1 Department of Obstetrics and Gynaecology at the Medical University of Lübeck, Germany, 2 Centre for Reproductive Medicine of the Dutch-Speaking Free University of Brussels, Belgium and 3 ASTA-Medica AG, Frankfurt/Main, Germany
![]() |
Abstract |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Key words: Cetrorelix/gonadotrophin-releasing hormone antagonists/human menopausal gonadotrophins/ovarian stimulation
![]() |
Introduction |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
Materials and methods |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
|
|
Cetrorelix (ASTA-Medica AG, Frankfurt/Main, Germany) was to be injected once daily in doses of 0.25 mg s.c. into the lower abdominal wall, starting from day 6 of treatment with HMG (Humegon®; Organon, Oss, The Netherlands/Menogon®, Ferring GmbH, Kiel, Germany) of the ovarian stimulation cycle up to and including the day of human chorionic gonadotrophin (HCG) administration. Although Cetrorelix should always have been initiated on stimulation day 6, some centres started the administration on day 5 in some patients. This was considered to be a minor protocol violation and did not lead to patients' exclusion. In case, of premature LH rise (LH 10 IU/l and progesterone
1 ng/ml) before HMG day 6, Cetrorelix was administered immediately in order to interrupt a possible spontaneous ovulation and therefore to rescue the cycle. Each Cetrorelix injection was given after a blood sample had been taken for hormone assessments [follicle stimulating hormone (FSH), LH, oestradiol and progesterone] at intervals of 24 ± 2 h. In cases of cycle cancellation before HCG administration due to multifollicular development (
12 follicles >15 mm in diameter) and/or oestradiol concentrations >4000 pg/ml, the Cetrorelix administration was continued for at least one week. This procedure was followed in order to prevent spontaneous ovulation accompanied by the release of multiple oocytes, the increased risk of development of OHSS, and multiple pregnancies.
Since the investigation was designed as an open study, all patients were treated in accordance with the same schedule.
To proceed with the administration of 10 000 IU of HCG (Predalon®; Serono, Geneva, Switzerland/Choragon®; Ferring GmbH), the following prerequisites had to be fulfilled: at least one follicle with a diameter of 20 mm or an oestradiol concentration
1200 pg/ml.
Luteal phase support was given according to the centre's rules regarding start, duration, medication and dosage. The protocol allowed two medications: either injections of HCG according to the centre's rules (though not in the case of oestradiol concentration 2000 pg/ml), or vaginal administration of progesterone (e.g. 600 mg per day for 14 days).
Concentrations of LH, FSH, oestradiol and progesterone were measured regularly on the day of screening, HMG day 1, Cetrorelix day 1, and during the Cetrorelix administration on each morning and on the evening of ovulation induction before HCG administration. Furthermore, hormone concentrations were measured at the day of oocyte retrieval, day of embryo transfer, and 68 days after embryo transfer. All analyses were performed locally at each centre's laboratory. However, to enable an additional analysis of these hormones in a central laboratory, a second serum sample was taken at the same time as the morning blood collection. The second serum samples were immediately frozen and stored at 20°C until being analysed at the clinical chemistry laboratory of ASTA-Medica AG.
Statistical methods
All statistical evaluations and analyses were performed using SASTM 6.09 (SAS Institute Inc., Cary, NC, USA). The primary aim of the present study was to estimate the response rate defined as successful ovarian stimulation, the number of patients reaching the day of HCG, the rate of patients with oocyte retrieval, embryo transfers and pregnancies, as well as to assess serious adverse events. As a response rate of at least 95% was to be expected in order to obtain lower one-sided 95% confidence limits (CL) of 92.5%, a sample size of 319 patients was required. Assuming a rate of about 6% for non-evaluable patients, the inclusion of 340 patients seemed to be appropriate. A sample size of 340 patients and a pregnancy rate of about 20% would lead to about 65 babies being delivered. For this reason at least one adverse experience would have been observed with 95% probability given an assumed incidence of 4.5%. One-sided 95% lower CL were calculated according to ClopperPearson for the efficacy parameters.
![]() |
Results |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
As expected, the HMG stimulation had an important impact on hormone concentrations. FSH rose continuously to a mean concentration of 13.8 mIU/ml (day of HCG administration) as long as the HMG treatment continued. Concentrations of oestradiol increased to a mean of 1544 pg/ml (morning value; central laboratory) on the day of HCG injection.
LH concentrations were clearly suppressed during the entire stimulation period (Figure 1). The median evening value on the day of HCG injection was 1.0 IU/l (evening value, central laboratory).
|
A mean of 25.2 ampoules (median 23 ampoules) of HMG were given for a mean of 10.4 days. HMG was administered in all patients for a minimum of 6 and up to a maximum of 19 days.
