New Insights into Single Embryo Transfer Evidence with HP-hMG

Joan-Carles Arce, MD PhD Vice President Reproductive Health, Global Clinical R&D Ferring Pharmaceuticals

II Simposio de Reproduccin Asistida, Madrid, 21 Feb 2014

GnRH Antagonist Protocol

Limited comparative data between HP-hMG and rFSH preparations in GnRH antagonist cycles Bosch et al. (2008): RCT N=280 women up to 37 years, IVF/ICSI, up to 3 embryos transferred at cleavage stage
HP-hMG rFSH P-value

Estradiol, day of hCG (pg/mL)

Progesterone, day of hCG (ng/mL) Oocytes retrieved Embryos transferred Ongoing pregnancy rate

2066 1011
0.73 0.42 11.3 6.0 1.7 0.8 35%

1750 973
0.99 0.48 14.4 8.1 1.7 0.8 32%

0.02
<0.001 0.001 0.745 0.61

Bosch et al., Hum Reprod 2008

Single Embryo Transfer

Europe
100%

United States

80%

4 3 2 1

60%

40%

2009: 24.2%
20%

0%

1999 2001 2003 2005

Nyboe Andersen, 2008

2009: The highest proportions of SETs were found in Sweden (70.7%), Norway (53.4%), Belgium (48.9%) and Denmark (42.0%).
Ferraretti et al, 2013

Transfer at Blastocyst Stage

Blastocyst transfers have been associated with higher live birth rates

Papanikolaou et al., NEJM 2006; Hum Reprod 2008

Transfer at Blastocyst Stage

Glujovsky et al, Cochrane Review 2012

Design

MEGASET Trial Design

Randomised, assessor-blind, parallel groups, multicentre, non-inferiority trial N= 749

< 35 years of age 1st or 2nd IVF/ICSI cycle BMI 18-25 kg/m2

Treatment regimen: HP-hMG (MENOPUR) or rFSH (PUREGON)

GnRH antagonist (ganirelix 0.25 mg/day) starting on day 6 of simulation

ICSI and culture to blastocyst stage (quality evaluation by Gardner & Schoolcraft, 1999) Patients underwent compulsory SET on Day 5 Luteal support from day after oocyte retrieval to hCG test / menses (~18-20 days) Primary endpoint: Ongoing pregnancy rate (at least one intrauterine viable fetus 10-11 weeks after blastocyst transfer) Non-inferiority limit of -10.0%; PP and ITT population

Vitrification of all surplus blastocysts

1-year FER: compulsory SET on Day LH +7 in a natural cycle
Devroey et al., Fertil Steril 2012

MEGASET Trial Design

Trial flow
GnRH antagonist 0.25 mg Key design features: Women 18-34 years BMI 18-24.9 kg/m2 No programming 150 IU starting dose ICSI Blastocyst culture Transfer on Day 5 Non-elective SET 2 weeks luteal support Vitrification Frozen natural cycle Frozen non-elective SET

HP-hMG or rFSH
150 IU x 5 days
Adjustment by 75 IU; minimum 4 days on dose

rhCG 250 g

Progesterone 3x200 mg
Oocyte/embryo/ blastocyst evaluation

-hCG

Clin. P

Ong. P

6
3 follicles 17mm

OR

OR +5

13-15 days after ET

5-6 10-11 weeks weeks after ET after ET

ET
1 blastocyst

Post-trial follow-up
1-year post-randomisation frozen embryo replacement (FER) cycles
Ongoing pregnancy No ongoing pregnancy FER 1 blastocyst natural cycle

Ongoing pregnancy

No ongoing pregnancy

Pregnancy outcome and neonatal health follow-up

Pregnancy outcome and neonatal health follow-up

MEGASET Biomarkers Investigations

Endocrine profile Serum profile
FSH LH hCG Prolactin Estradiol Progesterone Total testosterone SHBG FAI AMH Inh B

