose be fixed or flexible? At what stage of the cycle should LH be
administered?
FSH
LH
2:1? 1:1? Fixed? Mimic of natural LH levels?
Presenter
Presentation Notes
Even if we are able to identify those women who may require LH supplementation, there is currently no consensus on the most suitable LH protocol. Indeed, the protocol used may even depend on the subgroup being treated. Some of the treatment parameters that still need to be established are below. How much LH should be used? Should the dose be fixed or flexible? At what stage of the cycle should LH be administered?
*derives primarily from the hCG component, which preferentially is concentrated during the purification process and sometimes was added
to achieve the desired amount of LH-like biological activity.
Alfa Unit Beta unit (biological action
and receptor affinity)
Carboxyl terminal segment
(determines half-life) LH 92 AA; 121 AA Absent; half life of 20’
hCG Identical to LH 144 AA Higher receptor affinity
Present; half-life of 24h
Purity (LH content)
FSH activity (IU/vial)
LH activity (IU/vial)
Rec-hLH >99% 0 75
Rec-hLH + rec-hFSH >99% 150 75
hMG-HP Unknown* 75 75*
ASRM Practice Committee. Fertil Steril. 2008; 90:S13-20. Esteves, 39
Presenter
Presentation Notes
Human chorionic gonadotropin (hCG) is similar in structural attributes compared with follitropin. A notable exception is the presence of a long carboxy terminal segment that is O-glycosylated (O-linked CHO). This segment is not visible in the hCG crystal structure (PDB files 1XUN and 1HCN), but it is shown here for illustrative purposes. Of importance is that this extension confers a long half-life to hCG; when grafted onto the hFSH beta subunit, this extension likewise confers a longer circulatory half-life to hFSH. The C-terminal extended hFSH is currently in clinical trials. Although the alpha subunits of LH and hCG are identical to that of FSH, the beta subunits are different. Luteinizing hormone has a beta subunit containing 121 amino acids that confers its specific biologic action and is responsible for its interaction with the LH receptor. This beta subunit of LH contains the same amino acids in sequence as the beta subunit of hCG, but the hCG beta subunit contains an additional 23 amino acids. The two hormones differ in the composition of their carbohydrate moieties which, in turn, affects bioactivity and half-life. The half-life of LH is 20 minutes, and that for hCG is 24 hours.
Esteves, 40 Buhler KF, Fisher R. Gynecol Endocrinol 2011; 1-6.
Matched case-control study; N=4,719 pts.; long GnRH-a protocol
31 26 25
0
5
10
15
20
25
30
35
2:1 r-hFSH+r-hLH
HMG rec-hFSH +HMG
Duration ofStimulation (days)
Mean No. oocytesretrieved
IR (%)
CPR per transfer(%)
P=0.02
Differences in LH activity of rec-hLH and HMG preparations
Level 2a
Presenter
Presentation Notes
New fixed combination of rec-hFSH and rec-hLH filled by Mass at a 2:1 ratio; Pergoveris™: rec-hFSH (150 UI) + rec-hLH (75 UI); Bosch et al. Expert Opin Biol Ther 2010; 10: 1001-9.
Lower expression of LH/hCG receptor gene as well as genes involved in in biosynthesis of cholesterol and steroids in granulosa cells in pts. treated with HMG preparations May reflect down-regulation of LH receptors, as shown in animals: Caused by a constant ligand exposure during the follicular phase due to longer half life and higher binding affinity of hCG to LHr May explain the observed lower progesterone levels: Caused by lower LH-induced cholesterol uptake, a decrease in the novo cholesterol synthesis and a decrease in steroid synthesis.
