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

Gene expression in Mammalian cells and its applications

The production of proteins in appropriate quantity and quality is an essential requirement of the present time. There appears to be a progressive increase in the application of mammalian cells for proteins production. Expression systems utilizing mammalian cells for recombinant proteins are able to introduce proper protein folding, post-translational modifications, and product assembly, which are important for complete biological activity. This review article is totally based on literature survey. In this article much emphasis has been done on the mammalian expression system. The author focused on different mammalian cell lines that express the gene. The different vector systems that transfer the gene into mammalian cells like plasmid based expression vectors, adenovirus vectors, vaccinia vectors, retroviral vector and baculovirus as vectors were explored. The processes for the transfer of gene into mammalian cells were also reviewed. Application and limitations of mammalian expression system were also focused. The purpose of research in writing this article is to create awareness in researchers, starting their career in gene expression related to mammalian cells. The principal result and major conclusion of this article is to make available the molecular technologies, expression system and applications of gene expression in mammalian cell lines.

Efficacy of recombinant human follicle stimulating hormone at low doses in inducing spermatogenesis and fertility in hypogonadotropic hypogonadism

BACKGROUND

Recombinant-FSH (rFSH) added to hCG at dose of 450 IU weekly is effective in inducing spermatogenesis in patients with hypogonadotropic hypogonadism (HH), but there are no data on the use of lower doses.

AIM

This observational retrospective study evaluated whether 150-225 IU of rFSH weekly were able to induce spermatogenesis in HH men who failed to start it with hCG alone.

SUBJECTS AND METHODS

Thirty-four patients with pre-pubertal onset HH (20-44 yr old) without adverse fertility factors were considered for this study. After hCG pre-treatment they received also either rFSH (Group 1) or highly purified urinary FSH (hpFSH) (Group 2) 75 IU sc 2 or 3 times weekly. Semen analysis was performed every 3 months during pre-treatment and the 1st yr of combined therapy. Patients were also invited to refer pregnancies in their partners during the subsequent 12 months.

RESULTS

Total sperm count/ejaculate did not show significant difference between 2 groups, while a significantly higher forward motility was observed in Group 1 (p<0.05). The median times to achieve sperm output thresholds (first sperm appearance, sperm concentration >1.5 or >5 mil/ml) were significantly lower in Group 1 (p<0.04, 0.03, and 0.001, respectively). A tendency to a shorter time to pregnancy was shown in partners of Group 1.

CONCLUSIONS

Our data indicate that lower rFSH week dose than that so far used was able to induce potentially fertilizing sperm output in HH men previously treated with hCG. The rFSH effects are comparable to those of hpFSH but with a trend to a faster outcome achievement.

Recombinant FSH in the treatment of oligozoospermia

BACKGROUND

FSH plays a crucial role in human reproduction. Treatment with gonadotrophins has been shown to be effective in males affected by hypogonadotrophic hypogonadism. The success of this treatment has brought about the utilization of the same therapy in infertile oligozoospermic subjects, aimed at obtaining increased sperm count. This physiological role in spermatogenesis has induced various attempts to treat idiopathic oligozoospermic men with FSH, often inducing the restoration of normal spermatogenesis and spontaneous pregnancy.

OBJECTIVE

To evaluate clinical efficacy of recombinant FSH in male infertility.

METHODS

Evaluation of pharmacokinetic, pharmacodynamic properties, efficacy and safety of this hormone preparation, on the basis of the data published in literature.

CONCLUSIONS

Recombinant FSH is effective, safe and well tolerated. Treatment with this hormone may represent a valid tool for infertile men. However it should be performed on selected patients utilizing some predictive parameters able to identify a priori responder subjects with high probability.

Pharmacokinetics of gonadotropin therapy

Ovulation is the result of an integrated action of the hypothalamus, pituitary and ovaries. During the process, gonadal steroids, peptides and growth factors are produced and influence the synthesis and release of gonadotropin-releasing hormone (GnRH), follicle stimulating hormone (FSH) and luteinizing hormone (LH). These latter compounds play a crucial role in folliculogenesis and are frequently used in the management of infertility.

