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Ovarian response to 150 µg corifollitropin alfa in a GnRH-antagonist multiple-dose protocol: a prospective cohort study
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Ovarian response to 150 µg corifollitropin alfa in a GnRH-antagonist multiple-dose protocol: a prospective cohort study Tamara Lerman a, Marion Depenbusch a, Askan Schultze-Mosgau a, Soeren von Otte b, Markus Scheinhardt c, Inke Koenig c, Axel Kamischke d, Milan Macek e, Arne Schwennicke f, Sabine Segerer g, Georg Griesinger a,* a
Department of Reproductive Medicine and Gynecological Endocrinology, University Hospital of SchleswigHolstein, Campus Luebeck, Luebeck, Germany b Universitaeres Kinderwunschzentrum Kiel, Kiel, Germany c Institute for Medical Biometrics and Statistics, University of Luebeck, Luebeck, Germany d Kinderwunschzentrum Muenster, Muenster, Germany e Department of Biology and Medical Genetics, University Hospital Motol, Prague, Czech Republic f Klinikk Hausken, Haugesund, Norway g Amedes Experts Hamburg, Hamburg, Germany
Georg Griesinger is a full Professor at Luebeck University and Chair at the Department of Gynecological Endocrinology and Reproductive Medicine, University Hospital of Schleswig-Holstein, Luebeck, Germany. He obtained his MD at the University of Vienna, and his MSc in prenatal genetics and fetal medicine at University College London. KEY MESSAGE As a single predictor, AMH can reliably identify patients undergoing ovarian stimulation for IVF who are unlikely to experience hypo- or hyperresponse to corifollitropin alfa 150 µg. Thus, utilization of 150 µg corifollitropin alfa should take the pre-treament serum AMH concentration of patients into account to achieve optimal treatment outcomes.
A B S T R A C T The incidence of low (<6 oocytes) and high (>18 oocytes) ovarian response to 150 µg corifollitropin alfa in relation to anti-Müllerian hormone (AMH) and other biomarkers was studied in a multi-centre (n = 5), multi-national, prospective, investigator-initiated, observational cohort study. Infertile women (n = 212), body weight >60 kg, underwent controlled ovarian stimulation in a gonadotrophin-releasing hormone-antagonist multiple-dose protocol. Demographic, sonographic and endocrine parameters were prospectively assessed on cycle day 2 or 3 of a spontaneous menstruation before the administration of 150 µg corifollitropin alfa. Serum AMH showed the best correlation with the number of oocytes obtained among all predictor variables. In receiveroperating characteristic analysis, AMH at a threshold of 0.91 ng/ml showed a sensitivity of 82.4%, specificity of 82.4%, positive predictive value 52.9%
* Corresponding author. E-mail address: [email protected] (G Griesinger). http://dx.doi.org/10.1016/j.rbmo.2017.02.012 1472-6483/© 2017 Published by Elsevier Ltd on behalf of Reproductive Healthcare Ltd. Please cite this article in press as: Tamara Lerman, et al., Ovarian response to 150 µg corifollitropin alfa in a GnRH-antagonist multiple-dose protocol: a prospective cohort study, Reproductive BioMedicine Online (2017), doi: 10.1016/j.rbmo.2017.02.012
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and negative predictive value 95.1% for predicting low response (area under the curve [AUC], 95% CI; P-value: 0.853, 0.769–0.936; <0.0001). For predicting high response, the optimal threshold for AMH was 2.58 ng/ml, relating to a sensitivity of 80.0%, specificity 82.1%, positive predictive value 42.5% and negative predictive value 96.1% (AUC, 95% CI; P-value: 0.871, 0.787–0.955; <0.0001). In conclusion, patients with serum AMH concentrations between approximately 0.9 and 2.6 ng/ml were unlikely to show extremes of response. © 2017 Published by Elsevier Ltd on behalf of Reproductive Healthcare Ltd.
Introduction A number of biomarkers are clinically used to predict ovarian response to ovarian stimulation in the context of IVF (Broekmans et al., 2006). The aim of ovarian response prediction is to identify patients who will show an extreme of response. In such patients, management decisions can be taken, such as altering the FSH dose and stimulation protocol (Nelson et al., 2009). Furthermore, the patient can be counselled about the expected response. Anti-Müllerian hormone (AMH) has been reported as a key biomarker for predicting ovarian response (Broer et al., 2013; Nelson et al., 2015a). Corifollitropin alfa is a hybrid FSH molecule with an increased serum half-life, allowing the initiation and sustainment of multifollicular growth for seven days after a single subcutaneous injection (Fauser et al., 2009). Corifollitropin alfa has been introduced to the market in two dosages, 100 µg and 150 µg. In contrast to ovarian stimulation with daily FSH injections, no dose adaptions are possible for a full week after administration of corifollitropin alfa. Furthermore, corifollitropin alfa 150 µg produces, on average, a slightly stronger ovarian response as compared with daily FSH 200 IU (Devroey et al., 2009). This makes correct response prediction paramount for routine use of corifollitropin alfa. However, in three out of four corifollitropin alfa phase III trials (Corifollitropin alfa Ensure Study Group, 2010; Devroey et al., 2009; Norman et al., 2011), the key biomarker AMH has not been assessed. Furthermore, phase III trial populations are different from routine patients in many aspects such as body weight, age and the expected incidence of extremes of ovarian response. While there is a wealth of literature to date on ovarian response prediction by AMH, only two studies on predicting ovarian response in the corifollitropin alfa protocol, e.g. cycles utilizing a gonadotrophinreleasing hormone (GnRH)-antagonist multiple-dose protocol and a dose of 150 µg, have been published (Oehninger et al., 2015; Polyzos et al., 2013). While one study (Polyzos et al., 2013) was retrospective and used an AMH immuno-assay, which is no longer available, the other study (Oehninger et al., 2015) employed the widely-used Gen II AMH assay, but the population under study was restricted to women of advanced reproductive age (36–42 years). This study presents a prospective, clinical cohort study on a broad range of patients undergoing ovarian stimulation with 150 µg corifollitropin alfa with the primary aim of testing the performance of AMH, among other endocrine, demographic and sonographic variables that are available pre-treatment, to predict low and high ovarian response, respectively.
Materials and methods Study design The study was a multi-centric (n = 5), prospective, investigatorinitiated, observational cohort study conducted between 2012 and 2013
(protocol ID: GR 3422/3–1). Four centres were located in Germany (Luebeck, Kiel, Wuerzburg, Muenster), one centre was located in Norway (Haugesund). Institutional review board approval was granted (Ethical Review Board of the University of Luebeck, reference number 10–143) on 26 August 2010 and all patients signed an informed consent sheet. The protocol was prospectively registered (NCT01206803). All eligible patients were prospectively and centrally registered by telephone or fax.