Primary parameters of efficacy
Among 346 patients treated according to the described treatment modalities, 333 fulfilled the criteria for administration of HCG to induce final oocyte maturation. This reflected a 96.2% efficacy rate in respect of the primary parameter of success with a lower 95% CL of 94.1%.
Two of the patients without HCG administration showed a rise in LH, one on HMG day 7 and one on HMG day 13. In the case of the first patient, no central laboratory analysis was available. However, this patient was considered to be one of the major protocol violators, as the FSH concentration at HMG day 1 was >12 mIU/ml, and HMG started on day 4 of the cycle instead of day 2 or 3. Finally, the cycle was cancelled in this case as the woman refused to continue ovarian stimulation. In the case of the second patient, the response to ovarian stimulation was very poor, and although progesterone did not reach a concentration of 1 ng/ml, the cycle was cancelled because LH values were above 24 IU/l.
Premature rises of LH
The incidence of premature LH rises above 10 IU/l during stimulation, and premature luteinization of the follicles as indicated by progesterone values above 1 ng/ml, were analysed once by the results from the local laboratory, and once by the results from the central laboratory (Tables III and IV).
|
|
HCG was administered in 12 out of 13 cases with elevations of LH above 10 IU/l without rising concentrations of progesterone. Oocyte retrieval and subsequent fertilization were performed as planned in eight of these patients; cumulusoocyte complexes were obtained in seven of these cases. The fertilization led to embryos of good to excellent quality in six of the eight cases, and to embryos of fair quality in two cases. The treatment cycle of one of these patients led, after replacement of two embryos of excellent quality, to a viable ongoing clinical pregnancy.
On HMG day 6, the frequency of patients with follicles of a given size was distributed as follows: 80% of patients had follicles of 1114 mm, 33% of 1519 mm, and 3% large follicles (20 mm). This turned on the day of HCG injection when 72% of patients had follicles of 1114 mm, 96% of 1519 mm, and 89% had large follicles (
20 mm). On the day of HCG administration, 10.1 follicles were seen on average, and the mean number of follicles with a diameter
20 mm was 2.4.
Fertilization rate, quality of embryos and pregnancy rate
Among a total of 324 patients with oocyte retrieval, 2971 cumulusoocyte complexes were obtained. No oocyte was retrieved from two patients. The mean percentage of mature oocytes, as assessed according to microscopic criteria was 63.7% for patients submitted to IVF, while the mean percentage of metaphase II oocytes for ICSI patients was 75.1% of the oocytes retrieved (Staessen et al., 1989; Van Steirteghem et al., 1993
). The fertilization rate, defined as the number of fertilized (two pronuclear, 2PN) oocytes per inseminated (IVF) or injected (ICSI) metaphase II oocyte, was nearly the same for both methods of fertilization, which means 60% for IVF and 59% for ICSI per cumulusoocyte complex. In total, 149 patients were submitted to the IVF procedure, while metaphase II oocytes of 162 patients were the subject of the microinjection method, and 11 patients were submitted to both procedures (Table V
).
|
Adverse drug reaction
Injection site reactions were seen in only three patients (0.9%), while one case of hot flushes was reported and attributed to the use of the GnRH antagonist Cetrorelix. None of these events led to premature discontinuation of the study medication.
Severe OHSS (grade III)
Only two cases of severe OHSS World Health Organization (WHO) grade III were reported, reflecting an incidence of 0.6% (2/346).
![]() |
Discussion |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
The number and quality of recovered oocytes, the percentage of metaphase II oocytes to be used for ICSI, and fertilization rates after ICSI or IVF must be considered absolutely normal as expected after normal oocyte maturation for assisted reproduction techniques (Küpker et al., 1995; Ubaldi et al., 1995
). A clinical pregnancy rate of 24% per transfer is an acceptable result, and within the estimated limits of an open non-comparative study. These results are even higher than that reported in available European national IVF registers (French IVF Registry, 1995; Deech, 1996
; Deutsches IVF-Register, 1997). However, this clinical pregnancy rate of 24% may be influenced by the fact that the population of patients recruited for this study excluded difficult cases such as patients suffering from polycystic ovarian disease, known low responders, or women aged more than 39 years.
It is reassuring to observe that, when using Cetrorelix, the percentage of babies born per embryo replaced was 10%.