Trinchard-Lugan I et al. Reprod Biomed Online 2002; 4:106-115; Menon KM et al. Biol Reprod 2004; 70:861-866; Grondal ML et al. Fertil Steril 2009; 91: 1820-1830. Esteves, 41
Level 1a
Presenter
Presentation Notes
Possible reasons: 1 - longer half life of hCG and higher binding afinity to LH receptors: Trinchard-Lugan I et al: Pharmacokinetics and pharmacodynamics of recombinant human chorionic gonadotrophin in healthy male and female volunteers. Reprod Biomed Online 2002; 4:106-115. 2 - Down-regulation of LH receptors for up to 48h as shown in animal models: Menon KM et al: Regulation of luteinizing hormone/human chorionic gonadotropin receptor expression: A perspective. Biol Reprod 2004; 70:861-866. 3 - Differences in gene expression profiles in granulosa cells after COS with r-hFSH and u-HMG: consistent lower expression of LH/hCG receptor gene in granulosa cells of in the u-HMG group. The lower gene expression may reflect down-regulation caused by a constant ligand exposure during the follicular phase. This would also explain the lower progesterone levels reported in these patients. The expression level of hCG/LH receptors genes and genes involved in in biosynthesis of cholesterol and steroids were expressed at lower levels in the HMG treated group; These findings indicate that granulosa cells of u-HMG treated pts have lower LH-induced cholesterol uptake, a decrease in the novo cholesterol synthesis and a decrease in steroid synthesis. Contrary, r-hFSH induced up-regulation of LH/hCG receptors that may increase cholesterol and steriod synthesis in pts treated with recFSH: Grondal ML et al. Differences in gene expression of granulosa cells from women undergoing controlled ovarian hyperstimulation with either recombinant follicle-stimulating hormone or highly-purified human menopausal gonadotropin. Fertil Steril 2009; 91: 1820-1830.
To whom to give rec-hLH? Differences between rec-hLH and HMG preparations
15-20% women have less sensitive ovaries and worse outcomes in IVF.
LH supplementation to OS is an evidence-based strategy to maximize pregnancy results.
Esteves, 42
LH activity in HMG is hCG-dependent: hCG is concentrated during purification or added to achieve the desired amount of LH-like biological activity.
Lower expression of LH receptor gene in pts. Treated with HMG (LHr down-regulation). Preparations used are important for granulosa cell function and may influence the developmental competence of the oocyte and the function of corpus luteum.
Esteves, 43
Use of Biomarkers to Individualize Ovarian Stimulation Protocols
Recent Advances in Gonadotropins Preparations Rec-FSH vs urinary products GnRH Agonist versus Antagonist To whom to give rec-hLH? Differences between rec-
hLH and LH activity in HMG preparations? Strategies to Improve Ovarian Stimulation Best Protocols to Minimize Risks and Reduce Dropout Rates in IVF
Up to 65% of couples dropout from IVF without achieving pregnancy before they
complete 3 cycles
Olivius K et al, Fertil Steril 2004;81:258; Land JA et al, Fertil Steril 1997; 68:278; Schroder AK, et al, RBM Online 2004; 5:600; Osmanangaoglu K et al, Hum Reprod 2002; 17:2655; Rajkhowa M et al,
Hum Reprod 2006; 21:358; Brandes M et al, Hum Reprod 2009; 24:3127; Hammarberg K et al, Hum Reprod 2001; 16:374.
Reasons
Strategies to Improve Ovarian Stimulation
Pregnancy loss 94% Unsuccessful cycle 87% Waiting after ET 81% Waiting to find out how many eggs fertilized
68%
Result of pregnancy scan 47%
Esteves, 44
Presenter
Presentation Notes
Despite being neglected by some practitioners, patient satisfaction is of utmost importance for the success of an IVF Clinic. Dropout rates during IVF treatment are huge, and these numbers are disturbing. We often think that financial/cost issues and poor prognosis are the main causes for dropout. However, studies show that costs may not be primary cause since high dropout rates occur in countries with national healthcare programs covering IVF (Domar AD. Fertil Steril 2004;81:271). Several studies show that stress is the leading cause for dropout, either during or after treatment.
