Administration of recombinant human FSH (solution in cartridge) with a pen device in women undergoing ovarian stimulation

First pre-filled pen device with highly purified human menopausal gonadotropin (HP-hMG, Menopur) in liquid is shown to be bioequivalent to powder for reconstitution

OBJECTIVE

To determine whether serum human follicle-stimulating hormone (FSH) levels after single subcutaneous dosing of highly purified human menopausal gonadotropins (HP-hMG) in a liquid formulation and a powder formulation are bioequivalent.

MATERIALS AND METHODS

This was a randomized, two-way, crossover, single-dose, bioequivalence trial comparing Menopur liquid injected by pre-filled pen, with Menopur powder injected by conventional syringe and needle. The primary endpoints were AUC_t and C_max of baseline-adjusted FSH. Pituitary-suppressed, healthy women were administered single subcutaneous injections of 450 IU Menopur liquid (600 IU/0.96 mL) and 450 IU Menopur powder (by 2 subcutaneous injections of 225 IU in 1 mL) in a randomized order. The pharmacokinetic parameters of FSH and human chorionic gonadotropin (hCG) were assessed by non-compartmental methods with adjustment for endogenous pre-dose levels.

RESULTS

In total, 76 women were randomized, and 56 completed the trial. The mean FSH and hCG serum concentration-time profiles were comparable between the two HP-hMG formulations. The geometric mean ratios and 90% confidence intervals of FSH for HP-hMG liquid versus HP-hMG powder were 1.12 (1.0562 - 1.1889) for AUC_t and 1.17 (1.0946 - 1.2490) for C_max, showing that the two formulations were bioequivalent. The incidence and severity of adverse events were similar between the two preparations, and both preparations were well tolerated.

CONCLUSION

The 90% CIs for the geometric mean ratios of serum FSH AUC_t and C_max were both within 0.8000 - 1.2500, thus the two formulations are bioequivalent.

Recombinant Human Follicle-Stimulating Hormone Alfa Dose Adjustment in US Clinical Practice: An Observational, Retrospective Analysis of a Real-World Electronic Medical Records Database

PURPOSE

To determine the pattern of dose adjustment of recombinant human follicle-stimulating hormone alfa (r-hFSH-alfa) during ovarian stimulation (OS) for assisted reproductive technology (ART) in a real-world setting.

METHODS

This was an observational, retrospective analysis of data from an electronic de-identified medical records database including 39 clinics in the USA. Women undergoing OS for ART (initiated 2009-2016) with r-hFSH-alfa (Gonal-f^® or Gonal-f RFF Redi-ject^®) were included. Assessed outcomes were patients' baseline characteristics and dosing characteristics/cycle.

RESULTS

Of 33,962 ART cycles, 13,823 (40.7%) underwent dose adjustments: 23.4% with ≥1 dose increase, 25.4% with ≥1 dose decrease, and 8.1% with ≥1 increase and ≥1 decrease. Patients who received dose adjustments were younger (mean [SD] age 34.8 [4.58] years versus 35.9 [4.60] years, p<0.0001) and had lower BMI (25.1 [5.45] kg/m² versus 25.5 [5.45] kg/m², p<0.0001) than those who received a constant dose. The proportion of patients with non-normal ovarian reserve was 38.4% for those receiving dose adjustment versus 51.9% for those with a constant dose. The mean (SD) number of dose changes/cycle was 1.61 (0.92) for cycles with any dose adjustment, 1.72 (1.03) for cycles with ≥1 dose increase, 2.77 (1.00) for cycles with ≥1 dose increase and ≥1 decrease (n=2,755), and 1.88 (1.03) for cycles with ≥1 dose decrease.

CONCLUSIONS

Dose adjustment during OS is common in clinical practice in the USA and occurred more often in younger versus older patients, those with a high versus non-normal ovarian reserve or those with ovulation disorders/polycystic ovary syndrome versus other primary diagnoses of infertility.