Population Women with an indication for IVF or intracytoplasmic sperm injection (ICSI), eligible to undergo ovarian stimulation, were prospectively recruited from the routine patient population, age limit 18–45 years. Patients with immediate sex-steroid pre-treatment (e.g. cycle scheduling with an oral contraceptive) were excluded. This exclusion criterion was chosen so that the impact of sex-steroid pre-treatment would not constitute a potential confounding variable of ovarian response.
Protocol On cycle day 2 or 3 of a spontaneous menstruation (stimulation day 1), patients were scheduled for a monitoring visit at the clinic, a transvaginal scan was performed and a blood sample was drawn for later, centralized analysis. The following parameters were recorded at this visit: woman’s age (years), weight (kg), body-mass-index (kg/m2), average number of cigarettes per day, duration of infertility (months), cycle length (in days, by patient recall), cycle regularity (yes/no; deviation of >5 days from two consecutive cycles is considered an irregular cycle), total number of antral follicles (2–10 mm) in both ovaries, and serum AMH (ng/ml), oestradiol, progesterone, FSH and LH. The patient received corifollitropin alfa 150 µg s.c. (Elonva®; MSD Sharp and Dohme GmbH, Germany) on the same day and initiated GnRH-antagonist 0.25 mg (Orgalutran®; MSD Sharp and Dohme GmbH, Germany) on stimulation day 5 and continued GnRH-antagonist treatment up to and including the day of triggering final oocyte maturation. On stimulation day 7 or 8, the patient was seen for a transvaginal scan, and in case that the triggering criteria had not been met, continued ovarian stimulation with a fixed dose of 200 IU daily recombinant FSH (Purgeon®; MSD Sharp and Dohme GmbH, Germany) until ≥3 follicles ≥17 mm were visualized or one day thereafter. Low response (e.g. growth of one or two follicles) was not a cancellation criterion and in these cases physicians were free to induce final oocyte maturation at a leading follicle size of ≥17 mm. Induction of final oocyte maturation was performed with urinary human chorionic gonadotrophin (HCG) (5000 IU if body weight ≤80 kg, 10,000 IU if body weight >80 kg) (Predalon®; MSD Sharp and Dohme GmbH, Germany). In case of an increased risk of ovarian hyperstimulation syndrome risk (defined as ≥19 follicles ≥11 mm and/or oestradiol >4500 pg/ml), triptorelin 0.2 mg (Decapeptyl®; Ferring GmbH, Germany) was administered instead of HCG for triggering final oocyte maturation, followed by
Please cite this article in press as: Tamara Lerman, et al., Ovarian response to 150 µg corifollitropin alfa in a GnRH-antagonist multiple-dose protocol: a prospective cohort study, Reproductive BioMedicine Online (2017), doi: 10.1016/j.rbmo.2017.02.012
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cryopreservation of all 2 PN oocytes for a later frozen-thawed embryo transfer cycle. Oocyte retrieval and IVF or ICSI were performed according to the standard practice in each participating study centre.
Hormone assays Serum samples were immediately centrifuged, frozen at −20°C and shipped frozen in batches at regular intervals to Luebeck, were they were stored at −80°C for later, centralized analysis. Serum oestradiol, LH and progesterone concentrations were assayed with the electrochemiluminescence immunoassay ‘ECLIA’ (Roche Diagnostics Inc., Germany) on the Roche Elecsys 2010 automated immunoassay analyser by the central laboratory. Intra-assay and inter-assay coefficients of variation were <2.0% and <7% for oestradiol, <2.5% and <5% for LH and <2.5% and <5% for progesterone, respectively. AMH was measured with the Beckman Coulter Gen II AMH ELISA kit (Beckman Coulter, Inc., Brea, 120, California, USA). The intra- and inter-assay coefficients of variation were <10% and the functional sensitivity was <0.1 ng/ml. At the time of the study, concerns were raised in the literature that storage conditions and/or storage duration would affect AMH measurement with the AMH Gen II assay (Han et al., 2014). Therefore, 24 randomly picked frozen samples were thawed, analysed, re-frozen, thawed after 3 months and re-analysed. The Pearson correlation coefficient was 0.991 for the two measurements indicating very good reliability and replicability of the measurements.
Data analysis and statistics Ovarian response prediction was restricted to patients with a body weight >60 kg (e.g. in line with the posology of the product at the time of conducting the study which stipulated the usage of 150 µg corifollitropin alfa exclusively in women >60 kg). Furthermore, protocol violations were defined a priori leading to exclusion of patients (Supplementary Figure S1). Limits of low and high ovarian response used in the current analyses were set at <6 oocytes and >18 oocytes retrieved, respectively (Broekmans et al., 2014; Oehninger et al., 2015). Continuous variables are presented as mean and SD and t-test, analysis of variance or Kruskal–Wallis comparisons were performed, as appropriate. Pearson correlation coefficients and corresponding P-values were calculated for the candidate predictive variables and oocyte yield as outcome parameter. P-values <0.05 were considered statistically significant. The ability of AMH and antral follicle count (AFC) to predict low or high response was evaluated using receiver operating characteristic (ROC) curves as well as 95% confidential interval (CI) of the area under the curve (AUC) of the ROC curve. Optimal cut-off points were determined by the combination of specificity and sensitivity closest to the optimal. All calculations were performed using SPSS version 20.0.0 (IBM Incorp., USA).
Results 294 patients were prospectively and centrally registered, 32 patients were excluded because of protocol violations, 45 patients were excluded because they were ≤60 kg bodyweight and five cycles were
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cancelled before oocyte retrieval (Figure S1). Accordingly, the analysis is based on 212 patients. Table 1 depicts demographic, sonographic and endocrine variables on stimulation day 1, overall, and by response type. 19.8% of patients were low responders, while 13.7% of patients were high responders. The following predictors were statistically significantly different between the response groups: age, AFC, AMH, FSH and cycle length (all P < 0.001, Table 1). Of note, stimulation characteristics, such as FSH dosage or duration of stimulation, were highly similar between response groups.
Ovarian response markers Figure 1 depicts the ovarian response, defined as numbers of oocytes retrieved, by quantiles of the five predictor variables identified in Table 1. AMH shows the strongest association with the number of oocytes obtained. As depicted in Table 2, AMH furthermore shows the strongest correlation with ovarian response (r = 0.727, P < 0.0001), followed by AFC (r = 0.486. P < 0.0001). As expected, AFC and AMH are positively, while age and FSH are negatively correlated with the number of oocytes obtained.
ROC analysis ROC analysis showed that AMH had a better discriminatory capacity than AFC to predict low response (Figure 2a), AUC (95% CI; P-value): 0.853 (0.769–0.936; <0.0001) versus 0.778 (0.689–0.868; <0.0001). The optimal threshold of AMH for identifying low response was 0.91 ng/ ml, relating to a sensitivity of 82.4%, specificity of 82.4%, positive predictive value 52.9% and negative predictive value 95.1%. Likewise, AMH had better discriminatory capacity than AFC for high response (Figure 2b): AUC (95% CI; P-value) for AMH 0.871 (0.787– 0.955; <0.0001) and AUC for AFC 0.763 (0.643–0.882; <0.0001). The optimal threshold of AMH for identifying high response was 2.58 ng/ ml, relating to a sensitivity of 80.0%, specificity 82.1%, positive predictive value 42.5% and negative predictive value 96.1%. Age, cycle duration and FSH were also associated with low and high response in ROC analysis but to a much lesser extent (data not shown).
