1. Corifollitropin alfa is a recombinant gonadotropin that provides a single dose alternative to multiple daily injections of recombinant FSH for controlled ovarian stimulation.
2. Clinical trials have found corifollitropin alfa to be as effective as daily recombinant FSH with similar outcomes for number of oocytes retrieved, ongoing pregnancy rates, and live birth rates.
3. Safety profiles were also similar between corifollitropin alfa and daily recombinant FSH with no evidence of immunogenicity found.
Elonva is a new drug for ovarian stimulation in IVF that has to be studied through randomised controlled trials. Moreover, Meta-analysis of RCTs would enable clinicians and researchers to identify potential benefits and risks
What trigger agent can be used when using assisted reproductive technologies when dealing with infertility?
Pros and cos of different techniques and what is used where.
IVF related information
Ovulation Stimulation Protocols for IUI - Dr Dhorepatil BharatiBharati Dhorepatil
What are important factors to be considered important
Ovarian reserve
Previous ovarian response
Basic hormone profile
Role of LH
Trigger
Luteal phase support
Pregnancy rate/cycle
Elonva is a new drug for ovarian stimulation in IVF that has to be studied through randomised controlled trials. Moreover, Meta-analysis of RCTs would enable clinicians and researchers to identify potential benefits and risks
What trigger agent can be used when using assisted reproductive technologies when dealing with infertility?
Pros and cos of different techniques and what is used where.
IVF related information
Ovulation Stimulation Protocols for IUI - Dr Dhorepatil BharatiBharati Dhorepatil
What are important factors to be considered important
Ovarian reserve
Previous ovarian response
Basic hormone profile
Role of LH
Trigger
Luteal phase support
Pregnancy rate/cycle
Since the first formal description of LPD in 1949 as a possible cause of infertility and recurrent miscarriage by Jones. Innumerable investigations have been undertaken in an effort to verify its existence or to characterize its pathophysiology, diagnosis, and treatment. The consensus of the literature is that LPD does exist and that its cause is multifactorial like abnormal folliculogenesis, inadequate LH surge,inadequate secretion of progesterone by the corpus luteum, aberrant end-organ response by the endometrium.
Luteal phase insufficiency is one of the most important aspect of fertility treatment . But due to lack of proper understanding many unwanted medications are prescribed . This ppt will give an idea on the best evidence based luteal phase support for an ivf cycle.
Intrauterine insemination (IUI) is procedure which involves placing sperm inside a woman's uterus to facilitate fertilization. The ovaries are stimulated with tablets and injections and then monitored for the probable time of ovulation. For more info visit :-//www.newhopeivf.com/intrauterine-insemination-iui.html
Since the first formal description of LPD in 1949 as a possible cause of infertility and recurrent miscarriage by Jones. Innumerable investigations have been undertaken in an effort to verify its existence or to characterize its pathophysiology, diagnosis, and treatment. The consensus of the literature is that LPD does exist and that its cause is multifactorial like abnormal folliculogenesis, inadequate LH surge,inadequate secretion of progesterone by the corpus luteum, aberrant end-organ response by the endometrium.
Luteal phase insufficiency is one of the most important aspect of fertility treatment . But due to lack of proper understanding many unwanted medications are prescribed . This ppt will give an idea on the best evidence based luteal phase support for an ivf cycle.
Intrauterine insemination (IUI) is procedure which involves placing sperm inside a woman's uterus to facilitate fertilization. The ovaries are stimulated with tablets and injections and then monitored for the probable time of ovulation. For more info visit :-//www.newhopeivf.com/intrauterine-insemination-iui.html
28-30 мая 2015 года в Одессе состоялся Х международный симпозиум Украинской ассоциации репродуктивной медицины «Теория и практика репродукции человека».
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
2. 2
1923 The founding of Organon by Dr. Saal van Zwanenberg
1930’s Gonadotrophins from animal material
1932 Gonadotrophins extracted from urine of postmenopausal women (hMG)
and from pregnant women (hCG) women: Pregnyl®
1963 Human Menopausal Gonadotropin: Humegon®
1996 Biotechnology results in recombinant FSH: Puregon®
1999 GnRH antagonist: Antagon®,
Orgalutran®
,ganirelix acetate
2006 One million children born following treatment with Puregon®
2010 EU Approval corifollitropin alfa: Elonva®
A Proud History of Innovation R&D in Fertility
3. 3
Corifollitropin alfa: Timeline
First publication: Fares et al., 1992 PNAS 89; 4304-8
US Patent 5,338,835 Aug 16, 1994 I. Boime (Washington
University, St. Louis, MO) CTP-extended form of FSH
First Human Exposure (Phase I): Bouloux et al., 2001
Human Reproduction; 16: 1592-7.