Hormonal medication in medically assisted reproduction: a systematic review of assessments from patients

Several hormonal fertility medications have comparable effectiveness. A literature review was conducted into patients' assessments regarding seven medication characteristics including 'side effects' and 'ease of use'. Medline, CINAHL and PsycINFO were searched for female fertility patients' written assessments of a hormonal medication. The tools used were appraised and common (i.e. ≥10%) unpleasant consequences were distinguished from rare ones. The 35 eligible studies did not rely on valid and reliable tools and did not provide patient assessments regarding all seven medication characteristics for any of the globally used medications. Evidence on medications for oocyte triggering was absent and for induction of pituitary quiescence it was scarce. Regarding medications for ovarian stimulation and luteal support, evidence on general side effects (mostly headache), local side effects (mostly pain), 'interference with home life' and 'impact on psychological wellbeing' was found. Evidence on 'ease of use' and 'required education' was only identified for medication for ovarian stimulation. Evidence on 'interference with work life' and 'compliance worry' was absent. This review calls for randomized controlled trials questioning patients with valid and reliable tools. In the meantime, this review's summary of the best available evidence can be integrated in decision aids facilitating personalized and informed medication choices.

A questionnaire-based survey to assess patient satisfaction, ease-of-learning, ease-of-use, injection site pain and overall patient satisfaction of the follitropin-alpha (Gonal-f) filled-by-mass (FbM) prefilled pen compared with other systems of gonadotrophin administration

BACKGROUND

Gonadotrophins are used routinely for follicular stimulation during ovarian induction and assisted reproduction techniques. Developments in recombinant follicle-stimulating hormone preparations and their injection devices have improved patient quality of life by enabling patients to self-administer treatment at home. The objective of this study was to investigate patient experiences of learning to use and overall satisfaction with the follitropin-alpha (Gonal-f) filled-by-mass (FbM) prefilled pen.

METHODS

This questionnaire-based survey study was conducted in 23 fertility centres in Japan over a period of 14 months. Patients who were receiving fertility treatment with the follitropin-alpha (FbM) prefilled pen were asked to complete a questionnaire to assess their satisfaction, ease of learning and use, and injection site pain following treatment.

RESULTS

A total of 663 women participated in the study. The majority of patients found the instructions for administering follitropin-alpha with the prefilled pen easy to understand (83.0%; n = 546/658) and patients found that a hands-on demonstration by a nurse or doctor was the most useful tool for learning to use the follitropin-alpha (FbM) prefilled pen (80.0%; n = 497/621). Forty-eight percent (n = 318) of patients in the study had previous experience with different types of fertility medications and the majority of these patients found the follitropin-alpha (FbM) prefilled pen easier to use (75.1%; n = 232/309) and less painful (89.0%; n = 347/390) than their previous medication. The majority (80.2%; n = 521/650) of patients reported overall satisfaction with the follitropin-alpha (FbM) prefilled pen.

CONCLUSIONS

The follitropin-alpha (FbM) prefilled pen is an easy-to-use injection device according to this questionnaire-based survey. Patients who had experience of different types of fertility medication preferred the follitropin-alpha (FbM) prefilled pen to other injection devices.

Drug tolerability in assisted reproduction techniques: a longitudinal study

A longitudinal, observational prospective panel cohort study of 61 patients lasting one year was undertaken. Explanatory variables included sociodemographic factors along with factors related to the underlying pathology as well as the protocol used and the type of treatment received. These variables were analyzed both individually and in combination to account for confounding effects and model interactions. A generalized estimating equation (GEE) model was constructed for each adverse effect. Associations were calculated as odds ratios (OR). Confounding variables related to drug tolerability were identified. Follitropin-alpha and cetrorelix exhibited the poorest safety profile. With respect to local adverse drug reactions (ADEs), the results obtained in our study point to statistically significant tolerability improvements for menotropin when administered in insemination. For gastrointestinal ADEs, ganirelix was the drug that showed the highest tolerability in in vitro treatments whereas follitropin-alpha showed the lowest tolerability in insemination treatments. Diverse factors related to assisted reproduction techniques (ART) influence the incidence of adverse effects. Each drug has a different safety profile with possible interactions depending on the type of assisted reproduction therapy used.

Patient preferences for characteristics differentiating ovarian stimulation treatments

BACKGROUND

Little is known concerning patient preferences for IVF treatments. The objective of this study was to elicit patient preferences for characteristics differentiating ovarian stimulation treatments.

METHODS

Women undergoing IVF were recruited from six clinics in Sweden between May 2010 and December 2010. Included patients completed a study questionnaire consisting of one contingent valuation (CV) question (with six different bids) and 16 conjoint analysis (CA) questions formulated as discrete choices between two hypothetical ovarian stimulation treatments (defined in terms of manufacturing method, method of administration, time required for administration, dose variability and hypothetical price). Patient preferences were derived using multinomial logit modelling.