Esteves, 45
68%
25% 7%
Folitropin alfaprefilled
ready-to-usepen
Follitropin betacartridge andreusable pen
Needle-freereconstitution,conventional
syringe
Patient Preferences Easy of use 58% Dosing mechanism 43% Less chance of error 26%
Reasons
Weiss N. RBMonline 2007;15:31-7
Level 2a
• Allowed injections at home
• Improved pts. satisfaction (QOL)
• Same injection device
design for all gonadotropins;
• Color-coded for differentiation;
• Pre-filled, ready-to-use family of pens for fertility treatment.
Esteves, 46
Esteves, 47
*Bologna criteria: Ferraretti et al. Hum Reprod 2011; Broer et al. Hum Reprod Update 2011; Nelson et al. Hum Reprod. 2009; Broer et al. Fertil Steril. 2009; Hendricks et al. Fertil Steril 2007. Esteves, 48
Response to Ovarian
Stimulation
Anti-Mullerian Hormone (ng/mL)
Antral Follicle Count
False Positive
Rate
Risk of Excessive Response (≥15 oocytes or OHSS)
≥ 3.5
> 15
~15% Risk of Poor Response (≤ 4 oocytes)*
< 1.1
< 5
pmol/L X1000/140
AMH and AFC to Determine Who is Who Prior to OS
Level 2a
Presenter
Presentation Notes
The evaluation of ovarian reserve may enable the identification of patients who will have a better or worse response to gonadotropin stimulation than would be expected for their chronological age. This help clinicians to individualize patient management by selecting an appropriate treatment protocol. Nevertheless, a patient’s true ovarian reserve can be determined only after a cycle of ovarian stimulation. In terms of CUT-OFF, there is no homogeneity among studies. Best are the 2 meta-analyses (Boer 2009 e 2010). Aflatoonian, J Assist Reprod Genet 2009:. The sensitivity and specificity for prediction of high ovarian response were 89 % and 92 % for small AFC (≥ 16) and 93% and 78% for AMH (≥ 34.5 pmol/l) - 4,83 ng/ml La Marca Hum Rep. (2007): All the cancelled cycles due to absent response were in the group of the lowest AMH quartile ((<0.4 ng/ml)) , whereas the cancelled cycles due to risk of ovarian hyperstimulation syndrome (OHSS) were in the group of the highest AMH quartile (>7 ng/ml) . Lee et al, hum repro 2008: CUT OFF: 3,36,. The basal serum AMH level predicted OHSS with a sensitivity of 90.5% and specificity of 81.3%. Nardo et al fertile Steril. (2009) : cutoff of AMH >3.5 ng/mL would have 88% sensitivity in predicting overstimulation with a specificity of 70%. For poor response a cutoff of 1.0 ng/mL would have 87% sensitivity and 67% specificity Gnoth C, Hum Reprod 2008: When the calculated optimal AMH cut-off of ≤1.26 ng/ml was used to predict responses to COS, it was found to have a 97% sensitivity for predicting poor responses (< 4 oocytes retrieved) and a 98% accuracy in predicting a normal COS response.
31.3% 31.1% 35.3%
50.0%
20.0%
0%
10%
20%
30%
40%
50%
60%
75 IU 112.5 IU 150 IU 187.5 IU 225 IU
Clinical pregnancy rates/cycle started
Olivennes F, et al. The CONSORT study. Reprod Biomed Online. 2009;18:95–204.
