P-677 Increasing the efficacy of FSH with a potentiating monoclonal antibody

Study question

Can we potentiate FSH activity with antibodies to improve ovarian stimulation?

Summary answer

IGYXOS developed a potentiating monoclonal antibody that improves FSH potency and efficacy in vitro and in vivo as demonstrated in different animal models.

What is known already

FSH plays a key role in reproduction. For a controlled ovarian stimulation in IVF cycles, FSH-containing preparations are injected to patients in order to obtain mature and fertilizable oocytes. However, the efficacy of these treatments is frequently limited and sometimes several attempts are needed before reaching a pregnancy and a live birth.

It was previously demonstrated that breeding animals treated with gonadotropins could develop anti-gonadotropin antibodies that enhance their bioactivity instead of inhibiting it. These females had a high kidding rate and sometimes were hyperprolific.

Study design, size, duration

IGYXOS developed a monoclonal antibody (mAb) directed against human FSH. The mAb CF12 was selected based on its ability to increase FSH activity in vitro and in vivo in female rat. Its potentiating activity was tested on different human FSH preparations. The potentiating effect of CF12 was further investigated in ewe treated with mAb alone or FSH alone.

Participants/materials, setting, methods

CF12 was tested in vitro on HEK 293 cells expressing the human FSH receptor and a cell reporter system for cAMP. In vivo, the mAb was tested according to the Steelman and Pohley protocol on different human FSH preparations. Its potentiating effect was also investigated in an ovulation induction protocol on mature ewes.

Main results and the role of chance

In HEK 293 cells expressing the human FSH receptor, CF12 combined to FSH improved both the potency (EC50) and the efficacy (Emax) of FSH by increasing the cyclic AMP production at all tested FSH concentrations. The potentiating activity was confirmed in immature female rats treated with hCG+FSH alone or combined to mAb, twice a day, during 3 days. The animals were sacrificed the fourth day of treatment and the weight of the ovaries was compared. Ovaries weight was significantly increased in the group treated with hCG/FSH+CF12 compared to hCG/FSH only.

To further analyze the effect of CF12 on ovulation induction, it was investigated in ewe as a breeding animal model. Animals were first synchronized with a progestagen and then treated either with FSH alone or with CF12 alone. The number of ovulations was investigated by endoscopy by counting corpora lutea and the progesterone secretion was measured over the luteal cycle. All females treated with CF12 ovulated (100%) by contrast 40% ovulated with FSH treatment. The ovulation rate was 1.8 fold higher in group treated with CF12 compared to FSH group. Moreover, progesterone secretion during luteal phase was increased in animals treated with CF12 suggesting a better quality of corpora lutea.

Limitations, reasons for caution

After several proofs of concept obtained in different animal models, the compound is currently in the humanization phase before starting the CMC process and then preclinical studies.

Wider implications of the findings

The potentiating antibody CF12 is a new concept. It represents an interesting strategy in reproductive health, particularly to improve the IVF outcome. CF12 is currently developed for human application by our company and could be a game changer in the field of ovarian stimulation by enhancing the efficacy of FSH.

Trial registration number

not applicable

Is there a link between plasma progesterone 1-2 days before frozen embryo transfers (FET) and ART outcomes in frozen blastocyst transfers?

OBJECTIVE

To study the efficacy of combined administration of subcutaneous and vaginal progesterone for priming frozen blastocysts transfers, looking at progesterone levels and ART outcome.

DESIGN

Retrospective study.

SETTING PATIENTS

Three hundred and twenty frozen blastocyst transfer cycles conducted in 213 women aged up to 42 years, BMI between 18 and 30 kg/m², with anatomically normal uterus who underwent frozen embryo transfers (FETs) from February 2019 to December 2019 with a combined luteal-phase support (LPS) associating subcutaneous and vaginal progesterone. Patients with recurrent pregnancy loss (RPL) were excluded.

RESULTS

When using combined vaginal and subcutaneous LPS, SPL >10.50 ng/mL in 95% of cases, with a minimum value of 7.02 ng/mL. CPR, OPR, and global miscarriage rates were 38.4%, 30.9%, and 19.5%, respectively. Analyzing results per quartiles, revealed that miscarriage rates were significantly inferior, and IR were higher in the upper two quartiles of serum progesterone (>21.95 ng/mL) on the day before FET, while there was no difference in CPR and OPR.

CONCLUSIONS

We report ART outcome of frozen blastocyst transfers performed using a combination of vaginal and subcutaneous progesterone for LPS. ART results were honorable and SPL favorable 1-2 days before FET in 99% of cases.