FSH in therapy: physiological basis, new preparations and clinical use

Follicle stimulating hormone (FSH) is a glycoprotein hormone secreted by the pituitary gland that, together with luteinizing hormone (LH), controls development, maturation and function of the gonad. Like the related hormones, LH, thyroid stimulating hormone (TSH) and human chorionic gonadotropin (hCG), FSH consists of two polypeptide chains, α and β, bearing carbohydrate moietiesN-linked to asparagine (Asn) residues. The α subunit is common to all members of the glycoprotein hormone family, whereas the β subunit, although structurally very similar, differs in each hormone and confers specificity of action.

Comparison of the efficacy and safety of a new recombinant human follicle-stimulating hormone (DA-3801) with follitropin-? (Gonal-F�) in women undergoing controlled ovarian hyperstimulation for assisted reproductive technology

AIM

To compare the efficacy and safety of a new recombinant human follicle-stimulating hormone (FSH; DA-3801) with follitropin-alpha (Gonal-F) in women undergoing controlled ovarian hyperstimulation (COH) for assisted reproductive technology (ART).

METHODS

This was a phase III, multicenter, randomized, non-inferiority study. A total of 97 women were randomized to receive COH using DA-3801 (DA-3801 group, n = 49) or Gonal-F (Gonal-F group, n = 48). All subjects underwent COH using a gonadotropin-releasing hormone (GnRH) antagonist protocol. The primary efficacy endpoint was the number of oocytes retrieved, and the secondary efficacy endpoints included the total dose of FSH, the duration of stimulation, the serum estradiol levels on the day of human chorionic gonadotropin (hCG) administration, and the fertilization, implantation and pregnancy rates. Safety was evaluated using pre- and post-treatment laboratory tests and all adverse events were recorded.

RESULTS

The number of oocytes retrieved was 13.0 +/- 6.2 (DA-3801) versus 10.6 +/- 6.7 (Gonal-F) in the intention-to-treat (ITT) population, and 12.7 +/- 6.4 (DA-3801) versus 11.0 +/- 7.1 (Gonal-F) in the per-protocol (PP) population. The non-inferiority of DA-3801 was demonstrated with differences of 2.3 +/- 6.5 (95% confidence interval [CI] = 0.13, infinity) and 1.7 +/- 6.7 (95% CI = -0.74, infinity), respectively, in the ITT and PP populations. The total dose of FSH used (1789.8 +/- 465.5 vs 2055.6 +/- 646.7 pg/mL, P = 0.027) and duration of stimulation (8.3 +/- 1.4 vs 9.1 +/- 1.9 days, P = 0.036) in the ITT population were significantly lower in the DA-3801 group. Other secondary efficacy endpoints, including pregnancy and implantation rates and the incidence and severity of adverse events, were comparable between the two groups.

CONCLUSIONS

The results of this study demonstrate that DA-3801 is not inferior to follitropin-alpha in terms of its efficacy and safety in women undergoing COH for ART.

Recombinant-follicle stimulating hormone is more effective than urinary human menopausal gonadotropin in ovarian hyperstimulation for assisted reproductive technology treatment

Aim:  The aim of the present study was to establish a standard protocol for ovarian stimulation with gonadotropin-releasing hormone analog (GnRH-a) long protocol using recombinant-follicle stimulating hormone (rec-FSH) preparations for assisted reproductive technology (ART) treatment. Methods:  In 86 patients who underwent ovarian stimulation with GnRH-a long protocol for ART treatment, 53 were stimulated by rec-FSH preparations (rec-FSH group) and the others were stimulated by urinary-hMG (u-hMG group) preparations. The subjects were randomly assigned to either of these preparations. Hormonal profiles, total doses of gonadotropins, duration of stimulation and ART results were compared in both groups. Results:  The duration of stimulation was similar in both groups (9.2 ± 0.3 days and 9.2 ± 0.2 days, respectively). The total doses of gonadotropin in the rec-FSH group (1505.3 ± 29.2 IU) was significantly lower than those in the u-hMG group (2130.3 ± 54.6 IU, P < 0.0001). The FSH and LH values on the day of human chorionic gonadotropin (hCG) administration in the rec-FSH group were significantly lower than those in the u-hMG group. Pregnancy rates were 31.3% in the rec-FSH group and 33.3% in the u-hMG group, respectively. Conclusions:  The present study showed that rec-FSH preparations were more potent than conventional u-hMG preparations and the protocol of the present study with rec-FSH was a new ovarian stimulation protocol with GnRH-a long protocol. (Reprod Med Biol 2007; 6: 27-32).

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.