RESULTS

The final study population consisted of 294 women (mean age of 35). Respondents were willing to pay €360 [95% confidence interval (CI): €340-€390] to receive FSH derived from DNA technology instead of highly purified extract from urine from post-menopausal women, €300 (95% CI: €280-€320) to administer the FSH using a prefilled injection pen instead of a conventional syringe, €30 (95% CI: €20-€40) per saved minute required for administration and €530 (95% CI: €500-€570) to reduce the dose variability from 10-20% to 1-2% (P< 0.001 for all estimates). The result from the CV was similar to the CA.

CONCLUSIONS

Women undergoing IVF place significant value on characteristics differentiating ovarian stimulation treatments. Product-specific aspects should be taken into account by decision-makers when discriminating between commercial gonadotrophins in clinical practice to align health-care decision-making with patient preferences and potentially improve the effectiveness of IVF interventions through enhanced patient satisfaction and treatment compliance. Preferences for treatment characteristics should also be considered in evaluations of ovarian stimulation products to capture their true value from a patient perspective.

Drug delivery for in vitro fertilization: rationale, current strategies and challenges

In vitro fertilization has experienced phenomenal progress in the last thirty years and awaits the additional refinement and enhancement of medication delivery systems. Opportunity exists for the novel delivery of gonadotropins, progesterone and other adjuvants. This review highlights the rationale for various medications, present delivery methods and introduces the status of novel ideas and possibilities.

Gonadotropin preparations: past, present, and future perspectives

This Educational Bulletin offers past, present and future perspectives on gonadotropin preparations.

Comparison of follitropin-beta administered by a pen device with conventional syringe in an ART programme - a retrospective study

OBJECTIVES

This study compares the efficacy and patient tolerance of follitropin-beta (recagon) administered using a pen device with conventional syringe in infertile couples undergoing in vitro fertilization/intracytoplasmic sperm injection treatment.

METHODS

Data for 481 patients were retrieved retrospectively for the analysis. Conventional syringe group constituted 204 patients with 217 cycles and 265 patients with 294 cycles in the pen-device group. Down-regulation was achieved with GnRH agonist.

RESULTS

Comparison of follitropin-beta administered with pen and syringe showed the following data, respectively. A total dose of 1909.38/2100.65 IU (P < 0.001), duration of stimulation, 9.70/10.47 days (P < 0.05), oestradiol levels on the day of human chorionic gonadotropin, 1488.34/1067.63 pg/ml, number of follicles reaching >16-mm size, 9.75/7.34 (P < 0.05), number of oocytes retrieved, 13.84/9.55 (P < 0.001) and number of embryos available for freezing, 4.56/1.30 (P < 0.05), the above data were observed in pen/conventional syringe groups, respectively. The live birth rates per cycle were 28.85% and 30.95% in the conventional syringe/pen-device groups, respectively. Patient tolerance with respect to pain at injection site was better with the pen device (P < 0.025).

CONCLUSION

The data show that follitropin-beta administered with pen device is well tolerated and more efficacious with respect to ovarian stimulation outcome compared with the conventional syringe.

Patient and nurse evaluation of recombinant human follicle-stimulating hormone administration methods: comparison of two follitropin injection pens

OBJECTIVE

Ovarian stimulation by injection of gonadotrophins is an essential part of assisted reproductive technology (ART) protocols. Two studies (a German pilot study and an Australian study) aimed to assess and compare the ease-of-use, safety and efficacy of two follitropin injection pens.

METHODS

Patient satisfaction (questionnaire) and safety were assessed in patients undergoing ART at a German centre for in vitro fertilisation (IVF), randomised either to the follitropin alfa pen or to the follitropin beta pen. Patient satisfaction (questionnaire) was assessed in patients undergoing ART at an Australian IVF centre, using the follitropin alfa pen, and previous experience with the follitropin beta pen was compared. The experience of IVF nurses with both pens was assessed using a similar questionnaire. Statistical significance was not determined in either study.

RESULTS

In the German study (n = 31), patients favored the follitropin alfa pen over the follitropin beta pen because they found preparation faster, were more confident of accurate dosing and had to make fewer dose adjustments. Treatments delivered by both pens were well tolerated; eight adverse events (AEs) occurred, two AEs (including one case of ovarian hyperstimulation syndrome, OHSS) in two patients using the follitropin alfa pen and six AEs (including three cases of OHSS, one of which was serious) in six patients using the follitropin beta pen. Patients (n = 140) and nurses (n = 11) in the Australian study scored the follitropin alfa pen highly and patients favored it over the follitropin beta pen; the risk of OHSS was also considered greater in the follitropin beta pen group, with nearly a twofold higher rate of cycle cancellation due to OHSS risk compared with the follitropin alfa pen group.

