ART products and usage TOTAL CYCLE CONTROL

1. ART products and usageTOTAL CYCLE CONTROL Leong Ka Hong MDCM DSc Adjunct Professor Dept of Obs/Gyn McGill University Montreal Canada Specialist Reproductive Medicine Hong Kong Shanghai 14 May 2004

2. BRAVELLETM Highly purified urofollitropin Ferring Pharmaceuticals

3. BRAVELLE • Highly purified urinary FSH • NOT a generic Metrodin-HP • NDA in USFDA • Indications • Ovulation induction • IVF

4. BRAVELLE vs Metrodin-HP

5. BRAVELLE vs rFSH • Sources • Bravelle: pooled human urine • rFSH: rFSH containing culture media with Fetal Bovine serum • Purification steps • Bravelle: ion exchange chromatography • rFSH: immuno-chromatography • Other industrial steps • More or less the same

6. Risks of Prion Contamination • Bravelle: • Low possibility, from pooled human urine • Urine from Argentina (CJD low risk) • rFSH • Possibility 1, Fetal Bovine Serum used in culturing CHO cells (FBS were from US or Canadian sources in which BSE cases found recently) • Possibility 2, immunopurification step which employed monoclonal FSH antibody. Mab was also made from cultured cells which grown in media with FBS

7. Dickey et al., 2003

8. Dickey et al., 2003

9. Dickey et al., 2003

10. Dickey et al., 2003 • Conclusions • Bravelle(R) and Follistim(R) had comparable efficacy in controlled ovarian hyperstimulation in women undergoing IVF-ET. There were no differences in the nature or number of adverse events between the treatment groups although Bravelle(R) injections were reported to be significantly less painful.

11. Feigenbaum et al., 2001

12. Feigenbaum et al., 2001

13. Feigenbaum et al., 2001

14. Feigenbaum et al., 2001 • Conclusion • The efficacy and treatment toleration of Bravelle™, a new, highly purified, human-derived FSH, is comparable to that of recombinant follitropin beta in patients undergoing ovulation induction.

15. BRAVELLE HKIVF DATA

16. Progesterone Sites of production • Corpus luteum • Placenta Functions • Increase endometrial receptivity • Maintain pregnancy

17. Oral vs Vaginal Administration Oral • Liver first-pass metabolism • Low serum level (low bioavailability) • Side effects due to metabolites Vaginal • Avoids liver first-pass metabolism • Fewer systemic side effects • Low serum level • Uterine first-pass effect • High tissue conc. (High bioavailability)

18. Progesterone - Natural vs Synthetic

19. Structure & Synthesis of Progesterone

20. Plasma Progesterone Levels • Follicular phase: <2 ng/ml • Luteal phase: 2 - 20 ng/ml • 1st trimester of pregnancy: ~10 - 40 ng/ml • Near term: ~ 100 - 200 ng/ml • 15% drop: 1 hr after a meal & in the early morning

21. Endometrin® Product Description • Progesterone vaginal tablet (with applicator) • Developed in Israel • Micronized progesterone (100 mg) Indication • Progesterone supplementation or replacement in cases such as treatment of infertile women and IVF

22. Endometrin Characteristics • Prolong release for 12 hours (100 mg) • Bid • Uterine 1st pass effects • Ensures maximal uterine/endometrial exposure • Advanced formulation • Easy administration with specific applicator • Without messy discharge • Unaltered vaginal pH – minimized risks of infection

23. Progesterone supplement

24. General Principles of combined pituitary suppression / ovarian stimulation therapy (From Insler and Lunenfeld)

25. The structure of GnRH agonistic analogues

26. Outcome results according to type of protocol and gonadotrophin used (n=13426)

27. Crude pregnancy rates using different GnRH agonist protocols in IVF (From Daya)

28. Schematic representation of different protocols using GnRH agonists in combination with gonadotrophins for ovarian stimulation in IVF

29. Trade names, plasma half-lives, relate potency, route of administration and recommended dose for the clinically available gonadotrophins

