Pharmacokinetics and follicular dynamics of corifollitropin alfa versus recombinant FSH during ovarian stimulation for IVF

Evaluation of the safety and efficacy of corifollitropin alfa combined with GnRH agonist triggering in oocyte donation cycles. A prospective longitudinal study

Objective:

In order to help make the dream of parenthood come true for oocyte acceptors, it is essential that the procedure is not dangerous or unpleasant for oocyte donors. The aim of this study was to identify differences in safety, efficacy and patient acceptability between a traditional stimulation antagonist protocol with recombinant-FSH (rFSH) with hCG-triggering, compared with an innovative antagonist protocol with corifollitropin alfa (Elonva^®) plus GnRH agonist triggering in oocyte donors.

Methods:

A prospective longitudinal study was conducted at an in vitro fertilization center in Greece. The same eighty donors underwent two consecutive antagonist stimulation schemes. Primary outcomes were patient satisfaction (scored by a questionnaire) and delivery rate per donor. Secondary outcomes were mean number of cumulus-oocyte-complexes, metaphase II (MII) oocytes and ovarian hyperstimulation syndrome (OHSS) rate.

Results:

Donors reported better adherence and less discomfort with the corifollitropin alpha + GnRH agonist-triggering protocol (p<0.001). No significant differences were identified in the clinical pregnancy rate per donor (p=0.13), the delivery rates, the number of oocytes (p=0.35), the number of MII oocytes (p=0.50) and the number of transferred embryos, between the two protocols. However, the luteal phase duration was significantly shorter (p<0.001) in the corifollitropin alpha + GnRH agonist-triggering protocol. Moreover, three cases of moderate OHSS (3.75%) were identified after hCG triggering, whereas no case of OHSS occurred after GnRH agonist ovulation induction (p=0.25).

Conclusion:

The use of corifollitropin alpha combined with a GnRH agonist for triggering is a safe, effective and acceptable protocol for oocyte donors.

Novel Physiology and Definition of Poor Ovarian Response; Clinical Recommendations

Poor ovarian response (POR) to controlled ovarian stimulation (OS) presents a major challenge in assisted reproduction. The Bologna criteria represented the first serious attempt to set clear criteria for the definition of POR. However, the Bologna criteria were questioned because of the persistent heterogeneity among POR patients and the inability to provide management strategies. Based on these facts, a more recent classification, the POSEIDON (Patient-Oriented Strategies Encompassing IndividualizeD Oocyte Number) classification, was developed to provide a homogeneous and refined definition of POR that significantly reduces the heterogeneity of the Bologna criteria definition of POR and helps in the clinical handling and counseling of patients. In this review, we discuss the impact of the POSEIDON classification on the clinical management of patients with POR.

Dual stimulation using corifollitropin alfa in 54 Bologna criteria poor ovarian responders - a case series

RESEARCH QUESTION

What are the reproductive outcomes of Bologna criteria poor responders undergoing dual stimulation (DuoStim) and subsequent cryopreserved embryo transfer?

DESIGN

Case series of patients treated during the period August 2015 to March 2018 in a public fertility clinic. The study included 54 Bologna criteria poor responder IVF patients younger than 42 years receiving a follicular stimulation (DuoStim 1) followed by a luteal phase stimulation (DuoStim 2) within the same cycle, both stimulations being performed with corifollitropin alfa followed by a subsequent cryopreserved embryo transfer cycle. The primary endpoint was the number of oocytes retrieved in DuoStim 1 compared with DuoStim 2. The secondary endpoint was ongoing pregnancy rate (OPR) at 12 weeks of gestation.

RESULTS

The mean number of oocytes retrieved in DuoStim 1 and DuoStim 2 was 2.4 ± 2.1 versus 3.7 ± 2.6, respectively; thus, a total of 1.2 (95% CI, 0.46-1.96) more oocytes was retrieved in DuoStim 2 compared with DuoStim 1 (P = 0.002). The OPR at 12 weeks was 20% (11/54) in this poor ovarian response population with a mean age of 36.7 years.

CONCLUSIONS

Luteal phase stimulation results in more oocytes in poor responders compared with follicular phase stimulation. DuoStim, using corifollitropin alfa followed by individualized FSH dosing, appears to be an alternative to conventional follicular phase stimulation, decreasing the risk of cycle cancellation.

Management Strategies for POSEIDON Groups 3 and 4

In the POSEIDON classification, patients belonging to groups 3 and 4 share the same common feature of a poor ovarian reserve which independently of age renders them at high risk of a poor reproductive outcome. Overall, POSEIDON groups 1-4 constitute approximately 47% of patients attending assisted reproductive technology (ART) treatment. With the increasing delay in childbearing, POSEIDON group 4 seems to increase in numbers now in some centers constituting more than 50% of the total POSEIDON population, whereas group 3 patients constitute approximately 10%. Both POSEIDON groups 3 and 4 patients require special attention as regards pre-treatment strategy, ovarian stimulation, adjuvant treatment, and ovulation trigger strategy in order to optimize the probability of having at least one euploid blastocyst for transfer. Although more evidence is needed, recent advances seem to have increased the reproductive outcomes in the poor prognosis patient. The key to success is individualization in all steps of ART treatment. Herein, we review the recent evidence for the management of POSEIDON groups 3 and 4.

Effectiveness of corifollitropin alfa used for ovarian stimulation of poor responder patients

Purpose

To evaluate the efficiency and efficacy of corifollitropin alfa (follicle-stimulating hormone–carboxy terminal peptide) in the treatment of poor responder patients.

Methods

A total of 85 poor responder patients with a mean age 40.2±3.9 years entered our assisted fertilization program. The patients were prospectively randomized into two groups based on the ovarian stimulation regimen used: group A (study group) (n=42) received clomiphene citrate and corifollitropin alfa for the first 7 days of stimulation followed by recombinant follicle stimulating hormone (rFSH) in a gonadotropin-releasing hormone antagonist protocol, and group B (control group) (n=43) received clomiphene citrate and a daily injection of rFSH in a gonadotropin-releasing hormone antagonist protocol. We analyzed the stimulation outcome, the number of retrieved oocytes, cleaving embryos, and pregnancy and implantation rates as well.

Results

Comparable results were observed between the two groups in terms of demographic data, stimulation outcome, and the number of canceled cycles. There were no differences evident between groups A and B with respect to the number of retrieved oocytes (3.0±0.8 and 2.7±0.7, respectively) and the number of cleaving embryos (1.8±0.6 and 1.7±0.7, respectively). Higher, though not statistically significant, differences were observed in favor of group A compared to group B in terms of pregnancy rate per cycle (19% and 16.3%, respectively), pregnancy rate per transfer (21.6% and 17.9%, respectively), and implantation rate (14.7% and 13.4%, respectively). Also, miscarriage rate was similar between patients treated with corifollitropin alfa and those treated with daily rFSH injection (12.5% and 14.2%, respectively).

Conclusion

The results show that ovarian stimulation with corifollitropin alfa appears to be as efficacious and efficient as daily injection rFSH regimen to treat patients with poor ovarian response.