First Live birth published: Beckers et al., 2003; Fertil Steril
79(3): 621-3.
First Approval, Centralized procedure European Union, 25
Jan 2010 (International birth date).
First markets to launch: Germany and UK, Jan 2010.
4. 4
Molecular Structure of Corifollitropin alfa
A recombinant fusion molecule of
FSH and the CTP of the hCGβ-
subunit
The first of a new class of
gonadotropins with different
pharmacokinetic properties but
similar pharmacologic features as
rFSH
Interacts only with the FSH
receptor and not with the
LH receptor
FSH
CTP
FSH, follicle-stimulating hormone; CTP, carboxy-terminal peptide; hCG, human chorionic gonadotropin;
LH, luteinizing hormone; rFSH, recombinant FSH.
Fares FA, et al. Proc Natl Acad Sci U S A. 1992;89:4304-4308.
5. 5
Fauser et al, Hum Reprod Update, 2009;15:309-321
Treatment regimen of corifollitropin alfa in
comparison to daily rFSH
10987654321
Stimulation Days
FSHActivity
Therapeutic
threshold
Corifollitropin alfa
rFSH
6. 6
Clinical development program
corifollitropin alfa
23 completed trials
21 trials reported
24 clinical trials
Controlled Ovarian
Stimulation
Ovulation
Induction
GnRH antagonist GnRH agonist
Phase IIPhase I Phase III Phase II Phase II
38801
38802
38803
3882305909
38807
38826
Engage
Ensure
Trust
Pursue
Realize 38805
107010
Pregnancy and infant follow-up trials Frozen Thawed Embryo Transfer trials
8. 8
Corifollitropin alfa: clinical development program
In total 24 trials: 23 trials completed
Ongoing trials: FTET cycles of Pursue trial
Subjects exposed to corifollitropin alfa in reported trials
142 healthy volunteers in the Phase I trials
415 patients in Phase II trials exposed to 7.5 to 240 µg
1705 patients in Phase III trials exposed to 100 or 150 µg
677 pregnant patients exposed to corifollitropin alfa in pregnancy follow-up
806 infants evaluated in neonatal follow-up
10. 10
Corifollitropin alfaCorifollitropin alfa
Placebo
Corifollitropin alfa
Placebo
Corifollitropin alfa
Engage and Ensure Treatment Regimen
GnRH antagonist (ganirelix 0.25 mg/d)
day 5 through day of hCG
GnRH antagonist (ganirelix 0.25 mg/d)
day 5 through day of hCG
Stimulation
day 5
hCG as soon as 3
follicles ≥17 mm
(or the day thereafter)
Stimulation
day 8
Cycle day 2-3 =
stimulation day 1
Daily rFSH
(daily dose for 7 days)
Daily rFSH
(daily dose for 7 days)
Investigational group
Reference group
Placebo rFSH
(daily dose for 7 days)
Placebo rFSH
(daily dose for 7 days) Daily rFSHDaily rFSH
Daily rFSHDaily rFSH
IVF
or
ICSI
IVF
or
ICSI
Luteal
phase
support
Luteal
phase
support
11. 11
Mean (SD) number of oocytes per started cycle
Corifollitropin alfa
recFSH
Estimated
difference*
ANOVA (95% CI)
Engage
150 µg
n = 756
13.7 (8.2)
200 IU
n = 750
12.5 (6.7)
1.2 (0.5, 1.9)
Ensure
100 µg
n = 268
13.3 (7.3)
150 IU
n = 128
10.6 (5.9)
2.5 (1.2, 3.9)
*Adjusted for age group and center
12. 12
(Cumulative) Ongoing Pregnancy Rates &
Live Birth Rates in Engage trial
Corifollitropin alfa
150 µg
n = 756
Puregon®
200 IU/day
n = 750
Estimated
differencea
(95% CI)
Ongoing PR
per started cycle
per transfer
38.9%
294/756
43.8%
38.1%
286/750
40.6%
0.9% (–3.9 to 5.7)
3.1% (–2.0 to 8.2)
Live birth rates/
started cycle
35.6%
275 in FU
34.4%
266 in FU
Cumulative ongoing
PR/ started cycle
47.2%
148 ≥1 FTET
44.9%
147 ≥1 FTET
Boostanfar R, et al. Hum Reprod. 2010;25(supple 1):i47 [O-119].
a
Adjusted for age and region. CI, confidence interval; FTET, frozen-thawed embryo transfer.
