P-788 A proof-of-concept study evaluating the effect of personalized dosages of follitropin delta in intra-uterine insemination (IUI): Personalized IUI Treatment Study (PITS)

Study question

Would a personalized dosing regimen of follitropin delta based on AMH and body weight allow better management of women’s IUI cycle?

Summary answer

A personalized regimen of follitropin delta based on AMH and body weight has increased pregnancy rate without having increased multiple pregnancies in our studied population.

What is known already

IUI has been widely used as a common treatment for infertile couples due to its simplicity and low cost. Some studies have shown that cumulative live birth rate (LBR) can be increased by use of controlled ovarian stimulation. A recent meta-analysis reported that a protocol based on exogenous gonadotropins increases the LBR. Hence, this technique remains a treatment option reaching a LBR ranging from 8.5 to 12.2%. Nevertheless, this increase in LBR is associated with a non-negligible rate of adverse events, including ovarian hyper-stimulation syndrome (OHSS) and multiple pregnancies (7.2% - 9% of twins and 0.4% - 0.5% of triplets).

Study design, size, duration

This prospective, phase 2, open-label study enrolled 110 women 18 - 42 years of age from January 2020 to January 2021. Participants had received up to 3 IUIs.

The primary efficacy variable was the number of cycles where target number of 2 or 3 mature follicles (MII) were reached. The secondary objective and safety variable were the incidence of cycle cancellations, the clinical pregnancy rate and the proportion of multiple pregnancies over 3 consecutive cycles.

Participants/materials, setting, methods

Follitropin delta dosing algorithm is modeled to achieve 8-14 oocytes in IVF cycles. To achieve 2-3 mature follicles, the algorithmically derived dose was divided by 4. Follitropin delta adjustment for subsequent IUIs were based on number of MII at previous IUI and age.

Dose modification was made when excessive or no response were observed at stimulation day 8 during ultrasound monitoring. If urine pregnancy test was positive, a viability ultrasound was prescribed at 6-8 weeks.

Main results and the role of chance

Descriptive statistics were used in this proof-of-concept study. The mean age of all subjects was 34.46 years (± 4.5). The mean weight was 69.2 kg (± 11.24), AMH - 3.84 ng/ml (± 13), FSH - 6.3 IU (± 2.61), antral follicular count - 15 (± 8.6). The mean number of years of infertility was 2.48 ± 3.57.

The percentage of patients who obtained 2 or 3 follicles during the 3 consecutive IUI was 34%, 37% and 47% respectively. The percentage of patients who reached ≥3 follicles was 1.9%, 0% and 1.4% respectively, demonstrating the ability of the proposed dosing regimen to achieve the desired goal.

The percentage of cycle cancelation was stable throughout the 3 cycles: 8.5%, 2.4% and 8.8% respectively. Only 6 multiple pregnancies over 40 clinical pregnancies (15%) were observed, showing the proposed dosing regimen’s safe approach. The cumulative clinical pregnancy rate over the 3 cycles among patients completing the study was 37.7%, and the cumulative live birth rate (calculated ad hoc, as it was not part of the study protocol) was 33%, leading to the personalized dosing regimen proposed in this study to be considered for use in clinical practice.

Limitations, reasons for caution

The study’s limitations are its exploratory nature, open-label design and small sample size.

Wider implications of the findings

PITS study is the first one using follitropin delta for stimulation in intra-uterine insemination. It confirms the initial hypothesis of a potential benefit of a personalized dosing regimen of follitropin delta. A larger, randomized controlled study will be needed to confirm these initial findings.

Trial registration number

NCT03830723

P-617 Cost-effectiveness analysis of In Vitro Fertilization (IVF) antagonist protocols utilizing highly purified human menopausal gonadotropin (HP-hMG) and three different recombinant FSH (rFSH) preparations

Study question

Is there a mixed ovarian stimulation antagonist protocol for IVF that obtains more good quality blastocysts with less cost?

Summary answer

Mixed protocol of HP-hMG and follitropin delta obtains a significantly more good quality blastocysts with significantly lower cost per embryo obtained.

What is known already

FSH and LH are used for controlled ovarian stimulation (COS) to increase the number of oocytes produced in IVF. Determination of a stimulation protocol and FSH dosage is generally established by the physician based on the patient’s age, body weight and ovarian reserve profile. Mixed protocols (concomitant HP-hMG and rFSH) for ovarian stimulation have been used to obtain better quality oocytes and embryos and thus, higher pregnancy rates compared to the use of rFSH alone. However, to date no data exist comparing cost-effectiveness of mixed protocols using different rFSH preparations.