An incidence of 0.6% of severe OHSS (WHO grade III) leading to hospitalization of the patient is low in comparison with the incidence (6.6%) reported after long-protocol agonist treatment (Ron-El et al., 1991). Taking into account all the complications and risks that severe OHSS implies for the patient (such as thrombosis, embolism, putative myocardial infarction and even occasional death), this suggests a major improvement in safety aspects. It is possible that modifications of the stimulation procedures, incorporating softer agents such as clomiphene citrate, may allow this severe, purely iatrogenic disease within assisted reproduction treatment to be abolished (Diedrich and Felberbaum, 1998
).
As yet, it may be too early to predict an end of the agonist era for ovarian stimulation, and these agents will likely retain their importance in special indications such as endometriosis patients in whom assisted reproduction treatment is envisaged. However, if confirmation is obtained in large comparative studies, there may be clear advantages of antagonist co-treatment with gonadotrophins in ovarian stimulation with regard to the patient's comfort, and reductions in treatment duration, medication and costs, while achieving the same range of therapeutic outcome.
In summary, this study has demonstrated the efficacy and safety of Cetrorelix in ovarian stimulation with HMG for IVF, with a pregnancy rate of 24% per embryo transfer being satisfactory. The incidence of severe OHSS grade III as low as 0.6% indicated that Cetrorelix makes an important contribution to the safety of the treatment.
![]() |
Acknowledgments |
---|
![]() |
Notes |
---|
* Prof. Dr K.H.R.Diedrich and Dr med. R.E.Felberbaum, Lübeck, Germany; Prof. Dr M.Breckwoldt, Dr med. C.Keck and Dr med. D.Vogelsang, Freiburg, Germany; Prof. Dr H. van der Ven, Prof. Dr D. Krebs, Dr D.M.Indefrei and Dr C.C.Dibelius, Bonn, Germany; Dr E.Siebzehnrübl and Prof. Dr N. Lang, Erlangen, Germany; Prof. Dr F.Fischl and Dr A.Obruca, Wien, Vienna, Austria; Prof. Dr W.Urdl, Dr H.Auner and Dr A.Giuliani, Graz, Austria; Prof. Dr J.-R.Zorn, Dr N.Ledee and Dr A.Coffineau, Paris, France; Prof. Dr B.C.Tarlatzis, Thessaloniki, Greece; Prof. Dr P.G.Crosignani and Dr G.Ragni, Milan, Italy; Prof. Dr M.Filicori, Prof. Dr C.Flamigni and Dr G.E.Cognigni, Bologna, Italy; Prof. Dr R.Ron-El, Zerefin, Israel; Dr P.N.Barri and Dr F.Martinez, Barcelona, Spain; Dr V.von Düring and Prof. Dr A.Sunde, Trondheim, Norway.
![]() |
References |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Albano, C., Smitz, J., Camus, M. et al. (1997) Comparison of different doses of gonadotropin-releasing hormone antagonist Cetrorelix during controlled ovarian hyperstimulation. Fertil. Steril., 67, 917922.[ISI][Medline]
Biljan, M.M. and Tan, S.L. (1998) GnRH agonists in gonadotropin ovulation induction: characteristics of long regimens. In Filicori, M. and Flamigni, C. (eds), Ovulation Induction: Update 98. The Parthenon Publishing Group, New York, London, pp. 7582.
Deech, R. (1996) A patient's guide to donor insemination and in-vitro fertilization clinics. Hum. Reprod., 11, 13631364.
Deutsches IVF-Register Jahrbuch (1997) Bundesgeschäftsstelle Bad Segeberg, Bismarckallee 116, 22353 Bad Segeberg.
Diedrich, K. and Felberbaum, R. (1998) New approaches to ovarian stimulation. Hum. Reprod., 13 (Suppl. 3), 113.
Diedrich, K., Diedrich, C., Santos, E. et al. (1994) Suppression of the endogenous luteinizing hormone surge by the gonadotrophin-releasing hormone antagonist Cetrorelix during ovarian stimulation. Hum. Reprod., 9, 788791.[Abstract]
Edwards, R.G., Lobo, R. and Bouchard, P. (1996) Time to revolutionize ovarian stimulation. Hum. Reprod., 11, 917920.[ISI][Medline]
Felberbaum, R.E., Reissmann, T., Küpker, W. et al. (1995) Preserved pituitary response under ovarian stimulation with HMG and GnRH-antagonists (Cetrorelix) in women with tubal infertility. Eur. J. Obstet. Gynecol. Reprod. Biol., 61, 151155.[ISI][Medline]
Felberbaum, R., Reissmann, T., Küpker, W. et al. (1996) Hormone profiles under ovarian stimulation with human menopausal gonadotrophin (hMG) and concomitant administration of the gonadotrophin releasing hormone (GnRH)-antagonist Cetrorelix at different dosages. J. Assist. Reprod. Genet., 13, 216222.[ISI][Medline]
French IVF registry FIVNAT Report (1995) Contracept. Fertil. Sex., 24, 694699.
