the role of recombinant hcg in ivf

Sandro C. Esteves, MD, PhD Medical Director, ANDROFERT

Campinas, Brazil

The Role of Recombinant hCG in IVF

2nd SGH SOAR, Singapore 2014

Learning objectives At the completion of this presentation, participants should be able to: •  Understand the differences between urinary

and recombinant hCG •  Learn the clinical advantages of rec-hCG in

IVF as used for oocyte maturation triggering •  Be aware of the additional potential use of

rec-hCG in other IVF-related conditions

ANDROFERT androfert.com.br

ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 2 2014 SEPTEMBER

ANDROFERT

Human Chorionic Gonadotropin •  Glycoprotein produced

during pregnancy by syncytiotrophoblast cells and by the pituitary in menopause women

•  In early pregnancy, hCG rescues the corpus luteum and maintains progesterone production until placental steroidogenesis is established

ANDROFERT

In IVF, hCG administration has been the gold standard for final follicular maturation as a surrogate for the mid-cycle LH surge

Extracellular fluid

Cytoplasm

Plasma membrane

LH hCG

LH/hCG receptor

ANDROFERT

LH hCG No. AA beta subunit 121 145 Receptor binding affinity Low High* No. glycosylation sites1 1 6 Half-life (t ½) 20-30 min 24h Bioequivalency 6 – 8 IU 1 IU

1N-linked and O-linked glycosylation sites in beta subunit *2-3x higher than LH

Native LH and hCG are not identical “sisters”

Leao & Esteves. Clinics 2014;69:279-93.

ANDROFERT

hCG and IVF - History •  Zondek & Ascheim (1927)

found that urine of pregnant women contained a substance capable of inducing follicular maturation and ovarian stromal luteinization

•  First hCG preparations developed in 1931 from urine of pregnant women

ANDROFERT

Urinary hCG production The source: •  Pooled urine from pregnant

women The process: •  Urine pool is processed to

concentrate gonadotropins •  hCG is extracted and purified

by either antibody affinity column or conventional chromatography

ANDROFERT Source: Dr. Shelley Slaughter, FDA

Randomized 21-22 day old female rats

hCG injected sc 1x for 3 days

Sacrifice day 4 and collect ovaries

Ovaries are weighed and

data processed

Quantification of hCG activity based on rat ovarian weight gain

ANDROFERT Steelman & Pohley Endocrinol. 53:604-16, 1953

Proportion of total immunoreactivity (%)

Pregnyl® Choragon® Profasi®

Intact bioactive hCG 50 30 96 Hyperglycosylated hCG 0.6 4 0.5 Free β subunit 6.2 8 2.4 β-core fragment1 43 58 1.2 Epidermal growth factor2 181-204 154 4-10

Yarram et al. Fertil Steril 2004;82:232-3

1degradation product of hCG; 2EGF is a contaminant (ng/5000IU)

Level of functionally intact hCG and contamination among formulations

ANDROFERT

Non-gonadotropin proteins identified in u-hCG products

PLoS ONE 2011; 6(3): e17815

What is the ideal gonadotropin preparation?

•  Originating from a safe and consistent source •  Manufactured using consistent and

standardized processes •  Fully physiochemically characterized •  Effective •  Favorable safety profile •  Patient-convenient

ANDROFERT

2001: rec-hCG (Choriogonadotropin alfa)

Adapted from Leao & Esteves. Clinics 2014;69:279-93

ANDROFERT

Secretion of hCG molecules

Incorporation into host cell chromosome

Bulk hCG Released

Bulk hCG

ANDROFERT

Purity (hCG content)

Specific activity (hCG/mg protein)1,2

Protein/IU (mcg = IU)

u-hCG <70% ~13,500 IU/mg ~550 = 5000

rec-hCG 99.9% 27,000 IU/mg 250 = 6750

1Bassett R et al Current Med Res Opinion 2005, 21:1969-76; 2Stenman U-H et al Br

J Pharmacol 2008; 154:569-83; Van Dorsselaer A et al PLoS One. 2011;6:e17815

u- hCG rec- hCG

CG beta CG alpha

Contaminants

ANDROFERT

Size Exclusion High Performance Liquid Chromatography (SE- HPLC)

Gervais et al. Glycobiology 2003;13:179-189; Leao & Esteves Clinics 2014;69:279-93.

Filled by Mass Approach

Proven consistency of rec-hCG physiochemical characteristics

Consistent specific activity i.e. the same biological activity measured in IU/mg of protein

Approval to fill (vials, pens) by mass

(protein content in solution)

ANDROFERT

rec- hCG

u- hCG: lyophilized powder to be reconstituted

ANDROFERT

Rec-hCG has higher purity and better safety profile compared with u-hCG

Consistent physiochemical characteristics allow rec-hCG to be filled by mass, thus offering better dose precision and low batch-to-batch variation compared with u-hCG (filled by bioassay)

High specific activity of rec-hCG allows SC administration using a pre-filled syringe or a pen device while u-hCG needs to be reconstituted and is primarily indicated for IM route

Differences between urinary and recombinant hCG

Key points

ANDROFERT

Clinical advantages of

rec-hCG in IVF as used for oocyte maturation triggering

Approved for use in the treatment of: •  Adult women undergoing superovulation

prior to ART such as IVF to trigger final follicular maturation and luteinization after stimulation of follicular growth;

•  Anovulatory of oligo-ovulatory women to trigger ovulation and luteinization after stimulation of follicular growth.

