Follicle-stimulating Hormone Products Research Articles

Follicle-Stimulating Hormone Biological Products: Does Potency Predict Clinical Efficacy?

Follicle-stimulating hormone (FSH), together with luteinizing hormone (LH) and human chorionic gonadotropin (hCG), plays a fundamental role in human reproduction. The discovery of FSH and other gonadotropins was a defining moment in our understanding of reproduction and led to the development of many treatments for infertility. In this regard, exogenous FSH has been used to treat infertility in women for decades. Today, several recombinant and highly purified urinary forms of FSH are used in medically assisted reproduction (MAR). However, differences in the macro- and micro-heterogeneity of FSH result in a variety of FSH glycoforms, with glycoform composition determining the bioactivity (or potency), pharmacokinetic/pharmacodynamic (PK/PD) profiles, and clinical efficacy of the different forms of FSH. This review illustrates how the structural heterogeneity of FSH glycoforms affects the biological activity of human FSH products, and why potency does not predict effects in humans in terms of PK, PD, and clinical response.

O-279 The type of gonadotrophin: Does it improve ART outcome?

Abstract Ovarian stimulation is a vital clinical component of an IVF cycle, with gonadotrophins being the main stimulation drugs. Follicle stimulating hormone (FSH), the key driver of follicle recruitment during an ovarian cycle is a complex glycosylated protein comprised of an α and β subunit with four glycosylation sites. Differences in glycosylation lead to heterogeneity with the FSH isoforms varying in their receptor binding and biological activity. The cyclic physiological variation of FSH isoforms and the FSH threshold/ window concept lead to the selection of a single dominant follicle during a menstrual cycle. Surpassing the FSH threshold and extension of the FSH window with ovarian stimulation using gonadotrophins salvages follicles with higher FSH sensitivity leading to multi-follicular development and retrieval of multiple oocytes. The first IVF birth in 1978 was from a natural cycle and was preceded by several unsuccessful attempts at oocyte retrieval. Ovarian stimulation was therefore incorporated into IVF treatment to overcome the inefficiencies encountered with a natural cycle. The objective of ovarian stimulation during IVF treatment is to obtain several mature oocytes, leading to good quality embryos for immediate replacement and cryopreservation for future use. An ideal stimulation wherein gonadotrophins are the mainstay is one that achieves maximal efficacy, safety and cost-effectiveness. Several gonadotrophin preparations have been available for clinical use over the years since the first use of pregnant mare serum gonadotrophin (PMSG) in 1940 and the first successful birth using human pituitary gonadotrophin (hPG) in 1961. These initial preparations were soon abandoned due to concerns with antigenicity and safety. Subsequent important milestones in the development gonadotrophins for clinical use include the urinary derived products, recombinant FSH preparations, long acting FSH and the biosimilars. Given the selection of gonadotrophins currently available, the apparent question is if they differ? Circulating FSH isoforms change during different stages of the menstrual cycle and through the reproductive stages. More acidic isoforms are predominant during the early follicular phase, with less acidic or basic isoforms predominant in the late follicular phase of the menstrual cycle, and more acidic isoforms during the menopausal stage. Similarly, the different FSH products vary in their properties owing to differences in their production and purification. Urinary derived products are more acidic compared to recombinant preparations and the different recombinant products vary in degree of acidity due to differences in the extent and pattern of glycosylation. The acidic and basic properties of gonadotrophin types influence metabolic stability, half-life and their biological activity. The question then remains if these differences in bioactivity affect clinical outcomes? Clinical effectiveness of the various gonadotrophins types should be addressed in the context of the different pituitary suppression regimens, ovarian response categories and patient variables given the implementation of individualised stimulation protocols. It is also imperative to clearly define successful clinical outcomes incorporating both efficacy and safety. Cumulative live birth rate (CLBR) following fresh and frozen embryo transfers resulting from one episode of ovarian stimulation should be adopted as the measure of the overall efficiency along with OHSS as a measure of immediate safety. There are several studies and systematic reviews comparing the different gonadotrophin types and products for various outcomes including surrogate endpoints, with inconsistent results attributed to differences in the inclusion/ exclusion criteria, heterogeneity across studies and varied quality of the primary studies. Furthermore, there have been sparse studies reporting on CLBR and there is a continuing debate on what would be considered as a relevant clinical difference in efficacy. In addition to efficacy and safety, the ultimate choice of gonadotrophin should be based on regional availability, patient acceptability and cost-effectiveness for a live birth.