Evaluation of mixed protocols with bravelle® (human-derived FSH) and repronex® (hMG) to assess clinical efficacy (EMBRACE) in women undergoing in vitro fertilization

OBJECTIVE

To compare the efficacy and safety of three different ratios of human-derived follicle-stimulating hormone/human menopausal gonadotropin (human-derived FSH:hMG, Bravelle and Repronex) mixed together in the same syringe and administered subcutaneously once daily, to in vitro fertilization (IVF) patients <34 years or 34 to 40 years of age.

DESIGN

Two randomized, prospective, age stratified, IVF studies.

SETTING

Twenty-one academic and private clinics with experience in IVF/embryo transfer (ET).

PATIENT(S)

Infertile premenopausal women undergoing IVF-ET.

INTERVENTION(S)

Pituitary suppression with leuprolide acetate, randomization to one of three treatment groups, followed by gonadotropin stimulation (GS) for up to 15 days. The human-derived FSH:hMG ratios were the following: Group 1, a 1:1 ratio throughout; Group 2, a 3:0 ratio that was changed to 1:1 after GS day 5; Group 3, a 2:1 ratio that was increased to 3:1, 4:1, or 5:1 after GS day 5, as needed.

MAIN OUTCOME MEASURE(S)

Mean number of oocytes retrieved; peak estradiol levels; dose and duration of stimulation; implantation rates; adverse events; injection site pain; and pregnancy and live birth rates.

RESULT(S)

Overall, women <34 years had higher E(2) levels, more oocytes retrieved, and improved implantation and live birth rates compared with women 34 to 40 years old. Nonetheless, each ratio of human-derived FSH:hMG produced comparable implantation rates, and continuing pregnancy and take-home baby rates.

CONCLUSION(S)

All three ratios of human-derived FSH:hMG in both age groups produced comparable pregnancy and live birth rates with similar safety results.

Highly purified human-derived follicle-stimulating hormone (Bravelle) has equivalent efficacy to follitropin-beta (Follistim) in infertile women undergoing in vitro fertilization

BACKGROUND

These data compare the efficacy and safety of highly purified human-derived follicle-stimulating hormone (Bravelle) and recombinant follitropin-beta (Follistim) in women undergoing in vitro fertilization.

METHODS

This report describes the pooled data from two, nearly identical, randomized, controlled, parallel-group, multicenter studies conducted in a total of 19 academic and private IVF-ET centers in the United States. Infertile premenopausal women underwent pituitary down-regulation using leuprolide acetate followed by a maximum of 12 days of subcutaneous Bravelle (n = 120) or Follistim (n = 118), followed by administration of human chorionic gonadotropin, oocyte retrieval and embryo transfer. The primary efficacy measure was the mean number of oocytes retrieved; secondary efficacy measures included the total dose and duration of gonadotropin treatment; peak serum estradion levels; embryo transfer and implantation rates; chemical, clinical and continuing pregnancies; and live birth rates. All adverse events were recorded and injection site pain was recorded daily using a patient, self-assessment diary.

RESULTS

Similar efficacy responses were observed for all outcome parameters in the two treatment groups. Although patients receiving Bravelle consistently reported a greater number of chemical, clinical and continuing pregnancies, as well as an increased rate of live birth, the data did not attain statistical significance (P > 0.05). The overall incidence of adverse events was similar in both groups, but compared to Follistim, injections of Bravelle were reported by patients to be significantly less painful (P < 0.001).

CONCLUSIONS

Bravelle and Follistim had comparable efficacy in controlled ovarian hyperstimulation in women undergoing IVF-ET. There were no differences in the nature or number of adverse events between the treatment groups although Bravelle injections were reported to be significantly less painful.

Comparison of controlled ovarian stimulation with human menopausal gonadotropin or recombinant follicle-stimulating hormone

OBJECTIVE

To carefully examine the features of controlled ovarian stimulation performed with recombinant FSH-alpha or hMG.

DESIGN

Controlled, prospective, randomized comparison of fixed gonadotropin regimens.

SETTING

Academic research institution.

PATIENT(S)

Fifty infertile patients who were candidates for IUI.

INTERVENTION(S)

Patients were randomized to receive a fixed regimen of recombinant FSH-alpha (150 IU/day, 25 patients) or hMG (150 IU/day, 25 patients), after GnRH-agonist suppression (long regimen).

