Impact of gonadotropin type on progesterone elevation during ovarian stimulation in GnRH antagonist cycles.
Does hormonal stimulation with corifollitropin alpha (CFA) only, mimicking a step down protocol, result in lower incidence of progesterone elevation on the day of hCGtrigger as compared to sustained stimulation with recombinant FSH (rFSH)?



The current findings support the concept that sustained FSH stimulus contributes to premature progesterone elevation in stimulated IVF cycles.



Serum progesterone rise during the follicular phase of ovarian stimulation for IVF treatment seems to be related to a poorer reproductive outcome. However, the mechanism by which the rise in progesterone is caused is not yet fully understood.



This study was a post hoc analysis of data from two multi-center, randomized, double-blind, double-dummy, active-controlled, non-inferiority trials, ENGAGE and PURSUE, conducted from June 2006 to January 2008 and from July 2010 to October 2012 respectively.



In the ENGAGE-study, 1506 women, aged 18-36 years, were allocated to either a single injection of 150 mg CFA or daily injections of 200 IU rFSH in the first week of stimulation, using a standard GnRH antagonist protocol. In the PURSUE-study, a total of 1390 women, aged 35-42 years, were allocated to either a single injection of 150 mg of CFA or daily 300 IU of rFSH for the first week, again using a standard GnRH antagonist protocol. In both trials, daily rFSH was continued until three follicles reached >17 mm in size. All women had a body weight of between 50 and 90 kg, regular menstrual cycles and an indication for ovarian stimulation before IVF. The incidence of progesterone elevation on day of hCG-trigger in patients with CFA only or rFSH stimulation, and triggered on Day 8 of stimulation, was analyzed.



Of patients with CFA only stimulation, 5.4% (13/239 patients) showed a progesterone elevation above 1.5 ng/ml on day of hCG-trigger, whereas patients with rFSH stimulation had a significant higher incidence of progesterone elevation (18.3%; 62/339 patients) (P < 0.001).



Post hoc analysis of data from previously published trials could be considered as a reason for caution.



Future studies should evaluate whether it would be possible to prevent a premature progesterone rise in cycles stimulated with daily FSH by using a step down protocol towards the end of the follicular phase.



Financial/Material Support was provided by Merck & Co., Inc., Kenilworth, NJ, USA. Davis Gates is an employee of Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA and may own stock and/or hold stock options in the company. Fabiola Beligotti is an employee of MSD, Italy, a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA and may own stock and/or hold stock options in the company. Barbara Lawrenz, Nils Engelmann and Human M. Fatemi have no conflict of interest.



ENGAGE study: ClinicalTrials.gov identifier NTC00696800. PURSUE-study: NCT01144416.
IVI Middle East, Fertility Clinic, Royal Marina Village, Villa B 22-23, Abu Dhabi, UAE barbara.lawrenz@ivivf.com.
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Lawrenz
MSD Italia S.r.L., Via Vitorchiano151, 00189, Rome, Italy.
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Beligotti
IVI Middle East, Fertility Clinic, Royal Marina Village, Villa B 22-23, Abu Dhabi, UAE.
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Engelmann
Merck & Co., Inc., Kenilworth, 2000 Galloping Hill Road, NJ 07033, USA.
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D
Gates
IVI Middle East, Fertility Clinic, Royal Marina Village, Villa B 22-23, Abu Dhabi, UAE.
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HM
Fatemi
D000293:Adolescent; D000328:Adult; D004311:Double-Blind Method; D005260:Female; D005307:Fertilization in Vitro / Q000379:methods*; D043373:Follicle Stimulating Hormone, Human / Q000008:administration & dosage*; D007987:Gonadotropin-Releasing Hormone / Q000008:administration & dosage / Q000031:analogs & derivatives / Q000037:antagonists & inhibitors; D006727:Hormone Antagonists / Q000008:administration & dosage; D006801:Humans; D010062:Ovulation Induction / Q000379:methods*; D011374:Progesterone / Q000097:blood*; D055815:Young Adult
D043373:Follicle Stimulating Hormone, Human; D006727:Hormone Antagonists; C437186:follicle stimulating hormone, human, with HCG C-terminal peptide; D007987:Gonadotropin-Releasing Hormone; D011374:Progesterone; C061018:ganirelix
IVF; corifollitropin alpha; ovarian stimulation; progesterone elevation; recombinant FSH