Discussion The present study demonstrates that AMH, among an array of prospectively assessed biomarkers, has the best capacity, as a single predictor, to discriminate patients with low or high response, who undergo ovarian stimulation with 150 µg corifollitropin alfa in a fixed, multiple dose GnRH-antagonist protocol. In that respect, this studies findings further substantiate other work (Nelson et al., 2015a) and accordingly, AMH should be taken into account when deciding which patient to put on corifollitropin alfa stimulation. Corifollitropin alfa is a potent driver of follicular recruitment and was introduced to the market with the aim of reducing the number of injections for the patients. As such, the corifollitropin alfa protocol is supposed to be simple and patient friendly. However, it is likewise important that corifollitropin alfa is used in those patients, who will most benefit from it, that is patients who have a good chance of producing a sufficient number of ooyctes while not hyperresponding. This is important, since a low number of oocytes available for IVF in
Please cite this article in press as: Tamara Lerman, et al., Ovarian response to 150 µg corifollitropin alfa in a GnRH-antagonist multiple-dose protocol: a prospective cohort study, Reproductive BioMedicine Online (2017), doi: 10.1016/j.rbmo.2017.02.012
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Table 1 – Demographic, sonographic, laboratory and stimulation cycle variables according to ovarian response types. Response type All patients
Low (<6 oocytes)
Intermediate (6–18 oocytes)
High (>18 oocytes)
n = 42 (19.8%)
n = 141 (66.5%)
n = 29 (13.7%)
P-value
Mean ± SD
n = 212 Demographic variables Age (years) Weight (kg) Cigarettes/day Cycle length (days) Duration of infertility (months) Sonographic variables AFC (n) Follicle count at last assess (n) Laboratory variables AMH (µg/l) Oestradiol (ng/l) FSH (IU/l) LH (IU/l) Progesterone (µg/l) Stimulation cycle variables Duration of antagonist (days) FSH total dose (IU) Duration of stimulation (days) Total no. of assessments (n) Oocytes retrieved (n) GnRH-agonist triggering n (%)
33.3 72.1 1.7 28.4 41.3
± ± ± ± ±
4.0 11.1 4.4 2.7 31.1
12.0 ± 5.0 13.6 ± 7.1 2.1 48.7 8.1 5.6 0.7 6.4 497.6 10.5 2.9 11.3 33
± ± ± ± ±
35.6 72.0 1.7 27.5 38.9
± ± ± ± ±
3.4 12.7 4.5 2.0 22.3
33.0 71.9 1.7 28.5 41.2
8.5 ± 4.7 6.6 ± 4.1
1.9 76.3 3.1 2.1 0.4
0.8 44.6 10.8 5.6 0.6
± 1.6 ± 304.6 ± 1.5 ± 0.7 ± 7.1 (15.6)
6.1 473.8 10.4 2.9 3.1 1
± ± ± ± ±
± ± ± ± ±
4.0 10.5 4.5 2.9 30.6
12.2 ± 4.2 13.7 ± 5.7
1.0 22.6 4.7 1.9 0.2
1.9 52.8 7.8 5.6 0.7
± 1.9 ± 338.6 ± 1.6 ± 0.8 ± 2.2 (2.4)
6.5 518.1 10.6 3.0 11.0 18
± ± ± ± ±
31.5 73.2 1.9 29.2 44.8
± ± ± ± ±
3.6 11.7 4.2 2.5 43.2
<0.001 NS NS 0.03 NS
16.3 ± 5.7 21.7 ± 7.8
<0.001 <0.001
± ± ± ± ±
2.7 14.2 1.5 2.3 0.3
<0.001 NS <0.001 NS NS
± 1.0 ± 183.6 ± 1.0 ± 0.5 ± 6.5 (48.3)
NS NS NS NS <0.001 <0.001
1.2 92.2 2.2 2.2 0.5
4.7 34.6 6.1 5.6 0.8
± 1.7 ± 313.1 ± 1.6 ± 0.7 ± 3.3 (12.8)
6.2 432.8 10.2 2.9 24.5 14
All data are mean ± standard deviation. AFC = antral follicle count; AMH = anti-Müllerian hormone; NS = not statistically significant.
response to a high-dose gonadotrophin stimulation is associated with poor treatment efficacy, while an excessive number of oocytes after gonadotrophin stimulation is associated with increased burden to the patient and increased risks such as ovarian hyperstimulation syndrome or ovarian torsion. Furthermore, in a large proportion of high responder patients more oocytes are available than need to be utilized to achieve a live birth. Although no formal definition of ‘too low’ and ‘too high’ response exists that could be applied across all settings and patient populations, <6 oocytes and >18 oocytes have previously been used to define low and high response, respectively, in corifollitropin alfa (Oehninger et al., 2015) and GnRH-antagonist protocol (Broekmans et al., 2014) response prediction, respectively. Accordingly, this study used these cut-offs to allow cross comparison of results with these two recent studies. This study reports that an upper cut-off of AMH of 2.6 ng/ml measured in the Gen II AMH assay is related to a negative predictive value of 96% for hyperresponse. In other words, 96% of patients below that threshold within the present cohort indeed did not produce more than 18 oocytes. Polyzos et al. (2013) report an upper cut-off for AMH of 3.52 ng/ml, measured with the Immunotech (IOT) assay, for predict-
ing the retrieval of more than 20 oocytes with similarly high sensitivity and specificity of 89.5% and 83.8%, respectively. Although it has previously been claimed that the IOT assay and AMH Gen II assay have good agreement (Kumar et al., 2010), the difference in definition of high response and differences in patient population may account for this finding. In that context, it is important to note that any prediction algorithm tends to overperform in the data set from which it was generated and therefore, external validation is necessary. Furthermore, it is important to note that the association of AMH concentrations and risk of hyperresponse is likely to be linear (Oehninger et al., 2015; Polyzos et al., 2013) and that the combination of predictor variables in a multi-variate analysis may foster the discrimination of response types. Nevertheless, the establishment of cut-off values of a single predictor variable by means of ROC analysis is clinically useful, since most clinicians choose stimulation protocols and FSH doses not based on complex multi-variate models, but based on simple-to-follow algorithms (Nelson et al., 2009). With regard to multi-variate modelling, this study refrained from building yet another prediction model at this stage of the analysis, since already established models should first be tested and potentially
Table 2 – Pearson correlation coefficients.