Individualized dosing in increments of 37.5 IU of folitropin alfa possible by FbM technology
Age (28-32)
Oocytes retrieved (8-12)
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Reduced Starting Doses of r-hFSH for Ovarian Stimulation in
High Responders
Level 2a
Presenter
Presentation Notes
In this context, the CONsistency in r-hFSH Starting dOses for Individualized tReatmenT (CONSORT) approach represents a step towards personalized ART. 4 factors have been identified to be predictive of ovarian response to FSH stimulation in women aged <35 years. These factors have been combined into a model that predicts the optimum starting dose of rec-hFSH for individual patients. The availability of GONAL-f® FbM means that precise and accurate dosing can be achieved, allowing the opportunity to develop valid FSH daily dosing guidelines. The four most important predictive factors measured routinely are basal FSH level, body mass index (BMI), age and antral follicle count. These form the basis of the CONSORT calculator. An equation was created using a large database that described oocyte yield in terms of these four factors and FSH starting dose. By inverting the equation, a formula was created that enables calculation of the optimum FSH starting dose by entering values for the four factors and the desired oocyte yield (10). To validate the model, a prospective, open-label, multicentre study of ART at 18 centres worldwide was conducted. All cycles were stimulated using the GONAL-f® FbM prefilled pen, which provides precise and accurate dosing, and enables FSH dosing in relatively small increments. Patients enrolled had aged <35 and oocytes retrieved ranged from 8-12 (mean 10.2). Pregnancy rate were adequate by transferring an average of 1.8 embryos 1. Howles et al. Curr Med Res Opin 2006;22:907–916 2. F Olivennes, CM Howles, A Borini, M Germond, G Trew, M Wikland, F Zegers-Hochschild, H Saunders, V Alam. Reproductive BioMedicine Online 18: 195-204, 2009. The precision and accuracy of gonadotropin FbM preparations are so good that excellent clinical results are achieved even using low daily doses, as shown in this important study. In the CONSORT study, patients were included if they fulfilled the following criteria: between 18 and 35 years of age regular, spontaneous, ovulatory menstrual cycle, 21–35 days in length early follicular phase (days 2–4) serum levels of FSH (≤ 12 IU/L) and oestradiol (E2) within centre’s normal range both ovaries present. Patients were excluded if they had any of the following: previous poor response in two ART cycles (defined as ≤ 5 mature follicles and/or ≤ 3 oocytes collected) previous over response (> 24 oocytes) BMI > 30 kg/m2. All cycles were stimulated using the GONAL-f® FbM that enables FSH dosing in relatively small increments.
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GnRH Antagonist Protocol in High Responders
9 RCT; 966 PCOS women Relative Risk
Duration of ovarian stimulation -0.74 (95% CI -1.12; -0.36)
Gonadotropin dose -0.28 (95% CI -0.43; -0.13)
Oocytes retrieved 0.01 (95% CI -0.24-0.26)
Risk of OHSS Mild
Moderate and Severe
20% vs 32% 1.23 (95% CI 0.67-2.26) 0.59 (95% CI 0.45-0.76)
Clinical PR 1.01 (95% CI 0.88; 1.15)
Miscarriage rate 0.79 (95% CI 0.49; 1.28)
Pundir J et al. RBM Online 2012; 24:6-22.
40% reduction in moderate/severe OHSS by using antagonists rather than agonists
Cancellation 4 (2.7%) 1 (2.9%) CPR per transfer 40.1% 63.6%*
Adapted from Nelson SM et al . Anti-Müllerian hormone-based approach to controlled ovarian stimulation for assisted conception. Hum Reprod. 2009; 24(4):867-75.
*P ≤ 0.01
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Tailor OS in High Responders by AMH (AFC)
Combination of Reduced rFSH Doses and GnRH Antagonist
Level 1b
Presenter
Presentation Notes
The use of antagonists in combination with AMH determination in patients with risk of hyper-response can potentially decrease complications such as the occurrence of severe hypestimulation syndrome.
GnRH-a triggering (0.2-1.5 mg): antagonist protocol; Reduced if not eliminated risk for OHSS;
In specific high risk patients for OHSS and egg donation programs should become the choice.