Effects of Extra-Long-Acting Recombinant Bovine FSH (bscrFSH) on Cattle Superovulation.

Simple SummaryWhile the clinical effectiveness of medium-acting bovine follicle stimulating hormone (bFSH) is well-established for superovulation (SOV) protocols in cattle, the use of long-acting bovine recombinant follicle stimulating hormone (brFSH) remains the golden target. The application of a bFSH with prolonged half-life could improve substantially the results obtained regarding the ovarian superstimulation response and the quality and quantity of the embryos produced. Moreover, the management schemes may be improved by reducing the number of FSH applications needed during the SOV protocol. The development of a new extra-long-acting bovine single-chain recombinant follicle stimulating hormone (bscrFSH) provides interesting advantages to the SOV protocols as the present study shows, by improving the results obtained compared to the use of the conventional follicle stimulating hormone from purified pig pituitary extract (NIH-FSH-p).Over the last few years, several commercial FSH products have been developed for cattle superovulation (SOV) purposes in Multiple Ovulation and Embryo Transfer (MOET) programs. The SOV response is highly variable among individuals and remains one of the main limiting factors in obtaining a profitable number of transferable embryos. In this study, follicle stimulating hormone (FSH) from different origins was included in two SOV protocols, (a) FSH from purified pig pituitary extract (NIH-FSH-p; two doses/day, 12 h apart, four consecutive days); and (b) extra-long-acting bovine recombinant FSH (bscrFSH; a single dose/day, four consecutive days), to test the effects of bscrFSH on the ovarian response, hormone profile levels, in vivo embryo production and the pluripotency gene expression of the obtained embryos. A total of 68 healthy primiparous red Angus cows (Bos taurus) were randomly distributed into two experimental groups (n = 34 each). Blood sample collection for progesterone (P4) and cortisol (C) level determination was performed together with ultrasonographic assessment for ovarian size, follicles (FL) and corpora lutea (CL) quantification in each SOV protocol (Day 0, 4, 8, and 15). Moreover, FSH profiles were monitorised throughout both protocols (Day 0, 4, 5, 6, 7, 8, 9, 10, and 15). In vivo embryo quantity and quality (total structures, morulae, blastocysts, viable, degenerated and blocked embryos) were recorded in each SOV protocol. Finally, embryo quality in both protocols was assessed by the analysis of the expression level of crucial genes for early embryo development (OCT4, IFNt, CDX2, BCL2, and BAX). P4 and cortisol concentration peaks in both SOV protocols were obtained on Day 15 and Day 8, respectively, which were statistically different compared to the other time-points (p < 0.05). Ovarian dimensions increased from Day 0 to Day 15 irrespective of the SOV protocol considered (p < 0.05). Significant changes in CL number were observed over time till Day 15 irrespective of the SOV protocol applied (p < 0.05), being non- significantly different between SOV protocols within each time-point (p > 0.05). The number of CL was higher on Day 15 in the bscrFSH group compared to the NIH-FSH-p group (p < 0.05). The number of embryonic structures recovered was higher in the bscrFSH group (p = 0.025), probably as a result of a tendency towards a greater number of follicles developed compared to the NIH-FSH-p group. IFNt and BAX were overexpressed in embryos from the bscrFSH group (p < 0.05), with a fold change of 16 and 1.3, respectively. However, no statistical differences were detected regarding the OCT4, CDX2, BCL2, and BCL2/BAX expression ratio (p > 0.05). In conclusion, including bscrFSH in SOV protocols could be an important alternative by reducing the number of applications and offering an improved ovarian response together with better embryo quality and superior performance in embryo production compared to NIH-FSH-p SOV protocols.

