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Yu Y, Zhang Q, Sun K, Xiu Y, Wang X, Wang K, Yan L. The therapeutic effects of rFSH versus uFSH/uHMG on ovarian stimulation in women undergoing assisted reproductive technology: a meta-analysis of randomized controlled trials. Arch Gynecol Obstet 2024; 309:2529-2555. [PMID: 37470817 DOI: 10.1007/s00404-023-07095-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 05/08/2023] [Indexed: 07/21/2023]
Abstract
PURPOSE This systematic review and meta-analysis aimed to compare the therapeutic effects of rFSH versus uFSH/uHMG on ovarian stimulation in women undergoing assisted reproductive technology. METHODS The databases of PubMed, Embase, and the Cochrane Library were systematically searched to retrieve data on eligible trials from inception until July 2022. The relative risks (RRs) or weighted mean differences (WMDs) with 95% confidence intervals (CIs) were applied to assess categorical and continuous outcomes, and the pooled results were calculated using the random-effects model. Sensitivity, subgroup, and publication bias analyses were also performed. RESULTS Forty-eight trials that enrolled 10,127 women were included in this quantitative meta-analysis. There were no significant differences between rFSH and uFSH/uHMG in the clinical pregnancy rate (RR: 1.01; 95% CI 0.95-1.07; P = 0.760), live birth rate (RR: 0.98; 95% CI 0.91-1.06; P = 0.665), multiple pregnancy rate (RR: 0.92; 95% CI 0.77-1.09; P = 0.320), miscarriage rate (RR: 1.17; 95% CI 0.94-1.46; P = 0.151), and the incidence of ovarian hyperstimulation syndrome (RR: 1.25; 95% CI 0.91-1.70; P = 0.164). In addition, the administration of rFSH was associated with a higher number of oocyte retrieval compared with that of uFSH/uHMG (WMD: 0.61; 95% CI 0.03-1.20; P = 0.038), while no significant differences were found between rFSH and uFSH/uHMG in the dosage of gonadotrophin (WMD: 14.80; 95% CI - 136.97 to 166.57; P = 0.848) and the duration of ovarian stimulation (WMD: - 0.26; 95% CI - 0.62 to 0.10; P = 0.152). Thus, the exploratory analyses revealed several potential differences in the effects of rFSH versus uFSH/uHMG on ovarian stimulation. CONCLUSION The administration of rFSH significantly increased the number of oocytes retrieved, whereas there were no significant differences between the efficacies of rFSH and uFSH/uHMG for pregnancy outcomes.
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Affiliation(s)
- Yuexin Yu
- Department of Reproductive Medicine, General Hospital of Northern Theater Command, No. 83, Wenhua Road, Shenhe District, Shenyang, 110016, Liaoning, China.
| | - Qian Zhang
- Department of Reproductive Medicine, General Hospital of Northern Theater Command, No. 83, Wenhua Road, Shenhe District, Shenyang, 110016, Liaoning, China
| | - Kaixuan Sun
- Department of Reproductive Medicine, General Hospital of Northern Theater Command, No. 83, Wenhua Road, Shenhe District, Shenyang, 110016, Liaoning, China
| | - Yinling Xiu
- Department of Reproductive Medicine, General Hospital of Northern Theater Command, No. 83, Wenhua Road, Shenhe District, Shenyang, 110016, Liaoning, China
| | - Xiliang Wang
- Department of Reproductive Medicine, General Hospital of Northern Theater Command, No. 83, Wenhua Road, Shenhe District, Shenyang, 110016, Liaoning, China
| | - Kaiyue Wang
- Department of Reproductive Medicine, General Hospital of Northern Theater Command, No. 83, Wenhua Road, Shenhe District, Shenyang, 110016, Liaoning, China
| | - Li Yan
- Department of Reproductive Medicine, General Hospital of Northern Theater Command, No. 83, Wenhua Road, Shenhe District, Shenyang, 110016, Liaoning, China
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Hossein Rashidi B, Sayyari K, Heshmat R, Amanpour S, Shahrokh Tehraninejad E, Masoumi M, Rezaei F. Comparing a biosimilar follitropin alfa (Cinnal-fⓇ) with Gonal-fⓇ in women undergoing ovarian stimulation: An RCT. Int J Reprod Biomed 2022; 19:1015-1024. [PMID: 34977459 PMCID: PMC8717078 DOI: 10.18502/ijrm.v19i11.9917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 10/06/2020] [Accepted: 12/16/2020] [Indexed: 11/24/2022] Open
Abstract
Background Advances in recombinant DNA technology led to the development of recombinant follitropin alfa. Recombinant human follicle-stimulating hormone products are used to stimulate follicular maturation. Objective To compare the efficacy and safety of a biosimilar-candidate recombinant human follicle-stimulating hormone (Cinnal-fⓇ; CinnaGen, Iran) with the reference product (Gonal-fⓇ; Merck Serono, Germany) in women undergoing ovarian stimulation for intracytoplasmic sperm injection (ICSI). Materials and Methods In this randomized controlled trial, a total sample size of 200 women (age < 35 yr, candidate for ICSI) was calculated. Participants began a pituitary downregulation protocol with buserelin. They received 150 IU daily of either Cinnal-fⓇ or Gonal-fⓇ from the second day of their cycle. The primary outcome of the study was the percentage of metaphase II (MII) oocytes. The secondary outcomes included the number and quality of oocytes retrieved, duration of stimulation, fertilization rate, embryo quality, the number of clinical and ongoing pregnancies, and the incidence of ovarian hyperstimulation syndrome (as an important safety marker). Results A total of 208 women were enrolled, of whom, 200 completed the study period. Ovarian stimulation with Cinnal-fⓇ resulted in a comparable percentage of MII oocytes as with Gonal-fⓇ (78.64% vs 80.02%, respectively; p = 0.81). No statistically significant difference was seen in the secondary outcomes between the groups. Conclusion Cinnal-fⓇ proved non-inferior to Gonal-fⓇ, based on the percentage of MII oocytes in women aged < 35 yr undergoing ICSI. Our findings confirm that the efficacy and safety profiles of Cinnal-fⓇ and Gonal-fⓇ are similar.