Circulating Procoagulant Microparticles in Women with Unexplained Pregnancy Loss: a New Insight

One of the frequently proposed mechanisms for pregnancy losses refers to uteroplacental thrombosis. However the contribution of classical thrombotic risk factors remains questionable and, if real, does not account for a large number of pregnancy losses. The aim of this study was to investigate the presence of circulating procoagulant microparticles, a new marker of cell activation already associated with various prothrombotic clinical settings. Microparticles were assessed by an original prothrombinase assay on platelet depleted plasma obtained from 74 women with a history of pregnancy loss without apparent cause and 50 controls. Patients were studied at least 2 months after the last obstetrical event and were classified into 2 groups: 49 women with at least 3 consecutive spontaneous abortions at or before the 10th postmenstrual week and 25 with at least one fetal death beyond the 10th postmenstrual week. Among the 74 patients, 41 had increased levels of circulating microparticles, 29 belonging to the group of early pregnancy loss (59%) and 12 to the group of late pregnancy loss (48%). The high prevalence of increased levels of procoagulant microparticles in both groups makes this new marker very promising for the understanding, follow up and therapeutical handling of pregnancy loss.

Tadalafil for Endometrial Growth in Clomiphene Citrate stimulated cycles in an IUI programma: A pilot study

AIM OF THE STUDY

The objective of this study was to assess the impact of tadalafil on endometrial growth, the uterine artery pulsatility index (PI) and the uterine artery resistance index (RI) in patients under clomiphene ovarian stimulation for intrauterine insemination (IUI).

METHODS

This randomized crossover study included 30 patients with a normal endometrium over 53 cycles, and 46 of those cycles in 23 patients were included in the analysis. In group A the patients were under 100 mg clomiphene daily for five days (2-6) and 5 mg tadalafil daily for 7 days (4-10). For Group B (control) the patients only received clomiphene. Measurements of the endometrium, PI, RI and estradiol determinations were taken on cycle days 4, 8 and 10.

RESULTS

We observed a better endometrial growth in Group A compared to Group B: 7.5 ± 2.1 mm vs 5.5 ± 1.2 mm, P < 0.0002 and 8.9 ± 1.8 mm vs 6.3 ± 1.8 mm, P < 0.0002 on days 8 and 10, respectively. Additionally, a progressive decrease in the RI was observed in Group A but not in Group B from day 8 (0.77 ± 0.15 vs 0.85 ± 0.18, P = 0.059) to day 10 (0.74 ± 0.20 vs 0.87 ± 0.14, P < 0.017). However, no differences were observed in PI or serum estradiol between Group A and Group B.

CONCLUSION

The use of tadalafil improved endometrial growth in patients under clomiphene ovarian stimulation with no significant effect on the uterine artery Pulsatility Index and serum estradiol.

Single-port approach to benign gynecologic pathology. A review

Laparoscopy is the gold standard in gynecological surgery. Single-port laparoscopic surgery, has been developed in order to improve minimally invasive surgery. We analyzed single-port approach in benign gynecologic pathology and made a bibliographic research on Pubmed and Medline from January 2000 to January 2015. From what emerges from the papers taken into consideration, single-port laparoscopy can be used for salpingostomy or salpingectomy to treat tubal ectopic pregnancy, benign adnexal disease (ovarian cystectomy, salpingo-oophorectomy), and for hysterectomy. We do not have enough data for complex procedures like myomectomy or hysteropexy. Robotic single-port laparoscopy seems to be a very attractive perspective and its use in benign gynecology surgery is expanding. More and more ergonomic limitations of single-port laparoscopy are corrected by development of articulated or flexible instruments and camera. Beyond these preliminary results, more ample prospective studies with an adapted and standardized instrumentation are thus essential to highlight real profits.

Introduction: don't forget the environment of our patients

The Views and Reviews section of this issue deals with environmental consequences for gametes, embryos, the fetus, newborns, and childhood development.

Surgical strategies of fertility preservation in female cancers

Conservative and functional surgery is increasingly used in surgical oncology. Although radical surgery remains the gold standard for treatment of cervical, endometrial and ovarian cancers, conservative approaches have been developed, aiming at preserving the potential of fertility of young patients. These procedures are proposed to selected patients, depending on histological parameters and prognostic factors as well. Therefore, a multidisciplinary approach is mandatory to weight the benefits and risks of fertility-sparing surgery.

In vitro maturation remains an interesting procedure

The number of live births from IVM oocytes has been increasing over the past two decades. Data concerning the health of IVM infants are reported by the authors of this Views and Reviews.

Extreme infertility

New germ cells and new organs open new areas in the approach to treating infertility.