Study design, size, duration

This is a cost-effectiveness analysis of the retrospective cohort study encompassing COS for IVF with 3 different mixed protocols performed between January 2018 and September 2019 in 2 fertility clinics. The 267 subjects evaluated were between 18 and 42 years of age and were divided into 3 groups of 89 subjects each according to the rFSH used: group A follitropin alfa; group B follitropin beta and group D follitropin delta.

Participants/materials, setting, methods

HP-hMG was used in all three groups while different rFSH was prescribed. All three groups used an antagonist protocol. IVF or intra-cytoplasmatic sperm injection (ICSI) was used as clinically indicated. Resulting embryos were cultured until day 5 or 6. The dose of gonadotropins used, the number of mature oocytes (MII), the number of utilizable blastocysts and the FSH/blastocyst ratio were evaluated. For cost-effectiveness analysis we used prices accepted by the provincial healthcare system in Quebec.

Main results and the role of chance

The mean age of subjects was 34.62 years (± 3.74) and weight 71.65 kg (± 14.61). No significant differences were observed in age or weight among groups. Since follitropin delta is administered in micrograms, the comparison between rFSH preparations was performed using dose equivalence between (10 µg follitropin delta) and (150 IU follitropin alpha and beta). Statistically significant differences were observed among groups in mean total dose of FSH (IU) (A = 4269 IU vs. B = 3947 IU vs. D = 3713 IU, p = 0.01), and number of days of stimulation (A = 11.6 vs. B = 10.6 vs. D = 11.4, p < 0.01). Group D used less gonadotropins despite a longer stimulation. No statistically significant differences were observed in the number of MII oocytes. However, the number of good quality utilizable blastocysts was significantly higher in group D (4.8) than in group A (3.9) or B (3.6). The FSH/blastocyst ratio was significantly lower in group D (370) than in the other groups (A = 541, B = 653). The total price per cycle was similar (A= $4,028 vs. B= $3,649 D= $3,740), however the price per embryo obtained was significantly lower in group D ($779) than in the other groups (A= $1,033, B= $1,014).

Limitations, reasons for caution

The limitation of this cost-effectiveness analysis is the retrospective nature of the study.

Wider implications of the findings

Our analysis demonstrates that the price per cycle was similar between the groups, however the price per embryo obtained was significantly lower in group D compared to the other groups. This gives follitropin delta an advantage in terms of cost-effectiveness.

Trial registration number

NA

P-074 Sperm deoxyribonucleic acid integrity decreases with age and exhibits a rapid decline beyond the age of 35: a retrospective evaluation of 3446 semen samples

Study question

Does advancing paternal age correlate with sperm DNA fragmentation index (DFI) and is there a cut-off age beyond which sperm DFI increases significantly?

Summary answer

In infertile men, DFI correlate with advancing paternal age and should be routinely screened starting 35 years of age.

What is known already

In recent decades, birth rates have substantially increased for men older than 30 years because of advanced age of marriage, rising life expectancy at birth, modern societal norms, and accessibility to assisted reproductive technology (ART). Advanced paternal age has been associated with a decline in conventional semen parameters (volume, concentration, motility, DFI), as well as, reduced fertility, increased risk of miscarriage, structural chromosomal aberrations and complex epigenetic disorders. Several studies have recommended testing sperm DFI in infertile men with advanced age (≥40 years) as it may provide prognostic information for couple attempting natural and assisted reproduction.

Study design, size, duration

This is a retrospective study of 3446 semen samples from patients under investigation for infertility between April 2016 and January 2022. Semen samples were obtained after 2-3 days of sexual abstinence. Patients were stratified into seven groups based on their age: patients ≤ 29 years (n = 127; 3.7%), 30-35 years (n = 868; 25.2%), 36-39 years (n = 863; 25.0%), 40-45 years (n = 1017, 29.5%), 46-49 years (n = 321; 9.3%), 50-55 years (n = 179, 5.2%) and ≥ 56 years (n = 71, 2.1%).

Participants/materials, setting, methods

Conventional semen parameters were assessed according to the WHO criteria and DFI was evaluated by TUNEL assay using the APODirect Kit run on BDAccuriC6 flow cytometer. Pearson’s r was used for correlation analysis between sperm concentration, DFI and paternal age. DFI results for each stratified patient group were evaluated by one-way ANOVA, followed by Tukey pos-hoc multiple comparison test. Results are presented as the mean±standard error and a P-value of < 0.05 was considered statistically significant.

