RESULTADOS DEL ESTUDIO MEGASET

P Devroey

Megaset The clinical trial

Prof Dr P Devroey

Recent trends in ART practice

Increasing use of GnRH antagonists with lower doses of gonadotrophin Increasing use of ICSI over the last decade Increasing use of single embryo transfer Increasing use of embryo culture to blastocyst stage Increasing use of vitrification instead of slow-freezing

Why the MEGASET trial?

MEGASET compares HP-hMG (MENOPUR) with rFSH (PUREGON) in a setting that addresses these recent trends in ART practice Randomised, assessor-blind, parallel groups, multicentre trial to demonstrate non-inferiority of HP-hMG compared to rFSH with respect to ongoing pregnancy rates

Participating clinics

25 clinics in 7 countries

Key design features

Women 1834 years / BMI 1824.9 kg/m2 GnRH antagonist / No programming 150 IU starting dose ICSI Single blastocyst transfer on Day 5 2 weeks luteal support Vitrification Replacement of a single warmed blastocyst in a natural cycle

Trial design
GnRH antagonist 0.25 mg

HP-hMG or rFSH
150 IU x 5 days
Adjustment by 75 IU; minimum 4 days on dose

rhCG 250 g

Progesterone 3x200 mg

Oocyte/embryo/ blastocyst evaluation

-hCG

Clin. P

Ong. P

6
3 follicles 17mm

OR

OR +5

13-15 days after ET

5-6 10-11 weeks weeks after ET after ET

ET
1 blastocyst

Post-trial follow-up
FER 1 blastocyst natural cycle Ongoing pregnancy No ongoing pregnancy

Ongoing pregnancy

No ongoing pregnancy

Pregnancy outcome and neonatal health follow-up

Pregnancy outcome and neonatal health follow-up

Investigations: All patients

Endocrine profile / Follicular development Ovarian response Endometrial profile Pregnancy rates Oocyte maturation, fertilisation Blastocyst quality

Additional investigations: Subgroups of patients

Early-mid follicular phase endocrine profile Intrafollicular endocrine profile Uterine contractility Gene expression in cumulus cells
(mechanical dissection and enzymatic denudation)

METHODOLOGY

Primary endpoint of the study

Ongoing pregnancy rates beyond 1011 weeks after ET in a fresh cycle

Power calculation

Estimated ongoing pregnancy rate of 30% was derived from previous studies on single blastocyst transfer Non-inferiority margin was set at 10% (absolute) At least 660 cycles was required to achieve a study power of 80%

Analysis of data
Modified Intention-to-treat (ITT) analysis All subjects who have been randomised and exposed to at least one dose of investigational medicinal product were analysed according to the actual treatment Per protocol analysis All subjects from the modified ITT, except those who are excluded because of a major protocol deviation were analysed

EMBRYO ASSESSMENT

Embryo morphology assessment and grading Local embryologists only no central evaluation Interobserver agreement and intraobserver reproducibility were validated in the MERiT trial showing goodexcellent agreement on overall embryo morphology assessment and grading1 Embryos were graded according to the Gardner and Schoolcraft classification system2
1. Arce et al. Hum Reprod 2006; 21: 21412148 2. According to Gardner and Schoolcraft

Endometrial assessment

Thickness Triple-layer structure Echogenicity pattern

SUBJECT DISPOSITION

Consort diagram
Screened (N=810) Randomised and exposed (n=749)

HP-hMG (ITT; N=374) Oocyte retrieval N=362 Embryo transfer N=305 -hCG visit N=305

rFSH (ITT; N=375) Oocyte retrieval N=362 Embryo transfer N=316 -hCG visit N=316

Ongoing pregnancy visit N=116

Ongoing pregnancy visit N=107

BASELINE PARAMETERS

Demographics and treatment history ITT population

Primary reason of infertility Demographics
Unexplained 38% Mild male factor 62%

HP-hMG (N=374) 30.8 2.8 60.6 6.8 22.1 1.9 3.2 1.8 HP-hMG (N=374) 95% 49% 29%

rFSH (N=375) 30.4 2.6 59.9 7.0 21.9 2.0 3.1 1.7 rFSH (N=375) 95% 52% 31%

Age (years) Weight (kg) BMI (kg/m2) Duration of infertility (yrs) Treatment history

HP-hMG

Unexplained 40%

Mild male factor 60%

1st or 2nd COS cycle ever Previous IUI cycles, total Previous IUI cycles, with gonadotrophins

rFSH

ENDOCRINE PROFILE

Endocrine Profile Stimulation day 1

Endocrine profile FSH (IU/L) LH (IU/L) Estradiol (pmol/L) Progesterone (nmol/L) Total testosterone (nmol/L) Inhibin B (ng/L) AMH (pmol/L)
Data are mean SD

HP-hMG (N=374) 7.5 2.3 6.2 2.3 180 106 2.2 1.1 1.6 0.8 87 40 27 19

rFSH (N=375) 7.4 2.4 6.2 2.2 177 100 2.2 1.1 1.7 0.8 85 35 27 20
ITT-population

Early-mid follicular phase: LH

Change over time
HP-hMG (N=49) rFSH (N=50) -26% -47% -61% 24% -57%

HP-hMG rFSH

Day 1 Day 2 Day 2 Day 4 Day 1 Day 4 Day 4 Day 6 Day 1 Day 6

-22% -42% -60% 10% -50%

Median values

ITT-population / early-mid follicular phase sub-group

Endocrine profile stimulation day 6

HP-hMG (N=374) rFSH (N=375) p value

LH (IU/L) hCG (IU/L) Estradiol (pmol/L) Progesterone (nmol/L) Total testosterone (nmol/L) Inhibin B (ng/L)
Data are mean SD

