Is There a Best Stimulation

Protocol in OI/IUI Cycles?

Sandro Esteves, M.D., Ph.D.

Director, ANDROFERT

Andrology & Human Reproduction Clinic

Campinas, BRAZIL

ASPIRE III, Istanbul, September 2013

Esteves, 2

Is There a Best Stimulation Protocol in OI/IUI Cycles?

Review this Lecture at:

http://www.androfert.com.br/review AS

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Esteves, 3

Level Type of evidence

1a Meta-analysis of randomized trials

1b At least one randomized trial

2a Well-designed controlled study without

randomization

2b At least one other type of well-designed quasi-

experimental study

3 Well-designed non-experimental studies

(comparative and correlation studies, case series)

4 Expert committee reports or opinions or clinical

experience of respected authorities

Adapted from Sackett et al. Oxford Centre for EBM Levels of Evidence (2009)

Level of Evidence

OI and IUI population

Grade A recommendation

Esteves, 4

Top Problems

Concerning Ovarian

Stimulation in OI/IUI

and How to Solve Them

What is in it for me?

Esteves, 5

Do We Need to

Individualize the

Protocol per Patient?

Esteves, 6

Singleton live birth at

term

Maximize Beneficial

Effects

1Delvigne & Rozenberg Hum Reprod Update. 2003;9:77-96; 2Cantineau et al.,

Cochrane Database Syst Rev. 2007; 18:CD005356; 3Aboulghar. Fertil Steril. 2012;97:523-6.

Multiple Pregnancy2

10-40%

Cycle Cancellation1

2-8%

Risk of OHSS

OHSS3

Severe 2%

Moderate 3-6%

Minimize Complications

and Risks

Age, BMI, Race

Genetic profile

Cause

Duration

Health

Nutrition

Esteves, 7

Reproductive Hormones Report - GCC Countries (Feb 2011)

Bologna criteria: Ferraretti et al. Hum Reprod 2011. Esteves, 8

Up to 68%

Infertile Patients (WHO II) with PCO in Clinical Practice

Up to 45% Patients Aged ≥35 have Poor

Response to Stimulation

Esteves, 9

La Marca et al, Hum Reprod 2009;24:2264; Fleming et al, Fertil Steril 2012;98:1097;

Broekmans et al. Fertil Steril, 2010; 94:1044-51; Scheffer et al. Hum Reprod 2003;18:700

.

Reflect No. Pre-antral and Small Antral

Follicles (≤4-8mm)

Low inter and intra-cycle variation

AM

H

AF

C

2D-TVUS at early follicular phase

2-10 mm (mean diameter)

Reflect No. AF at a given time that can be

stimulated by medication

Relatively low inter-cycle variation

Esteves, 10

Evidence Level

1a B

iom

ark

ers

1Nardo et al. Fertil Steril 2009; 2Checa et al. Fertil Steril 2010 Esteves, 11

AMH (ng/mL)

AFC False

Result

Risk

OHSS1,2 >3.5 >16 ~15%

pmol/L X1000/140

Level

2a

Esteves, 12

Individualized approaches maximize treatment

beneficial effects and minimize complications

and risks.

Biomarkers, AMH and AFC, are useful to predict

ovarian response and to define an

individualized stimulation.

Esteves, 13

Clomiphene Citrate for

How Many Cycles and

How?

Pituitary

GnRH

FSH/LH estrogen

Hypothalamus

Ovary

Clo

mip

hen

e C

itra

te

Esteves, 14

Similar to estrogen

Extended binding depletes ER levels1

Ovulatory women

Increase GnRH pulse frequency2

PCOS

Increase GnRH amplitude3

1Clark & Markaverich. Pharmacol Ther 1982;15:467; 2Kerin JF et al. J Clin Endocrinol Metab

1985;61:265; 3Kettel et al. Fertil Steril 1993;59:532; 4Ibrahim et al. Arch Gynecol Obstet.

2012;286:1581; 5Annapurna et al. Int J Fertil Womens Med 1997;42:215.

Negative Effect on

Endometrium4 and

Cervical Mucus5

Clo

mip

hen

e C

itra

te

Esteves, 15

How to Use?

Dose: 50 mg/d for 5 days

Ultrasound Menses

Start day

CC

2 3 4 5 7 6 8 9 10 11 12 13 1

Adapted form the ASRM Practice Committee. Fertil Steril 2003;5:1302–8

Ultrasound

Points to Consider C

lom

iph

en

e C

itra

te

Esteves, 16

PCOS: >75% of anovulatory infertility

~25% CC-resistant (mainly obese & hyperandrogenic)

~15% who ovulate have thin endometrium/poor mucus

Ultrasound monitoring

1. Dose can be adjusted, if necessary, in subsequent

cycles.