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Affiliation(s)
- Batool Hossein Rashidi
- Vali-e-Asr Reproductive Health Research Centre, Tehran University of Medical Sciences, Tehran, Iran
| | - Khashayar Sayyari
- Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Ramin Heshmat
- Chronic Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Saeid Amanpour
- Vali-e-Asr Reproductive Health Research Centre, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Masoumeh Masoumi
- Vali-e-Asr Reproductive Health Research Centre, Tehran University of Medical Sciences, Tehran, Iran
| | - Farhang Rezaei
- Medical Department, Orchid Pharmed Company, Tehran, Iran
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Bordewijk EM, Mol F, van der Veen F, Van Wely M. Required amount of rFSH, HP-hMG and HP-FSH to reach a live birth: a systematic review and meta-analysis. Hum Reprod Open 2019; 2019:hoz008. [PMID: 31206036 PMCID: PMC6561325 DOI: 10.1093/hropen/hoz008] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 02/07/2019] [Indexed: 11/30/2022] Open
Abstract
STUDY QUESTION In women undergoing IVF or ICSI cycles, do recombinant gonadotrophins differ from urinary-derived highly purified human menopausal gonadotropin (HP-hMG) or highly purified follicle-stimulating hormone (HP-FSH) in the total amount of gonadotrophins required to reach a live birth? SUMMARY ANSWER The difference between recombinant and urinary-derived HP-hMG or HP-FSH in the required amount to reach a live birth in IVF/ICSI cycles appears small. WHAT IS KNOWN ALREADY At present, gynecologists can choose between recombinant FSH (rFSH), urinary-derived HP-hMG and HP-FSH. These products are equally effective and safe, but it is unknown how these gonadotrophins compare in terms of IU required to reach a live birth. STUDY DESIGN, SIZE AND DURATION We conducted a search in Medline, Embase and CINAHL up to July 2018. We included randomized controlled trials (RCTs) that compared rFSH with HP-hMG or HP-FSH for ovarian stimulation in couples scheduled for IVF or ICSI treatment. From each randomized trial, we extracted the outcome data and information on participants, methods, interventions and funding. PARTICIPANTS/MATERIALS, SETTING AND METHODS Women undergoing ovarian stimulation with rFSH, HP-hMG or HP-FSH were included. We extracted data for the mean amount of gonadotrophins with SD, clinical pregnancy rate, live birth rate and cumulative live birth rate per woman from the included RCTs. We summarized these outcomes by calculating the individual and pooled mean difference (MD) or relative risk (RR) with 95% CI. We used the Review Manager software to perform the meta-analyses. We applied a random effect model to pool the data. We estimated the total amount of gonadotrophins used per extra live birth by STATA 14.2 and R software. MAIN RESULTS AND THE ROLE OF CHANCE A total of 28 studies with 7553 women were included in this review, of which 24 studies provided information on the total amount of gonadotrophins per woman who started an IVF/ICSI cycle. The total amount of gonadotrophins varied significantly between studies. The MDs in total amount were −37 IU (seven studies; N = 3220; 95% CI, −115 to 41; I2 = 68%) for rFSH versus HP-hMG and −31 IU (17 studies; N = 3629; 95% CI, −290 to 228; I2 = 97%) for rFSH versus HP-FSH. For rFSH versus HP-hMG, the RR for clinical pregnancy, live birth and cumulative live birth were 0.90 (95% CI, 0.81–1.00), 0.88 (95% CI, 0.78–0.99) and 0.91 (95% CI, 0.80–1.04), respectively. For rFSH versus HP-FSH, the RR for clinical pregnancy and live birth were 1.03 (95% CI, 0.94–1.13) and 1.03 (95% CI, 0.90–1.18), respectively; the data on cumulative live birth rate were lacking. The estimated difference in mean gonadotrophin amount per extra live birth was 789 IU (95% CI, −9.5 to 1570) for rFSH versus HP-hMG and −365 IU (95% CI, −2675 to 1945) for rFSH versus HP-FSH. LIMITATIONS, REASONS FOR CAUTION There was severe heterogeneity in the total amount of gonadotrophins between studies. A small fraction of women did not start gonadotrophin treatment; this was usually not accounted for in the provided mean amount of gonadotrophins per study and might have affected the averaged total amount of gonadotrophins but is unlikely to have affected the differences in the amount between rFSH and HP-hMG or HP-FSH. WIDER IMPLICATIONS OF THE FINDINGS The differences in the required amount to reach a live birth between rFSH, HP-hMG and HP-FSH appear to be small. Decision-making should be based on convenience, availability, actual costs and patient preferences. STUDY FUNDING/COMPETING INTERESTS The authors declare no conflict of interest. No external funding was either sought or obtained for this study. REGISTRATION NUMBER Prospero CRD42016038238
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Affiliation(s)
- E M Bordewijk
- Academic Medical Center, Center for Reproductive Medicine, Amsterdam, The Netherlands
| | - F Mol
- Academic Medical Center, Center for Reproductive Medicine, Amsterdam, The Netherlands
| | - F van der Veen
- Academic Medical Center, Center for Reproductive Medicine, Amsterdam, The Netherlands
| | - M Van Wely
- Academic Medical Center, Center for Reproductive Medicine, Amsterdam, The Netherlands
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Yilmaz N, Yilmaz S, Inal H, Gorkem U, Seckin B, Turkkani A, Gulerman C. Is there a detrimental effect of higher gonadotrophin dose on clinical pregnancy rate in normo-responders undergoing ART with long protocol? Arch Gynecol Obstet 2012; 287:1039-44. [PMID: 23233291 DOI: 10.1007/s00404-012-2673-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Accepted: 12/03/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND In recent years, it has become evident that ovarian stimulation, although a central component of in vitro fertilization (IVF), may itself has detrimental effects on oogenesis, embryo quality, endometrial receptivity, and perhaps also perinatal outcomes. OBJECTIVE To evaluate the effect of higher gonadotrophin dose on clinical pregnancy rate in normo-responder ICSI cycles with long protocol. METHODS A retrospective study was planned in the Department of Reproductive Endocrinology of Zekai Tahir Burak Women's Health Education and Research Hospital. 362 normo-responders undergoing ICSI cycles with long protocol were included in the study. Group 1 (n = 260): Total gonadotrophin dose <2198 IU and Group 2 (n = 102): Total gonadotrophin dose >2198 IU. Laboratory IVF outcome, clinical pregnancy rate were evaluated. RESULT(S) There was no statistically significant difference between peak estradiol levels, endometrial thickness, fertilization rates among the Group 1 versus Group 2 (p > 0.05). But there was a statistically significant difference in age, baseline FSH, oocyte number, 2PN, and clinical pregnancy among the Group 1 versus Group 2. Clinical pregnancy rate were significantly higher in Group 1 compared with Group 2 (p < 0.001). Lower gonadotrophin dose, 2PN was an independent positive predictor of clinical pregnancy (OR 2.65 for gonadotrophin dose, OR 1.1 for 2PN) CONCLUSION(S): Higher total gonadotrophin dose adversely affect clinical pregnancy in normo-responder patients undergoing ICSI cycles with long protocol.
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Affiliation(s)
- Nafiye Yilmaz
- Reproductive Endocrinology-IVF Department, Dr. Zekai Tahir Burak Women's Health Education and Research Hospital, Ankara, Turkey.
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Al-Inany HG, Abou-Setta AM. Are all human-derived follicle-stimulating hormone products the same? A systematic review and meta-analysis using direct and adjusted indirect analyses, to determine whether Fostimon® is more efficient than Metrodin-HP®. Gynecol Endocrinol 2012; 28:94-101. [PMID: 21591977 DOI: 10.3109/09513590.2011.569612] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Randomized trials (RCTs) and systematic reviews have challenged the claim for superiority of recombinant follicle-stimulating hormone (recFSH) compared with human-derived FSH (hFSH). Even so, much of the evidence comes from unavailable products. If the efficacy of the currently available Fostimon(®) is superior, the off-market Metrodin-HP(®), then data from the latter should not be used, gauge of the former. METHODS Electronic/hand searches were performed to identify RCTs comparing Fostimon(®) vs. Metrodin-HP(®) or either product with recFSH. Primary outcomes were live-birth rate (LBR), ongoing pregnancy rate (OPR), and OPR/LBR. Secondary outcomes were clinical pregnancy rate (CPR), multiple pregnancy rate (MPR), ovarian hyperstimulation syndrome (OHSS), abortion rates, and cycle demographics. Data were extracted, allowed for an intention-to-treat analysis, and meta-analyzed using combined direct/adjusted indirect methods. RESULTS Twenty-two RCTs met the inclusion criteria: Fostimon(®) vs. Metrodin-HP(®) (n = 2); Fostimon(®) vs. recFSH (n = 8); and Metrodin-HP(®) vs. recFSH (n = 12). LBR (odds ratio = 1.72; 95% confidence interval = 1.05-2.80), OPR/LBR, and CPR were all significantly higher favoring Fostimon(®). OPR, MPR, OHSS, and miscarriage rates were not significantly different. Pooled results for cycle demographics were not reported due to high heterogeneity. Conclusions. Fostimon(®) is superior to Metrodin-HP(®) regarding clinical outcomes. Therefore, care should be taken not to assume that all hFSH products have the same efficacy.
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Affiliation(s)
- Hesham G Al-Inany
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Cairo University, Cairo, Egypt.