MAIN OUTCOME MEASURES

Daily measurements of serum LH, immunoreactive FSH, hCG, E(2), P, and T. Transvaginal pelvic ultrasound every 2 days. Pregnancy and abortion rates. Cost of medications. Two recombinant FSH-alpha-treated patients did not respond. Despite matched daily FSH dose, duration of treatment (hMG 10.8 +/- 0.4 vs. recombinant FSH-alpha 12.4 +/- 0.5 days), gonadotropin dose (21.7 +/- 0.8 vs. 25.3 +/- 1.3 ampoules), gonadotropin cost (288 +/- 10 vs. 1,299 +/- 66 /cycle), serum P levels, and small preovulatory follicle number were significantly lower, and LH, hCG, immunoreactive FSH levels, and larger follicles on day 8 were significantly higher in hMG-treated patients. The pregnancy, abortion, and twin pregnancy rates did not differ.

CONCLUSION

The hMG administration was associated with: [1]. increased serum LH activity and immunoreactive FSH levels during treatment; [2]. reduced signs of premature luteinization; [3]. differential modulation of folliculogenesis; [4]. lower treatment duration, gonadotropin dose, and cost; and [5]. clinical outcome comparable to recombinant FSH-alpha.

Comparison of the efficacy and safety of a highly purified human follicle-stimulating hormone (Bravelle) and recombinant follitropin-beta for in vitro fertilization: a prospective, randomized study

OBJECTIVE

To compare the efficacy and safety of Bravelle s.c., Bravelle i.m., and Follistim s.c. in patients undergoing controlled ovarian hyperstimulation for IVF-ET.

DESIGN

Open-label, randomized, parallel group, multicenter study.

SETTING

Eleven academic and private fertility clinics with experience in IVF-ET.

PATIENT(S)

Infertile premenopausal women with regular ovulatory menstrual cycles undergoing IVF-ET.

INTERVENTION(S)

Down-regulation with leuprolide acetate followed by up to 12 days of Bravelle s.c. (n = 60), Bravelle i.m. (n = 59), or Follistim s.c. (n = 58); hCG administration, oocyte retrieval, and ET.

MAIN OUTCOME MEASURE(S)

Mean number of oocytes retrieved; patients with ET, chemical, clinical and continuing pregnancies; mean peak serum E2 levels; adverse events and injection site pain scores.

RESULT(S)

There were no significant differences among treatment groups in mean number of oocytes retrieved, peak serum E2 levels, patients with ET, continuing pregnancies, or live births. There were no significant differences among the treatment groups in the number, nature, or intensity of adverse events. Patients treated with Bravelle s.c. or Bravelle i.m. experienced significantly less injection site pain than patients treated with Follistim s.c.

CONCLUSION(S)

Bravelle s.c. and Bravelle i.m. are comparable in efficacy and safety to Follistim s.c. in patients undergoing controlled ovarian hyperstimulation for IVF-ET.

A prospective and randomized study of ovarian stimulation for ICSI with recombinant FSH versus highly purified urinary FSH

A prospective and randomized study of ovarian stimulation with human recombinant follicle-stimulating hormone (r-FSH; Gonal-F) versus highly purified urinary FSH (u-FSH-HP; Metrodin-HP) was conducted on patients submitted to an intracytoplasmic sperm injection (ICSI) program. A total of 120 patients aged 37 years or less were stimulated in a randomized manner with r-FSH (group I = 60 patients) or u-FSH-HP (group II = 60 patients). All received a fixed dose of FSH for 7 days and on the 8th day of stimulation the doses started to be adapted according to ovarian response. Human chorionic gonadotropin (hCG) at the dose of 5000 IU to 10,000 IU was administered to both groups when at least one follicle presented a diameter > or = 17 mm. The ovarian response did not differ significantly between groups I and II in terms of number of follicles > or = 16 mm (group I = 6.2 +/- 3.2; group II = 6.7 +/- 2.9; p = 0.26), number of oocytes collected (group I = 10.7 +/- 6.8; group II = 10.5 +/- 5.7; p = 0.91), number of oocytes in metaphase II (group I = 9.2 +/- 5.8; group II = 8.2 +/- 4.8; p = 0.56) or number of immature oocytes (group I = 1.8 +/- 0.9; group II = 1.9 +/- 1.7; p = 0.62). The normal fertilization rate after ICSI did not differ significantly between treatments (group I = 69.4 +/- 25; group II = 66.5 +/- 23; p = 0.38). No cases of cancellation of ovarian stimulation or of severe ovarian hyperstimulation syndrome occurred in either group. The total number of embryos obtained from patients who used r-FSH (group I = 6.3 +/- 4.5) was similar (p = 0.46) to the number obtained from patients who used u-FSH-HP (group II = 5.5 +/- 3.7), as also was the number of transferred embryos (group I = 2.8 +/- 0.8; group II = 2.6 +/- 0.9; p = 0.27). Implantation rate (26.1%) and clinical pregnancy rates per puncture (36.7%) and per embryo transfer (37.9%) were higher in patients who used r-FSH than in patients who used u-FSH-HP (19.5%, 31.7% and 32.2%, respectively), but the differences were not statistically significant. The abortion rate (p = 0.32) did not differ between groups (group I = 4.5%, n = 1 versus group II = 15.7%, n = 3). Thus far, the data do not demonstrate significant differences in ovary stimulation with r-FSH versus u-FSH in patients whose indication for assisted reproduction was the male factor.