Comparing a biosimilar follitropin alfa (Cinnal-fⓇ) with Gonal-fⓇ in women undergoing ovarian stimulation: An RCT.

BackgroundAdvances in recombinant DNA technology led to the development of recombinant follitropin alfa. Recombinant human follicle-stimulating hormone products are used to stimulate follicular maturation.ObjectiveTo 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 MethodsIn 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).ResultsA 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.ConclusionCinnal-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.

Development and characterization of in vitro self-assembled recombinant human follicle stimulating hormone originated from goat mammary epithelial cells

Follicle stimulating hormone (FSH), composed of FSHα and FSHβ subunits, is essential for female follicle development and male spermatogenesis. The recombinant human FSH (rhFSH) products on the market are mainly generated from mammalian cells and are expensive. Large animal mammary gland bioreactors are urgently needed to produce large amounts of rhFSH. However, there are currently no effective methods to prepare rhFSH by large animals mainly due to the fact that excessive accumulation of FSH might cause many adverse effects in animals. We herein report the development and characterization of functional self-assembled rhFSH produced in goat mammary epithelial cells (GMECs). FSHα and FSHβ stably expressed in Chinese hamster ovary (CHO) cell lines were secreted into culture medium and well glycosylated. Importantly, FSHα and FSHβ expressed apart were able to assemble into functional FSH. We next inserted human FSHα or FSHβ gene separately into goat β-Lactoglobulin locus in GMECs by CRISPR/Cas9. Inactive FSHα and FSHβ subunits expressed from GMECs assembled into rhFSH as analyzed by His-tag pull down assay. Functional assessment of rhFSH by cAMP induction assay, mouse ovulation induction and rat ovarian weight gain experiments showed that the bioactivity of self-assembled rhFSH expressed by GMECs was comparable to that of Gonal-F both in vitro and in vivo. Our study demonstrated that FSHα and FSHβ can be separately expressed and assembled into functional rhFSH, and provided the basis for future preparing FSH by goat mammary gland bioreactor with less health problems on the producing animals.

A cost-effectiveness evaluation of the originator follitropin alpha compared to the biosimilars for assisted reproduction in Germany.

Background and objectives: Demand for assisted reproduction technology (ART) in Germany is high, with 100,844 treatment cycles during 2016. Many ART procedures involve ovarian stimulation with follicle stimulating hormone (FSH). Recently, biosimilar FSH products have become available. The objective of this study was to evaluate the cost-effectiveness of the recombinant FSH Gonal-f® (Originator) in comparison to biosimilar follitropin alfa, Bemfola® (Biosimilar 1) and Ovaleap® (Biosimilar 2), from a German payer perspective in terms of cost per live birth.Methods: A decision tree model was developed, based on one cycle of assisted reproduction, to compare the original product to biosimilars. Clinical inputs, including live birth rates and adverse event rates were obtained from published randomized trials. Cost inputs were obtained from publicly available German sources. Clinical inputs, model structure and methodology were based on previous publications and validated by a clinical expert.Results: Results indicated that the live birth rate is higher for the Originator compared to Biosimilar 1 (40.7% vs 32.1% respectively), and Biosimilar 2 (32.2% vs 26.8%). The average cost per live birth for women treated with the Originator was estimated to be lower than those who were treated with biosimilars: Originator vs Biosimilar 1 (€10,510 vs €12,192), Originator vs Biosimilar 2 (€12,590 vs €13,606). The analysis also found that the Originator is associated with an incremental cost-effectiveness of €4,168 and €7,540 per additional live birth versus Biosimilar 1 and Biosimilar 2 respectively. Sensitivity analysis indicated probabilities of pregnancy, embryo transfer and live birth, were key drivers of model costs. Scenario analysis confirmed the robustness of the model outcomes.Conclusion: This study suggests that treatment with the Originator could result in a lower cost per live birth in comparison to biosimilars. Further analysis using real-world data, when available, is recommended to validate the results of the present study.

