A phase IIIB, multicentre, multinational, randomized, open-label trial to compare the efficacy and safety of ovarian stimulation with GONAL-f day 1 to day 5 followed by Pergoveris starting day 6 to Pergoveris starting day 1 in women between 36 and 40 years of age undergoing assisted reproductive technique (ART)

Ongoing data collection from the UK HFEA has demonstrated that a combination of
delayed childbearing and reduced natural fecundity with increasing age has
resulted in a steady increase in the number and proportion of women above the
age of 34 who are seeking assisted reproductive technology (ART) treatment.
Although ART treatments are available for patients experiencing fertility
problems, the likelihood of successful ART outcomes decreases with increasing
age of the woman, and is closely linked to the number and quality of oocytes
retrieved. Biological ageing leads to depletion of the size of the ovarian pool
of oocytes and a reduction in oocyte quality.

Ovarian stimulation with follicle stimulating hormone (FSH) has been the
central component to the success of ART procedures. By daily injection of
recombinant human follicle stimulating hormone (r hFSH), exogenous FSH levels
are maintained for a number of days above the threshold for follicle
development, allowing multiple follicles to develop and multiple oocytes to be
retrieved. The ideal yield of oocytes varies according to chronological as well
as ovarian age, and in women less than 40 years of age, reports in the
literature have considered 8 to 10 oocytes (range 5-14 oocytes) per stimulation
cycle as adequate. Such a yield should result in sufficient high quality
embryos being available to allow a choice in transferring 1 to a maximum of 3
embryos. The remaining embryos or in some countries, the oocytes are
cryopreserved, allowing multiple attempts of embryo transfer (ET) per
stimulation cycle and contributing to higher cumulative pregnancy rates.
As the ovaries become less sensitive to FSH with increasing age, a poor ovarian
response to stimulation is more common in women aged >=35 years, leading to a
multitude of treatment strategies. The probability of embryo implantation and
successful live birth after IVF declines progressively in women above the age
of 35 years. However, the outcome in patients using donor eggs remains
relatively constant with increasing age, demonstrating that poor outcomes in
older women relate to the oocyte rather than to uterine factors.

Despite major advances in medical technology, there is currently no ART
treatment strategy that can fully compensate for the natural decline of
fertility with increasing age. However, several useful biomarkers are emerging
that can identify women with accelerated biological ovarian ageing, and
potential options for improving ovarian response in these patients include the
use of luteinising hormone (LH) supplementation, and adjuvant therapies.
Treating patients with biologically older ovaries will require a tailored
approach based on the individual patient characteristics, to maximize the
chances of the low numbers of healthy follicles developing successfully.

LH promotes ovarian androgen production, and hence oestrogen formation,
throughout folliculogenesis, and therefore plays a key role in promoting
steroidogenesis and growth of the leading follicle. It is known that
stimulation of ovarian androgen production by LH starts to decline during the
third decade of life. Given the association between diminishing ovarian
response to gonadotrophins and increasing age, it is not surprising that some
studies have suggested a trend towards an increasing benefit of LH
supplementation during ART with increasing age, however there is not a
consensus view on this, nor on when is the optimum time to start LH
supplementation.

