Superovulation before IVF by recombinant versus urinary human FSH (combined with a long GnRH analog protocol): a comparative study

Is there a declining trend in ovarian function among infertility clinic patients?

BACKGROUND

There is a growing body of evidence that testicular function has decreased rapidly over the last 50 years. However, much less is known about corresponding trends in ovarian function. Herein, we examine the temporal changes in ovarian function in a large sample of infertile patients from the Czech Republic over a period of 14 years.

METHODS

In a retrospective study, we analysed a large body of data from women, 20-40 years of age, undergoing IVF/ICSI treatment between 1995 and 2008. We defined ovarian function using five variables: basal FSH level, estradiol (E2) level on the day of HCG administration, dose of gonadotrophins used for ovarian stimulation, number of retrieved oocytes and dose of gonadotrophins per oocyte. Controlling simultaneously for temporal changes in patient age and stimulation protocol, we applied generalized additive models to describe the temporal trends.

RESULTS

During the study period the mean age of the study population increased by 2.7 years. Whereas the basal FSH and gonadotrophin dose did not change over time, the E2 level and oocyte retrieval declined, and the dose of FSH per oocyte increased during the study period.

CONCLUSIONS

The results are indicative of a small, but detectable decrease in ovarian function over a period of 14 years, which is not causally related to the ageing population.

WITHDRAWN: Recombinant versus urinary follicle stimulating hormone for ovarian stimulation in assisted reproduction cycles

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

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

OBJECTIVE

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

DESIGN

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

SETTING

University IVF center.

PATIENT(S)

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

INTERVENTION(S)

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

MAIN OUTCOME MEASURE(S)

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

RESULT(S)

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

CONCLUSION(S)

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

Follicle-stimulating hormone in clinical practice: an update

Follicle-stimulating hormone (FSH), a glycoprotein produced by the anterior pituitary gland, plays an important role in the regulation of fertility in both men and women. FSH is used clinically to treat women with anovulatory infertility, for controlled ovarian stimulation in women being treated with assisted reproductive technologies (ART), and in the treatment of male hypogonadotrophic hypogonadism. Urine-derived gonadotropin preparations containing variable amounts of FSH together with urinary proteins have been available for many years. More recently, FSH preparations produced using recombinant DNA technology have become available. Recombinant FSH has a high specific activity, high purity, and guaranteed consistency among batches. Two recombinant FSH preparations have been available for clinical use for some years: follitropin-alpha and follitropin-beta. The continuing development of recombinant FSH has recently resulted in a new presentation (follitropin-alpha filled by mass [FbM]). This product can be filled by mass (microg) with an activity (IU), reflecting exceptional consistency as a result of refinement and improvement in the manufacturing process, allowing the clinician to deliver a guaranteed dose of FSH. Experience with recombinant FSH in the treatment of male hypogonadotrophic hypogonadism is limited, but the available data suggest that recombinant FSH has a similar efficacy to urine-derived preparations (urofollitropin). In patients with WHO group I anovulatory infertility, the use of recombinant FSH to stimulate follicular development is effective and well tolerated. In patients with WHO group II anovulation, protocols based on recombinant FSH are more effective than conventional protocols using urofollitropin. Comparative studies and a meta-analysis have shown that recombinant FSH is more effective than urofollitropin for controlled ovarian stimulation in women undergoing ART. Pharmacoeconomic modeling indicates that follitropin-alpha is more cost effective than urofollitropin in a range of different healthcare systems. The available evidence from comparative studies of the two recombinant FSH preparations suggests that follitropin-alpha may have an advantage over follitropin-beta in terms of efficacy. Follitropin-alpha is superior to follitropin-beta in terms of local tolerability. Recent preliminary studies suggest an efficacy advantage for follitropin-alpha FbM compared with standard follitropin-alpha. The FbM presentation appears to represent an advance on standard preparations of recombinant FSH in terms of consistency and clinical efficacy.

Embryo quality based on ovulation induction: defining the differences

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

Cost-effectiveness of recombinant versus urinary follicle-stimulating hormone in assisted reproduction techniques in the Spanish public health care system

PURPOSE

To evaluate the relative cost-effectiveness of recombinant and urinary follicle-stimulating hormone (FSH) in assisted reproduction techniques in the Spanish National Health Service.

METHODS

Markov modelling was used to compare costs and outcomes of three complete treatment cycles using recombinant or urinary FSH for controlled ovarian stimulation. Cost and effectiveness estimates were obtained from the literature and from Spanish clinicians. A Monte Carlo technique was used to randomise the distribution of outcomes at each stage. The analysis was performed by passing a virtual population of 100,000 patients through the computer simulation in each of 5000 Monte Carlo simulations.

RESULTS

The cost per pregnancy was Euro12,791+/-1202 ($11,346+/-1066) with recombinant and Euro13,007+/-1319 ($11,537+/-1170) with urinary FSH (p < 0.0001). The mean number of cycles per pregnancy was 4.69 and 5.21, respectively.

CONCLUSIONS

Recombinant FSH is more cost-effective than urinary FSH in the Spanish public health care system.

