Gonadotropin use in Ovulation Induction

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Mark Perloe, MD:  “I’m here with Ken Gelman at the Ferring meeting for Advances in Infertility and we’re going to be broadcasting on FerCenter.com and talking about the meeting and some of the presentations here.  This afternoon there was an intriguing presentation about new concepts in ovulation induction.  In the past we have been sold by drug companies and by studies that have suggested a potential benefit for recombinant FSH products and we’ve seen some data that said otherwise today.  I wonder what your feelings are about that information?” 

Kenneth M. Gelman, MD, FACE:  “I find it highly interesting.  I did hear about this data about a year ago and it was nice and reassuring to hear it again and especially some follow-up studies from Dr. Filicori about embryo quality related to some of the studies he was doing.  But I found it rather interesting that the data comparing the old hMG preparations versus recombinant FSH and hMG is probably as efficacious or even more so.  But the interesting data is how we can reduce the amount of small follicles that are undesirable during the course of the stimulation and hopefully reduce both the risk of hyperstimulation and multiple births with the use of these new regimens that he presented today, notably, using LH or actually even hCG during the course of the stimulation or late into the stimulation to actually bring about these outcomes.” 

Mark Perloe, MD:  “In the past we’ve been sold that the recombinant would avoid premature luteinization and would also allow us to have lower estradiol levels and perhaps less of a risk of hyperstimulation.” 

Kenneth M. Gelman, MD, FACE:  “Correct, and we’re finding the reverse.  We actually saw the reverse today.  The recombinants of the FSH products actually contribute to premature luteinization whereas we thought the opposite.” 

Mark Perloe, MD:  “So the FSH plays a bigger role in creating the risk of that to perhaps the hCG and LH.  Certainly with a switch to a protocol using hCG the cost will be reduced but it may be in a clinical setting, we’ll certainly need a bit more data I think before we apply that.  The other area that we’ve heard a lot about recently was the advent of antagonists and most of the studies in Europe came out before the trials in the United States.  Can you summarize the data that was presented today looking at the use of antagonists?” 

Kenneth M. Gelman, MD, FACE:  “I think the data looks, again, strong and I think as suggested by some of the investigators we still need a lot more studies that actually refine the protocols but it seems like it’s going to be very similar in terms of outcomes to using agonists - a lot easier for the patients to use and possibly even less of an incidence of hyperstimulation.  So again, the data looks very interesting but we just don’t have enough experience particularly in this country and even over in Europe for the experienced investigators.  One of them said he had only about 200 cycles worth of trials which to me doesn’t seem like that much experience yet.” 

Mark Perloe, MD:  “Most of the studies showed trends towards a slightly lower pregnancy rate but interestingly as the programs had more experience using the medication in their stimulations the results improved and equaled what they got with the analogues.  Do you have any thoughts about why that might be and how they modified the protocols with time?” 

Kenneth M. Gelman, MD, FACE:  “They didn’t really say too much about that; there wasn’t enough detail provided today about that but I think they probably changed the day they administered the antagonists, maybe a day or so earlier.  I think they mentioned today that possibly starting the longer agonists a day or two later might have had an effect so, as I said, I didn’t get enough detail yet to really understand that point.” 

Mark Perloe, MD:  “I think most of the European trials have looked at relatively pure FSH products and in the studies that we’ve seen the LH or hCG becomes increasingly important in that it may be in a late follicular phase adding in hCG or more LH support may actually improve the results that we see or experience with the antagonists.” 

Kenneth M. Gelman, MD, FACE:  “Right, for example, do we change to add even an hMG product at that point, I know Dr. Filicori had mentioned that in a previous lecture I heard and he seemed to say that might provide some new novel information, again, we don’t have that data yet either.  I know I’ve done that in my clinical practice with some success, I’ve had three or four cycles where I’ve actually added hMG instead of an ampule of FSH and these patients have gotten pregnant.” 

Mark Perloe, MD:  “In our program we tend to do about a 3 to 1 or 2 to 1 ratio of FSH but it may be that when the highly purified hMG products come on it may be appropriate to switch or even look at a hCG.” 

Kenneth M. Gelman, MD, FACE:  “Or even recombinant LH when that comes out, that might be of use too so we’re looking forward to a lot of interesting things in the future.” 

Mark Perloe, MD:  “How are you enjoying your stay down in Florida?  This is not too far from home for you.” 

Kenneth M. Gelman, MD, FACE:  “This is very close to home but I can count the number of times I’ve seen the ocean since I’ve lived here so it’s actually rather pleasant.” 

Mark Perloe, MD:  “Sounds like your program is quite busy.” 

Kenneth M. Gelman, MD, FACE:  “It’s very busy.” 

Mark Perloe, MD:  “Thanks for joining us today, I appreciate it.” 

Kenneth M. Gelman, MD, FACE:  “Thank you.”