2. Allows endometrial evaluation. In IUI, endometrial appearance/thickness more important than

follicle size for hCG administration

3. Assessment for the risk of OHSS.

50 mg/d 100 mg/d 150 mg/d

Ovulation Ovulation

2 – 3 cycles with the same dose

Ovulation

No

Ovulation

No

Ovulation

No

Ovulation

No pregnancy Suboptimal Endometrium

(thickness <7mm)

Injectable

Gonadotropins

Clo

mip

he

ne

Cit

rate

Esteves, 17

Hypogonadotropic

Hypogonadism

Adapted from the ASRM Practice Committee. Fertil Steril 2003;5:1302–8

How Many Cycles and How?

Esteves, 18

How to Use Injectable

Gonadotropins and

What to Expect?

Esteves, 19

Low Dose Step-up StimulationG

on

ad

otr

op

ins

Starting dose: 37.5 - 50 IU (rec-hFSH)

Step-up (by 37.5 IU) if no follicles >10mm after 7 days

Step-up every 7 days until dominant follicle appear

hCG ≥18mm and endometrium ≥7mm

2 3 4 5 7 6 8 9 10 11 12 13 1

Ultrasound

Menses

Start day

14 15

Go

na

do

tro

pin

s N = 968 Cycles

>70% ovulatory cycles

>85% monofollicular development

Threshold to produce a dominant follicle:

37.5 to 75 IU (~75%)

Average stimulation duration: 15 days

CPR after 6 cycles: ~60%

No OHSS; ~10-15% cancellation

(multifollicular development)

Low Dose Step-up Stimulation in PCO

Esteves, 20

Points to Consider

Esteves, 21

Go

na

do

tro

pin

s

Be patient!

It may take 10 days or more for a dominant follicle to

appear during the first treatment cycle with low-dose

gonadotropin.

TVUS scan before starting:

if endometrium thickness >8 mm, we use progestin

(medroxyprogesterone acetate, 5-10 mg/d) to induce a

withdrawal bleed.

Esteves, 22 Cantineau et al., Cochrane Database Syst Rev. 2007; 18(2):CD005356

Go

na

do

tro

pin

s

No.

Studies

No.

Participants

Odds-ratio

Pregnancy 7 556 OR: 1.76 (95% CI: 1.16 to 2.66)

Miscarriage 4 120 OR: 1.2 (95% CI: 0.67 to 1.9)

Multiple

Pregnancy

4 120 OR: 0.73 (95% CI: 0.32 to 1.67)

OHSS 2 200 OR: 4.44 (95% CI: 0.48 to 41.25)

Level

1a

Esteves, 23

Conventional vs Low Dose Step-up

Stimulation in IUI

Cantineau et al., Cochrane Database Syst Rev. 2007; 18(2):CD005356

2 RCT; n= 297 >75

IU/day

50-75

IU/day Odds-ratio

OHSS 13% 2.7% 5.52 (95% CI: 1.85-16.52)

Pregnancy 31.1% 28.2% 1.15

(95% CI: 0.69-1.92)

Level

1a G

on

ad

otr

op

ins

Esteves, 24

Injectable gonadotropins when… 3 CC ovulatory cycles but no pregnancy

Suboptimal endometrium thickness (< 7mm) after CC-OI

No response with CC 150 mg/d

WHO I (hypo-hypo) anovulation

Yields higher PR than CC without increased

risks.

Low-dose (37.5 to 50 IU) step-up (every 7d)

stimulation is the best protocol.

Recombinant or Urinary Gonadotropins?

Esteves, 26

Up to 70%

impurities

Bassett et al. Reprod Biomed Online 2005;10:169–177.

Purity

(protein

content)

Mean specific

activity

(IU/mg protein)

LH

activity

(IU/vial)

Injected

protein per

75 IU (mcg)

hMG < 5% ~100 75 ~750

hMG-HP < 70% 2,000–2,500 75 ~33

rec-hFSH* > 99% 13,645 0 6.1

Esteves, 27

Re

co

mb

ina

nt

vs

Uri

na

ry

*Follitropin alfa

Esteves, 28

Level

1a

Matorras et al. Fertil Steril. 2011;95(6):1937-42

3 RCT; “equal dose group”

Higher PR with rec-hFSH (16.4% vs 12.3%)

RR: 1.39 (95% CI: 1.00-1.96)

Meta-analysis Rec-hFSH vs HP-uFSH in IUI 6 RCT; (N=713 pts; 1,581 cycles)

Similar PR: 14.5% vs 14.9% with rec-FSH dose 50%

lower (RR: 0.970; 95% CI: 0.68-1.37)

Re

co

mb

ina

nt

vs

U

rin

ary

Esteves, 29

68%

25%

Folitropin alfa prefilled ready-to-

use pen

Needle-free reconstitution, conventional

syringe

Easy of use 58%

Dosing mechanism 43%

Less chance of error 26%

Reasons

Weiss N. RBMonline 2007;15:31-7

Level

2a

• Allowed injections at home

• Improved pts. satisfaction (QOL)

; Bassett et al. Reprod Biomed Online 2005;10:169–177;

Driebergen et al. Curr Med Res Opin 2003;19:41–46.