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GnRH Agonist for LH Triggering in High Responders
Level 1a
11 RCT – 1,055 women
LBR OPR Moderate/ severe OHSS
Fresh autologous cycles (8 RCT)
OR 0.44 (0.29 - 0.68)
OR 0.45 (0.31 - 0.65)
OR 0.10, (0.01 to 0.82)
Donor recipient cycles (3 RCT)
OR 0.90 (0.57 - 1.42)
OR 0.91 (0.59 -1.40)
OR 0.06 (0.01 - 0.31)
Youssef et al. Cochrane Database Syst Rev. 2011
Presenter
Presentation Notes
Prevention of OHSS: 1st level prevention: use instead of GnRH agonists 2nd level prevention: in patients on antagonist protocols identified to be at risk of developing severe OHSS, replacing hCG with GnRH-a as a trigger for final oocyte maturation; it should be combined to cryopreservation of all embryos 3rd level prevention: In patients with early onset of OHSS, reinitiation of GnRH-ant in the luteal phase might lead to rapid regression of the syndrome; however, only limited data on this new concept are available in the literature Comments: Youssef (Cochrane 2011): GnRH agonist to trigger x hCG in antagonista cycle 11 RCTs (n = 1055) 8 RCT fresh autologous cycles / 3 studies assessed donor-recipient cycles In fresh-autologous cycles: GnRH agonist was less effective than HCG in terms of: live birth rate per randomised woman (OR 0.44, 95% CI 0.29 to 0.68; 4 RCTs) ongoing pregnancy rate per randomised woman (OR 0.45, 95% CI 0.31 to 0.65; 8 RCTs). For a group with a 30% live birth or ongoing pregnancy rate using HCG, the rate would be between 12% and 22% using an GnRH agonist. Moderate to severe ovarian hyperstimulation syndrome (OHSS) incidence per randomised woman was significantly lower in the GnRH agonist group compared to the HCG group (OR 0.10, 95% CI 0.01 to 0.82; 5 RCTs). For a group with a 3% OHSS rate using HCG the rate would be between 0% and 2.6% using GnRH agonist. In donor recipient cycles, there was no evidence of a statistical difference in the live birth rate per randomised woman (OR 0.92, 95% CI 0.53 to 1.61; 1 RCT). Houve alguns artigos criticando, como do Humaidan, dizendo que: debatable conclusions are drawn from early studies, when the concept was still under development.
Challenge is to Rescue Luteal Phase Insufficiency.
Options are:
Vitrification and FET in subsequent natural cycle vs coasting and Fresh ET same cycle
CPR: 50% vs 29% (P<0.05) Garcia-Velasco, Fertil Steril, 2012
Modified luteal support improved delivery rate: hCG bolus OPU day (1,500 UI) or 3x 500 UI boluses;
Garcia-velasco : retrospective observacional study, comparing egg vitrification (n = 152) obtained after triggering final oocyte maturation with GnRH agonists and transferring the embryos at a later stage, with classical coasting (n = 96) . CPR na vitrif: 50% and coasting 29,5% (p<0,05) Humaidan: 6 RTC: hCG vs GnRH-a trigger: RD -0.06, 95% (CI: -0.14 to 0.02)
19992009
15%
54% Cycles with GnRH
Antagonists
Data supplied by REDLARA and ICMART
2009
12%
43%
45%
2009
Rec-hFSH
Rec-hFSH + HMG
HMG
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Evidence-based Strategies to Optimize COS in Poor Responders
Esteves, 56
14 RCT (1,127 patients) Duration of stimulation
Number Oocytes retrieved
Cycle cancellation
Clinical Pregnancy
-1.9 days (-3.6; -0.12)
-0.17 (-0.69; 0.34)
1.01 (0.71; 1.42)
1.23 (0.92, 1.66)
Pu D et al. Hum Reprod. 2011; 26:2742.
