Corifollitropin alpha Elonva P Devroey

GnRH antagonist Reduced patients’ burden and psychological stress Patient friendly Short duration Similar pregnancy outcome Meta – analysis Reduced risk of OHSS correlated with GnRH long protocols Strategy to erase OHSS with GnRH agonist trigger Safe OHSS risk Zero Devroey HR 2009

Meta-analysis of efficacy trials: probability of live birth

Oral Contraceptive Pretreatment Significantly Reduces Ongoing Pregnancy Likelihood in GnRH Antagonist Cycles: A Meta-Analysis The probability of an ongoing pregnancy per randomized woman was found to be significantly lower in patients who received oral contraceptive pill pre-treatment (RR 0.80, 95% CI: 0.66 to 0.97; p=0.02 Griesinger et al Fertil Steril 2010

Oral contraceptive pretreatment Meta-analysis Study OCP (n) No OCP (n) Total 670 673 Risk Ratio 0.80 (0.66, 0.97) In favour of no OCP 1 pregnancy loss/ 20 women treated Griesinger FS 2010

OCP + GnRH antagonist ( n) (%) Oral contraceptive pills in GnRH antagonist protocol versus long protocol OCP + GnRH antagonist ( n) (%) Long Protocol (n) (%) Ongoing PR 55/115 (48) 61/113 (54) Multiples 15/55 (27) 18/61 (30) Implantation Rate 75/207 (36) 80/204 (39) Live birth rate 51/115 (44) 53/113 (47) Garcia-Velasquo FS 2011

Randomization Patients received 10.000 IU of hCG as soon as ≥ 3 follicles of ≥ 17 mm were present in ultrasound early hCG group, 208 patients or 2 days later after this criterion was met late hCG group, 205 patients Kolibianakis Albano Camus Tournaye Van Steirteghem Devroey FS 2004

Prolongation of the follicular phase in IVF results in a lower probability of pregnancy Early-hCG group Late-hCG group P Ongoing pregnancy rate per OPU (n) 35.6% (69/194) 25% (49/196) 0.027 Ongoing pregnancy rate per ET (n) 39.2% (69/176) 27.7% (49/177) 0.024 Ongoing implantation rate (n) 22.6% (87/385) 15.1% (58/383) 0.009 Kolibianakis FS 2004

How to manage patients with elevated progesterone levels at initiation of stimulation ? Patients with elevated progesterone levels on day two of the cycle were always postponed for 1-2 days Stimulation with rec-FSH and GnRH antagonists was started only if progesterone levels returned to normal range Kolibianakis et al HR 2004

Elevated progesterone levels at initiation of stimulation are associated with a significantly lower chance of pregnancy Normal P group High P group P Difference (95% CI) Ongoing pregnancy rate Per started cycle % (n) 31.8 (124/390) 5.0 (1/20) 0.011 26.8 (7.7-33.1) Per oocyte retrieval % (n) 33.8 (124/367) 6.3 (1/16) 0.026 27.5 (5.0-34.7) Further research Initiation of antagonist on day 1? Kolibianakis HR 2004

Describe the LH concentration during the luteal phase ( post hCG ) in agonist gonadotrophin stimulated cycles LOW or HIGH Answer : Low Smitz HR 1988

Is the luteal phase LH concentration ( post hCG ) in antagonist - gonadotrophin cycles normal or decreased ? Answer : decreased

Impact on cycle outcome Bosch et al HR 2010

ONGOING PREGNANCY RATE AND ONGOING IMPLANTATION RATE ACROSS GROUPS OF PATIENTS WITH INCREASING LH LEVELS ACCORDING TO PERCENTILE ANALYSIS Groups of patients according to LH levels on day 8 Ongoing pregnancy rate per oocyte retrieval % (n) Ongoing implantation rate Pregnancy loss after hCG detection before 12 weeks LH level on day 8 mean min max 0 - 25th 0.3 0.1 0.5 56.0 (14/25) 39.1 (18/46) 6.7 (1) 25 - 75th 1.0 0.6 1.9 40.3 (25/62) 24.6 (31/126) 7.4 (2) 75 - 100th 3.3 8.4 24.1 (7/29) 15.7 (8/51) 12.5 (1) P < 0.010* P < 0.018* P < 0.71* * Exact Chi-square for trend Kolibianakis HR 2004