Oocytes retrieved
Age
Cycle length
AFC
AMH
FSH
−0.287**
0.166**
0.486**
0.727**
−0.445**
AFC = antral follicle count; AMH = anti-Müllerian hormone. *P = 0.001; **P < 0.0001. Please cite this article in press as: Tamara Lerman, et al., Ovarian response to 150 µg corifollitropin alfa in a GnRH-antagonist multiple-dose protocol: a prospective cohort study, Reproductive BioMedicine Online (2017), doi: 10.1016/j.rbmo.2017.02.012
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Figure 1 – Box and whisker plots of ovarian response by quartiles of woman’s age, cycle length, AFC, AMH and FSH on cycle day 2 or 3. Values are median (lines), 25th to 75th percentiles (boxes) and 10th to 90th percentiles (whiskers). Percentiles are for age: 25th 30 years, 50th 34 years and 75th 36 years; cycle length: 25th 27 days, 50th 28 days and 75th 29 days; AFC: 25th 9, 50th 12 and 75th 16; AMH 25th 0.81 µg/l, 50th 1.61 µg/l and 75th: 2.95 µg/l; FSH: 25th: 6.15 IU/l, 50th 7.36 IU/l and 75th 9.04 IU/l. AFC = antral follicle count; AMH = antiMüllerian hormone.
Please cite this article in press as: Tamara Lerman, et al., Ovarian response to 150 µg corifollitropin alfa in a GnRH-antagonist multiple-dose protocol: a prospective cohort study, Reproductive BioMedicine Online (2017), doi: 10.1016/j.rbmo.2017.02.012
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and could therefore contribute a quantitative (e.g. oocyte numbers) as well a as a binary outcome (e.g. hyperresponse defined as >18 oocytes) to the analyses. Limits to the external validity of the study findings are as follows: all patients received a fixed dose of 200 IU recombinant FSH (rFSH) after day 8 in case HCG criteria have not been met. This is not necessarily the way all patients should be treated, since it can be assumed that in some patients a dose lower than 200 IU rFSH would sufficiently sustain follicular growth. However, it is unlikely that the ovarian response, and thereby the study findings, have been confounded by this protocol rule, since it is well established that the recruitment of follicles is over by cycle day nine and the number of growing follicles will not be affected by a dose change at that stage (beyond stimulation day 8). Next, the measurement of serum AMH has recently been automated and it is possible that the AMH Gen II assay employed in this study will be replaced in routine clinical use by one, or more, automated assays with new specifications. Although it is reassuring that in one recent report two new automated AMH assays are in very good agreement with the clinical standard assay Beckman-Coulter AMH Gen II (van Helden and Weiskirchen, 2015), others have reported the values to systematically differ between a new automated AMH measurement (Roche Elecsys) from the values generated by AMH Gen II (Nelson et al., 2015b). Still the findings from this study will be useful in the future as the AMH cut-offs established herein can be used after approximation by a conversion factor, even though this factor may change at more extreme concentrations. Furthermore, it is important to understand the principal performance of response prediction by AMH in the context of corifollitropin stimulation. In conclusion, this study describes an AMH window from approximately 0.9 to approximately 2.6 ng/ml, measured in the Gen II AMH assay, within which patients >60 kg bodyweight are unlikely to show an extreme response to 150 µg corifollitropin alfa stimulation, defined as <6 or >18 oocytes, respectively.
Acknowledgements Study funding: The study was financed by university funds. Figure 2 – Receiver operator characteristic curves for low and high ovarian response (CI = confidence interval; ROCauc = area-under-the-receiver-operator-characteristic-curve).
refined on the current data set. It is reassuring that the sensitivity and specificity of AMH alone for predicting response in the current dataset is very similar to the sensitivity and specificity of the model by Oehninger et al. (2015), which included four predictor variables. A strength of the study was its prospective design, and the fact that all patients were treated in the same fixed protocol, which supports the replicability of the study findings. Furthermore, the inclusion criteria were broad in order to have sufficient variation in the predictive biomarkers to be tested and to achieve a high external validity. Another important aspect of the study protocol was that patients likely to produce a high response were not excluded (for example, patients with a high AFC) in order to generate sufficient observations in this part of the infertile patient population. In patients indeed hyperresponding, agonist triggering was used instead of cancelling the cycle, and thus, these patients still underwent oocyte retrieval
Appendix: Supplementary material Supplementary data to this article can be found online at doi:10.1016/j.rbmo.2017.02.012.
A R T I C L E
I N F O
Article history: Received 28 October 2016 Received in revised form 4 February 2017 Accepted 8 February 2017
Declaration: The authors report no financial or commercial conflicts of interest appart from the following: MD has received travel expenses/ accomodation from Merck Serono and has received consulting fees from
Please cite this article in press as: Tamara Lerman, et al., Ovarian response to 150 µg corifollitropin alfa in a GnRH-antagonist multiple-dose protocol: a prospective cohort study, Reproductive BioMedicine Online (2017), doi: 10.1016/j.rbmo.2017.02.012
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Finox; ASM has received payment for lectures from MSD, Merck Serono, TEVA and Finox and travel expenses/ accomodation from TEVA, Ferring; Finox, MSD and Merck Serono; SVO has received payment for lectures from MSD, Merck Serono, Ferring and travel expenses/accomodation from Ferring; Merck Serono and MSD; AK has consultancy fees from Merck Serono and travel expenses/accomodation from Finox; GG has received consulting fees and fees for lecturing from Ferring, Glycotope, Merck Serono, MSD, Finox, Vitrolife, IBSA, Abbott, ZIVA and ReprodWissen and has received travel expenses/accomodation from Ferring; Merck Serono, IBSA, Abbott and MSD.