Analysis of patient and nurse preferences for self-administered FSH injection devices in select European markets.

PurposeThe purpose of this study was to assess product-specific features for a variety of self-administered injection devices and identify key factors that patients and nurses in select European markets find most important when selecting injection devices for self-administration of recombinant human follicle-stimulating hormone and urinary human follicle-stimulating hormone for fertility/reproductive therapy.Patients and methodsPatients (N=402) in France, Italy, Spain, Germany, the UK, the Netherlands, and Belgium, as well as reproductive/fertility nurses (N=40) in Germany, Italy, France, Spain, and the Czech Republic were surveyed. All patients were previously prescribed a follicle-stimulating hormone (FSH) treatment for either in vitro fertilization or ovulation induction. Patient and nurse preferences for attributes across all injection devices in the market were obtained via an online questionnaire and evaluated using the maximum differential scaling (MaxDiff) and conjoint analyses, which captured the relative importance of the selected FSH injection device attributes to determine specific qualities in overall product preference.ResultsBoth the MaxDiff and conjoint analyses indicated that, for patients and nurses, the ideal FSH injection device would be a highly accurate, multi-use reusable pen injector with a dial-back function that would be easy for both use and education/instruction. Patients and nurses each selected attributes pertinent to their own experiences with the FSH injection device. Categorically, patients valued factors that resulted in minimal impact on daily life, including reduced injection volume to minimize injection-site pain, as well as a reusable device that would be easy to use; nurses placed greater value on a device that would be easy to teach in order to instruct the greatest number of patients while minimizing risk.ConclusionPatient and nurse preferences were aligned on certain selected attributes of the FSH products. Although this study was an unbranded examination of attributes across all injection devices currently in the market, results demonstrated that the preferred product attributes were all characteristics of the Ovaleap® Pen.

Bemfola® fixed dose pens potentially reduce drug wastage and associated costs of infertility treatment

Bemfola® is a recombinant follicle-stimulating hormone (FSH) used during infertility treatment. One main differentiator between FSH products is their delivery device; consisting of multi-dose pens (Gonal-f®), vials or multi-dose preparations (Menopur®), or adjustable daily disposable dose pens (Bemfola®). To determine the potential impact of delivery device on drug wastage during infertility treatment this study retrospectively analysed Gonal-f® and Menopur® prescription and usage data from five UK clinics. Incurred drug wastage was then compared to potential Bemfola® drug wastage. Data collected included: (i) number of treatment cycles; (ii) daily FSH dose; (iii) length of treatment; (iv) dose adjustment following ultrasound scan; (v) FSH formulation(s) prescribed and (vi) agonist/antagonist protocol used. Treatment with Gonal-f® (4078 cycles) and Menopur® (646 cycles) resulted in an average drug wastage of 160 and 294 IU per treatment cycle. Use of Bemfola® instead of Gonal-f® and Menopur® may reduce the wastage to 104 and 61 IU per cycle, respectively. The use of Bemfola®, across all 4724 cycles, could result in a drug wastage reduction of up to 376,800 IUs with an associated cost saving of £100,011. Bemfola® is a viable alternative to Gonal-f® and Menopur® with its drug delivery system potentially reducing drug wastage and associated costs during infertility treatment.

Follicle-Stimulating Hormone: A Review of Form and Function in the Treatment of Infertility.