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Zarek SM, Muasher SJ. Mild/minimal stimulation for in vitro fertilization: an old idea that needs to be revisited. Fertil Steril 2011; 95:2449-55. [DOI: 10.1016/j.fertnstert.2011.04.041] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2011] [Revised: 04/13/2011] [Accepted: 04/13/2011] [Indexed: 11/29/2022]
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Penzias AS. Improving results with assisted reproductive technologies: individualized patient-tailored strategies for ovulation induction. Reprod Biomed Online 2011; 22 Suppl 1:S83-6. [PMID: 21575854 DOI: 10.1016/s1472-6483(11)60013-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2004] [Revised: 03/08/2004] [Accepted: 04/14/2004] [Indexed: 12/01/2022]
Abstract
Infertility treatment should be made as efficacious as possible while being simple for patients. Although the treatment paradigm may be, at times, complex, patients deserve pure products that simplify protocol implementation while providing reliable outcomes. The more the treatment experience is simplified and improved, the more patients will benefit from the technology.
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Affiliation(s)
- A S Penzias
- Boston IVF, Harvard Medical School, Waltham, MA 02451, USA.
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van Wely M, Kwan I, Burt AL, Thomas J, Vail A, Van der Veen F, Al‐Inany HG. Recombinant versus urinary gonadotrophin for ovarian stimulation in assisted reproductive technology cycles. Cochrane Database Syst Rev 2011; 2011:CD005354. [PMID: 21328276 PMCID: PMC7388278 DOI: 10.1002/14651858.cd005354.pub2] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Several systematic reviews compared recombinant gonadotrophin with urinary gonadotrophins (HMG, purified FSH, highly purified FSH) for ovarian hyperstimulation in IVF and ICSI cycles and these reported conflicting results. Each of these reviews used different inclusion and exclusion criteria for trials. Our aim in producing this review is to bring together all randomised studies in this field under common inclusion criteria with consistent and valid statistical methods. OBJECTIVES To compare the effectiveness of recombinant gonadotrophin (rFSH) with the three main types of urinary gonadotrophins (i.e. HMG, FSH-P and FSH-HP) for ovarian stimulation in women undergoing IVF or ICSI treatment cycles. SEARCH STRATEGY An extended search was done according to Cochrane guidelines including the Menstrual Disorders & Subfertility Group's Specialised Register of controlled trials, The Cochrane Central Register of Controlled Trials, MEDLINE (1966 to May 2010), EMBASE (1980 to May 2010), CINAHL (1982 to May 2010), National Research Register, and Current Controlled Trials. SELECTION CRITERIA All randomised controlled trials reporting data comparing clinical outcomes for women undergoing IVF/ICSI cycles and using recombinant FSH in comparison with HMG or highly purified HMG, purified urinary FSH (FSH-P), and highly purified urinary FSH (FSH-HP) for ovarian hyperstimulation in IVF or ICSI cycles were included. DATA COLLECTION AND ANALYSIS Primary outcome measure was live birth rate and OHSS per randomised woman.Binary outcomes were analysed using odds ratios and also reported in absolute terms. Grouped analyses were carried out for all outcomes to explore whether relative effects differed due to key features of the trials. MAIN RESULTS We included 42 trials with a total of 9606 couples. Comparing rFSH to any of the other gonadotrophins irrespective of the down-regulation protocol used, did not result in any evidence of a statistically significant difference in live birth rate (28 trials, 7339 couples, odds ratio 0.97, 95% CI 0.87 to 1.08). This suggests that for a group with a 25% live birth rate using urinary gonadotrophins the rate would be between 22.5% and 26.5% using rFSH. There was also no evidence of a difference in the OHSS rate (32 trials, 7740 couples, OR 1.18, 95% CI 0.86 to 1.61). This means that for a group with 2% risk of OHSS using urinary gonadotrophins, the risk would be between 1.7% and 3.2% using rFSH. AUTHORS' CONCLUSIONS Clinical choice of gonadotrophin should depend on availability, convenience and costs. Further research on these comparisons is unlikely to identify substantive differences in effectiveness or safety.
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Affiliation(s)
- Madelon van Wely
- Academic Medical Centre, University of AmsterdamCentre for Reproductive Medicine, Department of Obstetrics and GynaecologyCenter Meibergdreef 9AmsterdamNetherlands1105 AZ
| | - Irene Kwan
- Institute of Education, University of LondonEvidence for Policy and Practice Information and Coordinating Centre (EPPI‐Centre), Social Science Research Unit (SSRU)10 Woburn SquareLondonUKWC1H 0NR
| | - Anna L Burt
- The Royal College of Obstetricians & GynaecologistsNational Collaborating Centre for Women`s and Children`s Health27 Sussex Place, Regent´s ParkLondonUKNW1 4RG
| | - Jane Thomas
- Auckland UniversityCochrane MSDG FMHSGrafton CampusAucklandNew Zealand
| | - Andy Vail
- University of ManchesterHealth Methodology Research GroupR & D Support Unit, Salford Royal HospitalStott LaneSalfordUKM6 8HD
| | - Fulco Van der Veen
- Academic Medical Center, University of AmsterdamCenter for Reproductive Medicine, Department of Obstetrics & GynaecologyUniversity of AmsterdamMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Hesham G Al‐Inany
- Faculty of Medicine, Cairo UniversityObstetrics & Gynaecology8 Moustapha Hassanin StManialCairoEgypt
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Wo ist die obere Grenze einer sinnvollen Gonadotropindosis bei Maßnahmen der ART. GYNAKOLOGISCHE ENDOKRINOLOGIE 2010. [DOI: 10.1007/s10304-009-0342-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Devroey P, Fauser BCJM, Diedrich K. Approaches to improve the diagnosis and management of infertility. Hum Reprod Update 2009; 15:391-408. [PMID: 19380415 PMCID: PMC2691653 DOI: 10.1093/humupd/dmp012] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2008] [Revised: 02/19/2009] [Accepted: 03/18/2009] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Recent advances in our understanding of the causes of infertility and of assisted reproductive technology (ART) have led to the development of complex diagnostic tools, prognostic models and treatment options. The Third Evian Annual Reproduction (EVAR) Workshop Meeting was held on 26-27 April 2008 to evaluate evidence supporting current approaches to the diagnosis and management of infertility and to identify areas for future research efforts. METHODS Specialist reproductive medicine clinicians and scientists delivered presentations based on published literature and ongoing research on patient work-up, ovarian stimulation and embryo quality assessment during ART. This report is based on the expert presentations and subsequent group discussions and was supplemented with publications from literature searches and the authors' knowledge. RESULTS It was agreed that single embryo transfer (SET) should be used with increasing frequency in cycles of ART. Continued improvements in cryopreservation techniques, which improve pregnancy rates using supernumerary frozen embryos, are expected to augment the global uptake of SET. Adaptation and personalization of fertility therapy may help to optimize efficacy and safety outcomes for individual patients. Prognostic modelling and personalized management strategies based on individual patient characteristics may prove to represent real progress towards improved treatment. However, at present, there is limited good-quality evidence to support the use of these individualized approaches. CONCLUSIONS Greater quality control and standardization of clinical and laboratory evaluations are required to optimize ART practices and improve individual patient outcomes. Well-designed, good-quality studies are required to drive improvements to the diagnosis and management of ART processes.
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Affiliation(s)
- P Devroey
- Center of Reproductive Medicine, Free University Brussels, Laarbeeklaan 101, Brussels 1090, Belgium.