ANDROFERT

250 μg rhCG=6,500 IU; SC

10,000 IU uhCG; IM

5,000 IU uhCG; IM

Trinchard-Lugan et al., 2002 Itskovitz et al., 1991

ANDROFERT

0% 20% 40% 60% 80% 100%

Doctors & embryologists

Nurses

Patients Safety

Effectiveness

Patient-centeredness

Hum Reprod 2013;26(6):1584-97

ANDROFERT

r-hCG (250 mcg)

r-hCG (500 mcg)

u-hCG (10,000 IU)

No. patients 94 89 92 Oocytes retrieved (mean) 13.6 14.6 13.7 2PN fertilized (mean) 7.2 8.8 P=0.02 7.8 Serum P (d6-7 after hCG) 133.0 163.5 P=0.03 147.4 Pregnancy rate (%) 35.1 36 35.9 OHSS (%) 3.2 9.0 3.1

Chang et al. Fertil Steril. 2001; 76: 67–74

ANDROFERT

RCT N Effect Oocytes retrieved 9 1409 MD: -0.04 (95% CI -0.69 to 0.61)

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)

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

ANDROFERT

Databases searched up to January 2010

Farrag et al. JARG 2008; 25:461-6.

ANDROFERT

8.4 7.3 7.1 4.7

0 2 4 6 8

No. Retrieved oocytes No. MII with mature cytoplasm

rec-hCG (250 mcg; n=42)

u-hCG (10,000 IU; n=47)

*p<0.01 *

Effectiveness RCT comparing rec-hCG (250 mcg) with u-hCG (10,000 IU) for oocyte maturation triggering on

delivery rates in eSET antagonist cycles

26.7% 44.1%

Delivery rate (%)

10,000 IU u-hCG 250 mcg rec-hCG

N=119 aged<32

OR: 2.16 (95% CI: 1.01-4.67; p=0.04) Papanikolaou EG et al. Fertil Steril 2010; 94:2902-4

ANDROFERT

Saleh L et al. Placenta. 2007;28(2-3):199-203

•  In vitro treatment of trophoblast cells with different hCG products

•  Phosporilation of EGC receptors after u-hCG treatment, but not with rec-hCG

•  Increased trophoblast invasion and syncytialization observed using EGF-free hCG (rec-hCG) compared with u-hCG (EGF-contaminated)

Urinary and rec-hCG differentially impact trophoblast differentiation

ANDROFERT

RCT N Odds-ratio

Local site reactions* rec-hCG vs. u-hCG 3 374 0.39

95% CI: 0.25 to 0.61

Driscoll et al. 2000: 27% vs 42% ERHCG Group 2000: 23% vs 45% Abdelmassih et al. 2005: 23% vs 45%

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

ANDROFERT

* Pain and/or inflammation

Human errors after hCG administration

•  0.5%-0.8% Empty follicle syndrome after u-hCG administration1,2

•  Case report of patient who injected only diluent3

•  Recurrent empty follicle syndrome successfully treated with rec-hCG4

1Quintans et al. Hum Reprod 1998;13:2703-5; 2Zegers Hochschild et al. Hum Reprod 1995;10:2262-5; 3Esposito & Patrizio J Reprod Med 2000;45:511-4;

4Penarrubia et al. Hum Reprod 1999;14:1703-6.

ANDROFERT

hCG preferences in treatment-experienced patients at Androfert

Total (n=76) 60% 29%

prefer new pen prefer pre-filled syringe prefer lyophilized powder to reconstitute Not matter

ANDROFERT

•  Safety originates from a safe and consistent contamination-free source; fully characterized

•  Effectiveness 250 mcg rec-hCG at least as effective as 10,000 IU u-hCG for final follicular maturation

•  Patient-centeredness better tolerated and preferred by treatment-experienced patients

Clinical advantages of rec-hCG in IVF for oocyte maturation triggering

Key points

ANDROFERT

Additional possibilities for using rec-hCG in IVF

•  Male Infertility •  Luteal phase

support •  Intrauterine

administration

1Shiraishi et al Hum Reprod 2012;27(2):331-9; Esteves Int Braz J Urol 2013;39(3):440

hCG in non-obstructive azoospermia prior to sperm retrieval

Microdissection TESE

ANDROFERT

•  Rescue ~15% of patients with failed SR attempts1

Modified LPS for fresh ET in GnRH-a trigger using hCG

No. follicles day OPU 1,500 IU hCG at OPU & 1,000

OPU+5 & standard LPS ≤ 14 1,500 IU hCG at OPU +

standard LPS 15-25 1,000 IU hCG at OPU +

standard LPS or Freeze all 26-30

Freeze all >30

14h 20h

48h 0 20 h

GnRHa Natural

Luteal phase defect

LH Surge

Humaidan et al. Hum Reprod. 2013;28(9):2511-21

ANDROFERT

Intrauterine hCG administration (500 IU) before embryo transfer

Positive effect on endometrial receptivity1 •  Inhibition of IGF-binding

protein 1 and M-CFS •  Stimulation of LIF, VEGF,

1Licht et al Hum Reprod Update 1998; 2Mansour et al Fertil Steril 2011; 3Santibañez et al Reprod Biol Endocrinol 2014

Improvement in implantation and pregnancy rates

ANDROFERT

Rec-hCG produces pharmacodynamic responses consistent with hCG physiology, thus offering the opportunity for use in the same clinical situations as u-hCG

The secure source and high purity of rec-hCG may offer advantages when used for male infertility, luteal support and intrauterine administration

Although preliminary data seems promising, safety, effectiveness and patient-centeredness still need to be evaluated in large RCT trials

Additional possibilities for using rec-hCG in IVF

Key points

ANDROFERT

the role of recombinant hcg in ivf

male reproductions esteves

lhleao esteves

hcg inivf

quantification of hcg

intact hcg andcontamination

urinaryand recombinant

urine pool

pooled urine

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