Hahn, D.W., McGuire, J.L., Vale, W.W. and Rivier, J. (1985) Reproductive/endocrine and anaphylactoid properties of an LHRH antagonist (ORF-18260). Life Sci., 37, 505514.[ISI][Medline]
Küpker, W., Al-Hasani, S., Schulze, W. et al. (1995) Morphology in intracytoplasmic sperm injection: preliminary results. J. Assist. Reprod. Genet., 12, 620626.[ISI][Medline]
MacLachlan, V., Besanko, M., O'Shea F. et al. (1989) A controlled study of luteinizing hormone-releasing hormone agonist (Buserelin) for the induction of folliculogenesis before in vitro fertilization. N. Engl. J. Med., 320, 12331237.[Abstract]
Olivennes, F., Fanchin, R., Bouchard, P. et al. (1994) The single or dual administration of the gonadotrophin-releasing hormone antagonist Cetrorelix in an in vitro fertilizationembryo transfer programme. Fertil. Steril., 62, 468476.[ISI][Medline]
Olivennes, F., Fanchin, R., Bouchard, P. et al. (1995) Scheduled administration of a gonadotrophin-releasing hormone antagonist (Cetrorelix) on day 8 of in-vitro fertilization cycles: a pilot study. Hum. Reprod., 10, 13821386.[Abstract]
Out, H.J., Mannaerts, B.M.J.L., Driessen, S.G.A.J. et al. (1996) Recombinant follicle stimulating hormone (rFSH; Puregon) in assisted reproduction: more oocytes, more pregnancies. Results from five comparative studies. Hum. Reprod. Update, 2, 162171.
Out, H.J., Driessen, S.G., Mannaerts, B.M. and Coelingh-Bennink, H.J. (1997) Recombinant follicle-stimulating hormone (follitropin beta, Puregon) yields higher pregnancy rates in in vitro fertilization than urinary gonadotropins. Fertil. Steril., 68, 138142.[ISI][Medline]
Porter, R.N., Smith, W. and Craft, I.L. (1984) Induction of ovulation for in vitro fertilization using Buserelin and gonadotrophins. Lancet, ii, 12841285.
Reissmann, T., Felberbaum, R., Diedrich, K. et al. (1995) Development and applications of luteinizing hormone-releasing hormone antagonists in the treatment of infertility: an overview. Hum. Reprod., 10, 19741981.[Abstract]
Ron-El, R., Herman, A., Golan, A. et al. (1991) Gonadotropins and combined gonadotropin-releasing hormone agonist-gonadotropin protocols in a randomized prospective study. Fertil. Steril., 55, 574578.[ISI][Medline]
Schally, A.V. and Comaru-Schally, A.M. (1997) Rational use of agonists of luteinizing hormone-releasing hormone (LH-RH) in the treatment of hormone-sensitive neoplasms and gynecologic conditions. Adv. Drug Del. Rev., 28, 157169.[ISI][Medline]
Smitz, J., Ron-El, R. and Tarlatzis, B. (1992) The use of gonadotrophin releasing hormone agonists for in-vitro fertilization and other assisted procreation techniques: experience from three centres. Hum. Reprod., 7, 4966.[Abstract]
Staessen, C., Camus, M., Khan, I. et al. (1989) An 18-month survey of infertility treatment by in vitro fertilization, gamete and zygote intrafallopian transfer, and replacement of frozen thawed embryos. J. In Vitro Fertil. Embryo Transfer, 6, 2229.[ISI][Medline]
Stanger, J.D. and Yovich, J.L. (1985) Reduced in vitro fertilization of human oocytes from patients with raised basal luteinizing hormone levels during the follicular phase. Br. J. Obstet. Gynaecol., 92, 385393.[ISI][Medline]
Ubaldi, F., Nagy, Z., Liu, J. et al. (1995) A survey of four years of experience with intracytoplasmic sperm injection. Acta Eur. Fertil., 26, 711.[Medline]
Van Steirteghem, A.C., Liu, J., Joris, H. et al. (1993) Higher success rate by intracytoplasmic sperm injection than by subzonal insemination. Report of a second series of 300 consecutive treatment cycles. Hum. Reprod., 8, 10551060.[Abstract]
Wildt, L., Diedrich, K., Van der Ven, H. et al. (1986) Ovarian hyperstimulation for in-vitro-fertilization controlled by GnRH agonist administered in combination with human menopausal gonadotrophins. Hum. Reprod., 1, 1519.[Abstract]
Submitted on October 11, 1999; accepted on February 9, 2000.