13. 13
Similar time interval to reach criteria for hCG for
100 μg (≤ 60 kg) and 150 μg (> 60 kg)
Note: Median duration of stimulation was 9 days both in the Engage and Ensure
and in each trial one third of the patients reached the criteria for hCG before or
on Stimulation Day 8.
0%
10%
20%
30%
40%
5 6 7 8 9 10 11 12 13 14 15 16 17 18
Day of hCG criteria
Proportionofsubjects
100 µg corifollitropin alfa
0%
10%
20%
30%
40%
5 6 7 8 9 10 11 12 13 14 15 16 17 18
Day of hCG criteria
Proportionofsubjects
150 µg corifollitropin alfa
Ledger et al RBMonline, 2011
14. 14
Distribution of Duration of Stimulation
Engage trial
0
5
10
15
20
25
30
35
40
5 6 7 8 9 10 11 12 13 14 15 16 17 18
Stimulation day
%ofpatients
Corifollitropin alfa 150 µg
rFSH 200 IU/d
One-third of the patients did not require any rFSHOne-third of the patients did not require any rFSH
15. 15
Similar exposure to corifollitropin alfa using
100 µg and 150 µg doses in Phase 3 Trials
0
500
1000
1500
Trial 107012 Trial 38819
AUC(h.ng/mL)
0
2
4
6
8
10
Trial 107012 Trial 38819Cmax(ng/mL)
De Greef et al. 2010 Clin Pharmacol Ther 2010;888:79-87
Data shown for non-Asian subjects, All-Subjects-Pharmacokinetically-Evaluable
AUC = area under the curve; Cmax = maximum concentration
16. 16
Trigger with urinary or
recombinant hCG as soon
as 3 follicles ≥ 17 mm
Cycle Day 2-3 =
Stimulation Day 1
Corifollitropin
alfa
150 µg/0.5 mL
GnRH antagonist (0.25 mg/daily)
Day 5 or 6 through day hCG
Stimulation
Day 5 or 6
7 days
Stimulation
Day 8
(rec)FSH/hMG daily
≤ 225 IU
Trust trial: treatment for up to 3 cycles
(rec)hCG
IVF
ICSI
Oocyte
retrieval
ET
(max 3)
Luteal phase support
(vaginal P)
17. 17
Trust trial: main clinical outcome
ITT-group
Trial 38825
Cycle 1
N=682
Cycle 2
N=375
Cycle 3
N=198
Number of oocytes
per started cycle
11.9 (7.2)
0 – 47
11.5 (6.8)
0 – 37
11.3 (7.6)
0 - 56
Total embryos at day 3
for patients with IVF/ICSI
Embryos transferred
for patients with ET
6.4 (4.5)
0-26
1.9 (0.7)
6.5 (4.4)
0-25
2.1 (0.7)
6.6 (4.8)
0-25
2.2 (0.7)
Ongoing PR
per started cycle
22.7% 20.5% 20.7%
Cumulative Ongoing PR
(3 cycles)
61%
Censored for discontinuation
51%
Not censored for discontinuation
Norman et al, Hum Reprod 2011
18. 18
Trust: immunogenicity testing
Cycle
Number of subjects
treated with
corifollitropin alfa
Number of
subjects tested
for antibodies
Observed
clinically relevant
immunogenicity incidence
Cycle 1 682 681 0.0
Cycle 2 375 372 0.0
Cycle 3 198 192 0.0
Conclusion: No immunogenicity found
All-subjects-treated group
Norman et al Hum Reprod 2011
19. 19
Ensure and Engage Trust
corifollitropin alfa
N=1023
recFSH
N=880
corifollitropin
alfa
N=682
Grade I (mild)
Grade II (moderate)
Grade III (severe)
3.0% (31)
2.2%(22)
1.8%(18)
3.5% (31)
1.3% (11)
1.3% (11)
1.8% (12)
0.9% (6)
0.9% (6)
Any grade 6.9% (71) 6.0% (53) 3.5% (24)
Percentage of Patients With OHSS per Grade
Patients included in Engage and Ensure Trials were ≤ 36 years and patients in the Trust trial ≤ 39 years
Tarlatzis et al RBMonline submitted
20. 20
OHSS incidences
(WHO criteria)
Cycle 1
N=682
Cycle 2
N=375
Cycle 3
N=198
Grade I (mild)
Grade II (moderate)
Grade III (severe)
1.8% (12)
0.9% (6)
0.9% (6)
0.8% (3)
0.5% (2)
0.5% (2)
0.0%
0.0%
0.0%
Any grade 3.5% (24) 1.9% (7) 0.0%
Trust trial: number of subjects with OHSS per grade
All-subjects-treated group
21. 21
PREGNANT SUBJECTS ENROLLED NUMBER OF LIVEBORN INFANTS
TRIALS corifollitropin
alfa recFSH Total corifollitropin
alfa recFSH Total
Phase II 67 21 88 78 23 101
Phase III
107012
38819
342 312 654 424 370 794
Phase III
38825 268 268 304 304
Total 677 333 1010 806 393 1199
Corifollitropin alfa pregnancy and neonatal follow-up
22. 22
Corifollitropin Alfa
N = 424
recFSH
N = 370