Follicular fluid hormones and cytokines

Potential markers of embryo quality and implantation

Oocyte to blastocyst

Gene expression Cumulus cells

Full profile by microarray Real-time Q-PCR etc genes of relevant

Blastocyst morphology
Relationship to treatment outcome

Uterus and endometrium

Uterine contractility

3D modelling of endometrium

MEGASET Biomarkers Investigations

Endocrine profile Serum profile
FSH LH hCG Prolactin Estradiol Progesterone Total testosterone SHBG FAI AMH Inh B

Follicular fluid hormones and cytokines

Potential markers of embryo quality and implantation

Oocyte to blastocyst

Gene expression Cumulus cells

Full profile by microarray Real-time Q-PCR etc genes of relevant

Blastocyst morphology
Relationship to treatment outcome

Uterus and endometrium

Uterine contractility

3D modelling of endometrium

Key Findings
Primary objective AMH Progesterone and treatment outcome Blastocyst quality and treatment outcome

End of Stimulation and Oocyte Retrieval

HP-hMG rFSH 6% 7022 4945 2.6 2.6 p NS <0.001 NS

Premature LH rise

6% 8797 6030 2.6 2.6

12

Estradiol (pmol/L) Progesterone (nmol/L)

10

Oocyte retrieval
Oocytes retrieved

97%
9.1 5.2

97%
10.7 5.8

NS
<0.001

Frequency (%) of patients

HP-hMG rFSH

0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35

Number of oocytes retrieved

Devroey et al., Fertil Steril 2012

Excessive Ovarian Response

Distribution of patients by number of oocytes retrieved

HP-hMG

15%
45% 40%
7 15

23% 41%

36%

rFSH

8-14

8-14

15 rFSH (N=375) 2 (0.5%) 5 (1.3%) 1 (0.3%) p

SAFETY RELATED TO EXCESSIVE RESPONSE

Early OHSS Mild (grade 1 and 2) Moderate (grade 3) Severe (grade 4 and 5)

HP-hMG (N=374) 1 (0.3%) 5 (1.3%) 1 (0.3%)

0.798

Signs of excessive response Cancellation due to excessive response Fluid collection (peritoneal ascites puncture) Preventive action (albumin administration) Any of the above signs of excessive response

0 5 (1.3%) 7 (1.9%) 11 (2.9%)

2 (0.5%) 9 (2.4%) 17 (4.5%) 24 (6.4%)

0.025

Devroey et al., Fertil Steril 2012

Pregnancy and Live Birth

HP-hMG rFSH

Per started cycle

PP-population ITT-population
%
40
39

%
40
40 36

36

32 30
29

30
27

31 29
26

30

29

29
27

28
26

20

20

10

10

0
Positive hCG Clinical pregnancy Ongoing pregnancy Live birth

0
Positive hCG Clinical pregnancy Ongoing pregnancy Live Birth

3.0% (-3.8; 9.8)

Primary endpoint
Treatment difference (95% CI)

2.2% (-4.2; 8.6)

Devroey et al., Fertil Steril 2012

Pregnancy and Live Birth

HP-hMG rFSH %
50
48 42

Per cycle with transfer

PP-population
%
50
48 42

ITT-population

40

39
34

36
32

40 35
30

38
34

35
32

35
30

30

30

20

20

10

10

0
Positive hCG Clinical pregnancy Ongoing pregnancy Live birth

0
Positive hCG Clinical pregnancy Ongoing pregnancy Live Birth

Devroey et al., Fertil Steril 2012

Live Birth after 1-year Cryopreserved Cycles

HP-hMG Oocytes retrieved Frozen blastocysts 9.1 5.2 1.8 2.4 % 50 40 40 38 rFSH 10.7 5.8 2.1 2.8
HP-hMG rFSH

PP-population

% 50 40

ITT-population

40

38

30
20 10 0

29

26

30
20 10 0

28

26

Fresh

Cumulative

Fresh

Cumulative
Devroey et al., Fertil Steril 2012

AMH

AMH Is the Best Predictor of Ovarian Response

AMH Basal FSH AFC

Arce et al., Fertil Steril 2013

AMH Can Predict Low and High Response

B. Poor response, rFSH
1.0

D. High response, rFSH

1.0

0.897

0.813
0.8 0.8

Sensitivity

0.4

Sensitivity
AMH (AUC = 0.897) FSH (AUC = 0.719) Inhibin B (AUC = 0.637) AFC (AUC = 0.741)