Increasing the daily dose of recombinant follicle stimulating hormone (Puregon) does not compensate for the age-related decline in retrievable oocytes after ovarian stimulation

A prospective, randomized, double-blind, multicentre (n = 6) study was conducted to compare the influence of either a 150 or 250 IU daily fixed-dose regimen of recombinant follicle stimulating hormone (FSH, Puregon) on the number of oocytes retrieved and the total dose used in down-regulated women between 30 and 39 years of age undergoing ovarian stimulation. In all, 138 women were treated with recombinant FSH, 67 with 150 IU and 71 with 250 IU. The number of oocytes retrieved in the low-dose group was 9.1 compared to 10.6 in the high-dose group (not significant). In the 30-33 years of age class receiving the 250 IU dose, a surplus of 4.2 oocytes (14.8 versus 10.6) was found, whereas in the 37-39 age class nearly one oocyte more was retrieved in the 150 IU group (8.1 versus 7.4). The total dose used to reach the criterion for human chorionic gonadotrophin (HCG) administration was 1727 IU for the women treated with 150 IU daily and 2701 IU for the 250 IU treated women (P < 0. 001). No significant relationships were found between serum FSH concentrations as obtained in the early follicular phase and the number of oocytes collected, or the total dose. It is concluded that in women between 30 and 39 years of age, the decline in number of oocytes retrieved with increasing age cannot be overcome by augmenting the daily dose of recombinant FSH from 150 to 250 IU.

Recombinant follicle stimulating hormone stimulation in poor responders with normal basal concentrations of follicle stimulating hormone and oestradiol: improved reproductive outcome

A total of 30 young infertile patients who exhibited a poor response in two previous consecutive cycles, despite having normal basal follicle stimulating hormone (FSH) and oestradiol concentrations, were invited to participate in a prospective randomized study comparing the clinical efficacy of recombinant (rFSH) and urinary (uFSH) follicle stimulating hormone. An evaluation of the total dose used (3800 IU versus 4600 IU, P < 0.05) and duration of treatment (10.2 days versus 13.2 days, P < 0.05) showed a significantly shorter treatment period as well as a significantly lower total dose of FSH required to induce ovulation successfully in the group of patients treated with rFSH. Significantly more oocytes (7.2 versus 5. 6, P < 0.05) as well as mature oocytes (5.9 versus 3.2, P < 0.01) were retrieved after rFSH treatment. In addition, significantly more good quality embryos were obtained (3.4 versus 1.8, P < 0.05) in the group of patients treated with rFSH and, as a result, higher pregnancy (33 versus 7%, P < 0.01) and implantation (16 versus 3%, P < 0.01) rates were achieved in these patients. It is concluded that rFSH is more effective than uFSH in inducing multifollicular development and achieving pregnancy in young low responders.

Recombinant follicle-stimulating hormone (FSH; Puregon) is more efficient than urinary FSH (Metrodin) in women with clomiphene citrate-resistant, normogonadotropic, chronic anovulation: a prospective, multicenter, assessor-blind, randomized, clinical trial. European Puregon Collaborative Anovulation Study Group

OBJECTIVE

To compare the safety and efficacy of recombinant FSH (follitropin beta, Puregon; NV Organon, Oss, the Netherlands) and urinary FSH (urofollitropin, Metrodin; Ares-Serono, Geneva, Switzerland).

DESIGN

A prospective, multicenter, assessor-blind, randomized, clinical trial.