[Cancer, fertility preservation and gonadotropins]

The recent emergence of oncofertility raises the question of ovarian stimulation and its risks when performed for oocyte or/and embryo cryopreservation in a fertility preservation program. The relation between ovarian stimulation and cancer has been marked by the possible direct or indirect tumorigenic role for pituitary gonadotrophins in the tumorogenesis. Although the growth of many gonadal and extragonadal tumors is stimulated by gonadal sex hormones, whose production is regulated by gonadotrophins, there is still a lack of data to consider FSH and LH as tumor promoters. The purpose of this brief review is to present on one hand, the questions raised by the administration of exogenous gonadotrophins in cancer patients and on the other, to evaluate both experimental and clinical data about the possible relation between gonadotrophins and tumorogenesis.

[Preimplantation diagnosis with HLA typing: birth of the first double hope child in France]

Preimplantation genetic diagnosis (PGD) is authorized in France since 1999. After 10 years, technical results are encouraging. With the development of new technologies, our team is able to diagnosis the large majority of chromosome translocations and 75 monogenic diseases. However, PGD remains limited because of the growing augmentation of demands causing an increasing delay for the first procedure of more than 18 months. Since 2006, 19 couples asked for a PGD with HLA typing. In January 2011, 11 couples have already been included in our PGD program. The birth of the first child after PGD with HLA typing offers new perspectives of treatment for these couples.

Fertility Preservation in Women with Cancer: Importance of a Multidisciplinary Approach

For all patients affected by a disease that could impair fertility before or during the reproductive lifespan, strategies to preserve their fertility and the ability to bear their own children is likely to be of utmost importance. While fertility preservation is a promising option, most of the technologies currently used are far from being well-established or are still experimental. Patients should be aware that no method guarantees success. Psychological and ethical impacts of fertility preservation are major concerns and should be included in the multidisciplinary approach to the patients.

Ureteral injury after transvaginal ultrasound-guided oocyte retrieval: a complication of in vitro fertilization-embryo transfer that may lurk undetected in women presenting with severe ovarian hyperstimulation syndrome

OBJECTIVE

To report a case of ureteral injury after transvaginal ultrasound-guided oocyte retrieval, initially misdiagnosed as an ovarian hyperstimulation syndrome (OHSS).

DESIGN

Case report.

SETTING

University hospital.

PATIENT(S)

A 26-year-old patient with a history of primary infertility due to polycystic ovary syndrome (PCOS) presented with acute pelvic pain after transvaginal ultrasound-guided oocyte retrieval for in vitro fertilization-embryo transfer.

INTERVENTION(S)

Initial clinical presentation, context, and imaging results were consistent with the diagnosis of mild OHSS. Recurrence of the pelvic pain with radiation to the right lumbar region suggested the possibility of a urinary complication.

MAIN OUTCOME MEASURE(S)

Successful detection and management of unilateral ureteral injury in a patient with PCOS.

RESULT(S)

Uro-computed tomography scan helped with the diagnosis of right pelvic-ureter lesion. Patient underwent cystoscopy with uncomplicated right ureteral stent placement and delivered a healthy baby at term.

CONCLUSION(S)

Although ureteral injury after transvaginal ultrasound-guided oocyte retrieval is a rare complication of IVF-ET, it could have serious sequelae such as fistula formation and renal dysfunction if untreated. Clinicians must be aware that it may lurk undetected in women presenting OHSS.

[Cancellation of IVF-ET cycles: poor prognosis, poor responder, or variability of the response to controlled ovarian hyperstimulation? An analysis of 142 cancellations]

INTRODUCTION

This retrospective study aimed at analyzing IVF-ET management and outcome after cancellation of a first cycle for poor response.

PATIENTS AND METHOD

One hundred and forty-two infertile patients were included in this observational study. After an overall analysis on the outcome of the second IVF-ET attempt, a sub-analysis was performed according to the presence or the absence of poor prognostic criteria defined as mentioned: patient age superior to 38 years old, antral follicle count (3-9 mm in diameter) inferior to 10 on cycle day 3 and day 3 serum AMH and FSH levels less than 1 ng/mL and more than 10 IU/mL, respectively. Main outcome measures were the cancellation rates, pregnancy and live birth rates.

RESULTS

When a controlled ovarian stimulation was performed, patients with poor prognosis had higher cancellation rates (37.8% vs. 13.3%, P<0.004) and lower pregnancy and live birth rates (22.2% vs. 35.0%, P<0.05 and 11.1% vs. 26.1%, P<0.05, respectively) as compared to good prognosis women.

CONCLUSION

The relatively high cancellation rate in patients with poor prognosis raises the question of the use of IVF modified natural cycle in this group.

