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

Comparison of recombinant human FSH biosimilar QL1012 with Gonal-f® for ovarian stimulation: a phase-three trial

RESEARCH QUESTION

Are QL1012 and Gonal-f® equivalent in women undergoing ovarian stimulation for assisted reproductive technology (ART)?

DESIGN

This multicentre, randomized, assessor-blinded, phase-three trial was conducted at 13 centres in China. Eligible patients were infertile women; age 20-39 years; body mass index 18-30 kg/m²; regular menstrual cycles; and indication for ART. After successful pituitary downregulation, patients were randomly assigned (1:1) to receive QL1012 or Gonal-f®, stratified by age (initial dose of 75-150 IU for women younger than 30 years, 150-225 IU for women aged 30-34 years and 225-300 IU for women aged ≥35 years, subcutaneously, once daily). The primary end point was the number of oocytes retrieved.

RESULTS

Between October 2018, and June 2019, 341 patients were included in the per-protocol set. The mean numbers of oocytes retrieved were 14.7 ± 7.0 in the QL1012 group (n = 169) and 13.4 ± 6.1 in the Gonal-f® group (n = 172). Adjusted by analysis of covariance model, the least-squares mean difference was 1.3 oocytes (95% CI -0.1 to 2.7; P = 0.0650), within the pre-defined equivalence margins of ±3.0. Similar results were observed in the full analysis set. Additionally, no statistical differences were found in secondary end points except oestradiol concentration (median 3948.0 pg/ml versus 3545.3 pg/ml; P = 0.0015). Ovarian hyperstimulation syndrome (12.4% versus 13.1 %) and other adverse events were similar between the two groups.

CONCLUSIONS

Therapeutic equivalence and similar safety profiles were demonstrated between QL1012 and Gonal-f® in women undergoing ovarian stimulation for ART.

Human Recombinant FSH and Its Biosimilars: Clinical Efficacy, Safety, and Cost-Effectiveness in Controlled Ovarian Stimulation for In Vitro Fertilization

Exogenous human follicle-stimulating hormone (hFSH), either derived from extraction and purification from the urine or obtained by recombinant technology in the form of follitropin α, β and δ (rFSH), has been used for decades in the treatment of infertility. The main applications of FSH treatment in the woman have been, and still are, ovulation induction in oligo-anovulatory subjects, and stimulation of the development of a cohort of follicles in patients undergoing controlled ovarian stimulation (COS) for in vitro fertilization (IVF). In the last years, two biosimilars of follitropin alfa, rFSH compounds structurally and functionally similar to the originator, have been approved and marketed for clinical use in Europe. Moreover, some other rFSH biosimilars are currently under investigation. The objective of this article is to review the available evidences comparing the efficacy, safety, and cost-effectiveness of rFSH follitropin alpha originator with its biosimilars, discussing the clinical trials that allowed biosimilars to get registration and marketing authorization.

Efficacy of follitropin-alpha versus human menopausal gonadotropin for male patients with congenital hypogonadotropic hypogonadism

OBJECTIVE

To compare human menopausal gonadotropin (hMG) and recombinant follicle-stimulating hormone (rFSH) with respect to successful spermatogenesis and pregnancy outcomes in patients with congenital hypogonadotropic hypogonadism (CHH).

MATERIAL AND METHODS

This retrospective study included a total of 112 male patients with CHH. Of these, 70 were to receive treatment with hMG and 42 with rFSH following the hCG administration.

RESULTS

The average age at diagnosis was 27.9 (range, 15-51) years. The baseline luteinizing hormone (LH), follicle-stimulating hormone (FSH), and testosterone levels were 0.53±0.77 IU/L, 0.63±0.61 IU/L, and 1.10±1.90 ng/dL, respectively. Following the combined hormonal treatment, 85.7% (96/112) of patients had sperm detected in ejaculate samples. In the hMG group, the mean baseline of a testicular size was slightly lower than in the rFSH group (5.0±3.5 mL and 5.3±3.9 mL), whereas these differences were not statistically significant (p=0.364). The mean baseline age, level of FSH, LH, and testosterone also showed no significant difference between the two treatment options. The rate of successful spermatogenesis was similar (85.7%) in both groups, while the pregnancy rates of patients who underwent hMG and rFSH treatments were 38.6% (n=27) and 51.2% (n=21); however, these differences were not statistically significant (p=0.314). No patients developed severe effects during the treatment period.

CONCLUSION

Successful spermatogenesis and pregnancy rates with hMG and rFSH are similar.