SETTING

Twelve European infertility clinics.

PATIENT(S)

One hundred seventy-two women (recombinant FSH: n = 105; urinary FSH: n = 67) with clomiphene citrate-resistant normogonadotropic chronic anovulation (World Health Organization group II).

INTERVENTION(S)

Eligible subjects were randomized (ratio of recombinant to urinary FSH, 3:2) and treated for a maximum of three cycles. A low-dose step-up regimen was used, with 75 IU of FSH given IM daily for a maximum of 14 days and, if needed, weekly increments of half an ampule given thereafter until the threshold dose for follicular development was achieved.

MAIN OUTCOME MEASURE(S)

Cumulative ovulation rate after three cycles, total FSH dose, and treatment period needed to achieve ovulation.

RESULT(S)

The cumulative ovulation rates after three treatment cycles were 95% and 96% for the recombinant and urinary FSH groups, respectively. Overall, ovulation was seen in 155 of 223 treatment cycles (69.5%) in the recombinant FSH group, compared with 92 of 138 treatment cycles (66.7%) in the urinary FSH group. In the first cycle, a statistically significantly lower total dose (750 versus 1,035 IU) and a shorter treatment period (10 versus 13 days) were needed in the recombinant FSH group to reach ovulation. Only one case of ovarian hyperstimulation syndrome led to hospitalization. Two sets of twins (one in each treatment group) and one set of triplets (in the recombinant FSH group) were born.

CONCLUSION(S)

Recombinant FSH (Puregon) is more efficient than urinary FSH (Metrodin) in inducing follicular development.

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

OBJECTIVE

To assess ongoing pregnancy rates (PRs) in IVF after treatment with recombinant FSH (follitropin beta, Puregon; NV Organon, Oss, The Netherlands) as compared with urinary gonadotropins.

DESIGN

A combined analysis of three prospective, multicenter, randomized, comparative trials.

SETTING

Twenty-five IVF centers in 13 countries.

PATIENT(S)

Six hundred ninety-seven infertile women receiving recombinant FSH and 463 women receiving hMG or urinary FSH and undergoing one cycle of controlled ovarian hyperstimulation and IVF-ET.

INTERVENTION(S)

A center-based and study-based analysis weighing the treatment differences in individual centers and studies, respectively.

MAIN OUTCOME MEASURES(S)

Pregnancy rate at least 12 weeks after ET per started cycle.

RESULTS(S)

In the center-based analysis, the ongoing PR was 22.9% for recombinant FSH and 17.9% for urinary gonadotropins. The 5.0% treatment difference (95% confidence interval [CI], 0.2% to 9.7%) was significant. When the results of the cryoprogram were included, the treatment difference increased to 6.4% (95% CI, 1.4% to 11.3%). Also in the study-based analysis, significantly higher PRs were seen after follitropin beta treatment.

CONCLUSION(S)

Follitropin beta (Puregon) used for controlled ovarian hyperstimulation in IVF yields significantly higher PRs compared with urinary gonadotropins.

Recombinant rat follicle-stimulating hormone; production by Chinese hamster ovary cells, purification and functional characterization

In order to obtain homologous follicle-stimulating hormone (FSH) for in vivo and in vitro studies in the rat, rat recombinant (rec) FSH was produced in Chinese Hamster Ovary (CHO) cells. The synthesized rat recFSH was purified and subjected to physico-chemical and biological characterization. including a comparison with two rat pituitary (pit) and reference preparations (NIDDK-rFSH I-8 and NIDDK-rFSH-RP2) as well as with human recFSH (Org 32489). The molecular masses of rat recFSH and human recFSH were determined by SDS-polyacrylamide (SDS-PAGE) and were found to be similar, about 40 kD. The pI distribution of rat recFSH is similar to rat pitFSH, and slightly more acidic than human recFSH (3.6-5.6 vs 3.9-5.5, respectively) as determined by isoelectric focussing in immobilized pH gradients. Rat recFSH displayed dose-response curves parallel and in the same dose range as the rat pitFSH in receptor binding and in vitro bioassays. However, the in vivo activities of rat recFSH and rat pitFSH were 8824 and 3051 IU/mg, respectively, determined by the Steelman Pohley assay. Rat (pit and rec) and human FSH are very different. Human recFSH bound to both calf testicular membranes and CHO cells expressing the human FSH receptor (CHO hFSH-R) with about 10-fold higher affinity (Ka) than pituitary and recombinant rat FSH. In in vitro bioassays with immature rat Sertoli cells and CHO hFSH-R cells human recFSH was also about 10-fold more potent than the rat FSH preparations. In the in vitro bioassays with immature rat granulosa cells the difference was about 5-10-fold. These studies indicate that the receptor binding and in vitro activities of rat pitFSH and rat recFSH are similar. The differences in in vivo activity are probably due to the differences in glycosylation. The biological behaviour of rat FSH (pit and rec) is different from that of human FSH. Therefore, if the rat is used as a model for physiology of gonadotropic action, the results may be greatly influenced by the type (species) of hormone preparation used. The availability of homologous hormone preparations is therefore crucial.

