Dose accuracy of the follitropin alfa pen injector 2.0, the follitropin alfa:lutropin alfa 2:1 combination pen injector 2.0 and the choriogonadotropin alfa pen injector 1.0 used for fertility treatment

BACKGROUND

This study aimed to confirm that the incremental dose/clicks system dispenses accurate doses for the Merck family of fertility pen injectors.

RESEARCH DESIGN AND METHODS

Set doses (Vset) for three dose dial settings (minimum dose [Vmin], midpoint dose [Vmid] and maximum dose [Vmax] for the follitropin alfa, choriogonadotropin alfa [D2 classification: single use/variable dose], and follitropin alfa:lutropin-alfa 2:1 combination pen injectors) or a single Vset for the choriogonadotropin alfa (D1 classification: single use/single dose) were assessed. Last dose administered by the multi-dose device was assessed for the 900 IU, 450 IU, 300 IU and 150 IU follitropin alfa, and the 900:450 IU, 450:225 IU and 300:150 IU follitropin alfa:lutropin-alfa 2:1 combination pen presentations.

RESULTS

Dose accuracy tests for Vmin, Vmid and Vmax for the follitropin alfa and the follitropin alfa:lutropin-alfa 2:1 combination pen injectors, and last dose administered, were within acceptable limits according to ISO 11,608-1:2012/2014. Dose accuracy tests for the single use/single dose device classification and the single use/variable dose device classification of the choriogonadotropin alfa pen injector were also within the acceptable limits, according to ISO 11608-1:2000/2014.

CONCLUSIONS

The Merck family of fertility pen injectors functions reliably and the incremental dose/clicks system dispenses accurate doses.

P-598 Dose accuracy of the follitropin-alfa, follitropin-alfa/lutropin-alfa and choriogonadotropin-alfa pen injectors used for fertility treatment

Study question

Do the Merck family of fertility pen injectors (follitropin-alfa, follitropin-alfa/lutropin-alfa, choriogonadotropin-alfa) meet the International Organization for Standardization (ISO 11608-1:2000/2012/2014) product-validation requirements?

Summary answer

Each presentation of the family of fertility pen injectors performed as per the state-of-the-art product-validation specifications for dose accuracy in ISO 11608-1:2000/2012/2014 under atmospheric conditions.

What is known already

Pen injectors for medically assisted reproduction must comply with ISO 11608-1:2000/2012/2014, which specifies essential performance requirements, including dose accuracy, and represent a benchmark for product reliability. Product-validation studies of the follitropin-alfa pen injector showed that three presentations (300 IU, 450 IU, and 900 IU) reliably dispensed accurate doses under a range of conditions, but no information was available for the follitropin-alfa/lutropin-alfa and choriogonadotropin-alfa pen injectors. This study was done to confirm that the incremental dose/clicks system was accurate for equivalence of volume (dose) delivered at standard atmospheric conditions for the complete Merck family of fertility pen injectors (follitropin-alfa, follitropin-alfa/lutropin-alfa, choriogonadotropin-alfa).

Study design, size, duration

Laboratory-based dose accuracy measurement testing was carried out under standard atmospheric conditions, as specified in ISO 11608-1:2000/2012/2014, between 2015 and 2020.

Participants/materials, setting, methods

Set doses (Vset) for three dose dial settings (minimum dose [Vmin], midpoint dose [Vmid] and maximum dose [Vmax] [follitropin-alfa, choriogonadotropin-alfa, and follitropin-alfa/lutropin-alfa]) or a single Vset (choriogonadotropin-alfa) were assessed, as appropriate. The last dose administered by the multi-dose device and cartridge and total extractable dose were assessed on the 900 IU and 300 IU follitropin-alfa and the 900 IU/450IU and 300/150 IU follitropin-alfa/lutropin-alfa-pen presentations. Sixty measurements per assessment were made for each Vset.