The use of gonadotropin therapy, including follicle-stimulating hormone (FSH), represents an indispensable part of fertility treatment. There are a number of FSH preparations commercially available or in development, including both urinary-derived products (urinary-derived FSH [uFSH]) and FSH produced through recombinant techniques (recombinant FSH [rFSH]). Differences in the glycosylation patterns of FSH give rise to a number of naturally occurring isoforms that may differ functionally. The relative concentrations of these isoforms vary over the course of the menstrual cycle and the lifetime, indicating that these differences in glycosylation may have physiologic relevance. Although both uFSH and rFSH contain human FSH, there are differences in the glycosylation patterns, which may give rise to differences in biologic activity between products. Current FSH products have been shown to have high purity and to exhibit consistent, favorable efficacy and safety profiles for the treatment of infertility, regardless of urinary or recombinant origin.

Characterisation of Population Pharmacokinetics and Endogenous Follicle-Stimulating Hormone (FSH) Levels After Multiple Dosing of a Recombinant Human FSH (FE 999049) in Healthy Women.

ObjectiveThe aim of this study was to characterise the population pharmacokinetics of FE 999049, a novel recombinant human follicle-stimulating hormone (FSH), after multiple dosing in healthy women, taking into account endogenous FSH levels and the reproductive hormone dynamics.MethodsLongitudinal measurements of FSH, luteinising hormone, progesterone, estradiol, and inhibin B levels were collected after repeated subcutaneous dosing with 225 IU of FE 999049 in 24 gonadotropin downregulated healthy women. The FSH data were described using nonlinear mixed-effects modelling.ResultsThe measured FSH levels were modelled as a sum of endogenous FSH and FE 999049. The FE 999049 population pharmacokinetics were best described using a one-compartment model with first-order absorption and elimination, and a transit model for delayed absorption. The apparent clearance and volume of distribution increased with body weight in accordance with an allometrically scaled power exponent of 0.75 and 1, respectively. Endogenous FSH levels were lower in individuals with higher progesterone levels at baseline and were further suppressed over time with increasing inhibin B levels.ConclusionsThis characterisation of FE 999049 population pharmacokinetics after repeated dosing is in line with previous findings after single-dose administration. The results provide a basis for study design and data evaluation in the future development of recombinant FSH products, and show it can be of importance to account for endogenous FSH levels and its variation over time for accurate estimation of exogenously administered FSH pharmacokinetic parameters. Thus, correcting FSH concentrations by the observed endogenous FSH baseline value at all time points may be incorrect.

Phase 1 safety, tolerability, and pharmacokinetic study of single ascending doses of XM17 (recombinant human follicle-stimulating hormone) in downregulated healthy women.

BackgroundXM17 is a recombinant human follicle-stimulating hormone (follitropin alfa) for stimulation of multifollicular development in women undergoing controlled ovarian hyper-stimulation during assisted reproductive therapy and for treatment of anovulation. Manufactured using Chinese hamster ovary cells transfected with the human follicle-stimulating hormone gene, XM17 has an identical amino acid sequence to that of the human protein as well as to those of the other approved recombinant human follicle-stimulating hormone products. Glycosylation patterns may differ slightly between products. The objectives of this first-in-human study were to assess the safety, tolerability, pharmacokinetics, and dose-proportionality of single ascending subcutaneous doses of XM17 in healthy young female volunteers.MethodsEndogenous follicle-stimulating hormone was downregulated by implanting a 1-month depot of goserelin acetate 3.6 mg on day 0 in eligible subjects. On day 14 of the experimental period, subjects received one of four ascending doses of XM17. Blood sampling to obtain the pharmacokinetic profile of XM17 was done at frequent intervals until 168 hours post-dose.ResultsFollowing downregulation of endogenous follicle-stimulating hormone to <4 IU/L, 40 subjects (of mean age 29±5.4 years) received single subcutaneous doses of 37.5 (n=4, pilot group), 75, 150, or 300 IU (n=12 each) of XM17. The mean serum concentration-time profiles of XM17 revealed dose-related increases in maximum concentration (Cmax) within 24 hours followed by monoexponential decay for the three higher dose levels. Slopes estimated by linear regression for Cmax and AUC0–168h were ~1.0 (0.9052 IU/L and 1.0964 IU·h/L, respectively). For each IU of XM17 administered, Cmax and AUC0–168h rose by 0.032 IU/L and 2.60 IU·h/L, respectively. Geometric mean elimination half-life ranged from 54 to 90 hours. No antibodies to XM17 were detected. The most common treatment-emergent adverse events were headache (12 events in eleven [27.5%] subjects) and dizziness (four events in four [10%] subjects); two subjects (5%) reported mild pain on touch at the injection site.ConclusionSingle subcutaneous doses of XM17 up to 300 IU in healthy young women exhibited dose-proportional pharmacokinetics with good safety and tolerability.