Keywords: Corifollitropin alfa GnRH antagonist Ovarian hyperstimulation syndrome Ovarian stimulation Poor response Response prediction
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Corifollitropin alfa Ensure Study Group, 2010. Corifollitropin alfa for ovarian stimulation in IVF: a randomized trial in lower-body-weight women. Reprod. Biomed. Online 21, 66–76. Erratum in: Reprod. Biomed. Online 29, 395. Devroey, P., Boostanfar, R., Koper, N.P., Mannaerts, B.M., IjzermanBoon, P.C., Fauser, B.C., ENGAGE Investigators, 2009. A doubleblind, non-inferiority RCT comparing corifollitropin alfa and recombinant FSH during the first seven days of ovarianstimulation using a GnRH antagonist protocol. Hum. Reprod. 24, 3063–3072. Fauser, B.C., Mannaerts, B.M., Devroey, P., Leader, A., Boime, I., Baird, D.T., 2009. Advances in recombinant DNA technology: corifollitropin alfa, a hybrid molecule with sustained follicle-stimulating activity and reduced injection frequency. Hum. Reprod. Update 15, 309–321. Han, X., McShane, M., Sahertian, R., White, C., Ledger, W., 2014. Premixing serum samples with assay buffer is a prerequisite for reproducible anti-Mullerian hormone measurement using the Beckman Coulter Gen II assay. Hum. Reprod. 29, 1042–1048. Kumar, A., Kalra, B., Patel, A., McDavid, L., Roudebush, W.E., 2010. Development of a second generation anti-Müllerian hormone (AMH) ELISA. J. Immunol. Methods 31, 51–59. Nelson, S.M., Yates, R.W., Lyall, H., Jamieson, M., Traynor, I., Gaudoin, M., Mitchell, P., Ambrose, P., Fleming, R., 2009. Anti-Müllerian hormone-based approach to controlled ovarian stimulation for assisted conception. Hum. Reprod. 24, 867–875. Nelson, S.M., Klein, B.M., Arce, J.C., 2015a. Comparison of antimüllerian hormone levels and antral follicle count as predictor of ovarian response to controlled ovarian stimulation in goodprognosis patients at individual fertility clinics in two multicenter trials. Fertil. Steril. 103, 923–930. Nelson, S.M., Pastuszek, E., Kloss, G., Malinowska, I., Liss, J., Lukaszuk, A., Plociennik, L., Lukaszuk, K., 2015b. Two new automated, compared with two enzyme-linked immunosorbent, antimüllerian hormone assays. Fertil. Steril. 104, 1016–1021. Norman, R.J., Zegers-Hochschild, F., Salle, B.S., Elbers, J., Heijnen, E., Marintcheva-Petrova, M., Mannaerts, B., Trust Investigators, 2011. Repeated ovarian stimulation with corifollitropin alfa in patients in a GnRH antagonist protocol: no concern for immunogenicity. Hum. Reprod. 26, 2200–2208. Oehninger, S., Nelson, S.M., Verweij, P., Stegmann, B.J., 2015. Predictive factors for ovarian response in a corifollitropin alfa/GnRH antagonist protocol for controlled ovarian stimulation in IVF/ICSI cycles. Reprod. Biol. Endocrinol. 31, 117. Polyzos, N.P., Tournaye, H., Guzman, L., Camus, M., Nelson, S.M., 2013. Predictors of ovarian response in women treated with corifollitropin alfa for in vitro fertilization/intracytoplasmic sperm injection. Fertil. Steril. 100, 430–437. van Helden, J., Weiskirchen, R., 2015. Performance of the two new fully automated anti-Müllerian hormone immunoassays compared with the clinical standard assay. Hum. Reprod. 30, 1918–1926.
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Article
Ovarian response to 150 µg corifollitropin alfa in a GnRH-antagonist multiple-dose protocol: a prospective cohort study Tamara Lerman a, Marion Depenbusch a, Askan Schultze-Mosgau a, Soeren von Otte b, Markus Scheinhardt c, Inke Koenig c, Axel Kamischke d, Milan Macek e, Arne Schwennicke f, Sabine Segerer g, Georg Griesinger a,* a
Department of Reproductive Medicine and Gynecological Endocrinology, University Hospital of SchleswigHolstein, Campus Luebeck, Luebeck, Germany b Universitaeres Kinderwunschzentrum Kiel, Kiel, Germany c Institute for Medical Biometrics and Statistics, University of Luebeck, Luebeck, Germany d Kinderwunschzentrum Muenster, Muenster, Germany e Department of Biology and Medical Genetics, University Hospital Motol, Prague, Czech Republic f Klinikk Hausken, Haugesund, Norway g Amedes Experts Hamburg, Hamburg, Germany
Georg Griesinger is a full Professor at Luebeck University and Chair at the Department of Gynecological Endocrinology and Reproductive Medicine, University Hospital of Schleswig-Holstein, Luebeck, Germany. He obtained his MD at the University of Vienna, and his MSc in prenatal genetics and fetal medicine at University College London. KEY MESSAGE As a single predictor, AMH can reliably identify patients undergoing ovarian stimulation for IVF who are unlikely to experience hypo- or hyperresponse to corifollitropin alfa 150 µg. Thus, utilization of 150 µg corifollitropin alfa should take the pre-treament serum AMH concentration of patients into account to achieve optimal treatment outcomes.
A B S T R A C T The incidence of low (<6 oocytes) and high (>18 oocytes) ovarian response to 150 µg corifollitropin alfa in relation to anti-Müllerian hormone (AMH) and other biomarkers was studied in a multi-centre (n = 5), multi-national, prospective, investigator-initiated, observational cohort study. Infertile women (n = 212), body weight >60 kg, underwent controlled ovarian stimulation in a gonadotrophin-releasing hormone-antagonist multiple-dose protocol. Demographic, sonographic and endocrine parameters were prospectively assessed on cycle day 2 or 3 of a spontaneous menstruation before the administration of 150 µg corifollitropin alfa. Serum AMH showed the best correlation with the number of oocytes obtained among all predictor variables. In receiveroperating characteristic analysis, AMH at a threshold of 0.91 ng/ml showed a sensitivity of 82.4%, specificity of 82.4%, positive predictive value 52.9%
* Corresponding author. E-mail address: [email protected] (G Griesinger). http://dx.doi.org/10.1016/j.rbmo.2017.02.012 1472-6483/© 2017 Published by Elsevier Ltd on behalf of Reproductive Healthcare Ltd. Please cite this article in press as: Tamara Lerman, et al., Ovarian response to 150 µg corifollitropin alfa in a GnRH-antagonist multiple-dose protocol: a prospective cohort study, Reproductive BioMedicine Online (2017), doi: 10.1016/j.rbmo.2017.02.012
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and negative predictive value 95.1% for predicting low response (area under the curve [AUC], 95% CI; P-value: 0.853, 0.769–0.936; <0.0001). For predicting high response, the optimal threshold for AMH was 2.58 ng/ml, relating to a sensitivity of 80.0%, specificity 82.1%, positive predictive value 42.5% and negative predictive value 96.1% (AUC, 95% CI; P-value: 0.871, 0.787–0.955; <0.0001). In conclusion, patients with serum AMH concentrations between approximately 0.9 and 2.6 ng/ml were unlikely to show extremes of response. © 2017 Published by Elsevier Ltd on behalf of Reproductive Healthcare Ltd.