Main results and the role of chance

Measurements were performed at two manufacturing sites. Dose accuracy tests for Vmin, Vmid and Vmax (dose dial settings of 12.5 IU, 87.5 IU and 150 IU, respectively, for the 150 IU pen [n = 2,226 (one site)]; dose dial settings of 12.5 IU, 162.5 IU and 300 IU, respectively, for the 300 IU pen [n = 742 per site]; and dose dial settings of 12.5 IU, 237.5 IU and 450 IU, respectively, for the 450 IU [n = 180 per site] and 900 IU pens [n = 410 per site]) for the follitropin-alfa and the follitropin-alfa/lutropin-alfa pen injectors were within the acceptable limits defined in ISO 11608-1:2000/2012/2014. The results of further assessments of last dose and total extracted volume for each presentation of these devices were also within acceptable limits. Dose accuracy tests for the single use/single dose device classification (D1) of the choriogonadotropin-alfa pen injector (n = 210 [one site]) showed that the Vset (6,500 IU) was within the acceptable limits according to ISO 11608-1:2000/2012/2014. Furthermore, dose accuracy tests for the single use/variable dose device classification (D2) of the choriogonadotropin-alfa pen injector (n = 180 [one site]) showed that the Vmin (260 IU), Vmid (3,380 IU) and Vmax (6,500 IU) values were also the within acceptable limits.

Limitations, reasons for caution

These assessments were carried out by laboratory scientists, who are not the intended users of the pen injectors, and were not delivered into human tissue; therefore, although these conditions meet the international standards, they do not reflect the real-world use of the pen injectors by patients.

Wider implications of the findings

The Merck family of fertility pen injectors functions reliably and the incremental dose/clicks system dispenses accurate doses, providing users with confidence that they can accurately administer the prescribed dose and minimize drug wastage outside of a clinic environment, which is more important than ever in light of the COVID pandemic.

Trial registration number

not applicable

Fertility technologies and how to optimize laboratory performance to support the shortening of time to birth of a healthy singleton: a Delphi consensus

PURPOSE

To explore how the assisted reproductive technology (ART) laboratories can be optimized and standardized to enhance embryo culture and selection, to bridge the gap between standard practice and the new concept of shortening time to healthy singleton birth.

METHODS

A Delphi consensus was conducted (January to July 2018) to assess how the ART laboratory could be optimized, in conjunction with existing guidelines, to reduce the time to a healthy singleton birth. Eight experts plus the coordinator discussed and refined statements proposed by the coordinator. The statements were distributed via an online survey to 29 participants (including the eight experts from step 1), who voted on their agreement/disagreement with each statement. Consensus was reached if ≥ 66% of participants agreed/disagreed with a statement. If consensus was not achieved for any statement, that statement was revised and the process repeated until consensus was achieved. Details of statements achieving consensus were communicated to the participants.

RESULTS

Consensus was achieved for all 13 statements, which underlined the need for professional guidelines and standardization of lab processes to increase laboratory competency and quality. The most important points identified were the improvement of embryo culture and embryo assessment to shorten time to live birth through the availability of more high-quality embryos, priority selection of the most viable embryos and improved cryosurvival.

CONCLUSION

The efficiency of the ART laboratory can be improved through professional guidelines on standardized practices and optimized embryo culture environment, assessment, selection and cryopreservation methodologies, thereby reducing the time to a healthy singleton delivery.

Is there an association between oocyte number and embryo quality? A systematic review and meta-analysis

This systematic review and meta-analysis determined the association between aspirated after ovarian stimulation and top/good quality embryos obtained in women undergoing ovarian stimulation for IVF/intracytoplasmic sperm injection (ICSI). MEDLINE, EMBASE, Scopus, CINAHL and Web of Science were searched for English-language publications on top/good-quality embryos at cleavage (day 2/3) and/or blastocyst (day 5/6) developmental stages, up to 18 November 2017. Twenty-eight studies (three prospective and 25 retrospective) reporting data on 291,752 assisted reproductive technology (ART) cycles were considered eligible. We confirmed a strong positive association between oocytes retrieved and top/good-quality day 2/3 embryos (weighted correlation coefficient [r_w] = 0.791), day 5/6 embryos (r_w = 0.901), metaphase II oocytes (r_w = 0.988), oocytes exhibiting two pronuclei (r_w = 0.987) and euploid embryos (r_w = 0.851); P < 0.001 for all correlations (evaluated in subsets of the 17 studies). Data from 5657 cycles showed that the group with the most oocytes aspirated had the most top/good-quality day 2/3 embryos (pooled standardized mean differences (high [>15] versus low [<4] 1.91, 95% confidence interval [CI] 1.05-2.77, P < 0.0001; high versus medium [4-15] 1.15, 95% CI 0.74-1.55, P < 0.0001; medium versus low 1.41, 95% CI 0.79-2.03, P < 0.0001). Individual participant meta-analysis would enable accurate determination of these associations and other outcomes.