Steelman-Pohley Bioassay

High variability

Rat ovary weight gain

Esteves, 30

Gonadotropin injected sc 1x 3days

Sacrifice day 4 and collect Ovaries

Ovaries are weighed and data processed

Uri

na

ry P

rod

ucts

Bassett et al. Reprod Biomed Online 2005;10:169–177;

Driebergen et al. Curr Med Res Opin 2003;19:41–46.

FbM: Novel analitycal method

Protein content in solution by mass

1.6% batch-to-batch variability

Follitropin alfa

Esteves, 31

Size Exclusion High Performance Liquid

Chromatography (SE- HPLC)

37.5

62.5 50

Re

co

mb

ina

nt

Pro

du

cts

hCG for Triggering Ovulation

Urinary lyophilized vials

(5,000-10,000 IU) IM

Recombinant

choriogonadotropin

alfa

pre-filled syringes

(250 mcg ≅ 6,750 IU) SC

Recommended Dose: 5,000 IU (or 250 mcg rec-hCG)

ASRM Practice Committee. Fertil Steril. 2008;90(Suppl 5):S13-20; Tsoumpou et al. Reprod Biomed Online. 2009;19:52-8

Re

co

mb

ina

nt

vs

U

rin

ary

Esteves, 33

When: 19–30 mm (~25 mm)1

2D TVUS

Mean Diameter of Dominant Follicle Size

23-28 mm (988 IUIs with CC & Letrozole)2

≥16 mm (620 IUIs with gonadotropins)3

hCG for Triggering Ovulation

1ASRM Practice Committee. Fertil Steril. 2008;90(Suppl 5):S13-20; 2Palatnik et al, Fertil Steril 2012;97:1089–94;

3da Silva et al. Eur J Obstet Gynecol Reprod Biol. 2012;164:156-60.

Clinical Efficacy

LH Surge

RCT N Odds-ratio

Live birth 6 1,019 OR: 1.04 (95% CI 0.79 to 1.37)

Miscarriage 7 1,106 OR: 0.69 (95% CI: 0.41 to 1.18)

Severe OHSS 3 549 OR: 1.49 (95% CI: 0.54 to 4.1)

Side Effects 3 374 OR: 0.39 (95% CI: 0.25 to 0.61)

Level

1a

Youssef et al. Cochrane Database Syst Rev. 2011; 13(4):CD003719. Esteves, 34

Re

co

mb

ina

nt

vs

U

rin

ary

Esteves, 35

Better safety, purity and potency with

recombinants.

Similar PRs using 50% less dose with rec-hFSH;

Higher PR with the same dosage.

SC self-injection and individualized stimulation

using small dose adjustments with Pen

injectors.

Better tolerability with rec-hCG.

Do We Need to give

LH in OI/IUI Cycles?

Steroidogenesis

Steroidogenesis and

Final Follicular

Maturation

Alviggi et al. Reprod Biomed Online 2006;12:221.

Balasch J, Fábreques F. Curr Opin Obstet Gynecol 2002, 14:265. Esteves, 38

• Normal androgen and estrogen biosynthesis

• Normal follicular growth and development

• Normal oocyte maturation

No

rma

l

• Suppression of GC proliferation

• Follicular atresia (non-dominant follicles)

• Premature luteinization

• Oocyte development compromised Hig

h

• Insufficient androgen (and estrogen) synthesis

• Follicular maturation impaired

• Inadequate endometrial proliferation Lo

w

WHO group I (LH levels <1.2 UI/L)

Level

1b

Esteves, 39

LH

in

OI/IU

I

Similar follicular development HMG vs FSH + rec-hLH;

Higher cumulative PR after 3 cycles in FSH + rec-hLH

(56% vs 23%; p=0.01)

Carone et al., 2012

Higher follicular

development pts.

receiving LH

(67% vs 20%; p=0.02)

Shoham et al., 2008

Level

1b

Esteves, 40

Clomiphene-resistant

Fewer intermediate-sized follicles and OHSS in LH-supl.

vs FSH group; similar ovulation rate. Plateau, 2006

Previous Excessive Response

Higher monofollicular development in LH group

(32% vs 13%; p=0.04). Hughes et al., 2005

IUI

Higher monofollicular development in LH group w/o

intermediate-size (42% vs 11%; p=0.03);