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Synthesis and characterization of biologically active recombinant elk and horse FSH. Anim Reprod Sci 2009; 117:331-40. [PMID: 19500922 DOI: 10.1016/j.anireprosci.2009.05.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2008] [Revised: 05/01/2009] [Accepted: 05/11/2009] [Indexed: 11/24/2022]
Abstract
The objective of this investigation was to clone and express the elk and horse common alpha-subunit and FSH beta-subunit cDNAs, and to produce recombinant FSH from both species in vitro. The RNAs extracted from elk and horse pituitary glands were reverse-transcribed and amplified by polymerase chain reaction. The cDNAs corresponding to both subunits of elk and horse were cloned into the expression vector pBudCE4.1 and transfected into CRL-9096 cells. Expression of both genes was determined in the transfected cells by Northern and Western blot analysis. Recombinant elk and horse FSH secreted in culture media were characterized by an in vitro bioassay and RIA. When the recombinant products were assessed as activity over mass of FSH measured by RIA, the horse product was 5.6 times more potent than the elk product. The recombinant products injected to immature female Wistar rats stimulated ovarian growth. The results suggest that the products obtained correspond to recombinant versions of the native elk and horse FSH. The availability of these recombinant products may aid in the development of more predictable and efficient techniques of ovarian stimulation in cervids, equids, and other species as well.
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Verberg MFG, Macklon NS, Nargund G, Frydman R, Devroey P, Broekmans FJ, Fauser BCJM. Mild ovarian stimulation for IVF. Hum Reprod Update 2009; 15:13-29. [PMID: 19091755 DOI: 10.1093/humupd/dmn056] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Mild ovarian stimulation for in vitro fertilization (IVF) aims to achieve cost-effective, patient-friendly regimens which optimize the balance between outcomes and risks of treatment. METHODS Pubmed and Medline were searched up to end of January 2008 for papers on ovarian stimulation protocols for IVF. Additionally, references to related studies were selected wherever possible. RESULTS Studies show that mild interference with the decrease in follicle-stimulating hormone levels in the mid-follicular phase was sufficient to override the selection of a single dominant follicle. Gonadotrophin-releasing hormone antagonists compared with agonists reduce length and dosage of gonadotrophin treatment without a significant reduction in the probability of live birth (OR 0.86, 95% CI 0.72-1.02). Mild ovarian stimulation may be achieved with limited gonadotrophins or with alternatives such as anti-estrogens or aromatase inhibitors. Another option is luteinizing hormone or human chorionic gonadotrophin administration during the late follicular phase. Studies regarding these approaches are discussed individually; small sample size of single studies along with heterogeneity in patient inclusion criteria as well as outcomes analysed does not allow a meta-analysis to be performed. Additionally, the implications of mild ovarian stimulation for embryo quality, endometrial receptivity, cost and the psychological impact of IVF treatment are discussed. CONCLUSIONS Evidence in favour of mild ovarian stimulation for IVF is accumulating in recent literature. However, further, sufficiently powered prospective studies applying novel mild treatment regimens are required and structured reporting of the incidence and severity of complications, the number of treatment days, medication used, cost, patient discomfort and number of patient drop-outs in studies on IVF is encouraged.
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Affiliation(s)
- M F G Verberg
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, Utrecht, The Netherlands.
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Gerli S, Bini V, Di Renzo GC. Cost-effectiveness of recombinant follicle-stimulating hormone (FSH) versus human FSH in intrauterine insemination cycles: a statistical model-derived analysis. Gynecol Endocrinol 2008; 24:18-23. [PMID: 18224540 DOI: 10.1080/09513590701690241] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVE Recently we proposed a randomized trial specifically designed to evaluate the cost-effectiveness of two different protocols of stimulation in intrauterine insemination (IUI) cycles. Computer-simulated clinical models have been developed to perform pharmacoeconomic studies, creating a decision tree in which the complex procedure is performed and repeated. The present study was designed to compare the cost-effectiveness of recombinant follicle-stimulating hormone (rFSH) and human-derived FSH (hFSH) in ovarian stimulation and to indicate which protocol should be used in IUI cycles. STUDY DESIGN Two computer-generated decision tree models were constructed to compare the clinical effects and costs of rFSH versus hFSH in IUI cycles. A first decision tree model was built according to the trial previously published. In a second model, 10 000 hypothetical infertile patients were entered in a computer-generated simulation and were stimulated with two different protocols for IUI. IUI was hypothetically performed in both groups of patients with a known pregnancy, cancellation, miscarriage and abandonment rate. The two protocols were compared using a cost-effective analysis: cost-effectiveness ratios (CE) and incremental cost-effectiveness ratios (ICER) were calculated. The cost-effectiveness acceptability curve (CEAC) was constructed. RESULTS The overall estimated costs with each ovarian stimulation strategy in the first model demonstrated that rFSH was a less cost-effective strategy, with an ICER of euro 13,727. The CEAC showed that at a level of euro 0 of willingness to pay, hFSH was cost-effective in 73% of the samples while rFSH was cost-effective in 27% only. Recombinant FSH would be more cost-effective than hFSH at an effectiveness threshold of 0.170 and at a cost per cycle of euro 235. This finding was also confirmed by the acceptability curve obtained with 10,000 Monte Carlo simulations, in which hFSH was cost-effective in about 96-98% of samples at any threshold of willingness to pay. CONCLUSIONS This study represents the first statistical model developed with a computer-generated clinical simulation with the intent to elaborate a pharmacoeconomic comparison between rFSH and hFSH in ovarian stimulation for IUI cycles. Results demonstrated that hFSH is more cost-effective than rFSH.
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Affiliation(s)
- Sandro Gerli
- Department of Medical-Surgical Specialties and Public Health, Obstetrics and Gynecology, University of Perugia, Perugia, Italy.
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Daya S, Gunby J. WITHDRAWN: Recombinant versus urinary follicle stimulating hormone for ovarian stimulation in assisted reproduction cycles. Cochrane Database Syst Rev 2007; 2006:CD002810. [PMID: 17636708 PMCID: PMC10732276 DOI: 10.1002/14651858.cd002810.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- S Daya
- Department of Obstetrics & Gynecology, Clinical Epidemiology & Biostatistics, 2407 Carrington Place, Oakville, Ontario, Canada, L6J 7R6.
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Mohamed MA, Sbracia M, Pacchiarotti A, Micara G, Linari A, Tranquilli D, Espinola SMB, Aragona C. Urinary follicle-stimulating hormone (FSH) is more effective than recombinant FSH in older women in a controlled randomized study. Fertil Steril 2006; 85:1398-403. [PMID: 16600226 DOI: 10.1016/j.fertnstert.2005.10.049] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2005] [Revised: 10/25/2005] [Accepted: 10/25/2005] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
- Mohamed A Mohamed
- Department of Obstetrics, Gynecology and Perinatology, Policlinico Umberto I Hospital, La Sapienza University, Rome, Italy
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Macklon NS, Stouffer RL, Giudice LC, Fauser BCJM. The science behind 25 years of ovarian stimulation for in vitro fertilization. Endocr Rev 2006; 27:170-207. [PMID: 16434510 DOI: 10.1210/er.2005-0015] [Citation(s) in RCA: 338] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
To allow selection of embryos for transfer after in vitro fertilization, ovarian stimulation is usually carried out with exogenous gonadotropins. To compensate for changes induced by stimulation, GnRH analog cotreatment, oral contraceptive pretreatment, late follicular phase human chorionic gonadotropin, and luteal phase progesterone supplementation are usually added. These approaches render ovarian stimulation complex and costly. The stimulation of multiple follicular development disrupts the physiology of follicular development, with consequences for the oocyte, embryo, and endometrium. In recent years, recombinant gonadotropin preparations have become available, and novel stimulation protocols with less detrimental effects have been developed. In this article, the scientific background to current approaches to ovarian stimulation for in vitro fertilization is reviewed. After a brief discussion of the relevant aspect of ovarian physiology, the development, application, and consequences of ovarian stimulation strategies are reviewed in detail.
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Affiliation(s)
- Nick S Macklon
- Department of Reproductive Medicine and Gynecology, University Medical Center Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands.