CONCLUSIONS

Taken together, results from these two small studies suggest that the follitropin alfa pen was effective, well tolerated, and patient and nurse acceptance appeared to be higher for the follitropin alfa pen versus the follitropin beta pen, which may benefit compliance, leading to improved outcomes.

Patient experience with follitropin alfa prefilled pen versus previously used injectable gonadotropins for ovulation induction in oligoanovulatory women

OBJECTIVE

To evaluate patient satisfaction with the follitropin alfa prefilled pen (Gonal-f RFF Pen), compared with previously used injectable gonadotropins (vial/ampoules and syringe), in women undergoing ovulation induction (OI).

RESEARCH DESIGN AND METHODS

Women aged 18-40 years undergoing OI for oligoanovulatory infertility were enrolled from nine US fertility centers in this prospective, open-label clinical trial. Participants received recombinant follitropin alfa using a prefilled pen. Patient satisfaction was determined using a pre-treatment questionnaire to assess gonadotropin treatments undertaken within 6 months of study initiation and an in-treatment questionnaire to assess satisfaction with the prefilled pen.

MAIN OUTCOME MEASURES

The primary endpoint was the proportion of patients who preferred the prefilled pen compared to previous injectable gonadotropin therapies. Efficacy and safety were also assessed.

RESULTS

Seventy-three subjects were screened for the study; 62 enrolled, were treated with the follitropin alfa pre-filled pen, and 61 completed the in-treatment questionnaire. Sixty-one of 61 patients who stated a preference preferred the prefilled pen to previous injectable gonadotropin therapies (61/61; 100%; 95% confidence interval: [94.1-100.0%]). One patient did not state a preference. Of these 61 patients, 54 (89%) found that the prefilled pen instructions were easy to understand compared to 17 of 59 (29%) who thought instructions for the conventional syringes were easy to understand. When preparing their dose, significantly fewer patients contacted their healthcare provider two or more times during the treatment cycle when receiving treatment with the prefilled pen (2/61, 3%) than during the first treatment cycle with prior gonadotropin treatment, 11/59 (19%, p = 0.007). The pen interfered slightly or not at all with patients' normal daily activities in 61 of 61 patients (100%) versus 50 of 59 patients (85%) who had this opinion regarding injections during their prior treatment cycles (p = 0.003). All 61 patients who stated a method of injection preference found the prefilled pen less stressful to use than syringes and would recommend the pen to another woman considering gonadotropin treatment. A total of 10/62 (16%) subjects reported 18 treatment-emergent adverse events (AEs). Two cases of ovarian hyperstimulation syndrome occurred post-treatment and one serious AE occurred (post-treatment ectopic pregnancy). Injection site reactions were generally mild to moderate, with mild itching (6 patients, 9.7%) and moderate redness in one patient. Fifteen patients reported mild redness (24.2%). Mild bruising (21.0%), mild pain (33.9%), and mild burning (32.3%) were also reported by patients. Seven patients (11.3%) had moderate pain.

CONCLUSIONS

In this open-label, non-comparative study, patients undergoing OI preferred administering gonadotropins using the follitropin alfa prefilled pen compared to their prior use of vials/ampoules and a syringe. Patients using the prefilled pen found it less stressful, easier to use and more convenient than a conventional syringe and would recommend the pen to another woman considering gonadotropin treatment.

Quality of life of patients undergoing ovarian stimulation with injectable drugs in relation to medical practice in France

The French study VISION is a multicentric, prospective and retrospective study, designed first to evaluate patients' quality of life during ovarian stimulation for ovulation induction, intrauterine insemination (IUI) or IVF, and secondly to analyse current medical practice in France. Answers were directly entered on a pocket PC. The study was conducted from January to August 2004 and 186 practitioners filled in a total of 1476 questionnaires. The percentages for the different treatments used were analysed according to type of technique [ovulation induction, IUI, IVF/intracytoplasmic sperm injection (ICSI)], type of product used [urinary gonadotrophins, recombinant FSH (rFSH), gonadotrophin-releasing hormone (GnRH) agonists and antagonists] and methods of administration (intramuscularly, subcutaneously, use of Pen-injector, nurses or self-injections). Initial and total amounts of urinary gonadotrophins per cycle were approximately 30% higher compared with rFSH for IUI and IVF. Generally, the impact of these treatments on professional or social life was less than expected. Patients saw self-injection as a significant improvement in their life, especially when using an injection pen, and when other drugs were also self-injected during treatment (human chorionic gonadotrophin, GnRH agonists or antagonists). Clear information is necessary to increase patient's compliance to the treatment. Simplification will make these procedures more patient-friendly and less of a struggle.