Introduction A number of biomarkers are clinically used to predict ovarian response to ovarian stimulation in the context of IVF (Broekmans et al., 2006). The aim of ovarian response prediction is to identify patients who will show an extreme of response. In such patients, management decisions can be taken, such as altering the FSH dose and stimulation protocol (Nelson et al., 2009). Furthermore, the patient can be counselled about the expected response. Anti-Müllerian hormone (AMH) has been reported as a key biomarker for predicting ovarian response (Broer et al., 2013; Nelson et al., 2015a). Corifollitropin alfa is a hybrid FSH molecule with an increased serum half-life, allowing the initiation and sustainment of multifollicular growth for seven days after a single subcutaneous injection (Fauser et al., 2009). Corifollitropin alfa has been introduced to the market in two dosages, 100 µg and 150 µg. In contrast to ovarian stimulation with daily FSH injections, no dose adaptions are possible for a full week after administration of corifollitropin alfa. Furthermore, corifollitropin alfa 150 µg produces, on average, a slightly stronger ovarian response as compared with daily FSH 200 IU (Devroey et al., 2009). This makes correct response prediction paramount for routine use of corifollitropin alfa. However, in three out of four corifollitropin alfa phase III trials (Corifollitropin alfa Ensure Study Group, 2010; Devroey et al., 2009; Norman et al., 2011), the key biomarker AMH has not been assessed. Furthermore, phase III trial populations are different from routine patients in many aspects such as body weight, age and the expected incidence of extremes of ovarian response. While there is a wealth of literature to date on ovarian response prediction by AMH, only two studies on predicting ovarian response in the corifollitropin alfa protocol, e.g. cycles utilizing a gonadotrophinreleasing hormone (GnRH)-antagonist multiple-dose protocol and a dose of 150 µg, have been published (Oehninger et al., 2015; Polyzos et al., 2013). While one study (Polyzos et al., 2013) was retrospective and used an AMH immuno-assay, which is no longer available, the other study (Oehninger et al., 2015) employed the widely-used Gen II AMH assay, but the population under study was restricted to women of advanced reproductive age (36–42 years). This study presents a prospective, clinical cohort study on a broad range of patients undergoing ovarian stimulation with 150 µg corifollitropin alfa with the primary aim of testing the performance of AMH, among other endocrine, demographic and sonographic variables that are available pre-treatment, to predict low and high ovarian response, respectively.
Materials and methods Study design The study was a multi-centric (n = 5), prospective, investigatorinitiated, observational cohort study conducted between 2012 and 2013
(protocol ID: GR 3422/3–1). Four centres were located in Germany (Luebeck, Kiel, Wuerzburg, Muenster), one centre was located in Norway (Haugesund). Institutional review board approval was granted (Ethical Review Board of the University of Luebeck, reference number 10–143) on 26 August 2010 and all patients signed an informed consent sheet. The protocol was prospectively registered (NCT01206803). All eligible patients were prospectively and centrally registered by telephone or fax.
Population Women with an indication for IVF or intracytoplasmic sperm injection (ICSI), eligible to undergo ovarian stimulation, were prospectively recruited from the routine patient population, age limit 18–45 years. Patients with immediate sex-steroid pre-treatment (e.g. cycle scheduling with an oral contraceptive) were excluded. This exclusion criterion was chosen so that the impact of sex-steroid pre-treatment would not constitute a potential confounding variable of ovarian response.
Protocol On cycle day 2 or 3 of a spontaneous menstruation (stimulation day 1), patients were scheduled for a monitoring visit at the clinic, a transvaginal scan was performed and a blood sample was drawn for later, centralized analysis. The following parameters were recorded at this visit: woman’s age (years), weight (kg), body-mass-index (kg/m2), average number of cigarettes per day, duration of infertility (months), cycle length (in days, by patient recall), cycle regularity (yes/no; deviation of >5 days from two consecutive cycles is considered an irregular cycle), total number of antral follicles (2–10 mm) in both ovaries, and serum AMH (ng/ml), oestradiol, progesterone, FSH and LH. The patient received corifollitropin alfa 150 µg s.c. (Elonva®; MSD Sharp and Dohme GmbH, Germany) on the same day and initiated GnRH-antagonist 0.25 mg (Orgalutran®; MSD Sharp and Dohme GmbH, Germany) on stimulation day 5 and continued GnRH-antagonist treatment up to and including the day of triggering final oocyte maturation. On stimulation day 7 or 8, the patient was seen for a transvaginal scan, and in case that the triggering criteria had not been met, continued ovarian stimulation with a fixed dose of 200 IU daily recombinant FSH (Purgeon®; MSD Sharp and Dohme GmbH, Germany) until ≥3 follicles ≥17 mm were visualized or one day thereafter. Low response (e.g. growth of one or two follicles) was not a cancellation criterion and in these cases physicians were free to induce final oocyte maturation at a leading follicle size of ≥17 mm. Induction of final oocyte maturation was performed with urinary human chorionic gonadotrophin (HCG) (5000 IU if body weight ≤80 kg, 10,000 IU if body weight >80 kg) (Predalon®; MSD Sharp and Dohme GmbH, Germany). In case of an increased risk of ovarian hyperstimulation syndrome risk (defined as ≥19 follicles ≥11 mm and/or oestradiol >4500 pg/ml), triptorelin 0.2 mg (Decapeptyl®; Ferring GmbH, Germany) was administered instead of HCG for triggering final oocyte maturation, followed by
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cryopreservation of all 2 PN oocytes for a later frozen-thawed embryo transfer cycle. Oocyte retrieval and IVF or ICSI were performed according to the standard practice in each participating study centre.
Hormone assays Serum samples were immediately centrifuged, frozen at −20°C and shipped frozen in batches at regular intervals to Luebeck, were they were stored at −80°C for later, centralized analysis. Serum oestradiol, LH and progesterone concentrations were assayed with the electrochemiluminescence immunoassay ‘ECLIA’ (Roche Diagnostics Inc., Germany) on the Roche Elecsys 2010 automated immunoassay analyser by the central laboratory. Intra-assay and inter-assay coefficients of variation were <2.0% and <7% for oestradiol, <2.5% and <5% for LH and <2.5% and <5% for progesterone, respectively. AMH was measured with the Beckman Coulter Gen II AMH ELISA kit (Beckman Coulter, Inc., Brea, 120, California, USA). The intra- and inter-assay coefficients of variation were <10% and the functional sensitivity was <0.1 ng/ml. At the time of the study, concerns were raised in the literature that storage conditions and/or storage duration would affect AMH measurement with the AMH Gen II assay (Han et al., 2014). Therefore, 24 randomly picked frozen samples were thawed, analysed, re-frozen, thawed after 3 months and re-analysed. The Pearson correlation coefficient was 0.991 for the two measurements indicating very good reliability and replicability of the measurements.
Data analysis and statistics Ovarian response prediction was restricted to patients with a body weight >60 kg (e.g. in line with the posology of the product at the time of conducting the study which stipulated the usage of 150 µg corifollitropin alfa exclusively in women >60 kg). Furthermore, protocol violations were defined a priori leading to exclusion of patients (Supplementary Figure S1). Limits of low and high ovarian response used in the current analyses were set at <6 oocytes and >18 oocytes retrieved, respectively (Broekmans et al., 2014; Oehninger et al., 2015). Continuous variables are presented as mean and SD and t-test, analysis of variance or Kruskal–Wallis comparisons were performed, as appropriate. Pearson correlation coefficients and corresponding P-values were calculated for the candidate predictive variables and oocyte yield as outcome parameter. P-values <0.05 were considered statistically significant. The ability of AMH and antral follicle count (AFC) to predict low or high response was evaluated using receiver operating characteristic (ROC) curves as well as 95% confidential interval (CI) of the area under the curve (AUC) of the ROC curve. Optimal cut-off points were determined by the combination of specificity and sensitivity closest to the optimal. All calculations were performed using SPSS version 20.0.0 (IBM Incorp., USA).