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Arslan M, Bocca S, Mirkin S, Barroso G, Stadtmauer L, Oehninger S. Controlled ovarian hyperstimulation protocols for in vitro fertilization: two decades of experience after the birth of Elizabeth Carr. Fertil Steril 2005; 84:555-69. [PMID: 16169382 DOI: 10.1016/j.fertnstert.2005.02.053] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2004] [Revised: 02/02/2005] [Accepted: 02/02/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To critically discuss the current protocols for the management of controlled ovarian hyperstimulation in assisted reproduction technology. DESIGN Review of the literature and presentation of our experience. MAIN OUTCOME MEASURE(S) Ovarian response (peak serum estrogen levels, number of oocytes retrieved, quality of oocytes and embryos) and pregnancy outcome (clinical, delivery, and multiple pregnancy rates). RESULT(S) Controversies still exist regarding selection of gonadotropin preparation, choice of adjuvant therapy with GnRH analogues, and use of oral contraceptive pills. Patients identified as intermediate responders have an excellent outcome with adjuvant therapy with either a GnRH agonist (long protocol) or a GnRH antagonist, but tailoring of gonadotropin dose must be performed to achieve optimized results. High responders perform favorably with gentler gonadotropin stimulation that minimizes the occurrence of ovarian hyperstimulation syndrome. On the other hand, results in low responders remain suboptimal both in terms of ovarian response and oocyte/embryo quality in spite of a variety of stimulation regimens used. CONCLUSION(S) Ovarian stimulation is a critical step in in vitro fertilization therapy. A variety of controlled ovarian hyperstimulation regimens are available and efficacious, but individualization of management is essential and depends on assessment of the ovarian reserve. Identification of the etiologies of poor ovarian response constitutes a formidable challenge facing reproductive endocrinologists.
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Affiliation(s)
- Murat Arslan
- Department of Obstetrics and Gynecology, The Jones Institute for Reproductive Medicine, Eastern Virginia Medical School, Norfolk, Virginia, USA
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18
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Levi-Setti PE, Cavagna M, Bulletti C. Recombinant gonadotrophins associated with GnRH antagonist (cetrorelix) in ovarian stimulation for ICSI: comparison of r-FSH alone and in combination with r-LH. Eur J Obstet Gynecol Reprod Biol 2005; 126:212-6. [PMID: 16377062 DOI: 10.1016/j.ejogrb.2005.11.023] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2004] [Revised: 08/21/2005] [Accepted: 11/03/2005] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective was to verify the outcome of intracytoplasmic sperm injection (ICSI) with ovulation induction performed with GnRH antagonists, comparing the use of recombinant follicle-stimulating hormone (r-FSH) alone and in combination with recombinant luteinizing hormone (r-LH) in a prospective and randomized trial. STUDY DESIGN Forty male-factor infertile normo-ovulatory patients undergoing ovarian stimulation for ICSI took part in the study. After initiating ovarian stimulation with only r-FSH, all patients were treated with GnRH antagonist (cetrorelix). When beginning cetrorelix administration, the patients were randomized into two groups: in group I, 20 patients continued to receive r-FSH alone and in group II, 20 patients received combined r-FSH and r-LH. The number of metaphase II oocytes, estradiol concentration at the time of hCG administration, fertilization rate, grade 1 embryo rate, pregnancy rate per cycle, and implantation rate were measured. Results are expressed as mean+/-S.D. RESULTS In group I, the women's age was 32.3+/-2.30 years, and FSH concentration was 7.8+/-1.7 IU/ml. In group II, the women's age was 32.2+/-2.46 years and FSH concentration was 7.5+/-1.7 IU/ml. The number of oocytes retrieved was 9.6+/-2.9 and the number of metaphase II oocytes was 6.7+/-2.2 in group I. In group II the number of retrieved oocytes were 9.9+/-2.6 and the number of metaphase II oocytes 6.9+/-2.1 (p>0.05). Estradiol concentration at the time of hCG was 4.6+/-1.8 nm/l in group I and 6.7+/-2.0 nm/l in group II (p<0.01). Fertilization rate was 73.0% in group I versus 78.2% in group II. In group I, we obtained 53.9% of grade 1 embryos versus 54.4% in group II (p>0.05). Pregnancy and implantation rates in group I were 30.0 and 16.7%, respectively and in group II 35.0 and 20.4%, respectively (p>0.05). CONCLUSIONS The use of recombinant LH in addition to recombinant FSH may prevent a decrease in estradiol after GnRH antagonist administration, but does not influence positively the outcome of oocyte number, maturation, embryo quality, fertilization rate, pregnancy rate per cycle, and implantation rate.
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Affiliation(s)
- Paolo E Levi-Setti
- Unità Operativa di Medicina della Riproduzione, Istituto Clinico Humanitas, Via Manzoni 56, 20089 Rozzano, Milan, Italy.
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Tan SL, Child TJ, Cheung AP, Fluker MR, Yuzpe A, Casper R, Leung P, Cadesky K, Davis VJ. A randomized, double-blind, multicenter study comparing a starting dose of 100 IU or 200 IU of recombinant follicle stimulating hormone (Puregon) in women undergoing controlled ovarian hyperstimulation for IVF treatment. J Assist Reprod Genet 2005; 22:81-8. [PMID: 15844733 PMCID: PMC3455475 DOI: 10.1007/s10815-005-1497-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
PURPOSE To compare the efficiency and efficacy of two starting doses of recombinant FSH (follitropin-beta, Puregon) in women undergoing IVF treatment. METHODS This prospective, randomized, double-blind, multicentric (N = 6) study included 192 women undergoing IVF using the long protocol of GnRH agonist who received either 100 IU or 200 IU of r-FSH per day. Gonadotropin dose adjustment was allowed after day 4 of stimulation. RESULTS The average (SD) number of oocytes retrieved was 10.9 (5.4) and 12.2 (5.6) in the 100 IU and 200 IU group respectively (p = 0.067). The total doses of Puregon administered were 1887 IU and 2559 IU in the 100 IU and 200 IU group respectively. The number of transferable embryos, and the rates of pregnancies, cancelled cycles, miscarriages and adverse events including OHSS were comparable between the two groups. CONCLUSIONS Women undergoing IVF have similar outcomes whether recombinant FSH is commenced in a dose of 100 IU or 200 IU for the first 4 days of stimulation.
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Affiliation(s)
- Seang Lin Tan
- Department of Obstetrics and Gynecology, McGill University, Royal Victoria Hospital, Montreal, Quebec, Canada.
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Arce JC, Nyboe Andersen A, Collins J. Resolving methodological and clinical issues in the design of efficacy trials in assisted reproductive technologies: a mini-review. Hum Reprod 2005; 20:1757-71. [PMID: 15890741 DOI: 10.1093/humrep/deh818] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The validity, importance and relevance of randomized controlled trials depend on identifying an appropriate target population, ensuring adequate power, careful attention to the details of randomization and blinding, and selection of an endpoint that is important to the target population. With efficacy trials more than effectiveness trials, additional constraints are needed to reduce the variability that is typical of clinical practice: a narrowly defined sample, unvarying pre-randomization procedures and post-randomization treatments and follow-up that are as identical as possible for all patients. Efficacy trials comparing ovarian stimulation protocols should have strict protocol definitions, specific concomitant medications and minimal variability between centres with respect to stimulation goals and dose adjustments. Additionally, there should be narrowly defined criteria for administration of chorionic gonadotrophin, type of luteal support, embryo transfer and freezing policies. The goal of efficacy trials is to minimize the variability that is extrinsic to the comparison. When efficacy has been proven, effectiveness trials are needed to determine whether the effect of the new intervention is robust in the variability of typical clinical settings.
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Affiliation(s)
- J-C Arce
- Ferring Pharmaceuticals A/S, Clinical Research and Development, Copenhagen, Denmark.