GnRH Antagonists in Poor Responders
Limited Clinical Benefit Shortcomings:
- Definition of poor responders - Different gonadotropins regimens for OS
Level 1b
Presenter
Presentation Notes
Liu et al performed this meta-analysis involving 566 IVF patients in a GnRH-ant protocol group and 561 patients in a GnRH-a protocol group. Fourteen eligible studies were included. GnRH-ant protocols resulted in a statistically significantly lower duration of stimulation compared with GnRH-a protocols (P = 0.04; WMD: -1.88, 95% CI: -3.64, -0.12), but there was no significant difference in the number of oocytes retrieved (P = 0.51; WMD: -0.17, 95% CI -0.69, 0.34) or the number of mature oocytes retrieved (P = 0.99; WMD: -0.01, 95% CI: -1.14, 1.12). Moreover, no significant difference was found in the cycle cancellation rate (CCR, P = 0.67; OR: 1.01, 95% CI: 0.71-1.42) or clinical pregnancy rate (CPR, P = 0.16; OR: 1.23, 95% CI: 0.92, 1.66).
Intervention Meta-analytic Studies Population Effect on
Pregnancy
Growth Hormone Kyrou et al,20091 Kolibianakis et al, 20092 Duffy et al, 20103
Poor responders
Higher LBR1,2,3 Higher PR2
Higher CPR3
Testosterone Bosdou et al , 2012 Poor responders
Higher LBR Higher CPR
Rec-hLH supplementation
to rec-hFSH
Mochtar et al, 20071
Bosdou et al, 20122
Hill et al, 20123
Poor responders1,2 Age ≥35 yrs3
Higher OPR1
Higher LBR2 Higher CPR3
Kolibianakis et al, Hum Reprod Update 2009,15:613-22; Kyrou et al, Fertil Steril 2009;91: 749–66; Duffy et al, Cochrane Database Syst Rev 2010;1:CD000099; Mochtar MH et al. Cochrane Database Syst Rev. 2007,2:CD005070; Bosdou JK et al, Hum Reprod Update 2012;8:127-45; Hill MJ et al. Fertil Steril
2012;97:1108-4.
Level 1a
Esteves, 57
Presenter
Presentation Notes
GH Duffy et al (Cochrane): Ten studies (440 subfertile couples) were included. In women who are not considered poor responders undergoing in IVF there is no evidence from randomised controlled trials to support the use of growth hormone. In women who are considered poor responders the use of growth hormone has been shown to significantly improve live birth (4 RCT- OR 5.39, 95% CI 1.89 to 15.35)and pregnancy rates (8 RCT - OR 3.28, 95% CI 1.74 to 6.20). Quality of the evidence; differences in participant number, cause of subfertility, treatment protocol and outcomes measured all varied considerably between the trials. There was no uniformity of dose and timing of the intervention. A large scale trial with a standardised treatment protocol and intervention protocol is required. Kolibianakis: 6 RCT (169) –only poor responder: clinical pregnancy (rate difference: +16%, 95% CI: +4 to +28; fixed effects model) (number-needed-to-treat (NNT) = 6, 95% CI: 4-25) and live birth rates (rate difference: +17%, 95% CI: +5 to +30; fixed effects model) (NNT = 6; 95% CI: 3-20). Furthermore, GH addition was associated with a significantly higher proportion of patients reaching embryo transfer (rate difference: +22%, 95% CI: +7 to +36; fixed effects model). Kyrou: Five eligible RCTs, poor responder (n = 128). Odds ratio for live birth: 5.22, confidence interval: 95% 1.09–24.99 Many different protocols of GH use: Owen et al. (1991) : 24 IU im/day on alternate days, starting simultaneously with hMG until the day of hCG administration Zhuang et al. (1994): 12 IU im/day on alternate days Suikkari et al. (1996): 4 or 12 IU/day, starting on cycle day 3 Tesarik et al (2005): 8IU of GH from day 7 of exogenous gonadotrophin administration till the day following the ovulation-triggering injection of hCG Bergh et al. (1994): 0.1 IU/kg body weight/day sc, starting simultaneously with FSH until the day of hCG administration Dor et al. (1995) 18 IU sc on cycle day 2, 4, 6, 8 Kucuk et al. (2008): 4 mg (12 IU) sc, from day 21 of the preceding cycle and until the day of hCG administration The grounds for supplementing GH in ART are multiple. Insulin-like growth factors 1 (IGF-1) and 2 (IGF-2) are both present in follicular fluid and believed to play a crucial role in the cytoplasmic maturation. In several animal models of in vitro maturation exogenous administration of GH increased