Gestational age, weeks 37.8 (3.2) 38.2 (2.8)
Female sex, n, (%) 210 (49.5%) 190 (51.4%)
Number of singletons, n (%) 241 (56.8%) 237 (64.1%)
Weight at birth—singletons only, g 3297 (534) 3247 (586)
Weight at birth—all, g 2860 (755) 2928 (715)
Length at birth, cm 48.2 (4.1) 48.6 (4.1)
Head circumference, cm 33.6 (2.2) 33.5 (2.6)
Apgar score: 1 min 8.2 (1.5) 8.1 (1.5)
Apgar score: 5 min 9.1 (1.0) 9.1 (0.9)
Characteristics of Live Born Infants
Values are mean (SD) unless otherwise stated.
Combined data of follow-up data Ensure and Engage trial
23. 23
Incidence of Congenital Malformations
Live-born Infants
Corifollitropin alfa recFSH
Combined phase 3 RCTs1
Engage and Ensure
Major
Minor
Any
4.0% (17/424)
12.3% (52/424)
16.3% (69/424)
5.4% (20/370)
11.6% (42/370)
17.0% (63/370)
All phase 2 and 3 trials Major
Minor
Any
4.5% (36/806)
10.0% (81/806)
14.5% (117/806)
Bonduelle M, et al. Hum Reprod. 2010;25(suppl 1):i22 [abstract O-055].
25. 25
Elonva®
: Not for (potential) high responders
Additional Contra-indications SmPC:
A history of OHSS
A previous COS cycle that resulted in more than 30 follicles
≥11 mm measured by ultrasound examination
A basal antral follicle count >20
26. 26
Single Injection of Corifollitropin Alfa to Induce
Multifollicular Development for Controlled Ovarian
Stimulation Using Daily Recombinant FSH as a
Reference in Women Aged 35 to 42 Years
(PURSUE)
27. 27
Key Inclusion Criteria
The subject must fulfill ALL criteria:
– Female ≥35 to ≤42 years of age
– Indication for COS and IVF or ICSI
– Body weight ≥50.0 kg, with a BMI ≥18.0 to ≤32.0 kg/m2
– Regular spontaneous menstrual cycle (cycle length 24 to 35 days)
– Availability of ejaculatory sperm
– Clinical laboratory tests (complete blood count [CBC], blood
chemistries, and urinalysis) within normal limits
– A normal cervical smear result - no atypical or abnormal cells, or in
case of atypical squamous or glandular cells, no signs of malignancy
– Must have results of a physical examination, including blood pressure,
within normal limits
MK-8962 P06029 27Protocol P06029 5/19/2011
28. 28
Key Exclusion Criteria
Recent history of/or any current endocrine abnormality
History of ovarian hyper-response (ie, previous COS cycle with more than 30
follicles ≥11 mm on ultrasound) or ovarian hyperstimulation syndrome (OHSS)
History of/or current polycystic ovary syndrome (PCOS)
More than 20 basal antral follicles <11 mm (both ovaries combined)
History of non- or low ovarian response to FSH / Human Menopausal
Gonadotropin (hMG) treatment
FSH >15.0 IU/L or LH >12.0 IU/L
History of recurrent miscarriage (3 or more, even when unexplained)
Less than 2 ovaries or any other ovarian abnormality
Unilateral or bilateral hydrosalpinx
Intrauterine fibroids ≥5 cm or any clinically relevant pathology, which could impair
embryo implantation or pregnancy continuationMK-8962 P06029 28Protocol P06029 5/19/2011
29. 29
Study Design: Controlled Ovarian
Stimulation (COS) Treatment Cycle
MK-8962 P06029 29
Placebo recFSH (follitropin beta)
(daily dose equivalent to 300 IU for 7 days)
recFSH (follitropin beta)
(daily dose ≤ 300 IU)
recFSH (follitropin beta)
(daily dose 300 IU for 7 days)
recFSH (follitropin beta)
(daily dose ≤ 300 IU)
Oocyte
retrieval
IVF
ICSI
ET
Luteal phase support
(vaginal progesterone gel 8%:
90 mg once daily)
GnRH antagonist (ganirelix, 0.25 mg/day)
Day 5 through Day of rechCG
rechCG
(250 µg)
Cycle day 2-3 =
Stimulation Day 1
Stimulation
Day 5
Stimulation
Day 8
As soon as 3 follicles ≥ 17 mm
(or the day thereafter)
Investigational group:
Reference group:
corifollitropin alfa
150 µg
Placebo
corifollitropin alfa
The maximum duration of stimulation is 19 days; recFSH should not be administered on the day of rechCG.