(1)H NMR based metabolic profiling of day 2 spent embryo media correlates with implantation potential

Morphological assessment is currently the primary technique for selection of viable embryos for uterine transfer during assisted reproductive techniques, however this method has limited predictive power. The objective of this study was to employ NMR based metabolic profiling analysis of spent embryo culture media to identify novel biomarkers of embryo viability and provide insight into the metabolism of a viable embryo. A total of 37 patients undergoing IVF/ICSI treatment were recruited and 58 media samples were collected from embryos that were transferred back to the uterus. 1H NMR spectra were acquired and analyzed resulting in the quantification of 12 metabolites in the media samples. Analysis of metabolite ratios revealed significant differences between those patients with positive (n = 27) and negative (n = 31) urinary βhCG results. Some of the most biologically relevant differences include a 17% increase in the formate to glycine ratio and a 22% decrease in the citrate to alanine ratio in the spent embryo media from the positive pregnancy group. Overall, the results indicate that metabolic profiling may provide a means of identifying biomarkers that aid selection of viable embryos.

Metabolic profiling of human follicular fluid identifies potential biomarkers of oocyte developmental competence

The use of metabolomic based techniques to aid oocyte and embryo selection has gained attention in recent years. Previous work from our laboratory has demonstrated that the (1)H NMR-based metabolic profile of follicular fluid correlates with oocyte developmental potential. Patients undergoing IVF at the Merrion Fertility Clinic had follicular fluid collected at the time of oocyte retrieval. The fatty acid composition of follicular fluid from follicles where oocytes fertilised and developed into multi-cell embryos (n=15) and from oocytes that fertilised normally but failed to cleave (n=9) (cleaved vs non-cleaved) was compared. Statistical analysis was performed on the data using univariate and multivariate techniques. Analysis of the fatty acid composition revealed that there were nine fatty acids significantly different between follicular fluid from the cleaved and the non-cleaved sample groups. Of particular interest were the higher concentration of total saturated (P=0.03) and the lower concentration of total polyunsaturated fatty acids in the non-cleaved sample group (P=0.001). Random forest classification models were used to predict successful cleavage in follicular fluid samples producing models with errors rates of <10%. Receiver operating characteristic analysis demonstrated that the model had good predictability with an area under the curve of 0.96. The panel of fatty acid biomarkers identified in this study indicates that the fatty acid composition of follicular fluid may be more predictive in comparison to other previously identified biomarkers. Following validation in a larger cohort, these biomarkers may have the potential to be used in fertility clinics to aid the selection of oocytes in the future.

Reducing twin pregnancy rates after IVF--elective single embryo transfer (eSET)

Multiple pregnancy is a major complication of IVF and is associated with increased maternal, fetal and neonatal morbidity. Elective single embryo transfer (eSET) during IVF, rather than the more standard transfer of two embryos (double embryo transfer or DET), has been shown to significantly reduce the multiple pregnancy rate associated with IVF, while maintaining acceptable pregnancy rates. Couples undergoing IVF in 2008 who met good prognostic criteria had eSET performed. Pregnancy and twinning rates were compared with those for similar couples in 2007 who had DET. Couples unsuccessful with a fresh cycle of treatment had subsequent frozen embryo transfer cycles with DET. The cumulative pregnancy rate was similar for each group. However there were no multiple pregnancies in the eSET group, compared to 4 twins of 5 pregnancies in the DET group. 96% of eligible couples agreed to eSET. ESET is successful in and acceptable to good prognosis Irish couples undergoing IVF.

Frozen-thawed transfer cycles: are they comparable with fresh?

Cryopreservation of zygotes and subsequent thaw and transfer is an established ART treatment. We assessed if success rates frozen-thawed (day 2) zygotes are comparable with the outcome in fresh cycles of treatment. We performed a prospective follow-up and analysis of all frozen (FZT) and fresh cycles of treatment during a 12 months period. One hundred and nineteen patients in the frozen-thawed and 652 in the fresh group had a transfer. The overall thaw-survival rate was 71.7%. Clinical pregnancy rates per thaw and transfer were respectively 15.1% and 21% in the frozen and 29.1% (per transfer) in the fresh group. Implantation rates in fresh and frozen cycles were 16% and 12.3% respectively. The pregnancy loss rate was higher in the FZT group (29% vs. 18.3%). Cryopreservation of good quality zygotes, after fresh transfer offers optimal success rates in subsequent frozen treatment. It also encourages consideration of elective single zygote transfers.