Are intra follicular estradiol and oocytes quality in women undergoing assisted reproductive technology different between the right and left ovaries? An observational study

Objective

Controlled Ovarian Stimulation (COS) for In-Vitro Fertilization (IVF) or Intracytoplasmic Sperm Injection (ICSI) is considered as an assisted reproduction technology. There are established structural and biological differences between both ovaries which may affect their responsiveness to COS. Whether the right or the left ovary responds superior to COS is a question which is unresolved in the literature.

Study design

The present study was conducted as a prospective observational to make a comparison between right and left ovaries’ oocytes based on oocyte quality and follicular fluid estradiol level. A total of 100 infertile women who had referred to Infertility and Reproductive Health Research center at Shahid Beheshti University of Medical Sciences, Tehran, Iran, were investigated.

Results

The total number of very good and good oocytes were 63.01% vs. 50.3%, and immature and interstitial oocytes were 36.99% vs. 49.6% in the right and the left ovaries, respectively. There were no significant differences between oocyte rates between the two ovaries (P > 0.05).

Conclusion

Good and very good quality oocytes and fertilization rate (P < 0.001) are higher in the right ovary compared with the left ovary; however, no significant difference was observed between the right and the left ovaries in oocyte yields and cleavage rates. Moreover, despite higher follicular estradiol levels in the left ovary, there was no relationship noticed between follicular fluid estradiol and oocyte quality among oocytes of each ovary.

Ovarian stimulation: from basic science to clinical application

Treatment for infertility, including ovarian stimulation, was first introduced almost 100 years ago. At this time, radiation therapy became an established treatment, and it was only some decades later that the problem of radiation-induced cancer emerged. Non-human gonadotrophins, such as pregnant mare serum gonadotrophin (PMSG), and human pituitary gonadotrophins (HPG), were commonly used for hormonal stimulation procedures. However, use of PMSG led to antibody formation, and it was therefore only useful for the first treatment cycle. HPG produced good results, but its use came to an end in the late 1980s when it was linked to the development of Creutzfeldt-Jakob disease. The first hormonal product from human menopausal urine to be used was human menopausal gonadotrophin (HMG), followed later by purified preparations of this product. All of these preparations contained a high percentage of unknown urinary proteins, which interfered with batch-to-batch consistency. This changed with the introduction of recombinant gonadotrophins, produced from an immortalized/standardized mammalian cell line (CHO). More recent developments include the introduction of long-acting gonadotrophin formulations. The development of gonadotrophin-releasing hormone (GnRH) analogues and more recently the use of GnRH antagonists has helped to improve ovarian stimulation protocols by optimizing their efficacy, and making them easier to administer.

Ovarian stimulation: from basic science to clinical application

Treatment for infertility, including ovarian stimulation, was first introduced almost 100 years ago. At this time, radiation therapy became an established treatment, and it was only some decades later that the problem of radiation-induced cancer emerged. Non-human gonadotrophins, such as pregnant mare serum gonadotrophin (PMSG), and human pituitary gonadotrophins (HPG), were commonly used for hormonal stimulation procedures. However, use of PMSG led to antibody formation, and it was therefore only useful for the first treatment cycle. HPG produced good results, but its use came to an end in the late 1980s when it was linked to the development of Creutzfeldt-Jakob disease. The first hormonal product from human menopausal urine to be used was human menopausal gonadotrophin (HMG), followed later by purified preparations of this product. All of these preparations contained a high percentage of unknown urinary proteins, which interfered with batch-to-batch consistency. This changed with the introduction of recombinant gonadotrophins, produced from an immortalized/standardized mammalian cell line (CHO). More recent developments include the introduction of long-acting gonadotrophin formulations. The development of gonadotrophin-releasing hormone (GnRH) analogues and more recently the use of GnRH antagonists has helped to improve ovarian stimulation protocols by optimizing their efficacy, and making them easier to administer.

Ovarian responses to recombinant FSH or HMG in normogonadotrophic women following pituitary desensitization by a depot GnRH agonist for assisted reproduction