A prospective, randomized study to assess the tolerance and efficacy of intramuscular and subcutaneous administration of recombinant follicle-stimulating hormone (Puregon)

OBJECTIVE

To compare local tolerance and clinical efficacy after i.m. or s.c. injection of recombinant FSH (Puregon; NV Organon, Oss, The Netherlands).

DESIGN

An open-label, prospective, randomized, group-comparative, multicenter study.

SETTING

Twelve IVF clinics in 10 countries.

PATIENT(S)

Two hundred eighteen infertile pituitary-suppressed women undergoing IVF-ET were randomized, of whom 195 (i.m., n = 77; s.c., n = 118) received recombinant FSH.

INTERVENTION(S)

One cycle of controlled ovarian hyperstimulation induced by either i.m. or s.c. injection of recombinant FSH, followed by IVF-ET.

MAIN OUTCOME MEASURE(S)

Local tolerance symptoms, number of oocytes retrieved, ongoing pregnancy rate.

RESULT(S)

The incidences after i.m. injection of bruising, pain, redness, swelling, and itching were 37.7%, 31.2%, 13.0%, 7.8%, and 6.5%; after s.c. injection, the corresponding figures were 54.2%, 28.0%, 16.1%, 5.9%, and 3.4%. Only bruising was significantly lower in the i.m. group, which could be attributed to the more visible superficial injection site with s.c. administration. The overall occurrence of local symptoms were 63.6% after i.m. injection and 68.6% after s.c. injection. The mean numbers of oocytes recovered were 9.8 (i.m) and 10.4 (s.c.) and the ongoing pregnancy rates per attempt were 27.1% (i.m.) and 26.1% (s.c.), respectively.

CONCLUSION(S)

There were no marked differences in local tolerance symptoms and clinical efficacy between i.m. and s.c. administration of recombinant FSH.

Recombinant technique and gonadotropins production: new era in reproductive medicine

OBJECTIVE

To review current knowledge regarding recombinant DNA technology and its safety and efficacy in relation to recombinant gonadotropin production.

DATA IDENTIFICATION AND SELECTION

Studies that relate specifically to recombinant DNA technology, method of laboratory production, and the clinical aspects of using recombinant gonadotropins were identified through literature and Medline searches.

RESULTS

Recent developments in recombinant DNA technology have resulted in a rapidly expanding range of new diagnostic and therapeutic opportunities. This technology paves the way to the identification, isolation, cloning, and production of specific proteins. Recently, recombinant human gonadotropins became available for clinical use. The pharmacokinetics, receptor availability, pharmacodynamics, and safety were studied extensively and the drugs were found to be identical if not superior to urinary gonadotropins that have been used in reproductive medicine for the last 30 years. It is clear today that the use of recombinant human gonadotropins is expected to provide better batch-to-batch consistency, steady supply, and most importantly, a purified compound with high specific activity, which accounts for >99% of the preparation's protein content, allowing SC administration.

CONCLUSION

There is no doubt that recombinant gonadotropins produced by genetic engineering technology are here to stay and will represent an important treatment modality in various fertility disturbances.

Pharmacokinetics of follicle-stimulating hormone: clinical significance

OBJECTIVE

To review studies that examine the pharmacokinetics and pharmacodynamics of endogenous, as well as several exogenous FSH preparations.

DESIGN

Related studies were identified through a computerized bibliographic search.

PATIENTS

Initial pharmacodynamic studies were done in animal models and in women and men with either hypogonadotropic hypogonadism or suppressed hypothalamic-pituitary-gonadal axis. More recent studies evaluated FSH pharmacokinetics during ovulation induction treatment in women with normal ovulatory cycles or polycystic ovarian syndrome.