0.6

0.6

0.4

0.2

0.2

AMH (AUC = 0.813) FSH (AUC = 0.731) Inhibin B (AUC = 0.534) AFC (AUC = 0.636)

0.0 0.0 0.2 0.4 0.6 0.8 1.0

0.0 0.0 0.2 0.4 0.6 0.8 1.0

1-Specificity

1-Specificity

Low response
(<4 oocytes retrieved or cycle cancellation due to poor response)

High response
(15 oocytes retrieved or cycle cancellation due to excessive response)

Arce et al., Fertil Steril 2013

AMH vs AFC as Predictor of Ovarian Response

Analysis of individual clinics data with respect to performance of AMH and AFC as predictor of number of oocytes retrieved
Clinics 10 patients
AMH
0.60575
0.54131 0.58104 0.75623 0.65039 0.60914 0.57741 0.54339 0.68255 0.51407 0.67043 0.50980 0.71831 0.49253 0.59483 0.66819 0.38223

Clinics 25 patients
AMH
0.58104
0.65039 0.60914 0.57741 0.54339 0.50980 0.49253 0.59483

Multiple regression analysis

(simultaneous inclusion; full dataset)

AFC
0.45577
0.47070 0.52216 0.26343 0.46526 0.40751 0.19460 0.46817 0.75580 0.33362 0.28023 0.57046 0.49646 0.35018 0.51104 0.49425 0.23277

AFC
0.52216
0.46526 0.40751 0.19460 0.46817 0.57046 0.35018 0.51104

AMH: p<0.0001 AFC: p=0.0938

AMH was a strong significant predictor of number of oocytes retrieved, while AFC provided no added predictive value

AMH has higher correlation coefficient to number of oocytes retrieved than AFC in 7 of 8 clinics

0.27011

-0.04152

AMH has higher correlation coefficient to number of oocytes retrieved than AFC in 16 of 18 clinics

When evaluating each clinic, the overall conclusion is that AMH is a better predictor of ovarian response to gonadotropin therapy than AFC.

Arce et al., Fertil Steril 2013 (b)

Ovarian Response and OHSS / Interventions by AMH Quartiles (HP-hMG vs rFSH)

Number of oocytes retrieved Percentage of patients with early OHSS or safety interventions due to excessive ovarian response
16
HP-hMG rFSH

30

15
HP-hMG rFSH

25

14
146

126

12
126

Oocytes retrieved

20
104 84
63 62

115

10 % 8 6 4 4 3 1 Q1 Q2 3 3

10 9

15

10

Q1

Q2

Q3

Q4

Q3

Q4

AMH quartile

AMH quartile

rFSH was associated with higher oocyte yields in Q2, Q3 and Q4, compared to HPhMG. Where biology restricted the follicular recruitment (Q1), there was no difference.

Interventions: cycle cancellation due to excessive response, paracentesis, albumin administration

Arce et al., Fertil Steril 2013

Hyper-response and Live Birth in AMH Q4

AMH highest quartile 15 oocytes
% 60
p=0.015

HP-hMG rFSH

Live birth
% 40
p=0.075

49

34

30
40 31 20 23

20
10

0 Q4

0 Q4
Arce et al., Fertil Steril 2013

Progesterone

Ongoing Pregnancy Rate According to Progesterone Level at End of Stimulation

Agonists (n=1117)
60
43.9 (32.655.9) 9.7 (31.948.1) 37.7 (34.541.1) 22.7 21.0 (10.143.4) (8.643.3) 24.0* (14.337.4)

Antagonists (n=2855)
50
34.2 (25.240.5)

Mean ongoing pregnancy rate (%)

50

40
27.9 (26.129.8) 27.9 (23.033.4)

