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Ovarian reserve is related to chronological age and age 35 years is the accepted threshold for significant decline in assisted reproductive technologies (ART) success with scarce follicular recruitment and poor oocyte retrieval. New therapeutic schemes are sought to improve follicular response in ovarian ageing because of the increasing number of infertile women aged > 35 years who are seeking pregnancy. The advent of gonadotropin releasing hormone analogue antagonist (GnRHant) offers new perspectives to address the advanced reproductive age since it allows for preventing premature luteinizing hormone (LH) surges while not causing suppression in the early follicular phase. Gonadotropin releasing hormone analogue antagonist are administered in the latter stage of the ovarian stimulation to prevent LH surge by competitive blockade of GnRH receptors, thus producing a marked decrease in LH levels just when the interplay between follicle stimulating hormone (FSH) and LH is important to complete follicular development and oocyte competence. Some studies in the past have shown the potential of recombinant human LH (r-hLH) supplementation in older reproductive age to improve oocyte quality, but these studies are of small size and did not provide data on the physiological mechanism behind the benefit obtained.
This randomised, comparative with parallel control, phase II study will be conducted in infertile female subjects aged 35-42 years undergoing in-vitro fertilisation/intra cytoplasmic sperm injection (IVF/ICSI), to investigate whether the addition of r-hLH (when the lead follicle is > 14 mm in size), to the standard protocol with recombinant human FSH (r-hFSH) under GnRHant, improves the number and quality of oocytes retrieved, implantation rate, and pregnancy rate, while assessing the hormonal milieu in ovarian follicular fluid. Comparison will be performed against ovarian stimulation without addition of r-hLH, i.e. with r-hFSH under GnRHant alone.
Preclinical pharmacology studies have demonstrated that r-hLH has a LH/human menopausal gonadotropin (hCG) receptor affinity similar to pituitary hLH (p-hLH), and is biologically active in-vitro in stimulating steroidogenesis and in promoting oocyte germinal vesicle breakdown. Several clinical studies in the past have investigated the usefulness of r-hLH supplementation in normal ovulatory women undergoing ART and almost all of them have been identified as sub-populations of subjects who will benefit, when r-hLH is added along with FSH.
- To assess the efficacy of mid-follicular addition of r-hLH versus no addition of r-hLH, in subjects aged between 35 and 42 undergoing COS with r-hFSH under GnRH antagonist protocol prior to IVF or ICSI, in terms of oocyte number and quality
- To assess the safety of using r-hLH in combination with r-hFSH under a GnRH antagonist protocol, including incidence of ovarian hyperstimulation syndrome (OHSS) and adverse events (AEs) as well as local tolerance
- To complete efficacy with additional assessments such as follicular development, oocyte fertilisation, embryo quality and pregnancy rates
- To investigate the underlying mechanism of potential improvement in oocyte quality by measuring hormonal [LH, FSH, T, estradiol (E2), and human chorionic gonadotropin (hCG)] levels in follicular fluid
All subjects will undergo treatment with r-hFSH at a daily dose of 300-450 IU by subcutaneous (s.c.) route starting on the stimulation Day 1 until r-hCG administration. Upon detection of a lead follicle > 14 mm in size, GnRHant 0.25 mg/day s.c. administration will be initiated and continued up to r-hCG administration day. Subjects will then be randomly allocated (at any time between stimulation Day 1 (S1) and GnRHant initiation day) either to additional treatment with r-hLH at a daily fixed dose of 150 IU or continue treatment with r-hFSH alone. Gonadotropin releasing hormone antagonist and combined treatment with r-hLH + r hFSH or r-hFSH alone will be administered until at least one follicle > 18 mm and two additional follicles > 16 mm are present and E2 levels are commensurate with the number and size of follicles present. A single injection of 250-500 mcg of r-hCG, will be given to induce final follicular maturation within 36 hours of the last r-hLH and/or r-hFSH injections and on the same day of the last GnRHant morning administration. Oocytes will be retrieved 34-38 hours after r-hCG administration, assessed, and fertilised in-vitro by ICSI. Not more than 3 embryos will be replaced on day 2 or 3 after ovum pick-up (OPU). The luteal phase will be supported by a daily vaginal administration of natural progesterone, starting after OPU and continuing either up to menstruation or the pregnancy test or, if the subject is pregnant, for at least 30 days after laboratory evidence of pregnancy. Each subject will be followed-up and the treatment outcome (pregnancy or menstruation) will be recorded.
For all subjects who received r-hCG and do not menstruate, a blood sample will be collected for local determination of serum ß-hCG level between post-hCG days 15-20. If positive (ß-hCG > 10UI/l), it should be confirmed by performing a second test within one week later. An ultrasound scan (US) will be performed at post-hCG days 35-42 on all subjects who will become pregnant provided that no miscarriage has occurred. The number of foetal sacs and foetal heart activity will be recorded. Active follow-up of all pregnancies will be performed, including those subjects withdrawn from the study.
Allocation: Randomized, Endpoint Classification: Safety/Efficacy Study, Intervention Model: Parallel Assignment, Masking: Open Label, Primary Purpose: Treatment
Lutropin alfa for injection (r-hLH) + r-hFSH, r-hFSH preparation
Published on BioPortfolio: 2014-07-23T21:09:56-0400
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