strategies to improve ovarian stimulation

Strategies to Improve Success

in Ovarian Stimulation

MerckSerono Stand-alone Meeting

Cochin, India – August 2011

Learning Objectives

UN Census Estimates, 2008

Ovulation Induction

for ART

Pharmaceutical industry

One size fits all protocol for OS

suppress LH surge: GnRHa

ovarian stimulation with HMG/FSH

high doses of gonadotropin

high number oocytes

high number of embryos

Results not the same for all

poor response and OHSS

side effects

patient satisfaction neglected

Ovulation Induction

One size fits all?

Patient is the main

variable of OI response

Demographics and anthropometrics (Age, BMI, Race)

Genetics profile

Cause of Infertility

Years of Infertility

Health status

Nutritional status

How to define the right individual

treatment for the right patient to:

●Prevent poor response and OHSS (reduce cancellation)

●Reduce side effects

●Increase pregnancy rates

●Reduce physical, psychological and financial burden

What we really want to know in OI is...

Esteves, 9

Understanding the Problem

From cookery to science

Individualizing ovarian stimulation according to patients is important But how ?

There are several predictors of ovarian response

Can we make prediction more scientific but simple ?

Esteves, 10

Learning Objectives

Gonadotropins: better now

Age

Biomarkers

● Hormonal Biomarkers, FSH, Inhibin-B, AMH

● Functional Biomarkers: Antral Follicle Count (AFC)

● Genetic Biomarkers: Single Nucleotide Polymorphisms for

FSH-R/LH/LH-R/E2-R/AMH-R

Markers of Ovarian Response

Can we predict ovarian response?

Esteves, 12

Who has the highest chance of a live

birth following IVF?

Hana Age 26

Basal FSH 9

Maria Age 37

Basal FSH 5

Esteves, 13

1. Akande et al. Hum Reprod 2002;17:2003–2008

(n = 1019)

20–24 25–29 30–34 35–39 40–44 45–49

5

0

10

15

20 L

ive

birth

s (

%)

Age (years)

6–8.9

3–5.9

<3

FSH IU/L

≥12

9–11.9

Age and FSH

chronological vs biological in IVF

Maria Hana

Esteves, 14

Why do ovaries age at different rates?

Multifactorial, but genetics important

Single nucleotide polymorphisms

(SNPs) linked to: ●Ovarian response to gonadotrophins

●Premature menopause

Both activating and inactivating

mutations identified in the LH and

FSH receptor genes1

1. Themmen and Huhtaniemi. Endocr Rev 2000;21:551–583

Human FSH Receptor Mutations

FSH-R: Ser680 genotype

- NH2

- COOH

Ala189Val

Asp567Gly??

(Asn191Ile) Ile160Thr

Asp224Val

Arg573Cys

Leu 601Val

Ala419Thr

Pro346Arg Val341Ala

*

Pro519Thr Thr307Ala

Ser680Asn

*

*

*

Esteves, 15

La Marca, et al. Hum Reprod 2009.

AMH levels are

correlated with

the number of

follicles at

gonadotropin

independent

stage


Biomarkers and follicular development

Esteves, 16

AMH: a cut-off 1.26 ng/ml was able to predict

poor response (<4 oocytes) with 97% sensitivity

Gnoth, et al. Hum Reprod 2008.

Retrospective analysis, 316

patients (1st IVF cycle) in

GnRH-a long protocol

Variables: age, basal FSH, AMH,

Inhibin-B

Endpoint: number of oocytes

Cut-off of poor response: 4 oocytes


anti-Mullerian hormone (AMH)

Esteves, 17

Verhagenet al. 2008; Broer et al., 2010


Prediction of response by AMH

AMH category

(ng/mL)

0.14 to <0.7

(N=74)

0.7 to <2.1

(N=128)

>2.1

(N=148)

Agonist protocol +

rFSH

375 225 150

Oocytes (n) 5 (3-7) 10 (7-15) 14 (10-19)

Severe OHSS 0 (0%) 3 (2%) 20

(13.9%)

Cancellation 19 (25.7%) 3 (2.3%) 4 (2.7%)

CPR per transfer 11.1% 34.6% 40.1%

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.