follicular IGF-1 and IGF-2 in as well as oocyte competence. Growth hormone could possibly increase the DNA repair capacity in oocytes as shown in liver cells. In support of this hypothesis, Mendoza et al. showed a positive correlation between the oocytes’ ability to evolve in morphologically normal embryos and GH levels in follicular fluid. Furthermore, several reports looking at the function of Granulosa cells in vitro indicated that IGF-1 improved the response to gonadotropin stimulation. Testosterone 1 meta-analysis, Bosdou et al (2012): In two trials involving 163 patients, pretreatment with transdermal testosterone was associated with an increase in clinical preg- nancy [risk difference (RD): +15%, 95% confidence interval (CI): +3 to +26%] and live birth rates (RD: +11%, 95% CI: +0.3 to +22%) in poor responders undergoing ovarian stimulation for IVF. Only 2 trials: Massin 2006 (human reproduction): prospective, randomized, double-blind, placebo-controlled study.The design was set up to perform a paired comparison of the ovarian parameters recorded in two consecutive cycles, each woman being used as her own control. And then, comparing testosterone to placebo. 25 women with placebo ans 24 with trasndermic testosterone ( testosterone 1%), Women applied once-daily 1 g of gel (10 mg of testosterone) on the external side of the thigh. Testosterone absorption with the gel is approximately 10%. Either testosterone or placebo gels were applied for 15–20 days in the period preceding the second stimulation for IVF or ICSI, i.e. during the period of pituitary desensitization in women treated with a long GnRH agonist protocol or during pill administration in women treated with another analogue protocol. Comparing to previous cycle, the both groups there was an increase in the number of oocytes on the second. Placebo group: 3,6 to 5 (p<0,02) / testosterone: 3 to 5,31(p<0,02). Placebo x testo: p=0,8, no difference: numbers of pre-ovulatory follicles, total and mature oocytes and embryos did not significantly differ between testosterone and placebo-treated patients.. Kim, 2011 (Fertility and Sterility): poor responders, 55 with placebo and 55 with trasndermic testosterone ( testosterone 1%), with a 1.25 mg/d nominal delivery rate of testosterone was started from sixth day of E-P pretreatment and continued for 21 days. All antagonist cycle. The numbers of oocytes retrieved, mature oocytes, fertilized oocytes, and good-quality embryos were significantly higher in the TTG pretreatment group. Embryo implantation rate and clinical pregnancy rate per cycle initiated also were significantly higher in the women pretreated with TTG. Explanations to use: It has been suggested that the accumulation of androgens in the micro milieu of the primate ovary, plays a critical role in early follicular development and granulosa cell proliferation. Androgen excess has been shown to stimulate early stages of follicular growth and increase the number of preantral and antral follicles. In addition, increased intraovarian concentration of androgens seems to augment follicle stimulating hormone (FSH) re- ceptor expression in granulosa cells and thus, potentially lead to enhanced responsiveness of ovaries to FSH. Besides these experimental data, further clinical observa- tions on women with polycystic ovary syndrome or testosterone-treated female transsexuals, suggest that exposure to exogenous androgens may lead to increased number of developing follicles, regardless of gonadotrophin stimulation Furthermore, it has been reported that inadequate levels of endogenous androgens are associated with decreased ovarian sensitivity to FSH and low pregnancy rates after IVF. Bosdou et al also evaluated other interventions such as use of aromatase inhibitors, androgens, etc.
Best Strategies to Maintain Sustainable Pregnancy Results and Minimize Complications in
“High” Responders
Evidence
Low Starting Doses of r-hFSH, preferably filled by mass preparations
2a
GnRH Antagonists 1a
Biomarkers to tailor OS 1b
GnRH Agonist for LH Triggering1 1a
Strategies to Improve Success by Tailoring Ovarian Stimulation