Protocol P06029 5/19/2011
30. 30
Vital Pregnancy Rate
Full Analysis Set
Primary Endpoint
∆= -3.0 (-7.4; 1.4)*
∆ (95% CI)
30MK-8962 P06029
*Non-inferiority margin: lower bound of the 95% CI above -8%
31. 31
Number of Oocytes Retrieved
Full Analysis SetOocytesRetrieved(Mean)
∆=0.5 ( -0.2, 1.2)*
694 696
∆ (95% CI)
31
MK-8962 P06029
*Non-inferiority margin: Lower bound of the 95% CI of -3 oocytes
35. 35
Ovarian Hyperstimulation Syndrome
(OHSS)
MK-8962 P06029 35
All Subjects as Treated—based on the treatment actually received*
Corifollitropin alfa
150 µg
n = 692
recFSH
300 IU/day
n = 698
n (%) n (%)
Grade unknown 0 (0.0) 1 (0.1)
Grade I (mild) 7 (1.0) 1 (0.1)
Grade II (moderate) 5 (0.7) 4 (0.6)
Grade III (severe) 0 (0.0) 6 (0.9)
Total 12 (1.7) 12 (1.7)
OHSS reported as SAE 0 (0.0) 5 (0.7)
Hospitalization 0 (0.0) 2 (0.3)
Grade II and/or III 5 (0.7) 10 (1.4)
*Two subjects randomized to corifollitropin alfa actually received recFSH
36. 36
Conclusions from PURSUE
Non-inferiority margin met for primary study endpoint of vital
pregnancy rate and key secondary endpoint of number of oocytes
retrieved and live birth rate
Corifollitropin alfa was generally well tolerated and had a safety
profile comparable to recFSH
– Number, type, intensity and drug-relationship of adverse experiences
– Incidence, severity and grading of OHSS episodes
– Incidence of hypersensitivity reactions
– Incidence of congenital malformations
No evidence of clinically meaningful immunogenicity was observed
Safety evaluation of 321 ongoing pregnancies with 394 fetuses does
not suggest a clinically meaningful safety concern for either
pregnant subjects or their offspring.
36
MK-8962 P06029
37. 37
Indication, benefits and contra-indications
Indication:
Controlled Ovarian Stimulation in combination with a GnRH antagonist for
development of multiple follicles in women participating in an ART program
Benefits: one injection replaces 7 daily injections
simplified treatment
easier to understand, less worry
lower potential for medication errors
38. 38
Corifollitropin alfa
Prefilled syringe
Corifollitropin alfa 150 or 100 µg
Automatic (passive) safety system
with retractable needle to prevent
needle stick injuries
Administration
Self-administration
Subcutaneous
Preferably in the abdominal wall
EMEA PI. November 2009.
39. 39
Treatment Protocols in ART
Protocol
IVF/ICSI
OI/IUI
Responder Status
Poor Normal High
Antagonist
Agonist
PuregonELONVA (corifollitropin alfa)
40. 40
Treatment Protocol with corifollitropin alfa
ELONVA™ rFSH
1 2 3 4 5 6 7 8 9 10
hCG
GnRH Antagonist
Posology:
• Flexibility at the start of stimulation and at the day of hCG (plus or minus one day).