Esteves, 18


Antral Follicle Count (AFC)

No. of antral

follicles < 3 4-10 > 10

No. of cycles 16 76 57

Mean age

(years) 36.8 36.3 32.8

Day 3 FSH

(IU/l) 12.7 7.1 5.6

Cx rate 68.8% 5.3% 0%

Peak E2

(pg/ml) 432 1,001 1,912

Mean No. of

eggs 2.0 ± 0.9 6.3 ± 4.4 14.1 ± 8.5

Pregnancy

rate 0% 13.2% 26.3%

Chang, et al. Fertil Steril. 1998;69:505.

Hansen KR, et al. Fertil Steril

2003;80:577–83

Number of antral follicles

Me

an

nu

mb

er

of o

ocyte

s r

etr

eiv

ed

r=0.64

p<0.001

0 5 10 15 20 25

25

20

15

10

5

0

Esteves, 19

Broer et al. , 2010

AMH = AFC >Inhibin B >FSH >Age


Prediction of response

Esteves, 20

The patient individual

factors play a crucial

role in predicting ovarian

response.

AFC and AMH are helpful

to predict ovarian

response to stimulation.


Summary

Esteves, 21

Learning Objectives

Other:

Progesterone

Estradiol

Aromatase inibitor

Contraceptive pill

Antioxidants/vitamins

Gonadotropins:

Recombinant FSH/LH/hCG

Urinary FSH/LH/hCG

GnRH Analogues:

Agonist

Antagonist

Esteves, 23

Product Technology Brand name Manufacturer

hMG Urine-derived Menogon®; Repronex®

Merional®

Ferring

IBSA

hMG HP Urine-derived Menopur® Ferring

u-FSH Urine-derived Fostimon® IBSA

u-FSH HP Urine-derived Bravelle® Ferring

u-hCG Urine-derived Choragon®

Choriomon®

Ferring

IBSA

r-hFSH (follitropin beta)

Recombinant Puregon®; Follistim® MSD

r-hFSH (follitropin alfa) Recombinant GONAL-f® MerckSerono

r-hLH Recombinant Luveris® MerckSerono

r-FSH + r-hLH Recombinant Pergoveris® MerckSerono

r-hCG Recombinant Ovidrel®; Ovitrelle® MerckSerono

Gonadotropins: an overview

What is available?


Urinary-derived products

Culture media

Harvest Bioreactor

Production

Cell attachment and

proliferation

r-hFSH production and

secretion

Collection of cell

culture supernatant

medium containing

r-hFSH

In-process QC

Purification

Concentration of

supernatant

Chromatographic

purification

steps

Ultrasterile filtration

Characterization

and full QC of

bulk r-hFSH Esteves, 26


Recombinants


Differences

Bassett et al. Reprod Biomed Online 2005;10:169–177

Purity

(FSH

content)

Mean specific

FSH activity

(IU/mg protein)

Injected

protein

per 75 IU

(mcg)

hMG < 5% ~100 ~750*

hMG-HP < 70% 2000–2500 ~33*

r-hFSH

Follitropin beta

–

7000–10,000

8.1*

Follitropin alfa > 99% 13,645 6.1

Esteves, 27

1. Bassett et al. Reprod Biomed Online 2005;10:169–177

2. Driebergen et al. Curr Med Res Opin 2003;19:41–46

Conventional Bioassay

High variability

(~20%)

in vivo (rat)

Novel analitycal method

Physiochemical technique

Minimal batch-to-batch variability (1.6%)1,2


Product Quality: Filled by Mass (FbM)

Esteves, 28

Concept of Dose Precision

Clinical implications

Batch variability

+20%, -25%

225

270

170

IU

Bioassay

Urinary and Follitropin beta

16.5 mcg

(225 IU)

Filled by Mass

Folitropin alfa (Gonal-f FbM)

Batch variability

2%

Risk of OHSS

Poor response

Portable, ready-to-use device

Precise dose delivered

Gonal-f FbM

Group A (hMG; N=299)

Group B (HP-hMG; N=330)

Group C (r-hFSH; N=236)

Gonadotropin rFSH/hMG

112.5-450 UI Individualized dose

Agonist (nasal spray): Nafarelin acetate (400 mcg/day; fixed)

Day 1

Day 6

Day

of hCG

Cycle

day 21

Day 2-5 of menses

menses

Vaginal

progesterone

Esteves, 31

Outcome Measure HMG

n=299

HP-hMG

N=330

r-hFSH

n=236

P-

value

Total gonadotropin dose (IU) 2,685 2,903 2,268 <0.01

Retrieved oocytes (N) 10.9 10.7 10.8 NS

MII oocytes (N) 8.9 8.9 8.7 NS

2PN fertilization rate (%) 72 72 71 NS

Implantation rate (%) 24 27 23 NS

Live birth rate per cycle (%) 24.4 32.4 30.1 NS

Moderate/severe OHSS(%) 2.3 1.8 1.3 NS

r-hFSH vs hMG/HP-hMG in ART

Esteves et al. (observational study 2009)