At present, there is considerable debate about the utility of supplemental LH in assisted reproduction treatment. In order to explore this, the present authors used a depot gonadotrophin-releasing hormone agonist (GnRHa) protocol combined with recombinant human FSH (rhFSH) or human menopausal gonadotrophin (HMG) in patients undergoing intracytoplasmic sperm injection (ICSI). The response to either rhFSH (75 IU FSH/ampoule; group rhFSH, 25 patients) or HMG (75 IU FSH and 75 IU LH/ampoule; group HMG, 25 patients) was compared in normo-ovulatory women suppressed with a depot triptorelin injection and candidates for ICSI. A fixed regimen of 150 IU rhFSH or HMG was administered in the first 14 days of treatment. Treatment was monitored with transvaginal pelvic ultrasonographic scans and serum measurement of FSH, LH, oestradiol, androstenedione, testosterone, progesterone, inhibin A, inhibin B and human chorionic gonadotrophin (HCG) at 2-day intervals. Although oestradiol serum concentrations on the day of HCG injection were similar, both the duration of treatment and the per cycle gonadotrophin dose were lower in group HMG. In the initial 16 days of gonadotrophin treatment, the area under the curve (AUC) of LH, oestradiol, androstenedione and inhibin B were higher in group HMG; no differences were seen for the remaining hormones measured, including the inhibin B:inhibin A ratio. The dynamics of ovarian follicle development during gonadotrophin treatment were similar in both study groups, but there were more leading follicles (>17 mm in diameter) on the day of HCG injection in the rhFSH group. The number of oocytes, mature oocytes and good quality zygotes and embryos obtained were significantly increased in the rhFSH group. It is concluded that in IVF patients undergoing pituitary desensitization with a depot agonist preparation, supplemental LH may be required in terms of treatment duration and gonadotrophin consumption. However, both oocyte, embryo yield and quality were significantly higher with the use of rhFSH.

A short review of ovarian stimulation in assisted reproductive techniques

Ovarian stimulation during assisted human reproduction is currently a standard procedure in assisted reproductive techniques (ART). Its objective is to stimulate the growth of several follicles by injections of FSH-containing compounds, most recently recombinant FSH (rFSH). An injection of human chorionic gonadotrophin (HCG), or a luteinizing hormone-releasing hormone agonist to discharge pituitary LH is then given to invoke follicle and oocyte maturation. Various other medications are also used in addition to specific drugs such as human menopausal gonadotrophin, rFSH, HCG and rLH. Non-specific drugs include clomiphene citrate, other anti-oestrogens, bromoergocryptine, and gonadotrophin-releasing hormone (GnRH) agonists and antagonists. Numerous protocols have been utilized with these agents, the most common being clomiphene citrate and various regimens of gonadotrophins, including step-up, step-down and continuous. The regimens are used with or without GnRH agonists, and with or without GnRH antagonists. In this brief review, the advantages and disadvantages of each protocol are presented.

Intact follicle culture: what it can tell us about the roles of FSH glycoforms during follicle development

An important limiting factor in assisted reproduction treatment success rates is oocyte quality. In spite of improved results through several important innovations, the pregnancy rate per collected oocyte remains far too low. In order to improve this situation, it is necessary to learn more about fundamental factors modulating follicular development patterns. FSH is known to be the driving force for follicle development, but it is not yet understood how its multifarious functions are controlled and modulated. Evidence is accumulating that FSH glycoforms may be the key to this mystery. Intact follicle culture is a useful tool for the clarification of the actions of the different isoforms because the follicle unit is maintained and allowed to develop through several critical stages. Additionally important is the availability of the oocyte for functional evaluation. Because of these features, relationships can be uncovered that are not revealed with single cell test systems. The results so far obtained with this system suggest that follicle development pattern and oocyte quality is strongly influenced by FSH glycoform range, and that the requirements of the follicle may shift during progress through different stages of development. More studies are required, but these findings already suggest that the physiological shifts of circulating FSH glycoforms may indeed be important, and that attention should be paid to the glycoform distribution of exogenously applied FSH.

Pharmacokinetics and pharmacodynamics of recombinant human chorionic gonadotrophin in healthy male and female volunteers

The pharmacokinetics and pharmacodynamics of recombinant human chorionic gonadotrophin (rHCG) were investigated in three studies of healthy volunteers. After single intravenous doses of 25, 250 and 1000 microg, rHCG and urinary HCG (uHCG) showed linear pharmacokinetics described by a bi-exponential model, although the area under the curve (AUC) for uHCG was ~29% lower than for rHCG. After intramuscular or subcutaneous administration (absolute bioavailability, 40-50% for both), rHCG pharmacokinetics could be described by a first-order absorption, one-compartment model. During multiple subcutaneous dosing, the amount of HCG increased by approximately1.7-fold. A comparison of liquid and freeze-dried rHCG and freeze-dried uHCG showed pharmacokinetic bioequivalence. In down-regulated male subjects, single doses of 125 microg rHCG, given intravenously, intramuscularly or subcutaneously, produced comparable increases in serum testosterone, inhibin and 17beta-oestradiol, with little further increase during repeated subcutaneous administration (in female subjects, this produced a sustained comparable increase in serum androstenedione and testosterone concentrations). In conclusion, the pharmacokinetics and pharmacodynamics of rHCG are similar to those of uHCG and are not affected by the use of different formulations. In healthy subjects, rHCG produces pharmacodynamic responses consistent with HCG physiology and is suitable for use in the same clinical indications as uHCG. The secured source and high purity of rHCG may offer important advantages.