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21
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Racowsky C, Orasanu B, Hinrichsen MJ, Ginsburg ES. Embryo quality based on ovulation induction: defining the differences. Reprod Biomed Online 2005; 11:22-5. [PMID: 16102282 DOI: 10.1016/s1472-6483(10)61294-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Catherine Racowsky
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Room 082, 75 Francis Street, Boston, MA 02115, USA.
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Dorn C. FSH: what is the highest dose for ovarian stimulation that makes sense on an evidence-based level? Reprod Biomed Online 2005; 11:555-61. [PMID: 16409703 DOI: 10.1016/s1472-6483(10)61163-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The widely applied practice of a gonadotrophin dose increase in case of low response is not on an evidence-based level and not efficacious. All known comparative studies failed to show a difference in favour of the high-dose group regarding their pregnancy rate per embryo transfer. However if more oocytes and more embryos are available for cryopreservation, the real benefit in terms of cumulative pregnancy outcome might be with the high-dose regimen. This publication will show - as a review of the literature - that the frequent clinical practice of increasing the FSH dose does not lead to a higher pregnancy rate, which is in line with recommendation for milder stimulation regimes in IVF. Thus, the collective evidence to date would suggest that 150 IU/day to 250 IU/day of FSH or human menopausal gonadotrophin (HMG) is an appropriate starting dose for most women undergoing ovarian hyperstimulation for IVF as part of a gonadotrophin-releasing hormone (GnRH) antagonist or a long GnRH agonist protocol.
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Affiliation(s)
- Christoph Dorn
- University of Bonn, Department of Obstetrics and Gynecology, Medical School, Division of Reproductive Medicine and Gynecologic Endocrinology, Germany.
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Gerli S, Casini ML, Unfer V, Costabile L, Bini V, Di Renzo GC. Recombinant versus urinary follicle-stimulating hormone in intrauterine insemination cycles: A prospective, randomized analysis of cost effectiveness. Fertil Steril 2004; 82:573-8. [PMID: 15374698 DOI: 10.1016/j.fertnstert.2004.04.026] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2003] [Revised: 04/06/2004] [Accepted: 04/06/2004] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare the clinical results and the cost effectiveness of urinary FSH and recombinant FSH in ovarian stimulation for IUI cycles. DESIGN Prospective, randomized trial. SETTING University Hospital, Perugia, and A.G.UN.CO. Obstetrics and Gynaecology Centre, Rome, Italy. PATIENT(S) IUI cycles were performed in 67 infertile patients. INTERVENTION(S) Protocols of ovarian stimulation with urinary FSH or recombinant FSH were randomly assigned, for a total of 138 cycles performed (67 and 71, respectively). MAIN OUTCOME MEASURE(S) Number of mature follicles, days of stimulation, number of ampules, and IU used per cycle, biochemical/clinical pregnancy rates and cost-effectiveness ratio. RESULT(S) Follicular development, length of stimulation, pregnancy and delivery rates were not statistically different. Although in the urinary FSH group a significantly higher number of IU of gonadotropins were used (815.5 +/- 284.9 vs. 596.0 +/- 253.8), the cost per cycle remained significantly lower (220.73 +/- 94.72 vs. 318.50 +/- 125.21). The cost-effectiveness ratio was 1,848.61 euro in the urinary FSH group and 2,512.61 euro in the recombinant FSH group. CONCLUSION(S) Urinary FSH and recombinant FSH are both effective in ovarian stimulation in IUI cycles. The urinary preparation is more cost effective due to the difference of its cost per IU.
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Affiliation(s)
- Sandro Gerli
- Centre of Reproductive and Perinatal Medicine, Department of Gynecological, Obstetrical and Pediatric Sciences, University of Perugia, Policlinico Monteluce, Perugia 06122, Italy.
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Levi-Setti PE, Cavagna M, Baggiani A, Zannoni E, Colombo GV, Liprandi V. FSH and LH together in ovarian stimulation. Eur J Obstet Gynecol Reprod Biol 2004; 115 Suppl 1:S34-9. [PMID: 15196714 DOI: 10.1016/j.ejogrb.2004.01.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The authors review the physiology of the ovulatory cycle and the role of the gonadotrophins in ovulation induction in patients with anovulatory disorders and in multifollicular development for assisted reproductive technologies. The use of gonadotrophins with luteinizing hormone (LH) activity and the use of recombinant LH associated with follicle stimulating hormone (FSH) are discussed. The authors point out that administration of gonadotrophins with LH activity is essential in hypogonadotropic hypogonadal anovulation, and data available in the medical literature allow the conclusion that recombinant LH may be added to all ovarian stimulation protocols because it is difficult to determine which patients will benefit from LH administration and there is no evidence that LH affects adversely the outcome of ovarian stimulation. The use of recombinant LH in addition to recombinant FSH may be particularly useful when a GnRH antagonist is associated with the ovarian stimulation regimen, by preventing the fall in estradiol and diminishing FSH requirements.
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Affiliation(s)
- Paolo E Levi-Setti
- Unità Operativa di Medicina della Riproduzione--Istituto Clinico Humanitas, Rozzano, Milan, Italy.
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de Mouzon J, Allavena E, Schmitt C, Frappé M. La fécondation in vitro en France. Approche économique et influence du choix des gonadotrophines (urinaires ou recombinantes) sur le coût. ACTA ACUST UNITED AC 2004; 32:508-18. [PMID: 15217566 DOI: 10.1016/j.gyobfe.2004.05.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2003] [Accepted: 05/04/2004] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The objective of the study was to make an economic evaluation of in vitro fertilization and to determine the impact of some factors on its cost, particularly the choice between recombinant follicle stimulating hormone (r-FSH) and urinary FSH (u-FSH) for ovarian stimulation. PATIENTS AND METHODS Costs were calculated in a Public Health view, by studying two phases: the stimulation cycle (including down-regulation) and the pregnancy (including the neonatal period). The calculation has included the side effects and the frozen embryos transfers. Economic data came from various sources: the French nomenclature on medical treatments (NGAP), the French drugs dictionary (Vidal) and the French Information system medical plan (PMSI). FSH costs were computed according to the currently marketed products, i.e., Fostimon (Laboratoires Genévrier, Sophia-Antipolis, France) for urinary FSH, and Gonal-F (Laboratoires Serono, Boulogne-Billancourt, France) and Puregon (Laboratoires Organon, Puteaux, France) for recombinant FSH. Two different ways of efficacy between u-FSH and r-FSH were considered for the calculations, those reported in Daya's meta-analysis (3.7% in favour of r-FSH for the clinical pregnancy rate per initiated cycle) and in the only double-blind study (Frydman et al., no difference). RESULTS The annual cost of ART reaches approximately 130 million Euros in France, for the cycles only, and 170 million Euros when including the pregnancy costs. Urinary FSH is much cheaper than recombinant FSH. Whereas the number of administered FSH units was higher in u-FSH, this results in a mean lower cost of 500 Euros per cycle (2422 Euros for u-FSH and 2959 Euros for r-FSH). For one complete year, in France, the potential over cost of recombinant products reaches 24 million Euros when considering only the cycles (128.4 vs. 104.0 million Euros) and 24-31 million Euros when pregnancies and babies (neonatal period) are considered (171.4 vs 140.7 and 147.0 million Euros, respectively). The IVF per baby cost can be estimated at 16 463 Euros for r-FSH and at 14 116 Euros (in case of equivalence between the two drugs) to 15 805 Euros (in case of a difference of 3.7% pregnancy per oocyte recovery) for u-FSH. CONCLUSION This gives Public Health lighting to the choices in the matter of ovulation stimulation. It shows the economic impact of the choice in the FSH type.
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Affiliation(s)
- J de Mouzon
- Inserm U569, hôpital de Bicêtre, 78, avenue du Général-Leclerc, 94272 Le Kremlin-Bicêtre, France.