Results 294 patients were prospectively and centrally registered, 32 patients were excluded because of protocol violations, 45 patients were excluded because they were ≤60 kg bodyweight and five cycles were
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cancelled before oocyte retrieval (Figure S1). Accordingly, the analysis is based on 212 patients. Table 1 depicts demographic, sonographic and endocrine variables on stimulation day 1, overall, and by response type. 19.8% of patients were low responders, while 13.7% of patients were high responders. The following predictors were statistically significantly different between the response groups: age, AFC, AMH, FSH and cycle length (all P < 0.001, Table 1). Of note, stimulation characteristics, such as FSH dosage or duration of stimulation, were highly similar between response groups.
Ovarian response markers Figure 1 depicts the ovarian response, defined as numbers of oocytes retrieved, by quantiles of the five predictor variables identified in Table 1. AMH shows the strongest association with the number of oocytes obtained. As depicted in Table 2, AMH furthermore shows the strongest correlation with ovarian response (r = 0.727, P < 0.0001), followed by AFC (r = 0.486. P < 0.0001). As expected, AFC and AMH are positively, while age and FSH are negatively correlated with the number of oocytes obtained.
ROC analysis ROC analysis showed that AMH had a better discriminatory capacity than AFC to predict low response (Figure 2a), AUC (95% CI; P-value): 0.853 (0.769–0.936; <0.0001) versus 0.778 (0.689–0.868; <0.0001). The optimal threshold of AMH for identifying low response was 0.91 ng/ ml, relating to a sensitivity of 82.4%, specificity of 82.4%, positive predictive value 52.9% and negative predictive value 95.1%. Likewise, AMH had better discriminatory capacity than AFC for high response (Figure 2b): AUC (95% CI; P-value) for AMH 0.871 (0.787– 0.955; <0.0001) and AUC for AFC 0.763 (0.643–0.882; <0.0001). The optimal threshold of AMH for identifying high response was 2.58 ng/ ml, relating to a sensitivity of 80.0%, specificity 82.1%, positive predictive value 42.5% and negative predictive value 96.1%. Age, cycle duration and FSH were also associated with low and high response in ROC analysis but to a much lesser extent (data not shown).
Discussion The present study demonstrates that AMH, among an array of prospectively assessed biomarkers, has the best capacity, as a single predictor, to discriminate patients with low or high response, who undergo ovarian stimulation with 150 µg corifollitropin alfa in a fixed, multiple dose GnRH-antagonist protocol. In that respect, this studies findings further substantiate other work (Nelson et al., 2015a) and accordingly, AMH should be taken into account when deciding which patient to put on corifollitropin alfa stimulation. Corifollitropin alfa is a potent driver of follicular recruitment and was introduced to the market with the aim of reducing the number of injections for the patients. As such, the corifollitropin alfa protocol is supposed to be simple and patient friendly. However, it is likewise important that corifollitropin alfa is used in those patients, who will most benefit from it, that is patients who have a good chance of producing a sufficient number of ooyctes while not hyperresponding. This is important, since a low number of oocytes available for IVF in
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Table 1 – Demographic, sonographic, laboratory and stimulation cycle variables according to ovarian response types. Response type All patients
Low (<6 oocytes)
Intermediate (6–18 oocytes)
High (>18 oocytes)
n = 42 (19.8%)
n = 141 (66.5%)
n = 29 (13.7%)
P-value
Mean ± SD
n = 212 Demographic variables Age (years) Weight (kg) Cigarettes/day Cycle length (days) Duration of infertility (months) Sonographic variables AFC (n) Follicle count at last assess (n) Laboratory variables AMH (µg/l) Oestradiol (ng/l) FSH (IU/l) LH (IU/l) Progesterone (µg/l) Stimulation cycle variables Duration of antagonist (days) FSH total dose (IU) Duration of stimulation (days) Total no. of assessments (n) Oocytes retrieved (n) GnRH-agonist triggering n (%)
33.3 72.1 1.7 28.4 41.3
± ± ± ± ±
4.0 11.1 4.4 2.7 31.1
12.0 ± 5.0 13.6 ± 7.1 2.1 48.7 8.1 5.6 0.7 6.4 497.6 10.5 2.9 11.3 33
± ± ± ± ±
35.6 72.0 1.7 27.5 38.9
± ± ± ± ±
3.4 12.7 4.5 2.0 22.3
33.0 71.9 1.7 28.5 41.2
8.5 ± 4.7 6.6 ± 4.1
1.9 76.3 3.1 2.1 0.4
0.8 44.6 10.8 5.6 0.6
± 1.6 ± 304.6 ± 1.5 ± 0.7 ± 7.1 (15.6)
6.1 473.8 10.4 2.9 3.1 1
± ± ± ± ±
± ± ± ± ±
4.0 10.5 4.5 2.9 30.6
12.2 ± 4.2 13.7 ± 5.7
1.0 22.6 4.7 1.9 0.2
1.9 52.8 7.8 5.6 0.7
± 1.9 ± 338.6 ± 1.6 ± 0.8 ± 2.2 (2.4)
6.5 518.1 10.6 3.0 11.0 18
± ± ± ± ±
31.5 73.2 1.9 29.2 44.8
± ± ± ± ±
3.6 11.7 4.2 2.5 43.2
<0.001 NS NS 0.03 NS
16.3 ± 5.7 21.7 ± 7.8
<0.001 <0.001
± ± ± ± ±
2.7 14.2 1.5 2.3 0.3
<0.001 NS <0.001 NS NS
± 1.0 ± 183.6 ± 1.0 ± 0.5 ± 6.5 (48.3)
NS NS NS NS <0.001 <0.001
1.2 92.2 2.2 2.2 0.5
4.7 34.6 6.1 5.6 0.8
± 1.7 ± 313.1 ± 1.6 ± 0.7 ± 3.3 (12.8)
6.2 432.8 10.2 2.9 24.5 14
All data are mean ± standard deviation. AFC = antral follicle count; AMH = anti-Müllerian hormone; NS = not statistically significant.