• Start ganirelix day 5 as FSH activity is high during the first days of stimulation
• Daily 150 IU rFSH is enough to finish the cycle in normal responders
• Coasting is possible for up to three days in high responders
• No need for rFSH on the day of hCG
• High responders may receive GnRH agonist instead of hCG
Corifollitropin alfa is a novel fertility hormone and belongs to a new class of recombinant gonadotropins: sustained follicle stimulants.
Corifollitropin alfa has a half-life approximately twice that of rFSH.
A single injection of corifollitropin alfa can initiate and sustain multifollicular development for an entire week.
Use of corifollitropin alfa for controlled ovarian stimulation (COS) as part of an assisted reproductive technology program may reduce the required frequency of FSH administration.
This could reduce the treatment burden associated with COS.
May lead to improved treatment acceptability
A single injection of corifollitropin alfa replaces the first 7 daily injections of FSH.
As mentioned earlier, the elimination half-life of corifollitropin alfa is longer than the elimination half-life of rFSH.
The maximum serum concentration is reached after 2 to 3 days of corifollitropin alfa, whereas it is reached within approximately half a day for each rFSH injection (but the serum concentration accumulates over 4 to 5 days to reach a plateau).
A single subcutaneous injection of corifollitropin alfa is able to initiate and sustain multiple follicular development for an entire week. This is depicted by the blue curve, which shows FSH activity above the necessary threshold level.
Geometric means and predicted ranges for 90% of the patients
Two different doses were tested and developed: 100 µg in patients ≤60 kg and 150 µg in patients &gt;60 kg.
Corifollitropin alfa has longer absorption, prolonged circulating half-life, and enhanced biologic activity compared with wild-type human FSH1,2
Corifollitropin alfa is a recombinant glycoprotein that was created from the fusion of the β-subunit of FSH with a part of the β-subunit of human chorionic gonadotropin (hCG) called the carboxy-terminal peptide.
The gonadotropic hormones include thyroid-stimulating hormone (TSH), FSH, luteinizing hormone (LH), and hCG.
All of these glycoprotein hormones consist of 2 linked protein chains, which are called α- and β-subunits. They all have an identical α-subunit, which is 92 amino acids long, but each has a unique β-subunit. The number of amino acids in the β-subunit varies between the hormones, and the β-subunit is therefore responsible for the specific biological action of each hormone.
The corifollitropin alfa molecule consists of
The α-subunit, which is identical for all gonadotropins, and a hybrid β-subunit created through the fusion of the β-subunit of human FSH with the carboxy-terminal peptide of the β-subunit of hCG.
The carboxy-terminal peptide is a small peptide found on the β-subunit of the hCG molecule; it is not found on other gonadotropins, and it has a significant impact on the biologic activity of corifollitropin alfa (increases the half-life of the molecule from ≈30 hours to ≈70 hours).
These are the molecular details; the clinical details are next (what you will receive when it is delivered to your clinic).
Engage trial design
Phase 3 (pivotal efficacy and safety trial)
Active-controlled (vs daily rFSH), noninferiority
Double-blind, double-dummy
Randomization by interactive voice response system (IVRS)
Stratified by center and age (&lt;32 vs ≥32 years) in 1:1 ratio
Planned number of patients: 1400
Multicenter (34 sites: 20 in Europe, 14 in North America)
This slide depicts the treatment regimen used in the Engage trial.
Patients were randomized to receive
A single 0.5-mL injection of corifollitropin alfa (150 µg) on cycle day 2 or 3 (stimulation day 1) and daily rFSH placebo injections (equivalent of 200 IU) for 7 days, or
An injection of placebo corifollitropin alfa (0.5 mL) on cycle day 2 or 3 and daily rFSH (200 IU/d) for 7 days
Daily rFSH was administered only when required in the opinion of the investigator, and a reduced dose of rFSH could be administered from stimulation day 6 onwards if a high response was observed.
Both groups received daily GnRH antagonist (ganirelix 0.25 mg/d) from stimulation day 5 through the day of hCG.
Both groups received daily rFSH (≤200 IU) from stimulation day 8 through the day of hCG.
On the day that 3 follicles were ≥17 mm (or the day thereafter), final oocyte maturation was induced with hCG (10,000 or 5000 IU), and oocytes were collected.
Patients underwent IVF or ICSI.