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Penzias AS. Improving results with assisted reproductive technologies: individualized patient-tailored strategies for ovulation induction. Reprod Biomed Online 2004; 9:43-6. [PMID: 15257817 DOI: 10.1016/s1472-6483(10)62108-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Infertility treatment should be made as efficacious as possible while being simple for patients. Although the treatment paradigm may be, at times, complex, patients deserve pure products that simplify protocol implementation while providing reliable outcomes. The more the treatment experience is simplified and improved, the more patients will benefit from the technology.
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Affiliation(s)
- A S Penzias
- Boston IVF, Harvard Medical School, 40 Second Avenue, Waltham, MA 02451, USA.
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Gerli S, Casini ML, Unfer V, Costabile L, Mignosa M, Di Renzo GC. Ovulation induction with urinary FSH or recombinant FSH in polycystic ovary syndrome patients: a prospective randomized analysis of cost-effectiveness. Reprod Biomed Online 2004; 9:494-9. [PMID: 15588465 DOI: 10.1016/s1472-6483(10)61632-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The aim of this prospective, randomized trial was to compare the clinical results and the cost-effectiveness of urinary FSH (uFSH) and recombinant FSH (rFSH) in ovarian stimulation for intrauterine insemination (IUI) cycles in polycystic ovary syndrome (PCOS) patients. One-hundred and seventy PCOS infertile patients undergoing IUI were enrolled, and protocols of ovarian stimulation with uFSH or rFSH were randomly assigned. The total number of cycles performed was 379 (182 and 197, respectively). The main outcome measures were the number of mature follicles, the days of stimulation, the number of ampoules and IU used per cycle, the biochemical/clinical pregnancy rates, the number of multiple pregnancies and the cost-effectiveness. No statistically significant differences were found in the follicular development, length of stimulation, pregnancy rates, delivery rates and multiple pregnancies between the two groups. In the uFSH group, the cost per cycle remained significantly lower (218.51 +/- 88.69 versus 312.22 +/- 118.12; P < 0.0001), even though a significantly higher number of IU of gonadotrophins were used (809.3 +/- 271.9 versus 589.1 +/- 244.7; P < 0.0001). The cost-effectiveness (i. e. within a group, the total cost of all cycles divided by no. of clinical pregnancies) was 1729.08 in the uFSH group and 3075.37 in the rFSH group. In conclusion, uFSH and rFSH demonstrated the same effectiveness in ovarian stimulation in IUI cycles in PCOS patients. The urinary preparation is more cost-effective due to the difference of its cost per IU.
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Affiliation(s)
- Sandro Gerli
- Centre of Reproductive and Perinatal Medicine, Department of Gynecological, Obstetrical and Pediatric Sciences, University of Perugia, Italy.
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Calaf Alsina J, Ruiz Balda JA, Romeu Sarrio A, Caballero Fernandez V, Cano Trigo I, Gomez Parga JL, Gonzalez Batres C, Rodriguez Escudero FJ. Ovulation induction with a starting dose of 50 IU of recombinant follicle stimulating hormone in WHO group II anovulatory women: the IO-50 study, a prospective, observational, multicentre, open trial. BJOG 2003. [DOI: 10.1111/j.1471-0528.2003.02290.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Affiliation(s)
- Howard D McClamrock
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore 21201, USA.
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Yong PYK, Brett S, Baird DT, Thong KJ. A prospective randomized clinical trial comparing 150 IU and 225 IU of recombinant follicle-stimulating hormone (Gonal-F*) in a fixed-dose regimen for controlled ovarian stimulation in in vitro fertilization treatment. Fertil Steril 2003; 79:308-15. [PMID: 12568839 DOI: 10.1016/s0015-0282(02)04583-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To compare fixed daily doses of the recombinant FSH (rFSH) Gonal-F (150 IU vs. 225 IU) for ovarian stimulation in IVF-ET. DESIGN Single-center prospective, randomized study. Assisted conception unit of a university hospital. One hundred twenty-four women aged 23-41 years participated in the study. Exclusion criteria were as follows: FSH of >10 IU/L, polycystic ovarian syndrome, one ovary or previous ovarian surgery, previous poor response to ovarian stimulation, or ovarian hyperstimulation syndrome (OHSS). INTERVENTION(S) Randomized to commence 150 IU or 225 IU of Gonal-F per day without dose alterations during treatment. MAIN OUTCOME MEASURE(S) Number of oocytes retrieved and total rFSH dose. RESULT(S) More oocytes were retrieved in women aged <or=32 years in the 225-IU compared with the 150-IU group (11.8 +/- 8.0 vs. 7.0 +/- 5.8). In older women (>or=33 years), the number of oocytes retrieved in the two groups were similar. No significant differences were found for fertilization rate, number of embryos formed and cryopreserved, and pregnancy rates between the two groups. The total rFSH dose used was higher in the 225-IU group (2,595.0 +/- 510.0 vs. 1,897.5 +/- 457.5 IU). The cancellation rate due to insufficient ovarian response was higher in the 150-IU group (15.0% vs. 3.3%). All cases of ovarian hyperstimulation syndrome (n = 4) occurred in the 225-IU group. CONCLUSION(S) Two hundred twenty-five IU is more effective than 150 IU in younger women but requires a higher total dose of Gonal-F. The use of 225 IU in older women did not result in a higher oocyte yield, suggesting that 225 IU of rFSH does not compensate for the age-related decline in the number of follicles available for stimulation.
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Affiliation(s)
- Peter Y K Yong
- Assisted Conception Unit, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
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Daya S. Updated meta-analysis of recombinant follicle-stimulating hormone (FSH) versus urinary FSH for ovarian stimulation in assisted reproduction. Fertil Steril 2002; 77:711-4. [PMID: 11937121 DOI: 10.1016/s0015-0282(01)03246-0] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To determine the relative efficacy of recombinant FSH (rFSH) and urinary FSH (uFSH) for ovarian stimulation in assisted reproductive techniques (ART). DESIGN Systematic review and meta-analysis of randomized, controlled trials comparing rFSH and uFSH. SETTING Infertility centers providing treatment with ART. PATIENT(S) Patients undergoing IVF with or without ICSI. INTERVENTION(S) Controlled ovarian stimulation using uFSH or rFSH (follitropin alpha or follitropin beta). MAIN OUTCOME MEASURE(S) Primary: rate of clinical pregnancy per cycle. Secondary: rates of spontaneous abortion, multiple pregnancy, and severe ovarian hyperstimulation syndrome (OHSS); total gonadotropin dose; serum E(2) level and number of follicles at hCG administration; number of oocytes retrieved. RESULT(S) Eighteen trials were included in the meta-analysis. Subgroup analyses demonstrated higher pregnancy rates with both follitropins compared with uFSH. However, statistical significance was reached only in the follitropin alpha versus uFSH comparison in IVF cycles, with an additional pregnancy for every 19 patients treated. Fewer units of rFSH than uFSH achieved the same E(2) level and oocyte yield. No differences were found between treatments in rates of spontaneous abortion, OHSS, and multiple gestation. CONCLUSION(S) rFSH produced higher pregnancy rates per cycle than uFSH when follitropin alpha was used in IVF, and the total gonadotropin dose required was lower.
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Affiliation(s)
- Salim Daya
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada L8N 3Z5.