Are seminal fluid microorganisms of significance or merely contaminants?

OBJECTIVE

To determine the contribution of urethral and skin flora to seminal fluid cultures and the relation between bacteriospermia and seminal leukocytes.

DESIGN

Prospective study.

SETTING

IVF-ET unit at a university teaching hospital.

PATIENT(S)

Sixty men starting an IVF-ET program.

INTERVENTION(S)

Culture of sequential first-catch urine, midstream urine, and semen samples with evaluation of seminal leukocytes.

MAIN OUTCOME MEASURE(S)

A comparison of microbes from first-catch urine, midstream urine, and semen samples and the correlations of seminal microbes, elevated leukocyte concentrations, and pregnancy.

RESULT(S)

Microorganisms were detected in 37% of first-catch urine samples, 27% of midstream urine samples, and 51% of semen samples. Most microorganisms were gram-positive microbes and were common to both urine and semen samples. Mean and median leukocyte concentrations were 0.98 x 10(6)/mL and 0.10 x 10(6)/mL, respectively. There was no correlation between seminal microbes and raised leukocytes or between leukocytospermia and/or bacteriospermia and pregnancy.

CONCLUSION(S)

Microorganisms are commonly found in insignificant quantities in the semen of asymptomatic men. The frequent isolation of gram-positive microbes common to both urine and semen and the absence of a correlation with raised leukocyte concentrations suggest that bacteriospermia most commonly represents contamination.

Processing of semen in an antibiotic-rich culture medium to minimize microbial presence during in vitro fertilization

OBJECTIVE

To identify and determine the prevalence of microorganisms in preprocessed and postprocessed semen in an IVF-ET program.

DESIGN

Prospective study.

SETTING

University Teaching Hospital.

PATIENT(S)

Seventy-four men undergoing preprogram evaluation, each producing two semen samples.

INTERVENTION(S)

Semen processing with a wash and swim-up technique in a penicillin- and streptomycin-rich medium.

MAIN OUTCOME MEASURE(S)

The identity and prevalence of seminal microorganisms before and after processing.

RESULT(S)

Sixty-three percent of individual unprocessed semen samples grew microorganisms, the majority of which were nonpathogenic. Thirty-three men (44.6%) had microbes identified in repeat samples, four had identical organisms each time. Twenty (27%) had positive cultures in one sample, negative in the other. Twenty-one (28.4%) had consistently sterile semen. After seminal processing, the recovery rate for microbes was 5%. Microbial presence after processing did not correlate with either the sperm swim-up concentration or the initial microbial concentration.

CONCLUSION(S)

Bacteriospermia is common. The microorganisms found rarely are replicated and most likely represent contamination. Wash and swim-up semen preparation in an antibiotic rich culture medium effectively eliminates 95% of organisms.

Microbial contamination in an in vitro fertilization-embryo transfer system

OBJECTIVE

To determine sources and transmission of microorganisms in IVF-ET and efficacy of in-place controlling systems.

DESIGN

Prospective study.

SETTING

In Vitro Fertilization-Embryo Transfer Unit at a university teaching hospital.

PATIENTS

Twenty-eight couples undergoing 30 completed IVF-ET cycles.

INTERVENTIONS

Gamete and embryo processing in a penicillin and streptomycin-rich medium.

MAIN OUTCOME MEASURES

Presence of microorganisms at various stages of IVF-ET. Fertilization, cleavage, and pregnancy rates.

RESULTS

In 50% of cycles no microorganisms were isolated and in the other 50% microbes were cultured from various loci. Cultures of four preprocessed semen samples were positive and corresponding postprocessed samples negative. Microbes were detected in 27% of needle washes after oocyte collection; in 40% and 32% of follicular fluids from left and right ovaries, respectively; and in two culture media from egg-sperm incubations at 20 hours after insemination. No microorganisms were grown from media from zygote incubations. Fertilization, cleavage, and pregnancy rates were independent of microbial presence.