Esteves et al, Reprod Biol Endocrinol. 2009; 7:111

18.7 20.3

53.4*

% Cycles with “Step-down” during ovarian stimulation

HMG HP-HMG rec-hFSH (fbm)

*P<0.01

r-hFSH vs hMG and HP-hMG in ART



To achieve a

live birth,

21-52% more

HP-hMG and

hMG was

required

compared

with r-hFSH

Tota

l Do

se p

er L

ive

Bir

th (

IU)*

0

3.000

7.000

10.000

21.6%

r-hFSH HP-hMG

6,324*

7,739

hMG

9,690 52.2%

* Mean total dose per cycle/Live birth rate (≤35 years)

r-hFSH vs hMG and HP-hMG in ART



Other products for ART

What is available?

Product Brand name Manufacturer

GnRH-analogue

Nafareline Synarel® Pfizer

Leuprolide Lupron® Abbott

Triptoreline Decapeptyl® Ferring

Gosereline Zoladex® Astra-Zeneca

Busereline Suprefact®, Suprecur® Sanofi-Aventis

GnRH antagonist

Cetrorelix Cetrotide® Merck Serono

Ganirelix Orgalutran® MSD

Progesterone

8% gel Crinone® Merck Serono

100 capsules Utrogestan® Ferring

Oil solution 50mg Several Several

LH surge prevention

GnRH agonists

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

LH surge prevention

GnRH antagonists

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

LH surge prevention

GnRH antagonists

Follicular

Luteal

E2 ,

P4

LH

, F

SH

0 10

20

30

2-4 weeks

Synchronized follicles

Agonist

0

1

2

3

4

5

6

-6 0 6 12 18 24 30 36 42 48

Hours

LH

(IU

/L)

Antagonist

Antagonist

• Half-life ~20h (Cetrorelix)

• Suppress LH by 80% of

baseline levels

A comparison of Nafarelin and Cetrorelix for

LH suppression in COH-ICSI cycles with

Follitropin alfa

• Retrospective (2002-2008)

• Unselected group of NG women – COS with r-hFSH

• Group 1 (Nafarelin; N=1,362); Group 2 (Cetrorelix; N=414)

Individualized dose

Agonist: Nafarelin acetate (400 mcg/day; fixed)

Gonadotropin dose

112.5-450 UI

Day 1 of rFSH

Day 6

of rFSH Cycle

day 21

Day 2-5 of menses

menses

Vaginal

progesterone

Day

of hCG

Follitropin alfa dose

112.5-450 UI

Individualized

rFSH dose

0.25 mg/day of

Cetrorelix (flexible)

Follicle

13 mm

Day of hCG

Day 2 or 3 of menses

Day 1

of rFSH

menses

Vaginal

progesterone

Esteves et al., JBRA Assist Reprod (Suppl 1), 2010 Esteves, 39

A comparison of Nafarelin and Cetrorelix for

LH suppression in COH-ICSI cycles with

Follitropin alfa

1st ICSI cycles

Cetrorelix

N=163

Nafarelin

N=948

P-value

Age (yrs) 34.5 33.4 0.002

Total r-hFSH dose (IU) 2,313 2,453 0.001

Days of -hrFSH 9.9 10.3 0.01

E2 hCG day (pmol/L) 1,585 2,371 <0.001

Oocytes retrieved (n) 9.5 11.3 <0.001

2PN Fertilization (%) 63.3 62.5 NS

Transfer (n) 2.4 2.5 NS

Live birth (%) 35.5 36.3 NS

Embryo cryopreserved (%) 47.1 48.4 NS

85

64 54 50

15

36 46 50

cycle no.1(n=1111)

cycle no.2(n=378)

cycle no.3(n=194)

cycle no. ≥4 (n=93)

Nafarelin Cetrorelix

Esteves et al., JBRA Assist Reprod (Suppl 1), 2010

Distribution by ICSI cycle rank (%)

Kolibianakis et al (2006)2

N studies 22

Included non peer-reviewed data No

Included IUI cycles No

N patients 3176

Odds ratio 0.86 (0.72-1.02; p=.08)*

Duration of stimulation -1.54 days (OR: -2.42; -0.66; p=.0006)

Oocytes retrieved -1.19 (OR: -1.82; -0.56)

Risk of severe OHSS OR=0.61 (0.42; 0.89; p=.01)*

GnRH antagonists vs agonists

Meta-analysis

*For every 59 women treated with a GnRH agonist vs GnRH

antagonist, one additional case of severe OHSS will occur.