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

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

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

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

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

OBJECTIVE

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

DESIGN

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

MAIN OUTCOME MEASURE(S)

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

RESULT(S)

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

CONCLUSION(S)

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Definition and measurement of follicle stimulating hormone

FSH has a key role in the development and function of the reproductive system and is widely used both diagnostically and therapeutically in developmental and reproductive medicine. The accurate measurement of FSH levels, in patients for diagnosis and monitoring and in therapeutic preparations for clinical use, is essential for safe and successful treatment. Historically, FSH was defined on the basis of classical in vivo endocrine activity, and early therapeutic preparations were calibrated using in vivo bioassays. There was early recognition that reference preparations were required for calibration if the results from different laboratories were to be comparable. In response to the perceived need, the World Health Organization established the first standard for such preparations in 1959. Subsequent developments in biotechnology have led to recognition that there is no single molecule that can be uniquely defined as FSH, and that FSH can induce a range of biological activities. Several highly purified standards for FSH are now available, but discontinuity and heterogeneity of estimates of FSH activity in terms of these standards made using in vitro assays and binding assays have been noted. It is thus essential that any measurement of FSH include specification both of the standard with which the measured FSH is compared and the assay method used for that comparison.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

REVIEWER'S CONCLUSIONS

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

Recombinant human follicle stimulating hormone versus human menopausal gonadotrophin induction: effects in mature follicle endocrinology

To investigate follicular effects of recombinant human follicle stimulating hormone (rhFSH) induction on women with polycystic ovary syndrome (PCOS), steroid content was compared in mature follicles obtained using a long luteinizing hormone-releasing hormone agonist plus rhFSH or human menopausal gonadotrophin (HMG) in PCOS women and controls participating in an in-vitro fertilization programme. Follicular fluids (144 samples) were collected at oocyte retrieval by individual selective aspiration. Oocyte maturity and fecundability were assessed. Plasma and intrafollicular 17beta-oestradiol, progesterone, testosterone concentrations were assayed individually. No significant difference was seen in oocyte maturity and fecundability between PCOS and controls following rhFSH, or between PCOS rhFSH and HMG group. 17beta-oestradiol, testosterone and progesterone concentrations were lower in PCOS follicular fluid following rhFSH than HMG but the difference was not significant. Progesterone concentration, 17beta-oestradiol/progesterone, 17beta-oestradiol/testosterone were significantly different between the two induction groups, for PCOS fertilized oocyte follicles (P = 0.01, P < 0.05 and P < 0.05 respectively). Steroidogenic enzymatic activity seems to be regulated in healthy follicular cells in PCOS as well as in normal patients upon ovarian induction. Following rhFSH, higher PCOS follicular progesterone concentrations leading to a theoretically increased fecundability could suggest that recombinant FSH is a better inducer which needs to be confirmed.

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

The recent availability of recombinant follicle stimulating hormone (rFSH), with its high level of purity and batch-to-batch consistency has made it an attractive alternative to urinary FSH (uFSH) for ovarian stimulation. Several trials have compared the two preparations, but none had sufficient power to detect a clinically meaningful difference in pregnancy rates. The purpose of this study was to determine the clinical pregnancy rates per started cycle by pooling data from randomized trials which compared the use of rFSH and uFSH in treatment cycles using in-vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI). A thorough search of the literature identified 12 trials which met the inclusion criteria. In four trials, both IVF and ICSI were performed, in seven trials only IVF was performed and in one trial only ICSI was performed. Data were extracted and pooled using the principles of meta-analysis. There was no significant heterogeneity of treatment effect across the trials. The common odds ratio and the risk difference (and their 95% confidence intervals), obtained by pooling the data using a fixed effects model, were 1.20 (1.02-1.42) and 3.7% (0.5-6.9%) respectively, in favour of rFSH. The pregnancy rate with the alpha preparation of rFSH was statistically significantly higher than with uFSH in IVF cycles. The overall conclusion from this meta-analysis is that the use of rFSH in assisted reproduction is preferred over uFSH.

Infertility update: use of assisted reproductive technology

OBJECTIVE

To describe assisted reproductive technology (ART) and use of medications during these procedures.

DATA SOURCES

Recent clinical literature.

STUDY SELECTION

Not applicable.

DATA EXTRACTION

Not applicable.

DATA SYNTHESIS

ARTs are procedures used in treatment of infertility that involve removal of oocytes and their manipulation outside the woman's uterus. The simplest form of ART, in vitro fertilization, involves aspirating eggs from the ovaries, fertilizing them outside the body, and transferring the embryos into the uterus at the four- to eight-cell stage. Experimental regimens for in vitro fertilization include use of various medications (gonadotropin-releasing hormone agonists, human menotropins, follicle-stimulating hormone, growth hormone) at varying points in the menstrual cycle and after introduction of the embryo into the uterus. Human chorionic gonadotropin has been used to increase implantation of embryos during the woman's luteal phase. Gamete intrafallopian transfer (GIFT) involves transfer of oocytes and sperm into the fallopian tubes, where fertilization takes place. This technique has the advantage of causing the zygote to enter the uterus at the time it would during natural conception. Zygote intrafallopian transfer is similar to GIFT, except that fertilization occurs in vitro, with embryos placed in the fallopian tubes at the two-cell stage. Various micromanipulation techniques and innovative sperm aspiration procedures are currently under development.

CONCLUSION

Many advancements have been made in ART, and pharmacists who understand these procedures can serve patients by providing medication information in an empathetic and supportive manner.