RESULTS

Various types of FSH exist according to their sialic acid content. High estrogen levels induce the secretion of less sialylated molecules with higher receptor affinity and an increased clearance rate. It appears that there is a threshold FSH level that should be reached to achieve an ovarian response. A very narrow range exists between the threshold and ceiling level for monofollicular growth. This threshold level is surpassed intentionally during IVF treatment cycles to induce multiple follicular recruitment. The threshold level can change under situations such as polycystic ovaries, perimenopause, oral contraceptives, and GnRH analogue treatment.

CONCLUSIONS

To avoid the risk of ovarian hyperstimulation syndrome and multiple pregnancies, careful adjustments of serum FSH levels should be made by fine dosage modifications. By monitoring FSH levels and using less sialylated preparations, the efficacy of the treatment probably will improve.

Effects of oestrogen treatment on serum gonadotrophin bioactivity, immunoreactivity and isohormone distribution, and on immunoreactive inhibin levels, in prostatic cancer patients

OBJECTIVE AND DESIGN

No data are available on effects of long-term exposure to oestrogen on bioactivity of gonadotrophins in men. We studied the effects of a 6-month oestrogen therapy on serum FSH and LH bioactivity (B), immunoreactivity (I) and isohormone distribution, and on serum I-inhibin levels, in patients with prostatic carcinoma.

PATIENTS

Eleven men with advanced prostatic cancer were studied, each receiving 160 mg of polyoestradiol phosphate (Estradurin) once a month intramuscularly for 6 months.

MEASUREMENTS

Serum samples were collected before, and after 2 and 6 months of oestrogen treatment. Serum B- and I-FSH levels were measured by immature rat granulosa cell bioassay and immunofluorometric (IFMA, Delfia) assay, respectively, and those of B- and I-LH by mouse interstitial cell bioassay and IFMA, respectively. Serum oestradiol (E2) concentrations were measured by IFMA assay, and serum testosterone (T) and inhibin levels by radioimmunoassay. Isoelectric focusing was used for fractionation of the FSH and LH isoforms.

RESULTS

The pretreatment levels of B-FSH and I-FSH were 84.7 +/- 21.6 and 11.4 +/- 3.2 IU/l (mean +/- SEM), respectively, and the B/I ratio of FSH was 8.3 +/- 1.0. The pretreatment levels of B-LH and I-LH were 23.5 +/- 3.2 and 10.1 +/- 2.3 IU/l, respectively, and the B/I ratio was 3.0 +/- 0.4. After 6 months of oestrogen therapy, B-FSH and I-FSH decreased to 37.5 +/- 8.1 (P < 0.05) and 1.3 +/- 0.3 IU/l (P < 0.01), respectively, but the B/I ratio of FSH increased to 28.5 +/- 4.2 (P < 0.05). B- and I-LH levels decreased in 6 months to 7.4 +/- 0.9 and 2.3 +/- 0.5 IU/l (P < 0.01), respectively, but no change was found in the B/I ratio of LH. Serum T levels decreased from 19.0 +/- 2.6 to 2.7 +/- 0.9 nmol/l (P < 0.01) during the 6-month treatment, and the respective E2 levels increased from 0.2 +/- 0.01 to 4.4 +/- 0.5 nmol/l (P < 0.01). Serum I-inhibin levels were analysed from eight patients. The levels at 0, 2 and 6 months were 0.81 +/- 0.09, 0.50 +/- 0.03 and 0.54 +/- 0.01 microgram/l, respectively. Gonadotrophins in the pretreatment and 6-month samples of four patients were analysed by isoelectric focusing. In FSH of all subjects, and in LH of three subjects, a shift from acidic to more basic isoforms occurred after oestrogen therapy. This is in keeping with the increase of the B/I ratio of FSH. With LH, the isoform shift occurred between fractions with similar B/I ratios, and hence there was no shift in the overall B/I ratio.

CONCLUSIONS

Oestrogen therapy of men suppressed bioactive and immunoreactive levels of gonadotrophins. The B/I ratio of FSH increased, and this increase was associated with a shift in the isohormone profile to more basic forms. In contrast, no change occurred in the B/I ratio of LH, even though changes in the isohormone profile were observed. Hence, not all changes in the isohormone distribution of gonadotrophins result in changes of the intrinsic in-vitro bioactivity.