Administration of FSH and Low Dose hCG for Oocyte Maturity While Decreasing hCG Exposure in IVF Cycles

The success rate of assisted reproductive technology (ART) has dramatically increased due to
the improvements in embryo culture, laboratory conditions, and optimization of different
ovarian stimulation protocols. Recent data shows that if hCG is not administered for oocyte
maturation, severe OHSS is very rare. However, with gonadotropin releasing hormone (GnRH)
agonist cycles, hCG is required. Previous studies have revealed that a smaller dose of hCG
used for ovulation trigger versus the standard dose can have the same effect on the induction
of final oocyte maturation and can possibly reduce the risk of OHSS . However, the minimal
dose required of hCG to maintain maximal success rates of IVF is not known as it has not been
adequately studied in randomized controlled trials. Interestingly, our previous randomized
controlled study revealed that concomitant administration of FSH and hCG (10,000 IU), a more
physiological process, improved developmental oocyte competence. In that study, there was no
OHSS in the group that received the FSH co-trigger. A subsequent study performed a randomized
trial to determine if FSH co-trigger reduced the incidence of OHSS and found that, it may
prevent OHSS. Additionally, our own clinical experience (unpublished data) reveals that
administering 1,500 IU hCG plus 450 IU FSH co-trigger is enough to promote adequate oocyte
maturation while not increasing the risk of developing OHSS in high risk patients. Given
these findings, we propose a further modification of ovulation trigger with decreased
exposure to hCG. Our objective is to determine if concomitant administration of FSH with a
decreased dose of hCG versus a standard dose of hCG alone for ovulation will promote improved
oocyte maturation and quality, while decreasing the risk of OHSS. The selected FSH dose of
450 IU is thought to parallel the physiologic FSH surge observed in a natural cycle. We have
chosen 1,500 IU as the designated low dose of hCG based on previous studies showing that even
hCG doses as low as 2,000 IU allows oocytes to undergo maturation as well as our own clinical
experience that has demonstrated adequate oocyte maturity and fertilization in patients
chosen to receive 1,500 IU of hCG, due to the risk of OHSS.

Study participants will be recruited from the Reproductive Endocrinology and Infertility
Clinic at University of California at San Francisco Center for Reproductive Health. Couples
undergoing IVF will be offered participation in the study.

Approximately 100 subjects will be randomized at the time of enrollment to receive either the
standard dose of hCG alone or low dose hCG (1,500 IU) + FSH (450 IU) for oocyte maturation
trigger by the research coordinator. There will be about 50 subjects in each study arm.

Each subject will undergo a standard IVF stimulation protocol chosen by their primary
physician. Study participants will receive a syringe (prepared by the research coordinator)
on the day of ovulation trigger containing either the standard dose of hCG or low dose hCG +
FSH according to the randomization. The subjects will be triggered with the following:

1. Control arm: Standard dose of hCG (10,000 or 5,000 IU) or

2. Experimental arm: hCG 1,500 IU SQ + FSH 450 IU SQ.

For the control arm, the standard hCG dose will be given based on the estradiol (E2) level.
If the E2 level is less than 3,500 pg/ml then we will trigger with 10,000 IU of hCG. If the
E2 level is more than 3,500 pg/ml but less than 5,000 pg/ml then we will trigger with 5,000
IU.

Interventions to prevent OHSS in high risk patients:

Any patients in either arm with an E2 serum level >5,000 pg/ml on the day of expected trigger
administration will be excluded from the study. These patients will be individually assessed
by their primary physician. Their primary physician will decide the safest trigger option
based on the patient's risk of OHSS. From our own clinical experience, we expect that <5% of
subjects will have an E2 serum level of >5,000 pg/ml and be excluded.

The hCG and FSH trigger shots for each patient will be prepared by an unblinded nurse the
same day the patient will administer the medications. The subjects will self-administer the
ovulation trigger at the designated time given by the monitoring physician. Subjects will
return the day after oocyte maturation trigger for a blood draw to assess serum hormone
levels (estradiol, progesterone, hCG, FSH and LH).

The oocyte retrieval will be performed 36 hours after the oocyte maturation trigger. All egg
retrievals will be performed using transvaginal ultrasound and the associated needle guide in
the standard fashion. Both the physician and the laboratory personnel will be blinded to the
study. All visible follicles will be aspirated. The first follicle from each ovary on every
patient will be aspirated and the system (needle and tubing) will be flushed into a separate
tube prior to aspirating the remaining follicles so that direct correlation of follicular
size to oocyte recovery maturation, and embryo development can be separately assessed.
Additionally, the follicular fluid from the first aspirate will be collected for future
hormone assays. Oocyte stripping will be performed under the standard protocol. The status of
oocyte maturation at the time of stripping (approximately 38-40 hours after hCG
administration) and at the end of the intracytoplasmic sperm injection (ICSI) procedure
(approximately 40-42 hours after hCG administration) will be recorded. Fertilization will be
assessed 16-19 hours after insemination. The embryos will be transferred to growth media and
cultured with standard protocols.

To assess the incidence of OHSS, patients will be evaluated objectively by a change in the
abdominal circumference as well as subjectively by clinical symptomatology based on patient's
bloating symptoms.

Prior to starting the stimulation, the abdominal circumference (C) and body weight (BW) will
also be measured in centimeters at the baseline ultrasound visit (C baseline, BW baseline).
Five days after the oocyte retrieval the abdominal circumference and body weight will again
be measured in centimeters (C stimulated, BW stimulated). The difference in the abdominal
circumference and body weight will be calculated as follows: C baseline - C stimulated = CΔ.;
BW baseline - BW stimulated = BWΔ.

The patient's clinical symptoms will be evaluated based on a bloating score reported by each
patient before the trigger shot is administered and then 5 days after the oocyte retrieval
will be determined. A venipuncture will also be obtained for hormone assays 5 days after
oocyte retrieval.

Patients diagnosed with OHSS will be managed by a physician as clinically indicated. The
number of follow-up clinic visits and hospitalizations secondary to symptoms of OHSS will be
recorded.

Inclusion Criteria: The target population includes couples undergoing IVF. All eligible
couples will be asked to join the study. Study participants will be recruited from the
Reproductive Endocrinology Clinic at University of California at San Francisco Center for
Reproductive Health. Patients receiving any type of stimulation protocol for IVF will be
offered participation in the study.

Exclusion Criteria:

- Age >41 years old

- Antral Follicle Count (AFC; 2-10 mm) < 8

- Body Mass Index > 30 kg/m2

- History of ≥ 2 prior canceled IVF cycles secondary to poor response

- Diagnosis of cancer

- Any significant concurrent disease, illness, or psychiatric disorder that would
compromise patient safety or compliance, interfere with consent, study participation,
follow-up, or interpretation of study results

- Undergoing embryo co-culture

- Use of any of the following medications: Growth Hormone, Sildefanil, or Aspirin
(except if being used for hypercoagulable state)

- Severe male factor infertility diagnosis. Male factor infertility diagnosis should be
cleared for eligibility by the PI based on previous patient history of fertilization
outcomes and/or expected fertilization outcomes of the cause of male factor
infertility based on known scientific data.

- Ovulation trigger less than or greater than 36 hours to oocyte retrieval

- Serum estradiol level >5,000 pg/ml on the day of expected trigger due to high risk of
OHSS