Recombinant LH after antagonist initiation Pill pre-treatment/ 3 day interval, variable starting dose of rec FSH Single dose antagonist administration by a follicle of 14-16mm Cedrin-Durnerin HR 2004

Definition of OHSS Iatrogenic complication (!) of “controlled” (?) ovarian stimulation Potentially fatal (!) Risk factor (PCOS) Triggering mechanism of hCG

Intriguing Iatrogenic Who is responsible? Ovarian stimulation How to stimulate? HCG is the trigger HCG to be replaced?

Ovarian hyperstimulation syndrome PubMed ( 01 09 2011) n : 2 275 citations PubMed ( 30 01 2012) n : 2 333 citations Pubmed (30 05 2012) n : 2 396 citations Pubmed (17 03 2015) n: 2 837 citations

Fatal OHSS 25 years old Japanese lady Bilateral chest pain - dyspnoea Pleural effusion Fatal after respiratory insufficiency Autopsy massive pulmonary edema Semba Patol Int 2000 Fatal

Maternal death In IVF in the Netherlands (1984 – 2008) Death to OHSS : 3 / 100 000 IVF cycles Respiratory distress (n : 2) Cerebrovascular thrombosis (n : 1) Braat HR 2010 Does it mean 30 / 1 000 000 ?

Oocyte donors (GnRHa donors) Triggering GnRHa hCG P Subjects (n) 50 Age (y) 25 rFSH dose (U) 2 300 Eggs retrieved (mean) 17 19 OHSS rate 0 / 50 8 / 50 0.03 Melo RBMO 2009

GnRH agonist triggering in GnRH antagonist cycles in OHSS risk AIM avoiding OHSS Patients (n = 12) > 25 follicles GnRH agonist triggering and 1 500 hCG 35 hours later COC (n =20) Ongoing pregnancies 50 % (6/12) No OHSS Humaidan RBMO 2009

Oocyte banking (vitrification) RCT P Frozen Fresh Ongoing pregnancy rate / ET 43.7 % 41.7 % NS Clinical pregnancy rate / ET 55.0 % 56.0 % Implantation rate 40.0 % 41.0 % Similar results 95 % CI : 0.7 – 1.3 Cobo HR 2010

PubMed Search 18 02 2015 Keywords: corifollitropin alfa Publications : n=54

Today’s treatment GnRH antagonist 1 2 3 4 5 6 7 8 9 10 7-10 days FSH hCG Corifollitropin alfa rFSH 1 2 3 4 5 6 7 8 9 10 hCG

Sustained follicle stimulants A recombinant fusion molecule of FSH and the carboxy-terminal peptide (CTP) of the human chorionic gonadotropin-beta (hCG) subunit The first of a proposed new class of gonadotropins (Sustained Follicle Stimulants) with different pharmacokinetic properties but similar pharmacological features as wild-type FSH Interacts only with the FSH receptor and not with the luteinizing hormone (LH) receptor Fares et al Proc Natl Acad Sci USA 1992

Comparative pharmacokinetics Corifollitropin alfa rFSH FSH activity Therapeutic threshold 1 2 3 4 5 6 7 8 9 10 Stimulation days Duijkers et al. Hum Reprod. 2002 Devroey et al. J Clin Endocrinol Metab. 2004 Fauser et al. Reprod Biomed Online 2010