Lower cycle cancellation due to risk of OHSS (-7%

difference). Segnella et al., 2011

WHO group II L

H in

OI/IU

I

Esteves, 41

• ~80% normogonadotropic women undergoing Ovarian Stimulation1,2

No

rmal

• 15-20% of NG women have less sensitive ovaries • Older patients (≥35 years)3

• Poor responders4

• Slow/Hypo-responders5

• Deeply suppressed endogenous LH levels (hypo-hypo; endometriosis treated with GnRH-a)6

Lo

w

1Tarlatzis et al. Hum Reprod 2006;21:90; 2Esteves et al. Reprod Biol Endocrinol 2009;7:111; 3Marrs et al. Reprod Biomed Online 2004;8:175;4Mochtar MH, Cochrane Database, 2007;

5Alviggi, et al. RBMOnline 2009; 6De Placido et al. Clin Endocrinol (Oxf) 2004;60:637

LH

in

OI/IU

I

Reduced ovarian

paracrine activity

Hurwitz &

Santoro 2004

LH receptor

poly-morphisms

Alviggi et al.,

2006

Androgen secretory capacity reduced

• Piltonen et al., 2003

Decreased numbers of functional

LH receptors

• Vihko et al. 1996

Reduced LH

bioactivity while

imnuno-reactivity

unchanged

• Mitchell et al. 1995; Marama et al 1984

Action of LH at the follicular level increases androgen

production for its later aromatization to estrogens;

May restore the follicular milieu with positive impact on

oocyte quality.

LH

in

OI/IU

I

Mochtar et al,

2007

3 RCT (N=310)

r-hFSH+rLH vs.

r-hFSH alone*OPR

OR 1.85

(95% CI: 1.10; 3.11)

Bosdou et al,

2012

7 RCT (N= 603)

r-hFSH+rLH vs.

r-hFSH alone*

CPR

LBR

(only 1 RCT)

RD: +6%,

(95% CI: -0.3; +13.0)

RD: +19%

(95% CI: +1.0; +36.0%)

Hill et al, 2012

7 RCT (N=902) r-hFSH+rLH vs.

r-hFSH alone

CPR

OR 1.37

(95% CI: 1.03; 1.83)

*long GnRH-a protocol; OR=odds-ratio; RD=risk difference

Mochtar MH et al. Cochrane Database Syst Rev. 2007;2:CD005070; Bosdou JK et al,

Hum Reprod Update 2012; 8(2):127-45. Hill MJ et al. Fertil Steril 2012; 97:1108-4. Esteves, 43

Esteves, 44

PCOS w/previous excessive response Add 75 IU LH activity from D1 (min. 7 days)

Hypo-hypo Add 75 IU LH activity from D1

Poor responders 1:1 or 2:1 FSH/LH ratio from stimulation D1

Add 75 IU LH activity starting on D6

2 3 4 5 7 6 8 9 10 11 12 13 1

Ultrasound

Menses

14 15

LH

in

OI/IU

I

*derives from hCG

Beta unit

Carboxyl terminal segment

Longer in hCG; higher

receptor affinity

Absent in LH and present in

hCG (Longer Half-life)

Purity (LH

content)

hCG

content (IU/vial)

LH

activity (IU/vial)

Specific

activity (LH/mg

protein)

>99% 0 75 22,000 IU

3% ~70 75* ≥ 60 IU

Adapted from ASRM Practice Committee. Fertil Steril. 2008; 90:S13-20. Esteves, 45

Rec-hLH

hMG-HP*

HMG: lower expression of LH/hCG

receptor and other genes involved

in steroids biosynthesis in GC

Down-regulation due to constant

ligand exposure of receptors to hCG

Trinchard-Lugan I et al. Reprod Biomed Online 2002; 4:106-115; Menon KM et al. Biol

Reprod 2004; 70:861-866; Grondal ML et al. Fertil Steril 2009; 91: 1820-1830.

Esteves, 46

Level

2a

Esteves, 47

Mandatory in anovulation WHO I (~75 IU).

WHO II CC-resistent and hyper-responders Higher monofollicular growth and Lower cancellation

Diminished Ovarian Reserve May restore follicular millieu and optimize oocyte quality

LH activity is different in HMG and rec-hLH

May influence oocyte and corpus luteum competence.

Esteves, 48

Yes, we should individualize the

stimulation protocol.

CC can be your first line, but move to

gonadotropins after 3 ovulatory cycles.

Low dose step-up when using

gonadotropins.

Better safety and pt. tolerability

Higher purity, potency and efficacy

with recombinants.

LH supplementation has a role in

selected patients.