A pen injection device for self-administration of recombinant follicle-stimulating hormone for fertility treatments

A pen injection device modeled on the insulin pen used by diabetic patients has been introduced to deliver recombinant follicle-stimulating hormone to women undergoing controlled ovarian stimulation for in vitro fertilization or other forms of assisted reproductive technology. The pen device makes it easier and less painful for women to self-administer daily injections. The high precision and accuracy of the device enables physicians to fine-tune dosage. The woman simply inserts the multidose cartridge into the Puregon (Follistim) Pen, attaches a BD Micro-Fine Pen Needle, selects the prescribed dose on the dial at the base of the pen, inserts the needle subcutaneously and pushes the injection button to administer the injection. A fresh needle is used for each injection.

Prospective, randomized trial comparing cetrorelix acetate and ganirelix acetate in a programmed, flexible protocol for premature luteinizing hormone surge prevention in assisted reproductive technologies

OBJECTIVE

To compare the safety and efficacy of single-dose cetrorelix acetate (3 mg) and daily ganirelix acetate (0.25 mg) in the inhibition of premature LH surge in women undergoing cycle-programmed ovarian stimulation before Assisted Reproductive Technology (ART).

DESIGN

Prospective, open-label, randomized, comparative study.

SETTING

Sixteen ART centers in the United States.

PATIENT(S)

One hundred eighty-five infertile patients undergoing ART.

INTERVENTION(S)

Single injection of cetrorelix (3 mg SC) or daily dose of ganirelix (0.25 mg SC) was administered when the lead follicle was > or =14 mm. Daily cetrorelix (0.25 mg) was administered if the criteria for hCG administration were not met 4 days after receiving 3 mg of cetrorelix.

MAIN OUTCOME MEASURE(S)

Percentage of patients who did not have a premature LH surge, defined as LH <10 IU/L on the day of hCG administration. The IVF and embryo transfer (ET) outcomes were assessed.

RESULT(S)

No patient in either treatment group had a premature LH surge. There were no statistically significant differences between treatments for any IVF/intracytoplasmic sperm injection (ICSI) or ET outcomes, including pregnancy rate (PR). However, cetrorelix required significantly fewer injections than ganirelix. Similar safety profiles were observed.

CONCLUSION(S)

Cetrorelix and ganirelix effectively prevented LH surges in oral contraceptive (OC) pill-programmed, flexible protocols, with similar safety profiles and PRs; however, cetrorelix required significantly fewer injections, increasing patient convenience.

Evaluation of a pen device for self-administration of recombinant human FSH in clomiphene citrate-resistant anovulatory women undergoing ovulation induction

This open-label multicentre study evaluated ease of use, safety, and efficacy of a pen device for self-administration of recombinant follicle-stimulating hormone (rFSH) in 43 subjects undergoing ovulation induction. Follitropin beta was administered subcutaneously with the Follistim Pen within 3 days of onset of menses. A 75 IU starting dose could be increased by 25 or 50 IU on days 8 and 15 if no ovarian response was observed. Human chorionic gonadotrophin (HCG; 10,000 IU) was administered when one follicle > or =18 mm or two to three follicles > or =15 mm were observed. Subjects received standardized instruction for the pen device and subject comprehension was recorded as subjects practised and prepared injections. Ease of use was also evaluated by questionnaire. Forty-four subjects enrolled; 43 were treated with rFSH and 41 were treated with HCG. The comprehension questionnaire revealed that during the mock injection, 100% of subjects properly loaded the cartridge into the pen device, while 95% selected the correct dose and 100% self-injected the medication prescribed. During the second actual injection, 100% of subjects comprehended these pen-related steps. The ease-of-use questionnaire showed that 100% of the subjects rated the overall experience of self-administering with the pen as 'very good' to 'good'. Mean duration and total amount of follitropin beta were 11.4 +/- 4.2 days and 1070.3 +/- 580.3 IU respectively. Ovulation rate was 95%. Biochemical and ongoing pregnancy rates per attempt were 34.9 and 30.2% respectively. Three subjects experienced serious adverse events [asthma; ovarian hyperstimulation syndrome (OHSS) and pain; OHSS]. In conclusion, the pen device provides an easy, safe, and effective way for women to self-administer follitropin beta during ovarian stimulation.