Engage and Ensure treatment regimen Corifollitropin alfa Investigational group Placebo rFSH (daily dose for 7 days) Daily rFSH Placebo Corifollitropin alfa IVF or ICSI GnRH antagonist (ganirelix 0.25 mg/d) day 5 through day of hCG Luteal phase support Reference group Engage trial design Phase 3 (pivotal efficacy and safety trial) Active-controlled (vs. daily rFSH), noninferiority Double-blind, double-dummy Randomization by interactive voice response system (IVRS) Stratified by center and age (<32 vs. ≥32 years) in 1:1 ratio Planned number of patients: 1400 Multicenter (34 sites: 20 in Europe, 14 in North America) This slide depicts the treatment regimen used in the Engage trial. Patients were randomized to receive A single 0.5-mL injection of corifollitropin alfa (150 µg) on cycle day 2 or 3 (stimulation day 1) and daily rFSH placebo injections (equivalent of 200 IU) for 7 days, or An injection of placebo corifollitropin alfa (0.5 mL) on cycle day 2 or 3 and daily rFSH (200 IU/d) for 7 days Daily rFSH was administered only when required in the opinion of the investigator, and a reduced dose of rFSH could be administered from stimulation day 6 onwards if a high response was observed. Both groups received daily GnRH antagonist (ganirelix 0.25 mg/d) from stimulation day 5 through the day of hCG. Both groups received daily rFSH (≤200 IU) from stimulation day 8 through the day of hCG. On the day that 3 follicles were ≥17 mm (or the day thereafter), final oocyte maturation was induced with hCG (10,000 or 5000 IU), and oocytes were collected. Patients underwent IVF or ICSI. Luteal phase support was micronized progesterone (≥600 mg/d vaginally or ≥50 mg/d intramuscularly [IM]). Initiated on the day of oocyte collection and continued for at least 6 weeks or until either menses or negative pregnancy test performed at least 14 days after embryo transfer Daily rFSH (daily dose for 7 days) Daily rFSH Cycle day 2-3 = stimulation day 1 Stimulation day 5 Stimulation day 8 hCG as soon as 3 follicles ≥17 mm (or the day thereafter) Devroey et al. Hum Reprod 2009 28 28

Prediction of OHSS with corifollitropin alfa versus rFSH Patients at risk ≥ 18 or 19 follicles Sensitivity and specificity were 74.3% and 75.2% Preventive measure Switch from hCG to agonist triggering Tarlatzis BC et Reprod Biomed Online 2012

Risk of OHSS for corifollitropin alfa recFSH Patients(n) 71/1023 53/880 Mild (%) 3 3.5 Moderate (%) 2.2 1.3 Severe (%) 1.8 Tarlatzis BC et al Reprod Biomed Online 2012

Does hCG administration on or before day 8 decrease the chance of pregnancy?

Day when hCG criterion were met 40 40 Corifollitropin alfa 100 µg Corifollitropin alfa 150 µg 30 30 % of patients % of patients 20 20 10 10 5 6 7 8 9 10 11 12 13 14 15 16 17 18 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Day of hCG criteria Day of hCG criteria One-third of the patients, regardless of the corifollitropin alfa dose, met the criteria for hCG injection before or on stimulation day 8

Pregnancy rates for corifollitropin alfa group: Meeting criteria for hCG d8 vs. > d8 ≤ day 8 44.0 > day 8 38.1 Engage 150 microgram Pregnancy Rate (%) 248 485

Does delaying hCG administration by 1 day affect the chance of pregnancy?

