**3. Human menopausal gonadotropin**

hMG is a urinary gonadotropin preparation consisting equal activity of both LH and FSH and some hCG. It is available in highly purified forms, minimizing earlier preparation disadvantages of protein contamination leading to the risk of allergic reactions. Evaluating studies with hMG have the advantage of homogeneity. Due to the nature of hMG containing equal FSH and LH activity, all patients in the hMG group receive equal amounts of LH and FSH activity and start LH activity on the same day as the FSH activity is started. As hMG has been available for longer than rFSH, there are more studies and total data available for analysis.

When looking at intermediate outcomes and surrogate markers for ART, hMG has not been demonstrably different than rFSH for ovarian stimulation. The results are similar in the proportion of MII oocytes, the number of high quality embryos, zona pellucida morphology, and polar body evaluation (42, 67-69). Studies have also shown no benefit in the number of oocytes retrieved with hMG and indeed numerous studies have shown a small decrease in the number of oocytes retrieved (typically around 1 oocyte less per retrieval) (22, 25-28, 41, 67). In the majority of studies, the decrease in oocytes did not translate into a decrease in the number of MIIs retrieved per cycle, indicating the loss was in smaller, immature oocytes. hMG administration has been associated with higher serum and follicular fluids androgens and estrogens and lower serum progesterone levels on the day of hCG (22, 25, 41-43, 56, 70- 72). It has been proposed that this more favorable endocrine milieu reflects a healthier cohort of developing follicles in hMG cycles. One study also demonstrated increasing implantation rates with increasing doses of LH supplementation (73). This dose dependent benefit of LH could be due to an increase in the quality of the oocytes retrieved or due to an endometrial effect on implantation. However, this study was small and we are not aware that the findings have been confirmed.

There is a large body of randomized controlled trials available for analysis comparing hMG to rFSH only. These trials are relatively homogenous, with similar dosing strategies and primarily GnRH agonist pituitary downregulation. These RCT have been systematically evaluated in several meta-analyses shown in Table 1 (74-78). The number of patients required to show a benefit in hMG had been calculated at over 2100 (76). This is demonstrated in a 2005 meta-analysis by Al-Inany *et al.* where 8 RCTs including 2031 ART cycles failed to show a statistically significant improvement in live birth (OR 1.18, 95%CI 0.93-1.50) although a trend to benefit may have been seen (76). When the same authors repeated a meta-analysis in 2008, there were 11 RCTs including over 2900 patients available for analysis (75). This time a significant improvement in live birth (OR 1.20, 95%CI 1.01-1.42) was demonstrated with the use of hMG versus rFSH alone (75). This data was confirmed in a separate meta-analysis by Coomarasamy *et al*. showing an improvement in live birth with hMG (OR 1.18, 95%CI 1.02-1.38) (77). Two more recent meta-analyses in 2010 each failed to show a significant improvement in live birth with the use of hMG (74, 78). However, the p values for these studies were borderline significant (0.051-0.06) and the odds ratio of pregnancy was similar to the other trials. Indeed, the last four meta-analyses had all demonstrated between a 3-4% absolute increase in pregnancy and a 10-21% relative increase in pregnancy with the use of hMG as compared to rFSH alone. These numbers translate to a NNT of approximately 32 patients with hMG to achieve one additional live birth. The clinical relevance of this number has been a matter of debate, but there is a clear statistical benefit to utilizing hMG. The majority of these source RCTs for these meta-analysis were from cycles utilizing a GnRH agonist protocols.

The Use of rLH, HMG and hCG in Controlled Ovarian Stimulation for Assisted Reproductive Technologies 61

hMG in the pre-protocol analysis and +2% in the intent-to-treat analysis, although the findings did not achieve statistical significance (79). The cumulative live birth rate (fresh and frozen cycles) was 40% in the hMG group and 38% in the rFSH group. This study was in agreement with a prior publication evaluating 280 patients using a GnRH antagonist protocol with hMG or rFSH, also showing a non-significant 3% improvement in live birth rate (22). While there is not enough data to definitively conclude that hMG is beneficial in GnRH antagonist cycles, the available data shows a similar improvement to that seen in

1. hMG is a urinary derived gonadotropin formulation containing equal amounts of LH

2. hMG may decrease the number of oocyte retrieved by 1 oocyte per retrieval as

The advent of recombinant DNA technology eventually led to the availability of recombinant LH in clinical practice (80). Urinary isolation of LH is an inefficient process, with 60-250 IU/mg of protein isolate (81). Conversely, recombinant LH contains 20,000 – 30,000 IU/mg of protein (81). The pharmacodynamics of recombinant and urinary derived LH preparations show similar clearance, half-life, and concentration curves (16, 81). The pharmacodynamics profiles of rLH are similar whether it is administered subcutaneously or intramuscular and it does not impact the pharmacodynamics of co-administered rFSH (82- 84). In hypogonadotropic hypogonadal patients, a dose of 75IU of rLH has been demonstrated to promote adequate folliculogenesis when administered with FSH (85). rLH has potential advantages over the LH activity in hMG in that there is less risk of protein contamination and allergic reaction and it allows for the LH dose to be specifically adjusted

There are numerous RCT evaluating rLH plus rFSH versus rFSH alone, but the data is complicated by significant heterogeneity between the trials (29, 30, 36-41, 86-95). The fact that the rLH dose can be administered at a separate starting time and doses from the rFSH dose has allowed researchers and clinicians to be more varied in the approach to rLH administration as compared to hMG. While this has allowed for the investigation of interesting protocols, it makes interpretation and meta-analysis of the data more complex. rLH has been investigated as a priming agent started up to 7 day prior to rFSH administration, as an early follicular phase agent beginning on days 1-3 of rFSH, and as a late follicular agent starting day 5-8. The dosing of rLH has also varied from 75IU to 300IU

3. hMG increases live birth by 3-4% as compared to rFSH in GnRH agonist cycles

4. hMG may also increase live birth in GnRH antagonist cycles

**4. Recombinant luteinizing hormone** 

GnRH agonist cycles.

**3.1. Summary points** 

and FSH activity

compared to FSH

without affecting the FSH dose.

per day or as a fixed ratio to the FSH dose.


**Table 1.** Recent meta-analysis comparing hMG versus rFSH for ovarian stimulation in ART cycles.

A recent RCT published in 2012 has provided similar evidence for the benefit of hMG in GnRH antagonist cycles. Devroey *et al.* randomized 749 patients to receive either hMG or rFSH (79). There were numerous strengths to this trial: rigorously described randomization, allocation and concealment, the use of 25 clinics in 7 countries, all patients were only allowed a single blastocyst transfer, and the follow-up included live births from the fresh cycle plus subsequent frozen cycles of embryos obtained during the study. Patients in the hMG arm had higher estradiol, LH, and FSH measured in the serum on the day of hCG. There was a significant reduction in the number of oocytes retrieved in the hMG group (-1.6 oocytes per retrieval). Importantly, an absolute difference of +3% in live birth with the use of hMG in the pre-protocol analysis and +2% in the intent-to-treat analysis, although the findings did not achieve statistical significance (79). The cumulative live birth rate (fresh and frozen cycles) was 40% in the hMG group and 38% in the rFSH group. This study was in agreement with a prior publication evaluating 280 patients using a GnRH antagonist protocol with hMG or rFSH, also showing a non-significant 3% improvement in live birth rate (22). While there is not enough data to definitively conclude that hMG is beneficial in GnRH antagonist cycles, the available data shows a similar improvement to that seen in GnRH agonist cycles.