CONCLUSION

Seminal fluid and transvaginally collected oocytes are potential sources of microbial contamination of the IVF-ET culture system. A penicillin- and streptomycin-rich culture medium is effective in removing contaminating microbes. End point measures are not affected by commensal contamination.

A randomized prospective study of early follicular or midluteal initiation of long protocol gonadotropin-releasing hormone in an in vitro fertilization program

OBJECTIVE

To determine the optimum menstrual cycle time to initiate a long-protocol gonadotropin-releasing hormone agonist (GnRH-a) down-regulation regimen before hMG stimulation before IVF.

DESIGN

Randomized, prospective, single, first cycle study.

SETTING

University teaching hospital.

PATIENTS

Eighty-six infertile couples undergoing IVF-ET attempt under rules for Ireland.

INTERVENTION

Gonadotropin-releasing hormone agonist administered intranasally from day 1 or 21 of menstrual cycle. Human menopausal gonadotropin commenced when pituitary down-regulation was confirmed.

MAIN OUTCOME MEASURES

Ovarian response, cancellation, fertilization, and pregnancy rates.

RESULTS

No significant differences found between day 1 and day 21 initiation. But starting on day 1 is more easily recognizable by patients and avoids the possibility of administering GnRH-a in the presence of an unsuspected pregnancy.

CONCLUSIONS

Both follicular and luteal phase initiation of GnRH-a long-protocol down-regulation are equally efficacious. In our clinical context, patients and management favor commencing on day 1.

The value of subcellular elemental analysis in the assessment of human spermatozoa

The conventional sperm parameters of concentration, motility and morphology are descriptive and have proved of little value in predicting the fertilization potential of semen. New complementary tests of sperm function are required. Previous studies evaluating the subcellular elemental composition of spermatozoa using X-ray microanalysis with electron microscopy suggested that this technique may have the potential to confirm spermatozoal intracellular normality. This study compares the semen from 18 men of subfertile relationships and from 10 men of proven fertility with reference to concentration, motility, morphology and the elemental composition of spermatozoa. The elements phosphorus, sodium, potassium, chlorine and sulphur were detected and there were large intra- and intersample variations in the concentrations of these elements. There was no statistically significant difference in the elemental composition between the two groups. This study suggests that the spermatozoa of fertile and subfertile men are similar in subcellular elemental composition and in the maintenance of an ionic gradient. This test is therefore not a useful predictor of sperm function.

Should gonadotropin-releasing hormone down-regulation therapy be routine in in vitro fertilization?

OBJECTIVE

To compare the classic clomiphene citrate (CC) and hMG regime for ovarian stimulation before IVF in women who received hMG post-long protocol down-regulation with either 3 mg triptorelin [INN] IM or 150 mg buserelin acetate four times daily intranasally. Furthermore, if possible, to determine the preferred method of down-regulation.

DESIGN

A prospective study of 150 women randomized blind to the clinician to one of three alternative ovarian stimulation regimes when passing for the first time through an IVF program during 1992.

RESULTS

Triptorelin [INN] down-regulated significantly more quickly than buserelin acetate. The non-down-regulated group CC and hMG used significantly less hMG in a shorter time. In these women LH levels at hCG administration were significantly higher. No other intergroup differences were found. Pregnancy and take-home baby rates for the overall study were, respectively, 32%:25% (per cycle) and 42%:33%; (per ET) for the triptorelin [INN] group 28%:22% and 39%:31%; the CC group 32%:24% and 46%:34%; and the buserelin acetate group 34%:28% and 42%:34%.

CONCLUSIONS

Triptorelin [INN] and buserelin acetate were comparable in all parameters except down-regulation. The former was significantly quicker and more sure. In none of the clinical end points measured, however, was the classic CC and hMG non-down-regulation regime significantly less effective or troublesome than where down-regulation was used. These results therefore show that although indications for down-regulation before IVF exist, it should not be used on all patients.