Among women who did not receive r-hLH supplementation, pregnancy and
implantation rates were shown to be significantly lower in those >=35 years of
age compared with those <35 years of age; this difference was not observed in
the group given r-hLH supplementation. Similarly, Marrs et al. found that in
patients aged >=35 years at their first ART cycle, the clinical pregnancy rate
was significantly higher if patients received r-hLH than if they did not. In a
clinical trial including patients aged <39 years, the data obtained suggested
that LH supplementation, in the form of r-hLH or HMG, may optimize follicle
steroidogenesis in women treated with gonadotrophin-releasing hormone
(GnRH)-antagonists. Nevertheless, the evidence is insufficient to evaluate the
effect of such a treatment on implantation and pregnancy rates, at least in
unselected patients. The efficacy of an LH activity supplementation to a
flexible GnRH-antagonist protocol in patients at risk of poor ovarian response
(aged >37 years), having as control reference standard the GnRH-agonist flare
up protocol was conducted. No significant difference was observed in the total
number of oocytes retrieved, however, a statistically significant higher number
of mature oocytes was found in the group receiving LH supplementation. Thus, a
stimulation regimen provided in association with exogenous LH activity in form
of r-hLH, seems to be able to significantly improve the ovarian response in
women. This might be due to the quite physiological and stable hormonal
environment. Bosch and colleagues also recently described the effect of LH
supplementation in ART cycles where a GnRH-antagonist was used. This was a
randomized controlled trial in two age subgroups: a) patients aged < 35 years
or b) patient aged >= 36 and up to 39 years. The two treatment arms received
either 300 IU FSH alone or 225 IU FSH and 75 IU LH i.e. a total of 300 IU
gonadotrophin injected per day. They reported less oocytes retrieved in the LH
supplemented group (probably due to lower FSH dose used) but higher
implantation rates (26.7% vs. 18.9%; P=0.03) in patients aged 36 to 39, but not
in the younger sub-population. In contrast, young ovaries may be more sensitive
to LH levels and, thus, may experience a detrimental effect of LH
supplementation by exceeding the *LH ceiling*. Thus, the patient population
receiving LH supplementation should be carefully selected.

It is known that in the less sensitive ovaries, simply increasing the amount of
FSH stimulation is of limited use during ART and there may therefore be a place
for LH supplementation. Indeed, high doses of FSH could even be postulated to
have an adverse effect. It is interesting to note that a large study has shown
reduced pregnancy rates, despite the production of at least five oocytes, if a
high dose of FSH is required for ovarian stimulation during ART in a long GnRH
agonist protocol. One putative explanation for this is that continuously high
FSH drive combined with strong LH suppression can result in elevation of late
follicular phase progesterone from the follicular cohort being stimulated
(Fleming et al 2008), and this has been associated with a reduced implantation
potential. Thus, in such a situation, ability to adjust the FSH dose and/or
supplementation with LH may be beneficial for the treatment response. A study
in women aged 35-39 years undergoing ovarian stimulation with r-hFSH; 300-450
IU/day day1-5 and on day 6 were randomized to receive r-hFSH alone or r-hFSH +
r-hLH; 150 IU/day for the remainder of the stimulation period. No significant
differences were observed in markers of either oocyte or embryo quality or
quantity. However, higher rates of implantation and live birth per started
cycle were observed with r-hLH supplementation than with r-hFSH alone. Although
additional large studies are required to further investigate these findings,
r-hLH supplementation for women aged 35-39 years undergoing ICSI has been
recommended as it may have a beneficial action on implantation. In a study by
Bühler et al., 2009, the use of Pergoveris® in routine clinical practice in ART
was evaluated in 857 patients. It was found to be effective in achieving
clinical pregnancies and was associated with a favourable safety profile. The
study also concluded that Pergoveris® seemed to be beneficial in patients aged
>35 years, poor responders and those with low LH.

Although chronological age is the most important predictor of ovarian response
to follicle stimulating hormone (FSH), the rate of reproductive ageing varies
considerably among individuals. Both environmental and genetic factors
contribute to biological ovarian ageing. (Individual variation in response to
r-hFSH treatment may in part reflect genetic variation such as functional
differences in the FSH receptor (FSH-R), as activating and inactivating
mutations within the gene have been associated with ovarian dysfunction.
Polymorphisms in the gene coding for the LH beta subunit have also been shown
to influence the dose of r hFSH needed to achieve an apparently normal ovarian
response in ART (i.e. > 5 oocytes obtained).

In summary, certain sub-populations such as women with a higher chronological
age seem to benefit from the addition of LH and when used with FSH, in women
with severe gonadotrophin deficiency (as occurs during concomitant GnRH agonist
use) supports use of a 2:1 ratio of FSH to LH to optimise follicular response.