Esteves, 41

Agonist administration

Gonadotropin administration Long GnRH

agonist protocol

Antagonist

administration

Gonadotropin administration

Single or multiple

dose GnRH

antagonist protocol

Flare up

effect

Pituitary

suppression

Longer

treatment

Can exclude

early

pregnancy

Can be integrated

in spontaneous

and OI cycles

Pre-treatment cycle Treatment cycle

No hormonal

withdrawal

No flare

effect with

possible cyst

formation

Less gona-

dotropins

Prevent OHSS

by GnRH-a

LH surge prevention

GnRH antagonists vs agonists

Learning Objectives

AMH category (ng/mL) >2.1

GnRH analogue + r-hFSH 150UI Agonist Antagonist

Oocytes (n) 14 (10-19) 10 (8.5-13.5)

Severe OHSS 20 (13.9%) 0 (0%)*

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

Individualized Treatment with AMH

AMH + antagonists in hyper-responders

Esteves, 44

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;18:195–204.

Individualized dosing in

increments of 37.5 IU of

Gonal-f possible by FbM

technology

Use of algorithm of

patients characteristics ● basal FSH

● body mass index (BMI)

● age

● antral follicle count

Age (28-32)

Oocytes retrieved (8-12)

CONSORT = CONsistency in r-hFSH

Starting dOses for Individualized

tReatmenT

Esteves, 45

1. Alviggi et al. Reprod Biomed Online 2006;12:221–233; 2. Tarlatzis et al. Hum Reprod 2006;21:90–94

3. Esteves et al. Reprod Biol Endocrinol 2009;7:111; 4. Marrs et al. Reprod Biomed Online 2004;8:175–182

5. Mochtar MH, Cochrane Database, 2007; 6. De Placido et al. Clin Endocrinol (Oxf) 2004;60:637–643

7. Alviggi, et al. RBMOnline 2009.

LH supplementation in ART

What do we know today

The majority of patients do not need LH

supplementation as endogenous LH levels are

sufficient1–3

15-20% of women have less sensitive ovaries

Older patients (> 35 years)4

Low responders5

Deeply suppressed endogenous LH6

Hypo-responders7

FSH and AFC considered adequate

Genetic characteristics

Single nucleotide polymorphisms of FSH-R and LH-R

Esteves, 46

Mochtar MH, Cochrane Database, 2007

No difference in basal LH levels.

Less bioactive LH/LH receptor polymorphism ?


Cochrane review 2007: hypo-responders

r-hFSH vs r-hLH + r-hFSH (Ongoing PR)

Increasing FSH

drive of limited

value

LH

LH

FSH

• Theca cells

• Granulosa

cells

Consider

increasing LH

drive

There is a potential role for r-hLH in this

population

Esteves, 48


Biologic older (less sensitive) ovaries

Tailoring Ovarian Stimulation

Treatment individualization strategies

• Antagonist + r-FSH FbM 112.5-150 UI

• Normal oocyte yield

• Very low cancellation/OHSS

• Adequate LBR

High Responders

AFC >10

AMH >2.1

• Antagonist or Agonist + r-hFSH 187.5-262.5 UI

• Low cancellation & OHSS

• Adequate LBR

Normal Responders

AFC 4-10

AMH 0.7-2.1

• Antagonist + r-hFSH (+r-hLH) 300-375 UI

• Short stimulation

Moderate cancellation

Low LBR

Poor Responders

AFC <4

AMH <0.7

From cookery to science – Practical Points

We can we make prediction more scientific but simple

AMH and AFC We can tailor OS according to

patients characteristics Using markers Using better drugs (FbM) Dose reduction (PCOS) Antagonist protocol GnRHa LH triggering LH supplementation

Esteves, 50

Thank you...

strategies to improve ovarian stimulation

Health & Medicine

predictors of ovarian

r markers of ovarian

response demographics

poor response verhagenet

basal fsh

gnrha ovarian stimulation

fsh iul

mean age years