30. Modifications of natural GnRH to have GnRH agonistic properties 1 2 3 4 5 6 7 8 9 10 pyro (Glu) – His – Trp – Ser – Tyr – Gly – Leu – Arg – Pro – Gly – NH2 regulation of GnRH receptor affinity regulation of biologic activity activation of the GnRH receptor Structure of GnRH agonists

31. Action of GnRH agonists Down regulation GnRH LH + FSH GnRH - receptor post-receptor-cascade flare up effect GnRH - agonist pituitary suppression

32. Premature LH surge • Poor quality • No fertilization or very poor pregnancy rate • Cancel egg retrieval 5-20% All cycles treated in 1980’s

34. Results of first application of GnRH-agonists in the long protocol • 11 patients eligible for IVF • GnRH agonist s.c. (buserelin) started at day of menstruation or one day before • ovarian stimulation started with HMG or purified FSH when all ovarian follicles and the endometrial lining has disappeared on ultrasound (average: 15 days) • one ongoing pregnancy achieved Porter et al., 1984

35. ovulation induction embryo transfer oocyte pick up gonadotropin administration in an individualized dosage 22nd day of previous cycle 1st day of gonado- tropins 14 days The long luteal protocol start of GnRH agonist luteal phase support

39. DECAPEPTYL DOWN REGULATION 2000-2003

40. DECAPEPTYL DOWN REGULATION 2000-2003LABORATORY DATA

41. GnRH agonists Over-suppression: • LH becomes so low that it affects the production of estrogen, and possibly progesterone in the luteal phase • Leads to poor response, poor pregnancy outcome due to early abortion Also it is: • Too long and too much drug use, cost, cancelled cycles and it is unnatural.

42. Ovulation Stimulation Scheme • BCP to control cycle (or ovulation monitor) • BCP D16/ovulation +7day DECAPEPTYL • Decapepyl 100mcg/day x 7 days • D2 FSH, LH, E • D3 Bravelle 225-300IU/day with monitor • Choragon 10000IU for induction • Endometrin BD (+ Progesterone)

43. BRAVELLE HKIVF DATA

44. OVULATION STIMULATION Comparison of protocols: • Decapeptyl Down Regulation • Long Lucrin Down Regulation • Antagonist, no down regulation

45. 1 2 3 4 5 6 7 8 9 10 pyro (Glu) – His – Trp – Ser – Tyr – Gly – Leu – Arg – Pro – Gly – NH2 regulation of GnRH receptor affinity regulation of biologic activity activation of the GnRH receptor Structure of GnRH antagonists to achieve antagonistic properties of natural GnRH more modifications than only in position 6 and 10 are necessary

46. Action of GnRH antagonists GnRH LH + FSH GnRH - receptor post-receptor-cascade GnRH - antagonist pituitary suppression

47. no cyst formation no hormonal withdrawal early pregnancy? more physiologic less gona- dotropins longer treatment antagonist administration multiple dose protocol gonadotropin administration gonadotropin administration long protocol agonist administration Comparison of the long protocol and the antagonist protocols flare up effect pituitary suppression pre-treatment cycle treatment cycle

48. ovulation induction embryo transfer oocyte pick up gonadotropin administration in an individualized dosage 1st day of gonado- tropins Cetrotide® 0.25 mg administration daily s.c. starting on day 6 of stimulation The Cetrotide® 0.25 mg multiple dose protocol 1st day of menstruation luteal phase support

49. Possibilities to individualize the multiple dose protocol • To avoid a premature LH rise the administration of cetrotide® 0.25 mg on day 6 of stimulation should be the standard procedure • Using the standard procedure, a mean of 6.3 injections are necessary • This is in accordance with the package size of 7 ampoules cetrotide® 0.25 mg per patient

50. Possibilities to individualize the multiple dose protocol • Individualized administration of Cetrotide® 0.25 mg can be done • According to follicle size: only if leading follicle is  14 mm • Thereby, the multiple dose protocol can also be adapted to patients with a lower response