Pregnancy rates: hCG delay of 1 day Engage Pregnancy Rate (%) 40.3 38.9 37.3 42 N 472 244 490 243 Corifollitropin alfa Puregon

Pregnancy Rates: Oocytes Retrieved Engage Pregnancy Rate (%) 84 169 90 171 156 N 136 178 163 188 133 1-5 6-9 10-13 14-18 >18 Oocytes Retrieved Fatemi HM et al Hum Reprod 2013

Corifollitropin alfa on Day 2 versus Day 4 Prospective randomized trial Study population 52 patients Total dose of rFSH significantly reduced in CD4 (p=0.01) Significant reduction of duration in CD4 Number of COS is comparable (12,8 versus 14,7) Ongoing pregnancy rates in CD2 group 48% versus 41% in CD4 group Blockeel et al HR 2014

Estimated differencea (Cumulative) ongoing pregnancy rates & live birth rates in Engage trial Corifollitropin alfa 150 µg n = 756 Puregon® 200 IU/day n = 750 Estimated differencea (95% CI) Ongoing PR per started cycle per transfer 38.9% 294/756 43.8% 38.1% 286/750 40.6% 0.9% (–3.9 to 5.7) 3.1% (–2.0 to 8.2) Live birth rates/ started cycle 35.6% 275 in FU 34.4% 266 in FU Cumulative ongoing PR/ started cycle 47.2% 148 ≥1 FTET 44.9% 147 ≥1 FTET aAdjusted for age and region. CI, confidence interval; FTET, frozen-thawed embryo transfer. Boostanfar et al. Hum Reprod 2010

Ongoing PR per started cycle Serum LH on Day 8 Engage Treatment group Serum LH level IU/L Ongoing pregnancy rate N n % 95% CI Corifollitropin alfa P25≤0.62 P50=0.96 P75=1.58 <P25 P25-P75 >P75 216* 316 176 77 125 68 35.6 39.6 38.6 [34.1; 45.2] [29.3; 42.4] [31.4; 46.3] rFSH P25=0.91 P50=1.57 P75=2.66 169 340 60 65 35.5 36.8 38.5 [28.3; 43.2] [31.6; 42.1] [31.1; 46.2] *More than 25% of patients had a value below the LLOQ and were all included in the <P25 group. Doody KJ et al. Reprod Biomed Online 2011

Elonva in egg donors with GnRH agonist triggering Cycles (n) 223 Mean age (year) 26.1 ± 4.2 OHSS risk MII (mean +/-sd) 11 ± 9 Fertilization (%) 72 ET (mean) 1.8 PR/ET (%) 61 Miscarriage (%) 13 Implantation rate (%) 39 Pellicer A et al personal communication 2013

Evaluation of the degree of satisfaction (in egg donors) Corifollitropin alfa (n=60) recFSH Age (y) 23.2 24.4 Weight (kg) 65.6 64.9 Days of stim(n) 10 ready at D8 26% 27% COC 15.1 16.5 MII 85% 77% OHSS - One injection of corifollitropin alfa replaces 7 daily injections of rFSH during COS. The number of injections is reduced by about 70% compared with the long agonist protocol (from 35 to 10). In combination with the GnRH antagonist, this COS protocol can considerably reduce the treatment burden on patients. Additional daily rFSH after day 7 is to be determined by physician assessment. So what exactly is corifollitropin alfa? Let’s take a look at its molecular makeup on the next slide to see how it can perform as a sustained follicle stimulant. Requena et al. RBMOnline 2013

Evaluation of the degree of satisfaction (in egg donors) Corifollitropin (n=60) recFSH satisfaction (10=completely satisfied) 9.1 9.3 pain (VAS 0-100) 13.5 12.9 preference (if previous cycle) 75% 25% One injection of corifollitropin alfa replaces 7 daily injections of rFSH during COS. The number of injections is reduced by about 70% compared with the long agonist protocol (from 35 to 10). In combination with the GnRH antagonist, this COS protocol can considerably reduce the treatment burden on patients. Additional daily rFSH after day 7 is to be determined by physician assessment. So what exactly is corifollitropin alfa? Let’s take a look at its molecular makeup on the next slide to see how it can perform as a sustained follicle stimulant. Requena et al. RBMOnilne 2013

