The Role of Recombinant hCG in IVF
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Transcript of The Role of Recombinant hCG in IVF
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Sandro C. Esteves, MD, PhD Medical Director, ANDROFERT
Campinas, Brazil
The Role of Recombinant hCG in IVF
2nd SGH SOAR, Singapore 2014
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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
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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
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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
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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.
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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
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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
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ANDROFERT Source: Dr. Shelley Slaughter, FDA
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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
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ANDROFERT Steelman & Pohley Endocrinol. 53:604-16, 1953
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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
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Non-gonadotropin proteins identified in u-hCG products
PLoS ONE 2011; 6(3): e17815
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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
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2001: rec-hCG (Choriogonadotropin alfa)
Adapted from Leao & Esteves. Clinics 2014;69:279-93
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Secretion of hCG molecules
Incorporation into host cell chromosome
Bulk hCG Released
Bulk hCG
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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
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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)
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rec- hCG
u- hCG: lyophilized powder to be reconstituted
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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
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Clinical advantages of
rec-hCG in IVF as used for oocyte maturation triggering
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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.
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250 μg rhCG=6,500 IU; SC
10,000 IU uhCG; IM
5,000 IU uhCG; IM
Seru
m h
CG
leve
ls
Trinchard-Lugan et al., 2002 Itskovitz et al., 1991
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0% 20% 40% 60% 80% 100%
Doctors & embryologists
Nurses
Patients Safety
Effectiveness
Patient-centeredness
Hum Reprod 2013;26(6):1584-97
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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
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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.
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Databases searched up to January 2010
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Farrag et al. JARG 2008; 25:461-6.
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8.4 7.3 7.1 4.7
0 2 4 6 8
10
No. Retrieved oocytes No. MII with mature cytoplasm
rec-hCG (250 mcg; n=42)
u-hCG (10,000 IU; n=47)
*p<0.01 *
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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
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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
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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.
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* Pain and/or inflammation
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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.
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hCG preferences in treatment-experienced patients at Androfert
Total (n=76) 60% 29%
3%
8%
prefer new pen prefer pre-filled syringe prefer lyophilized powder to reconstitute Not matter
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• 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
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Additional possibilities for using rec-hCG in IVF
• Male Infertility • Luteal phase
support • Intrauterine
administration
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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
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• Rescue ~15% of patients with failed SR attempts1
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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
14h 20h
48h 0 20 h
4h
GnRHa Natural
Luteal phase defect
LH Surge
Humaidan et al. Hum Reprod. 2013;28(9):2511-21
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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,
MMP-9
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
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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
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