response to a high-dose gonadotrophin stimulation is associated with poor treatment efficacy, while an excessive number of oocytes after gonadotrophin stimulation is associated with increased burden to the patient and increased risks such as ovarian hyperstimulation syndrome or ovarian torsion. Furthermore, in a large proportion of high responder patients more oocytes are available than need to be utilized to achieve a live birth. Although no formal definition of ‘too low’ and ‘too high’ response exists that could be applied across all settings and patient populations, <6 oocytes and >18 oocytes have previously been used to define low and high response, respectively, in corifollitropin alfa (Oehninger et al., 2015) and GnRH-antagonist protocol (Broekmans et al., 2014) response prediction, respectively. Accordingly, this study used these cut-offs to allow cross comparison of results with these two recent studies. This study reports that an upper cut-off of AMH of 2.6 ng/ml measured in the Gen II AMH assay is related to a negative predictive value of 96% for hyperresponse. In other words, 96% of patients below that threshold within the present cohort indeed did not produce more than 18 oocytes. Polyzos et al. (2013) report an upper cut-off for AMH of 3.52 ng/ml, measured with the Immunotech (IOT) assay, for predict-
ing the retrieval of more than 20 oocytes with similarly high sensitivity and specificity of 89.5% and 83.8%, respectively. Although it has previously been claimed that the IOT assay and AMH Gen II assay have good agreement (Kumar et al., 2010), the difference in definition of high response and differences in patient population may account for this finding. In that context, it is important to note that any prediction algorithm tends to overperform in the data set from which it was generated and therefore, external validation is necessary. Furthermore, it is important to note that the association of AMH concentrations and risk of hyperresponse is likely to be linear (Oehninger et al., 2015; Polyzos et al., 2013) and that the combination of predictor variables in a multi-variate analysis may foster the discrimination of response types. Nevertheless, the establishment of cut-off values of a single predictor variable by means of ROC analysis is clinically useful, since most clinicians choose stimulation protocols and FSH doses not based on complex multi-variate models, but based on simple-to-follow algorithms (Nelson et al., 2009). With regard to multi-variate modelling, this study refrained from building yet another prediction model at this stage of the analysis, since already established models should first be tested and potentially
Table 2 – Pearson correlation coefficients.
Oocytes retrieved
Age
Cycle length
AFC
AMH
FSH
−0.287**
0.166**
0.486**
0.727**
−0.445**
AFC = antral follicle count; AMH = anti-Müllerian hormone. *P = 0.001; **P < 0.0001. Please cite this article in press as: Tamara Lerman, et al., Ovarian response to 150 µg corifollitropin alfa in a GnRH-antagonist multiple-dose protocol: a prospective cohort study, Reproductive BioMedicine Online (2017), doi: 10.1016/j.rbmo.2017.02.012
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Figure 1 – Box and whisker plots of ovarian response by quartiles of woman’s age, cycle length, AFC, AMH and FSH on cycle day 2 or 3. Values are median (lines), 25th to 75th percentiles (boxes) and 10th to 90th percentiles (whiskers). Percentiles are for age: 25th 30 years, 50th 34 years and 75th 36 years; cycle length: 25th 27 days, 50th 28 days and 75th 29 days; AFC: 25th 9, 50th 12 and 75th 16; AMH 25th 0.81 µg/l, 50th 1.61 µg/l and 75th: 2.95 µg/l; FSH: 25th: 6.15 IU/l, 50th 7.36 IU/l and 75th 9.04 IU/l. AFC = antral follicle count; AMH = antiMüllerian hormone.
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and could therefore contribute a quantitative (e.g. oocyte numbers) as well a as a binary outcome (e.g. hyperresponse defined as >18 oocytes) to the analyses. Limits to the external validity of the study findings are as follows: all patients received a fixed dose of 200 IU recombinant FSH (rFSH) after day 8 in case HCG criteria have not been met. This is not necessarily the way all patients should be treated, since it can be assumed that in some patients a dose lower than 200 IU rFSH would sufficiently sustain follicular growth. However, it is unlikely that the ovarian response, and thereby the study findings, have been confounded by this protocol rule, since it is well established that the recruitment of follicles is over by cycle day nine and the number of growing follicles will not be affected by a dose change at that stage (beyond stimulation day 8). Next, the measurement of serum AMH has recently been automated and it is possible that the AMH Gen II assay employed in this study will be replaced in routine clinical use by one, or more, automated assays with new specifications. Although it is reassuring that in one recent report two new automated AMH assays are in very good agreement with the clinical standard assay Beckman-Coulter AMH Gen II (van Helden and Weiskirchen, 2015), others have reported the values to systematically differ between a new automated AMH measurement (Roche Elecsys) from the values generated by AMH Gen II (Nelson et al., 2015b). Still the findings from this study will be useful in the future as the AMH cut-offs established herein can be used after approximation by a conversion factor, even though this factor may change at more extreme concentrations. Furthermore, it is important to understand the principal performance of response prediction by AMH in the context of corifollitropin stimulation. In conclusion, this study describes an AMH window from approximately 0.9 to approximately 2.6 ng/ml, measured in the Gen II AMH assay, within which patients >60 kg bodyweight are unlikely to show an extreme response to 150 µg corifollitropin alfa stimulation, defined as <6 or >18 oocytes, respectively.
Acknowledgements Study funding: The study was financed by university funds. Figure 2 – Receiver operator characteristic curves for low and high ovarian response (CI = confidence interval; ROCauc = area-under-the-receiver-operator-characteristic-curve).
refined on the current data set. It is reassuring that the sensitivity and specificity of AMH alone for predicting response in the current dataset is very similar to the sensitivity and specificity of the model by Oehninger et al. (2015), which included four predictor variables. A strength of the study was its prospective design, and the fact that all patients were treated in the same fixed protocol, which supports the replicability of the study findings. Furthermore, the inclusion criteria were broad in order to have sufficient variation in the predictive biomarkers to be tested and to achieve a high external validity. Another important aspect of the study protocol was that patients likely to produce a high response were not excluded (for example, patients with a high AFC) in order to generate sufficient observations in this part of the infertile patient population. In patients indeed hyperresponding, agonist triggering was used instead of cancelling the cycle, and thus, these patients still underwent oocyte retrieval
Appendix: Supplementary material Supplementary data to this article can be found online at doi:10.1016/j.rbmo.2017.02.012.
A R T I C L E
I N F O
Article history: Received 28 October 2016 Received in revised form 4 February 2017 Accepted 8 February 2017
Declaration: The authors report no financial or commercial conflicts of interest appart from the following: MD has received travel expenses/ accomodation from Merck Serono and has received consulting fees from
Please cite this article in press as: Tamara Lerman, et al., Ovarian response to 150 µg corifollitropin alfa in a GnRH-antagonist multiple-dose protocol: a prospective cohort study, Reproductive BioMedicine Online (2017), doi: 10.1016/j.rbmo.2017.02.012
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Finox; ASM has received payment for lectures from MSD, Merck Serono, TEVA and Finox and travel expenses/ accomodation from TEVA, Ferring; Finox, MSD and Merck Serono; SVO has received payment for lectures from MSD, Merck Serono, Ferring and travel expenses/accomodation from Ferring; Merck Serono and MSD; AK has consultancy fees from Merck Serono and travel expenses/accomodation from Finox; GG has received consulting fees and fees for lecturing from Ferring, Glycotope, Merck Serono, MSD, Finox, Vitrolife, IBSA, Abbott, ZIVA and ReprodWissen and has received travel expenses/accomodation from Ferring; Merck Serono, IBSA, Abbott and MSD.
Keywords: Corifollitropin alfa GnRH antagonist Ovarian hyperstimulation syndrome Ovarian stimulation Poor response Response prediction
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Please cite this article in press as: Tamara Lerman, et al., Ovarian response to 150 µg corifollitropin alfa in a GnRH-antagonist multiple-dose protocol: a prospective cohort study, Reproductive BioMedicine Online (2017), doi: 10.1016/j.rbmo.2017.02.012