Luteal phase support was micronized progesterone (≥600 mg/d vaginally or ≥50 mg/d intramuscularly [IM]).
Initiated on the day of oocyte collection and continued for at least 6 weeks or until either menses or negative pregnancy test performed at least 14 days after embryo transfer
This graph shows the distribution of the percentage of patients meeting the hCG criterion of at least 3 follicles ≥17 mm by stimulation day.
The criterion for hCG was reached at or before stimulation day 8 in 32.9% of patients treated with corifollitropin alfa.
This was following the single injection of corifollitropin alfa; no daily rFSH was needed in these patients.
Among patients treated with daily rFSH, 42.9% reached the hCG criterion at or before stimulation day 8.
Median duration of stimulation (days), from stimulation day 1 up to and including day of hCG for both groups = 9 days
Moderate and severe OHSS: P (two-sided F test = 0.15)
Common adverse drug reactions are listed in the left column. Incidence of these adverse reactions were comparable between the corifollitropin arm and the daily rFSH arm of both studies.
The most frequently reported adverse drug reactions with corifollitropin alfa in clinical trials are: OHSS (5.2%), pelvic pain (4.1%) and discomfort (5.5%), headache (3.2%), nausea (1.7%), fatigue (1.4%) and breast complains (including tenderness) (1.2%)
Less common adverse reactions are listed on the right. Incidences of these were balanced between the groups.
PURSUE: A Phase 3, Randomized, Double-Blind, Active-Controlled, Non-Inferiority Trial to Investigate the Efficacy and Safety of a Single Injection of MK8962 (Corifollitropin Alfa) to Induce Multifollicular Development for Controlled Ovarian Stimulation (COS) Using Daily Recombinant FSH (recFSH) as a Reference in Women Aged 35 to 42 Years (Protocol No. P06029)
Use of donated and/or cryopreserved sperm is allowed; sperm obtained via surgical sperm retrieval is not allowed [Protocol P06029, p37A]
Other exclusion criteria: [Protocol p38B, 39A]
positive for Human Immunodeficiency Virus (HIV) or Hepatitis B
subject has contraindications for the use of gonadotropins (eg, tumors, pregnancy/lactation, undiagnosed vaginal bleeding, hypersensitivity, or ovarian cysts) or GnRH antagonists (eg, hypersensitivity, pregnancy/lactation)
recent history of/or current epilepsy, thrombophilia, diabetes, cardiovascular, gastro-intestinal, hepatic, renal or pulmonary or auto-immune disease requiring regular treatment
sperm donor has known gene defects, genetic abnormalities, or abnormal karyotyping, relevant for the current indication or for the health of the offspring
subject smokes or has recently stopped smoking (ie, within the last 3 months prior to signing ICF)
history or presence of alcohol or drug abuse within 12 months prior to signing informed consent
has used corifollitropin alfa previously
has received any hormonal preparations (apart from occasional topical or inhaled use) more recently than washout period (1 menstrual period/1 month) prior to Screening
agents known to affect ovulation (eg, neuroleptics)
drugs known or suspected to be teratogenic (FDA – class X)
allergy/sensitivity to investigational products or their excipients
used any experimental drugs within 3 months prior to signing informed consent
subject is participating in any other clinical trial (excluding surveys)
subject is a member or a family member of the personnel of the investigational or sponsor staff directly involved with this trial
The COS treatment intervention part of the trial was double-blind. After completion of the intervention phase, the data of this part of the trial was locked/frozen and analysis on the primary endpoint and other intervention analyses were performed after unblinding for regulatory submission. Investigators/sites and subjects remained blinded until the database lock of the follow-up Protocol P06031. [Protocol P06029 p32B, 33A]
The independent external medical expert who performed the adjudication of (S)AEs as reported for the offspring into major or minor congenital malformations also remained blinded during the adjudication process. [Protocol P06029, p33A]
This slide presents the number and percentages of subjects with a vital pregnancy in the full analysis set. [CSR p104A]
The estimated difference was -3.0% and corresponding lower limit of the two sided 95% confidence interval (CI) was -7.4%.