4.9 5.0 1.7 0.6 2626 1405 2.2 1.9 1.9 0.9 604 324

5.5 6.0 2973 1702 2.8 10.8 1.9 0.9 722 424

0.558 0.003 0.025 0.169 <0.001

ITT-population

Endocrine profile last stimulation day

HP-hMG (N=374) LH (IU/L) hCG (IU/L) Estradiol (pmol/L) Progesterone (nmol/L) Total testosterone (nmol/L)
Mean SD

rFSH (N=375) 2.1 1.6 7022 4945 3.1 3.3 2.1 1.0

p value <0.001 <0.001 0.630 <0.001

ITT-population

2.8 2.8 2.1 0.8 8797 6030 3.1 3.4 2.5 1.2

Premature luteinization

HP-hMG (N=374) Premature luteinization* -LH 10 IU/L -Progesterone 1 ng/mL (3.18 nmol/L) 5.9%

rFSH (N=375) 6.1%

ITT-population

Both LH and progesterone criteria to be met at the same visit (ie. Stimulation Day 6 or Last Stimulation Day)

TREATMENT EFFICIENCY

Follicular development
Stimulation Day 6
HP-hMG rFSH p<0.05

Last Stimulation Day

p<0.05 HP-hMG rFSH

Mean data

ITT-population

Oocytes
0 0 0 0 0 0 0

Protocol target
HP-hMG (N=362) Oocytes retrieved 9.1 5.2

8 10
p value <0.001

rFSH (N=362) 10.7 5.8

t j b s f o ) % ( y c n u q e r F

0 0

HP-hMG

rFSH

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Number of oocytes retrieved

ITT-population with oocyte retrieval

Exposure to gonadotrophins and GnRH antagonist

HP-hMG (N=374) Duration of gonadotrophin use (days) Total gonadotrophin dose (IU) Dose on Day 6 Decreased Maintained Increased 1% 67% 31% 2% 73% 25%
ITT-population

rFSH (N=375) 8.5 1.3 1353 296

p value 0.077 0.009

8.8 1.6 1433 371

Percentages may not add to 100% due to rounding off

Endometrial pattern Day of embryo transfer

HP-hMG (N=374) Endometrial thickness (mm) Triple-layer structure Echogenic pattern Hypoechogenic Isoechogenic Hyperechogenic Not possible to evaluate 5% 17% 73% 5% 6% 17% 73% 4%
ITT-population

rFSH (N=375) 11.1 2.2 54%

p value 0.873 0.983

11.1 2.1 53%

Availability of blastocysts on the day of ET

ITT-population Subjects with blastocysts Subjects with frozen blastocysts

HP-hMG 82% 55%

rFSH 85% 58%

Ongoing pregnancy rate per started cycle: Primary endpoint

HP-hMG rFSH HP-hMG rFSH Difference (95% CI)

PP ITT

30.0% 28.9%

27.0% 26.7%

3.0% (-3.8; 9.8) 2.2% (-4.2; 8.6)

Non-inferiority was demonstrated for both PP- and ITT-populations, as the lower limit of the 95% confidence interval was above the preestablished non-inferiority margin of -10%

Pregnancy rates per started cycle

ITT-population
0 0 0 0 0 0
) % ( g a t n c r e P ) % ( g a t n c r e P
0 0 3 3 3 3 0 0 0 0

PP-population
HP-hMG rFSH
HP-hMG

0 0

0 0 3 3 0 0 3 3

rFSH

3 3

0 0

0 0 3 3

0 0

0 0 0

0 0

Positive Clinical Ongoing -hCG pregnancy pregnancy

Positive -hCG

Clinical pregnancy

Ongoing pregnancy

Significantly lower ongoing pregnancy rate in rFSH patients with higher progesterone levels at the end of stimulation
p=0.95
30

p=<0.05 29 Progesterone 4nmol/L Progesterone >4nmol/L

29

30

Ongoing pregnancy rate/cycle initiated (%)

25 20 15 10 5 0

16

HP-hMG

rFSH

Blastocyst quality and ongoing pregnancy rate

Subjects according to their highest blastocyst quality
00 0%

0% 0
0% 0 0(hatching blastocyst)

Ongoing pregnancy rate by quality of transferred blastocyst Expansion and hatching status 4-5 1-3
0(blastocoel filling 0 0 ) 0%

HP-hMG (N=304) 46% 13%

rFSH (N=315) 41% 14%

0% 0

0(expanded blastocyst)

0% 0

0% 0

ITT-population with embryo transfer

0% 0

0% 0 0 %

0(blastocoel filling 0% 0)

0 %

0 %

0(early blastocoel)
Blastocyst expansion and hatching status

ITT-population with blastocysts on Day 5

Pregnancy loss HP-hMG

Abortion N=8 Biochemical pregnancy N=18 Abortion N=7 Ectopic pregnancy N=1

rFSH
Biochemical pregnancy N=14

Ectopic pregnancy N=1

Intrauterine pregnancy without heart beat N=10

37/374 = 10%

Intrauterine pregnancy without heart beat N=12 @

34/375 = 9%

Conclusions
Primary endpoint of MEGASET study was achieved Largest multicentre, multinational RCT of HP-hMG vs rFSH addressing new trends in ART in a robust, high quality innovative trial with ICSI Demonstrates single blastocyst transfer is effective with mild stimulation and lower number of oocytes Reinforces the importance of progesterone during the late follicular phase
Higher pregnancy rate with HP-hMG than rFSH when progesterone >4 nmol/L