Characteristics of live born infants Care Corifollitropin Alfa N = 424 rFSH N = 370 Gestational age, weeks 37.8 (3.2) 38.2 (2.8) Female sex, n, mean (%) 210 (49.5%) 190 (51.4%) Number of singletons 241 237 Weight at birth—singletons only, g 3297 (534) 3247 (586) Weight at birth—all, g 2860 (755) 2928 (715) Length at birth, cm 48.2 (4.1) 48.6 (4.1) Head circumference, cm 33.6 (2.2) 33.5 (2.6) Apgar score: 1 min 8.2 (1.5) 8.1 (1.5) Apgar score: 5 min 9.1 (1.0) 9.1 (0.9) Values are n, mean (SD) unless otherwise stated. Bonduelle M et al. Hum Reprod 2012 43 43

Corifollitropin alfa in combination with GnRH agonist triggering (Pilot Study) Egg retrieval After 1 hour 1500IU HCG After 7 days 1500IU HCG Micronized progesteron vaginally Decleer et al. Facts Views Vision 2014

Corifollitropin alfa in combination with GnRH agonist triggering (Pilot study) Patients (n) 11 Age (y) 32 BMI (kg/m²) 24 COC (mean) 10 Pregnancies (n) 4 Decleer et al. Facts Views Vision 2014

Addition of highly purified HMG after corifollitropin alfa in POR Stimulation protocol Elonva + 300 IU Menopur GnRH antagonist from day 7 of the cycle Patients < 40 y Patients ≥ 40 y Number 29 18 Pregnancy rate 8/29 (28%) 0/18 (0%) Polyzos NP et al. Hum Reprod 2013

Most Important Entry Criteria (PURSUE Study) Inclusion criteria Indication for COS and IVF/ICSI Age ≥ 35 and ≤ 42 years Body weight ≥ 50 kg, and body mass index ≥ 18 and ≤ 32 kg/m2 Normal menstrual cycle (cycle length 24–35 days) Availability of ejaculatory sperm 47

Number of Oocytes Retrieved Corifollitropin Alfa 150 µg rFSH 300 IU/day Estimated Difference ANOVA (95% CI) Per attempt Mean (SD) n = 694 10.7 (7.2) n = 696 10.3 (6.8) 0.5 (–0.2 to 1.2) Per oocyte pick-up n = 675 11.0 (7.0) n = 671 10.6 (6.7) 0.4 (–0.3 to 1.1) 48

Primary End Point: Ongoing PR* Pursue ITT Group % of patients This slide shows the ongoing pregnancy outcome per started cycle (as a percentage of patients). For all of the measured end points, rates were comparable between corifollitropin alfa and daily rFSH. The absolute treatment difference slightly favored corifollitropin alfa. Ongoing pregnancy rate is defined as the presence of at least 1 fetus with heart activity at least 10 weeks after embryo transfer as assessed by USS or Doppler, or confirmed by live birth. 26.9% 23.9% Boostanfar et al. ASRM 2012 San Diego

Congenital malformations with corifollitropin alfa ( PURSUE study) recFSH Pregnancies (n) 154 167 Children(n) 183 196 Congenital malformations(n) 9 6 Congenital malformations (%) 4.9 3.1 Stegmann ASRM 2013 Boston

Number of Subjects With OHSS (All Subjects Treated Group) Corifollitropin Alfa 150 µg n = 692 rFSH 300 IU/day n = 698 Incidence of OHSS, n (%) Grade unknown 1 (0.1) Grade I (mild) 7 (1.0) Grade II (moderate) 5 (0.7) 4 (0.6) Grade III (severe) 6 (0.9) Total 12 (1.7) OHSS reported as SAE Hospitalization 2 (0.3) Grade II and/or III 10 (1.4) 51

Coda Yesterday Nowadays Pro GnRH agonist long protocol Daily rFSH injections hCG for final egg maturation Patient unfriendly OHSS ± 5% GnRH antagonist Corifollitropin alfa GnRH agonist for final egg maturation if needed Patient friendly OHSS ≈ 0% OHSS Free Clinic Safe and simple Safe Acknowledgements to Helena Deryckere