The lower limit of the 95% CI was higher than the pre-defined non-inferiority margin of -8%, indicating that treatment with corifollitropin alfa is non-inferior to treatment with recFSH with respect to vital pregnancy rates. [Protocol p104B]
Footnote:
CI= confidence interval; n = number of subjects with a vital pregnancy; N = total number of subjects treated
This slide presents the mean number of oocytes retrieved per attempt (started cycle) and the estimated treatment difference in mean number of oocytes retrieved per attempt. [CSR p106A, B]
The mean number of oocytes retrieved per attempt was 10.7 in the corifollitropin alfa group and 10.3 in the recFSH group. The estimated difference was 0.5 oocyte, and the corresponding lower limit of the two sided 95% CI was -0.2 oocyte.
The lower limit of the 95% CI was higher than the pre-defined non-inferiority margin of -3 oocytes. Since the first step of the hierarchical testing procedure for multiplicity correction was met (i.e., test for non-inferiority of the primary endpoint), it can be established that treatment with corifollitropin alfa is non-inferior to treatment with recFSH with respect to number of oocytes recovered.
This slide presents the number of subjects with various types of AEs starting during the In-treatment Period.
No meaningful differences were noted between the two groups with respect to the overall incidences of AEs, incidences of drug-related AEs, subjects who discontinued due to AEs, AEs that were considered severe or life-threatening, SAEs and drug-related SAEs. There were no deaths in the Intervention Period of this trial in either treatment group.[CSR p148A]
Footnote:
Drug-related AEs and SAEs = Relationship specified as &apos;Probable&apos;, &apos;Possible&apos;
Deaths = Irrespective of time point of death
Severe intensity specified as &apos;Severe&apos;, &apos;Life threatening&apos;.
This slide presents the summary of drug-related AEs in the All-Subjects-Treated population.
The drug-related AEs with the highest incidences in both treatment groups were headache, pelvic discomfort, nausea, breast tenderness, fatigue, OHSS, pelvic pain, injection site pain, and dizziness. Differences between the treatment groups were small and were not considered clinically relevant. [CSR p167A]
Reports of drug-related injection site hematomas and injection site pain were low in both treatment groups and were not considered to be significant. Two subjects had reports of drug-related, local skin reactions following injections: one in the MK-8962 group with an AE of injection site erythema, and one in the recFSH group with injection site pruritus. All but one of the injection site AEs were reported as mild in intensity. One subject in the MK-8962 group experienced injection site hematoma and injection site pain, which was reported as moderate in intensity.
One subject in the recFSH group had generalized pruritus considered to be drug-related by the investigator (itching on face and neck). Two subjects, both in the recFSH group, had a report of drug-related AE of urticaria: one subject with three hives (1-2 cm in size) on neck and another subject had hives on chest. Two other subjects in the recFSH had AEs of erythema which were reported as drug-related. All these AEs were reported as mild in intensity.
This slide presents the incidence rates of each grade (mild, moderate, severe) of OHSS.
OHSS was reported in 12 subjects (1.7%) in each treatment group. All 12 cases of OHSS in the corifollitropin alfa group and 10 of 12 cases in the recFSH group were considered related to study medication in the opinion of the investigator. [CSR p142A]
Incidences of mild OHSS (Grade I) were 1.0% and 0.1% in the corifollitropin alfa and recFSH group, respectively. The incidences of moderate OHSS (Grade II) were 0.7% and 0.6% in the corifollitropin alfa and recFSH group, respectively, whereas the incidences of severe OHSS (Grade III) were 0.0% and 0.9%, respectively.
For none of the subjects in the corifollitropin alfa group and five subjects (0.7%) in the recFSH group, OHSS was reported as an SAE. Two subjects (0.3%) in the recFSH group and none in the corifollitropin alfa group were hospitalized due to the SAE of OHSS.
Incidences of moderate or severe OHSS were 0.7% in the corifollitropin alfa group and 1.4% in the recFSH group (p-value=0.30, Fisher&apos;s exact test).
List of excipients
Sodium citrate
Sucrose
Polysorbate 20
Methionine
Sodium hydroxide (for pH adjustment)
Hydrochloric acid (for pH adjustment)
Water for injections
Passive safety system means that you do not need to take / do any additional action when using the device to activate it (at the end of a full stroke / injection)
Shelf life
2 years.
Special precautions for storage
Store in a refrigerator (2°C‑8°C). For convenience, the patient is allowed to store the product at or below 25°C for a period of not more than 1 month.
Do not freeze.
Keep the syringe in the outer carton in order to protect from light.
Opportunities:
CC treatments: refer patients quicker to IVF centers
IVF cycles:
Move from agonists to antagonists
Move MS within FSH/hMG market
Oocyte donors
Oocyte cryopreservation
Egg banks