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®

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.

Use of follicle-stimulating hormone for the treatment of female infertility – current concepts

Ovulatory dysfunction, which is common among women of reproductive age, often results in infertility. Over the last three decades, follicle-stimulating hormone (FSH), in the form of either urinary human menopausal gonadotropin or highly purified urinary FSH (uFSH), has been the mainstay in the treatment of women with ovulatory dysfunction. However, these preparations have several disadvantages, including variable composition, contamination with urinary proteins, and the limited availability of human menopausal urine from which uFSH is extracted. Recombinant human FSH (rhFSH) demonstrates higher purity and specific activity, and is suitable for subcutaneous administration. Additionally, rhFSH has facilitated the development of additional FSH products such as FSH-carboxy terminal peptide that possess different pharmacokinetic and pharmacodynamic properties and may provide more options in the treatment of ovulatory dysfunction and infertility. This article reviews the mechanism of action of FSH in folliculogenesis and ovulation, the current use of FSH in women for the medical management of infertility, and the published clinical experience to date with different rhFSH preparations.

Use of Follicle-Stimulating Hormone for the Treatment of Female Infertility – Current Concepts

Ovulatory dysfunction, which is common among women of reproductive age, often results in infertility. Over the last three decades, follicle-stimulating hormone (FSH), in the form of either urinary human menopausal gonadotropin or highly purified urinary FSH (uFSH), has been the mainstay in the treatment of women with ovulatory dysfunction. However, these preparations have several disadvantages, including variable composition, contamination with urinary proteins, and the limited availability of human menopausal urine from which uFSH is extracted. Recombinant human FSH (rhFSH) demonstrates higher purity and specific activity, and is suitable for subcutaneous administration. Additionally, rhFSH has facilitated the development of additional FSH products such as FSH-carboxy terminal peptide that possess different pharmacokinetic and pharmacodynamic properties and may provide more options in the treatment of ovulatory dysfunction and infertility. This article reviews the mechanism of action of FSH in folliculogenesis and ovulation, the current use of FSH in women for the medical management of infertility, and the published clinical experience to date with different rhFSH preparations.