Main results and the role of chance

In this cohort of men with a mean age of 39.5 years ± 0.1 (range 23-76 years), sperm deoxyribonucleic acid (DNA) fragmentation (21.1% ± 0.2) was positively correlated with age (r = 0.23, p˂0.001). In contrast, the correlation between sperm concentration and age was non-significant (r = 0.03, p = 0.07). Mean DFI in patients segregated into seven age groups were: ≤29 years (15.7% ± 0.8), 30-35 years (17.7% ± 0.4), 36-39 years (19.7% ± 0.4), 40-45 years (22.6% ± 0.4), 46-49 years (26.2% ± 0.9), 50-55 years (26.7% ± 1.2) and ≥ 56 years (31.1% ± 2.0). Mean %DFI level in the 26-29 and 30-35 age groups were non-significantly different (p = 0.65). However, mean %DFI level in the 36-39 age group was significantly higher than in the 26-29 and 30-35 age groups (p = 0.02 and p = 0.03, respectively). Mean %DFI level in the older age groups (40-45, 46-49, 50-55 and ≥ 56 years) were all significantly higher than in the 26-29 or 30-35 age groups (p˂0.001). Using a %DFI threshold level of 16.9%, 46.0% of patients ˂36, 52.2% of men aged 36-39, 60.2% of men aged 40-45, 67.3% of men aged 46-49, 72.6% of men aged 50-55 and 74.7% of men aged ≥56 years had an elevated DFI.

Limitations, reasons for caution

This is a retrospective analysis that did not account for confounding variables (e.g., clinical diagnosis, gonadotoxin exposure, febrile illness) that may affect conventional sperm parameters and DFI.

Wider implications of the findings

Our results underline the relationship between paternal age and sperm DFI and demonstrate a significant decline in sperm DNA fragmentation in men over the age of 35 years. The data suggest that we may want to reconsider the age cut-off we traditionally use to define advanced paternal age.

Trial registration number

No trial registration

P-106 Total motile sperm count and oral ovulation induction protocols are not predictors of success in donor insemination cycles: Results from a large retrospective cohort study

Study question

to investigate the effect of total motile sperm (TMS) count, and ovulation induction on clinical pregnancy rate in artificial insemination with donor (AID) cycles.

Summary answer

TMS count is not a predictor of sucess, and natural cycles are as effective as oral ovulation induction in donor inseminations

What is known already

There are inconsistent results regarding the effect of sperm parameters on success rates of artificial insemination with donor (AID). Besides, the use of gonadotropin stimulation for ovulation induction in this category of patients is questionable, and its effectiveness over natural cycles is not yet confirmed in the literature.

Study design, size, duration

Patients who underwent AID cycles at the university-affiliated fertility center-OVO clinic in Montreal, Canada between 2011 and 2015 were retrospectively selected. A total of 4333 AID cycles were performed on 1179 patients, resulting in 744 pregnancies.

Participants/materials, setting, methods

Cycles were divided into 8 groups based on TMS count: <0.5, [0.5-1[, [1-5[, [5-10[, [10-20[, [20-40[, [40-80[, and ≥80. A TMS of 10 to 20 million was selected as a reference level. Ovulation induction was divided into oral stimulation, combined oral and gonadotropin stimulation and gonadotropin-only stimulation, and compared to natural cycles. Regression analysis and a predictive model of clinical pregnancy in AID cycles were generated from patient demographic and cycle characteristics.

Main results and the role of chance

There was no significant difference in positive β-hCG result, clinical pregnancy, multiple pregnancy and miscarriage rates when comparing all ranges of TMS count to a reference of 10 to 20 million. When dividing patients based on the protocol for ovulation induction, clinical pregnancy rate was significantly higher in the gonadotropin-only stimulation group (OR 4.116,[1.379,12.287]) but not in other types of stimulation, as compared to natural cycles. hCG triggering resulted in a similar clinical pregnancy and miscarriage rates, but a higher multiple pregnancy rate when compared to urinary LH testing (7.7% versus 1.3%, p = 0.045). A multivariate logistic regression analysis for predictors of clinical pregnancy accounting for relevant demographic and cycle characteristics was conducted. No significant difference was noted in different ranges of TMS and the groups of ovulation induction. In this model, age was found to be a significant predictor. In particular, with every one-year increase in age, the odds of clinical pregnancy decreases by 6.4% (Adjusted OR 0.936; 95%CI [0.914, 0.958]).

Limitations, reasons for caution

In our study, cycles with TMS count below 1 million are limited. Thus, results should be viewed with caution in this group, without cycle cancellation, since clinical pregnancy can be achieved. Moreover, our results cannot be generalized on infertile couples given the characteristics of our population of interest.

Wider implications of the findings

Minimal or maximal cut-off values for TMS in AID cycles should not be used as indicators for cycle cancellation. Natural cycles are as successful as oral ovulation induction. hCG trigger, unless indicated, should not be used as it is associated with higher risk of multiple pregnancy without increasing clinical pregnancy.

Trial registration number

not applicable