Preparation of antibody free spermatozoa by in vitro immunodepletion using immunobeads

In the present study ejaculates from six infertile men with antisperm antibodies were processed on a six step discontinuous percoll gradient. This treatment yielded a sperm fraction with a different percentage of sperm with antisperm antibodies. The resultant sperm preparation was incubated with immunobeads. Sperm were recovered following incubation by swim-up. Sperm recovered at the end of processing showed reduced populations of antisperm antibodies. Even though sufficient numbers of sperm were obtained to consider assisted reproduction, reduced motility was recorded in four of the ejaculates when compared with routine processing. Following trial preparations of semen samples this technique may play a role in sperm selection for assisted conception.

Mid to late luteal phase steroids in minimal stage endometriosis and unexplained infertility

Serum and peritoneal fluid concentrations of progesterone and 17 beta-oestradiol were measured during days 20-27 of the luteal phase in 33 women with minimal stage endometriosis and 21 with unexplained infertility. The results were analysed using Student's t-test and straight line regression analysis. In both groups, 17 beta-oestradiol and progesterone values were several-fold higher than the corresponding serum values and there were significant correlations between the peritoneal fluid and the serum steroid values. In the peritoneal fluid there was a significant reduction in both progesterone and its ratio with 17 beta-oestradiol in women with minimal stage endometriosis (P < 0.03, P < 0.04, respectively). The peritoneal fluid levels of 17 beta-oestradiol in women with minimal stage endometriosis were, however, not significantly altered. Despite the correlations between peritoneal fluid and serum steroid levels, there were no significant changes in the serum concentrations of progesterone, 17 beta-oestradiol or the ratio of progesterone to 17 beta-oestradiol in women with minimal stage endometriosis. It is concluded that luteal phase progesterone and its relationship to 17 beta-oestradiol are subtly altered in infertile women with minimal stage endometriosis compared with women with unexplained infertility. These alterations may be more clearly demonstrated in peritoneal fluid rather than in peripheral blood, possibly because the latter contains steroids which are of non-ovarian origin and are also constantly affected by the liver enzyme activity and enterohepatic circulation of individual subjects.

Does patient semen quality alter during an in vitro fertilization (IVF) program in a manner that is clinically significant when specific counseling is in operation?

PURPOSE

It has been shown that the stress of infertility may impair semen quality. Whether counseling can attenuate this affect is unproven. This study examines, in an IVF program setting, where specific counseling is in operation, whether semen collected on the day of oocyte recovery is significantly different from that obtained during the prior clinical suitability assessment of the couple.

RESULTS

In the 125 consecutive couples examined, there were no significant overall differences in semen volume or sperm density. There was a significant increase in sperm motility on the day of oocyte retrieval (P < 0.001). Twenty-three patients (18.4%) showed an increase in quality, and 21 (16.8%) a decrease, on the day of oocyte recovery. The environment of production appeared to exert no influence. Fertilization failure occurred in seven couples, three (14%) of whom presented for the first time with decreased semen parameters on the day of IVF. This compares with 1 of 23 (4%) fertilization failure in those whose parameters increased.

CONCLUSION

The semen quality of the vast majority of the patients studied in this highly counseled program does not appear to be significantly affected by the superstress of participation in the day of oocyte recovery.

A mid-luteal phase comparison of peritoneal fluid volume and its content of PGF2 alpha and PGE2 in women with minimal stage endometriosis and a normal pelvis

The study was carried out following the approval of our Hospital Ethics Committee and an informed patient consent. Samples of peritoneal fluid were collected from the Pouch of Douglas at laparoscopy from 32 subjects with minimal stage endometriosis (MSE) and 16 without any visible signs of endometriosis (normal group). All the subjects were in 20 to 23 day period of their menstrual cycle which was histologically confirmed. The endometriosis score was estimated according to the American Fertility Score, 1985 and the fluid samples were collected in tubes containing heparin/indomethacin and standing in ice. The samples were estimated for volume, erythrocyte count, prostaglandin(PG) F2 alpha, and PGE2. Radioimmunoassay techniques were used for the estimation of PGs. Prostaglandin F2 alpha, was measured in its parent form while PGE2 was converted into bicyclic-PGE2 before estimation. The results indicate that the peritoneal fluid in women with MSE has higher than normal levels of PGF2 alpha and lower than normal levels of PGE2 and its PGE2: PGF2 alpha ratio is also below normal. There is no difference in the volume of peritoneal fluid in the two groups. Provided the fluid sample is not contaminated with abdominal blood its erythrocyte count is not related to its prostaglandin content.