Urofollitropin and Ovulation Induction

Anovulation is a common cause of female infertility. Treatment for women with anovulation is aimed at induction of ovulation. Ovulation induction with follicle-stimulating hormone (FSH) is indicated in women with WHO type II anovulation in whom treatment with clomifene citrate (clomifene) has failed. The majority of these women have polycystic ovary syndrome. The major disadvantages of ovulation induction with FSH are the risk of ovarian hyperstimulation syndrome and the risk of higher order multiple pregnancies. To reduce the rate of complications due to multiple follicular development, FSH should be administered using a chronic low-dose protocol with small dose increments. In women with WHO type I anovulation, an exogenous supply of luteinizing hormone (LH) is required to achieve an adequate follicular response to FSH treatment. Thus, ovulation induction with FSH is not the treatment of choice in these women. FSH is a hormone that stimulates follicle growth and oocyte maturation. Endogenous FSH is produced by the pituitary gland and exists as a family of isohormones exhibiting distinct oligosaccharide structures. FSH for exogenous administration is derived from urine or is produced as recombinant FSH. The commercially available FSH products all contain different mixtures of FSH isoforms. To determine the effectiveness of urofollitropin (urinary-derived FSH), a comparison with the other available gonadotropins was made (i.e. recombinant FSH and human menopausal gonadotropin). Urofollitropin and recombinant FSH appear to be equally effective and well tolerated for ovulation induction. Human menopausal gonadotropin is comparably effective to urofollitropin in terms of pregnancy outcomes. It remains unclear whether human menopausal gonadotropins have a higher risk of overstimulation and ovarian hyperstimulation syndrome compared to urofollitropin in women with polycystic ovary syndrome. In practice, recombinant products are more convenient to use but are also more expensive. Therefore, if availability is not an issue but costs are, there is still a place for the use of urofollitropins for ovulation induction.

Comparison of metaphase II oocytes after stimulation with recombinant follicle-stimulating hormone and urinary follicle-stimulating hormone in a pituitary down-regulation regimen

Comparison of metaphase II oocytes after stimulation with recombinant follicle-stimulating hormone and urinary follicle-stimulating hormone in a pituitary down-regulation regimen

Comparing Follicle Stimulating Hormone from Two Commercial Sources for Oocyte Production from Out-of-Season Dairy Goats

Until recently, two sources of follicle stimulating hormone (FSH-P; Schering-Plough; Kenilworth, NJ and Super-Ov; FSH-SOV; AUSA International, Tyler, TX) have been commercially available in the United States and routinely used for superovulation of ruminants. Because there have been no comparative follicle stimulating hormone studies on small ruminants, we determined the difference between the number of follicles induced and the number of oocytes that can subsequently be harvested from goats stimulated with either of these two follicle stimulating hormone products. Anestrous Saanen does were fitted with a progestin implant then randomly assigned to one of two ovarian stimulation groups. Starting 4 d after introducing the progestin implant, donors in treatment 1 were administered daily injections of FSH-P for 4 d. Does in treatment 2 were similarly treated but were administered FSH-SOV for 4 d. Follicle aspirations were performed by laparotomy in the morning of treatment d 8. In summary, no difference was detected between the two stimulatory agents for the number of follicles and quality of oocytes harvested from stimulated does, indicating that these two commercial FSH products could be used successfully for ovarian stimulation of anestrous dairy goats.

Generic human menopausal gonadotropin (hMG) in place of more costly follicle-stimulating hormone (FSH) for routine ovulation induction.

A large part of infertility treatment involves the use of exogenous gonadotropins. The last decade has seen a progressive switch from human menopausal gonadotropin (hMG), the original gonadotropin product, to progressively more costly products, primarily or exclusively containing follicle-stimulating hormone (FSH). Though obviously at least in part driven by marketing efforts of pharmaceutical companies, this switch has received relatively little scrutiny despite its obvious cost implications. We therefore investigated whether a switch back to a generic or less costly hMG-driven ovulation induction protocol would affect patient outcome after ovulation induction and, by implications, with other assisted reproductive technologies. We prospectively studied clinical pregnancy rates in a large number of consecutive ovulation induction cycles in a well-defined patient population (group 1) which, after October of 1997, had been switched from a predominantly FSH to an hMG-driven protocol, based on an institutional formulary change. Until a transition period (between July and September 1997), this patient population had been on a primarily FSH-driven protocol (between July 1996 and June 1997). In parallel, we evaluated a second patient population (group 2), which was managed by the same physicians outside of formulary requirements and remained almost exclusively on principally FSH-driven ovulation induction cycles. FSH- and hMG-driven ovulation induction protocols did not differ in pregnancy outcome during the prospective study period. Group 1 patients, however, demonstrated a significant increase in pregnancy rates after the switch from FSH to hMG stimulation had taken place (P = 0.02), while group 2 patients demonstrated no change in pregnancy rate during the same time period. Generic hMG products do not adversely affect pregnancy rates in comparison to more costly FSH products in routine ovulation induction cycles and should be considered an appropriate alternative to more expensive FSH products.