[Fertility preservation in cancer women: a multidisciplinary approach]

Over the past two decades, major advances in diagnostic modalities and treatment have markedly improved rates of cure for adult cancers. As a consequence, the number of long-term survivors is increasing, and fertility preservation has become a major issue for young patient about to start treatment for cancer. Whether fertility preservation is a promising option, most of the technologies currently used are far from being well established or are even still experimental. Patients should be aware that no method guarantees success. Psychological and ethical impacts of fertility preservation are major concerns and should be included in the multidisciplinary approach of the patients.

[Arguments for an infectious cause of IUGR]

Intra-uterine growth retardation (IUGR) is a frequent cause of consultation in antenatal care unit. The prognosis relies on the etiology: vascular, chromosomic, genetic, or infectious. Because of chronic fetal distress, hypotrophy increase morbidity, mortality and neurosensorial long term effect. Usually, infection is involved in 5 to 15% of the IUGR, mainly by Cytomegalovirus (CMV), Varicella Zoster virus, rubella, toxoplasmosis, herpes and syphilis. Maternal sera and amniotic liquid analysis make the diagnosis possible but fetal ultrasound scan is used to find other features. Most of the abnormalities are unspecific but their combination can worsen fetal prognosis. Infection should always be ruled out in the assessment of IUGR.

[Non-obstructive azoospermia: option of the testicular sperm extraction performed on the day of oocyte retrieval]

OBJECTIVE

Analyzing the results and validating the procedure of testicular sperm extraction (TESE) performed on the day of oocyte retrieval in non obstructive azoospermia (NOA) patients.

PATIENTS AND METHODS

Sixty TESE were performed on the day of oocyte retrieval (dOR), in 52 NOA men. Patients were sorted into three groups according to the results of the surgical procedure: 1: sperm recovery with possible sperm freezing (n=20); 2: sperm recovery without freezing (n=27); 3: "negative" biopsy (n=13). ICSI outcomes in the two groups with sperm recovery were compared to those of ICSI performed with frozen-thawed sperm obtained from TESE performed (n=13).

RESULTS

The rate of positive sperm retrieval was 78%. While the overall clinical pregnancy rate was 50%, no difference in the fertilization, implantation and clinical pregnancy rates was found in the two groups with positive sperm retrieval as compared to frozen-thawed sperm group. Twelve pregnancies were obtained in patients without further sperm cryopreservation.

CONCLUSION

After TESE in NOA men, cryopreserved sperm produced comparable results with freshly obtained sperm. However, TESE performed on dOR can offer the opportunity, in patients with rare sperm that might not survive freeze-thaw, to have a possible fresh embryo transfer. Couples should be counselled regarding the possibility of oocyte retrieval without sperm for ICSI.

Serum anti-Müllerian hormone levels are negatively related to Follicular Output RaTe (FORT) in normo-cycling women undergoing controlled ovarian hyperstimulation

BACKGROUND

Since in rodents anti-Müllerian hormone (AMH) has been shown to inhibit antral follicle responsiveness to FSH, we aimed at verifying whether a relationship exists between serum AMH levels and antral follicle responsiveness to exogenous FSH in normo-cycling women.

METHODS

Serum AMH, estradiol (E(2)) and FSH levels were prospectively measured on cycle day 3 in patients undergoing controlled ovarian hyperstimulation (COH) with a time-release GnRH agonist and standardized FSH doses. In 162 patients, follicles were counted after pituitary suppression and before FSH administration (baseline; small antral follicles; 3-8 mm), and on the day of hCG (dhCG; pre-ovulatory follicles; 16-22 mm). Antral follicle responsiveness to FSH was estimated by the Follicular Output RaTe (FORT), determined by the ratio pre-ovulatory follicle count on dhCG × 100/small antral follicle count at baseline.

RESULTS

Serum AMH levels were positively correlated with the number of small antral follicles at baseline (r = 0.59; P < 0.0001) and pre-ovulatory follicles on dhCG (r = 0.17; P < 0.04). Overall, FORT was 47.5 ± 1.4% and failed to be influenced by the woman's age, BMI or basal E(2) and FSH level. Conversely, multiple regression analysis showed that FORT was negatively correlated with AMH levels (r = -0.30; P < 0.001), irrespective of duration of COH and total FSH dose.

CONCLUSIONS

The percentage of follicles that effectively respond to FSH by reaching pre-ovulatory maturation is negatively and independently related to serum AMH levels. Although the mechanisms underlying this finding remain unclear, it is in keeping with the hypothesis that AMH inhibits follicle sensitivity to FSH.