In this trial, administration of Pergoveris®, a fixed combination product
containing recombinant human follicle stimulating hormone (r-hFSH) and
recombinant human luteinising hormone (r-hLH) will be initiated at day 1 and
day 6 in the two study arms respectively. The primary endpoint will be the
total number of oocytes retrieved following stimulation in the two study arms
and to document the stimulation characteristics and secondary endpoint measures

The overall objective of this trial is to generate data on the ovarian
stimulation profile obtained when Pergoveris® is started either on stimulation
day 1 or stimulation day 6 in ART patients between 36 and 40 years of age (both
inclusive). A secundary objective is to further investigate the efficacy and
safety profile of Pergoveris® in ART patients between 36 and 40 years of age.

This is a multicentre, multi-national, randomized, open-label comparative
trial. At the screening visit, the prospective subject will be informed of the
trial objectives and overall requirements. Informed consent will be obtained
prior to any assessments being made. The subjects who have completed the
screening assessments and fulfil all of the eligibility criteria will start
down-regulation treatment on day 21-22 of the cycle. Down-regulation treatment
must start within 2 months following the screening visit. The routine long
luteal phase protocol for GnRH agonist treatment will be followed. Once
down-regulation has been confirmed, a pregnancy test will be performed just
before randomisation and start of recombinant human follicle stimulating
hormone (r-hFSH) treatment to rule out any pre-existing pregnancy. If the
result is negative, the subject will be randomly assigned to one of the two
treatment arms of the trial:
- GONAL-f® (Liquid Pen; 300 IU of per day) stimulation day 1-5 followed by
Pergoveris® (vial/powder, 300 IU per day) from stimulation day 6 and until
required r-hCG level is met. The dose can be adjusted from stimulation day 6
(increased or decreased) based upon the subject*s ovarian response and
according to the centre*s standard practice.
- Pergoveris® (vial/powder, 300 IU per day) from stimulation day 1 and until
the required r-hCG level is met. The dose can be adjusted from stimulation day
6 (increased or decreased) based upon the subject*s ovarian response and
according to the centre*s standard practice.
Randomisation across the two treatment arms will be kept balanced in a 1:1
ratio. Follicular development will be monitored according to the centre*s
standard practice by US and/or E2 levels, until the protocol r hCG requirement
is met (i.e., at least 1 follicle ³ 18 mm and 2 follicles ³ 16 mm). After this,
a single injection of 250 mcg of r hCG (Ovidrel®/Ovitrelle®), will be
administered in order to induce final oocyte maturation.
At a time of 34-38 hours after r hCG administration, oocytes will be recovered
vaginally under US monitoring. Oocytes will then be fertilized in vitro and
embryos replaced 2-5 days after oocyte recovery. Ovum Pick Up (OPU), in vitro
fertilization (IVF), ET and luteal support will be performed as per centre*s
standard practice.
A post-treatment safety visit will be performed for all subjects who received r
hCG (pregnant and non-pregnant) on day 15-20 post-hCG. For subjects who have
withdrawn from treatment (i.e. after starting Pergoveris® or GONAL-f® but
before hCG is given) this visit will take place 20-30 days after their first
Pergoveris® or GONAL-f® treatment injection (excluding pregnancy testing).

* GONAL-f® (Liquid Pen; 300 IU of per day) stimulation day 1-5 followed by
Pergoveris® (vial/powder, 300 IU per day) from stimulation day 6 and until
required r-hCG level is met. The dose can be adjusted from stimulation day 6
(increased or decreased) based upon the subject*s ovarian response and
according to the centre*s standard practice.
* Pergoveris® (vial/powder, 300 IU per day) from stimulation day 1 and until
the required r-hCG level is met. The dose can be adjusted from stimulation day
6 (increased or decreased) based upon the subject*s ovarian response and
according to the centre*s standard practice.
Randomisation across the two treatment arms will be kept balanced in a 1:1
ratio.

The safety of Pergoveris® relies on extensive data cumulated during product
development and from data on GONAL-f® and Luveris®. Based on the pre-clinical
and clinical data available to date, the conduct of the trial is regarded as
justifiable at the planned dose ranges. The risk benefit ratio is determined to
be favourable