Comparison of ovulation induction with two different recombinant follicle-stimulating hormone products (puregon 50 and gonal F 75) for in-vitro fertilization

International Journal of Gynecology & ObstetricsVolume 70, Issue S3 p. C105-C105 Panel Infertility/assisted reproductive technology Comparison of ovulation induction with two different recombinant follicle-stimulating hormone products (puregon 50 and gonal F 75) for in-vitro fertilization N. Kanakas, N. KanakasSearch for more papers by this authorT. Mantzavinos, T. MantzavinosSearch for more papers by this authorK. Arvaniti, K. ArvanitiSearch for more papers by this authorG. Creatsas, G. CreatsasSearch for more papers by this author N. Kanakas, N. KanakasSearch for more papers by this authorT. Mantzavinos, T. MantzavinosSearch for more papers by this authorK. Arvaniti, K. ArvanitiSearch for more papers by this authorG. Creatsas, G. CreatsasSearch for more papers by this author First published: 11 December 2003 https://doi.org/10.1016/S0020-7292(00)80684-0AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume70, IssueS32000Pages C105-C105 RelatedInformation

Follitropin Alpha in Infertility

Follitropin alpha (recombinant human follicle-stimulating hormone; follitropin alfa) is a recombinant form of follicle-stimulating hormone (FSH), an endogenous gonadotrophin. Unlike FSH products derived from urine [menotropins (human menopausal gonadotrophins), urofollitropin and highly purified urofollitropin], follitropin alpha is readily available and shows batch-to-batch consistency. As well, it is free of luteinising hormone (LH) activity and contaminant urinary proteins and can be self-administered subcutaneously. In women undergoing in vitro fertilisation-embryo transfer (IVF-ET), follitropin alpha appears to have a greater stimulatory effect on follicular development than urine-derived FSH products as a group. In direct comparisons it had similar effects to urofollitropin but produced more oocytes per stimulated cycle than highly purified urofollitropin and menotropins. Preliminary results of 1 small trial indicate similar efficacy for follitropin alpha and follitropin beta. Rates of pregnancy, live births and multiple births have been similar among all treatment groups. As ovulation induction in women with clomifene-resistant WHO group II anovulation, follitropin alpha produces rates of ovulation, follicular development and pregnancy resembling those seen with urofollitropin or highly purified urofollitropin. A long term low-dose regimen of follitropin alpha is associated with a lower number of follicles and a trend toward fewer multiple births compared with conventional follitropin alpha or urofollitropin regimens. Data from women with WHO group I anovulation and from infertile men are scant. Tolerability has not differed between follitropin alpha and other FSH products. The incidence of general events (e.g. headache, nausea, ovarian cyst), local irritations at injection site and ovarian hyperstimulation syndrome resembled those for comparator FSH products. However, it appears that follitropin alpha can be tolerated in instances of severe allergic reaction to urine-derived products. In women undergoing IVF-ET, follitropin alpha appears to have a greater stimulatory effect on follicle development than urine-derived FSH products as a group and is at least as well tolerated as these preparations; preliminary data indicate similar efficacy to follitropin beta. At present, its efficacy in women with WHO group II anovulation disorder has been shown to be similar to that of the older products. Compared with urinary FSH products, the benefits of follitropin alpha lie in its reliable supply, consistency of production, lack of contaminant urinary proteins and ease of self-administration. Given these practical advantages, and the apparently greater effect on follicular development overall in women undergoing IVF-ET, recombinant products such as follitropin alpha are expected to eventually replace older urine-derived FSH preparations and claim a prominent position in the treatment of infertility.