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Ravhon A, Lavery S, Aurell R, Trew G, Margara R, Winston R. Clinical experience with recombinant follicle-stimulating hormone (FSH) and urinary FSH: a retrospective case- controlled analysis. Fertil Steril 2001; 75:920-5. [PMID: 11334903 DOI: 10.1016/s0015-0282(01)01684-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To compare the efficacy and efficiency of recombinant FSH (rFSH) and urinary FSH (uFSH). DESIGN Retrospective case controlled analysis. SETTING An assisted reproduction unit at a university center. PATIENT(S) 1388 patients undergoing long protocol in vitro fertilization/embryo transfer (IVF-ET) using buserelin acetate from day 2 of the cycle and either rFSH (follitropin beta) (n = 694) or uFSH (n = 694) with equal number of ampules started (rFSH: 50 IU, uFSH: 75 IU). INTERVENTION(S) Patients were included in the two groups of treatment after matching for similarity in age and type of treatment (IVF or intracytoplasmic sperm injection). MAIN OUTCOME MEASURE(S) Total dose of FSH, ovarian response, and IVF outcome. RESULT(S) Patients who received uFSH experienced a shorter period of stimulation, and a higher number of oocytes were collected. The total FSH used was lower in the rFSH group, and they required a lower FSH dose per oocyte retrieved. The implantation and pregnancy rates were similar between the uFSH and rFSH groups. In both groups implantation and pregnancy rates were higher when intracytoplasmic sperm injection was performed as compared with IVF. CONCLUSION(S) The implantation and pregnancy rates are similar when either rFSH or uFSH is used (when compared on an ampule-to-ampule basis, rFSH: 50 IU, and uFSH: 75 IU). However, a significantly lower total FSH dose was used in the rFSH group with a lower FSH dose per oocyte collected.
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Affiliation(s)
- A Ravhon
- Department of Reproductive Medicine and Science, Imperial College School of Medicine, Hammersmith Hospital, London, United Kingdom.
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Hugues JN, Bry-Gauillard H, Bständig B, Uzan M, Cedrin-Durnerin I. Comparison of recombinant and urinary follicle-stimulating hormone preparations in short-term gonadotropin releasing hormone agonist protocol for in vitro fertilization-embryo transfer. J Assist Reprod Genet 2001; 18:191-6. [PMID: 11432109 PMCID: PMC3455363 DOI: 10.1023/a:1009408029509] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE To compare the efficiency and efficacy of two recombinant human FSH (r-FSH) and urinary (u-FSH) preparations in patients undergoing superovulation for IVF-ET using a short-term gonadotropin releasing hormone agonist (GnRH-a) (Triptorelin) protocol. METHODS A total of 88 women undergoing IVF-ET were included in this prospective study. They were randomized to receive u-FSH (150 IU/d), follitropin-alpha (100 IU/d), or follitropin-beta (100 IU/d) for 2 days, and dosages were subsequently adjusted according to the ovarian response. RESULTS The FSH dose required for the overall stimulation was significantly lower in patients treated with r-FSH than in those treated with u-FSH while serum FSH values were higher in the latter group. There were no statistically significant differences in ovarian response and IVF outcome between r-FSH preparations. CONCLUSIONS Recombinant FSH preparations have a higher efficiency than urinary ones in patients undergoing IVF-ET using a short-term GnRH-a protocol. In this situation, the two recombinant follitropins have comparable effectiveness.
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Affiliation(s)
- J N Hugues
- Reproductive Medecine Unit, Department of Gynaecology and Obstetrics, University Paris XIII, France.
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Gordon UD, Harrison RF, Fawzy M, Hennelly B, Gordon AC. A randomized prospective assessor-blind evaluation of luteinizing hormone dosage and in vitro fertilization outcome. Fertil Steril 2001; 75:324-31. [PMID: 11172834 DOI: 10.1016/s0015-0282(00)01701-5] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine the effect of exogenous LH dosage on IVF outcome. DESIGN Single-blinded (assessor-blinded) study with random assignment of treatment groups. SETTING Human Assisted Reproduction Unit, Rotunda Hospital, Dublin, Ireland. PATIENT(S) Infertile normogonadotropic women undergoing their first cycle of IVF were studied. INTERVENTION(S) Patients were randomized to gonadotropin drugs with varying doses of LH per ampule: recombinant FSH containing no LH (group 0, n = 39), urinary FSH containing <1 IU of LH per ampule (group 1, n = 30), hMG containing 25 IU of LH per ampule (group 25, n = 30), and hMG containing 75 IU of LH per ampule (group 75, n = 29). The FSH dose was kept constant at 75 IU per ampule. A long-protocol GnRH-analog regimen was used. MAIN OUTCOME MEASURE(S) Dose and duration of gonadotropin stimulation, follicle and oocyte numbers, implantation rate, and pregnancy rate. RESULT(S) The median duration of ovarian stimulation; median number of gonadotropin ampules used; serum E2 levels; and numbers of follicles, oocytes, and embryos were similar among the four groups. Median LH levels on the day of hCG administration, however, differed significantly. Live birth rates per cycle differed markedly, but statistical significance was not achieved (23%, 7%, 20%, and 31% for groups 0, 1, 25, and 75, respectively). A significant trend in implantation rates was noted with increasing LH dosage of the urinary preparations (19%, 10%, 18%, and 28% for groups 0, 1, 25, and 75, respectively). CONCLUSION(S) In the present study, although the residual endogenous LH after down-regulation was adequate for ovarian response and E2 synthesis, the addition of exogenous LH improved implantation. An FSH/LH ratio of 75/75 IU per ampule appeared to be the optimum dose.
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Affiliation(s)
- U D Gordon
- Centre for Reproductive Medicine, University of Bristol, 4 Priory Road, Clifton, Bristol BS8 1TY, United Kingdom.
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Harrison RF, Jacob S, Spillane H, Mallon E, Hennelly B. A prospective randomized clinical trial of differing starter doses of recombinant follicle-stimulating hormone (follitropin-beta) for first time in vitro fertilization and intracytoplasmic sperm injection treatment cycles. Fertil Steril 2001; 75:23-31. [PMID: 11163812 DOI: 10.1016/s0015-0282(00)01643-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Comparison of the efficacy of differing starter doses of recombinant follicle stimulating hormone (rFSH) for IVF and intracytoplasmic sperm injection cycles when the treatment is administered both subcutaneously and intramuscularly. DESIGN Single center 1-year prospective randomized study. SETTING Academic teaching hospital. PATIENT(S) 345 couples in first cycle. INTERVENTION(S) Treatment with subcutaneous or intramuscular rFSH, followed by E(2) and ultrasound follicle tracking, with later oocyte collection and zygote transfer. MAIN OUTCOME MEASURE(S) Ovarian response and other clinically dependent variables. RESULT(S) Group 1 patients, with day-3 FSH levels of less than 8.5 U/L, were randomized to begin treatment with rFSH at 150 IU (n = 146) or 200 IU (n = 151). The total dose of the drugs used was significantly lower in 150 IU group, as was the number of ICSI metaphase II oocytes. No other significant differences found. The dosage was increased in 9% on day 5. Group 2 patients, with day-3 FSH levels of greater than 8.5 U/L, were randomized to treatment with rFSH at 300 IU (n = 24) or 400 IU (n = 24). No significant outcome differences found between the two subgroups. Pregnancy rates for this group were half that of Group 1.Intramuscular administration was significantly more likely to result in a need for increased dosage than was subcutaneous administration. The level of E(2) at the time of hCG treatment was significantly lower in the intramuscular 150 IU group. CONCLUSION(S) In the main study total dosage used, the ICSI metaphase II oocyte numbers were significantly lower and there was a trend toward a need for a dosage increase on day 5 when 150 IU rFSH was the starter dosage, as compared to a starting dosage of 200 IU. Otherwise, there is little advantage to using the higher dosage.
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Affiliation(s)
- R F Harrison
- RCSI Department of Obstetrics and Gynaecology and Human Assisted Reproduction Unit, Rotunda Hospital, Dublin, Ireland
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Daya S, Gunby J. Recombinant versus urinary follicle stimulating hormone for ovarian stimulation in assisted reproduction cycles. Cochrane Database Syst Rev 2000:CD002810. [PMID: 11034767 DOI: 10.1002/14651858.cd002810] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- S Daya
- Obstetrics & Gynecology, Clinical Epidemiology & Biostatistics, McMaster University, HSC-3N52, 1200 Main Street West, Hamilton, Ontario, Canada, L8N 3Z5.
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