20.4 (11.533.6) 17.8* (10.728.1)

40

30 30 20 20 10

6.8 (2.318.2)

10
p=0.023

1.5 ng/mL= 4.77 nmol/L

1.00 1.011.25 1.261.50 1.511.75 1.762.00 >2.00

p=0.022

1.5 ng/mL= 4.77 nmol/L

1.00 1.011.25 1.261.50 1.511.75 1.762.00 >2.00

Serum P on day of hCG (ng/mL)

*p<0.05 for comparison with previous progesterone level

Serum P on day of hCG (ng/mL)

Bosch et al., Hum Reprod 2010

Ongoing Pregnancy by Progesterone at End of Stimulation

p<0.05

Data on file

Ongoing Pregnancy by Progesterone at End of Stimulation

NS

p<0.05

Data on file

Ongoing Pregnancy by Progesterone at End of Stimulation

33%

Average ongoing pregnancy rate per cycle with transfer

NS

p<0.05

2.3

3.5

Data on file

Ongoing Pregnancy by Progesterone at End of Stimulation

Logistic regression model: Overall, there was a significant (p<0.011) decrease in ongoing pregnancy rate with increased progesterone levels at the end of stimulation Threshold (4 nmol/L)
1 ng/mL = 3.18 nmol/L 1.26 ng/mL = 4 nmol/L

40
p<0.05

HP-hMG rFSH

Ongoing pregnancy (%)

30

29

29

30

20

16

10

N=306 84%

N=308 86%

N=57 16%

N=49 14%

P4 4 nmol/L

P4 > 4 nmol/L
Devroey et al., Fertil Steril 2012

Progesterone at end of stimulation

Ongoing Pregnancy by Progesterone at End of Stimulation

Ongoing pregnancy (%) 40 30 20 10 0
P4 4 nmol/L P4 > 4 nmol/L Progesterone at end of stimulation HP-hMG rFSH

HP-hMG
40 rFSH 34 Ongoing pregnancy (%) 30 29 29

29 29

30
p<0.05

16

21 20 19

10

0
1.26 ng/mL = 4 nmol/L 1.76 ng/mL = 5.6 nmol/L

P4 4 nmol/L P4 >4-5.6 nmol/L P4 >5.6 nmol/L Progesterone at end of stimulation

Data on file

Blastocyst Quality

Blastocyst Morphology
Distribution of blastocysts according to individual morphology parameters
Ahlstrm et al Hum Reprod 2011 n % Expansion and hatching 6 5 4 3 2 1 0 Inner cell mass A B C Trophectoderm A B C Hill et al Fertil Steril 2013 n % Honnma et al Fertil Steril 2012 n % Van den Abbeel et al RBM online 2013 n %

0 0 465 407 154 70 21 665 200 7 469 378 25

0 0 42 36 14 6 2 76 23 1 54 43 3

{ 98 { 544

{ 14 { 77

52 0 619 73 2 520 166 8

7 0 89 10 1 75 24 1

54 424 437 172 696 366 25 341 687 59

5 39 40 16 64 34 2 31 63 5

0 152 255 106 52 53 270 184 59 235 217 61

0 25 41 17 8 9 53 36 12 46 42 12

Blastocyst Quality and Treatment Outcome

Live birth: Blastocyst expansion and hatching status was the only significant predictor (p=0.002) in the multiple regression analysis. Early pregnancy loss: inner cell mass was the only significant predictor (p=0.033).
Van den Abbeel et al., RBM Online 2012

Conclusions

Conclusions

HP-hMG is at least as effective in achieving pregnancy as rFSH when used for controlled ovarian stimulation in a GnRH antagonist cycle with compulsory single blastocyst transfer. Further evidence was provided that these gonadotropin preparations are associated with differential follicular response and serum endocrine profile during the stimulation phase.

The trial data supported the role of AMH as predictor of ovarian response to gonadotropin therapy and the influence of serum progesterone on treatment outcome. Further large multicentre datasets might help to elucidate the specific role of each blastocyst morphology parameter on treatment outcome.