U.S. patent application number 11/898470 was filed with the patent office on 2008-05-22 for unitary combinations of fsh and hcg.
This patent application is currently assigned to Ferring B.V.. Invention is credited to Marco Filicori.
Application Number | 20080119394 11/898470 |
Document ID | / |
Family ID | 33489458 |
Filed Date | 2008-05-22 |
United States Patent
Application |
20080119394 |
Kind Code |
A1 |
Filicori; Marco |
May 22, 2008 |
Unitary Combinations of FSH and hCG
Abstract
A novel ovulatory induction paradigm entails administration of
hCG in combination with FSH during all stages of treatment, where
the ratio of FSH to hCG is adjusted to optimize ovulatory
stimulation and minimize complications. The use of compositions
characterized by various FSH:hCG ratios enables the practitioner
readily to tailor the treatment regimen and accommodate different
therapeutic goals as well as individual patient responses to
gonadotropin administration.
Inventors: |
Filicori; Marco; (Bologna,
IT) |
Correspondence
Address: |
FOLEY AND LARDNER LLP;SUITE 500
3000 K STREET NW
WASHINGTON
DC
20007
US
|
Assignee: |
Ferring B.V.
|
Family ID: |
33489458 |
Appl. No.: |
11/898470 |
Filed: |
September 12, 2007 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
|
|
10452926 |
Jun 3, 2003 |
|
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11898470 |
|
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Current U.S.
Class: |
514/9.9 ;
514/20.9; 514/9.7 |
Current CPC
Class: |
A61P 5/06 20180101; A61P
15/08 20180101; A61K 38/24 20130101; A61K 38/24 20130101; A61K
2300/00 20130101 |
Class at
Publication: |
514/8 |
International
Class: |
A61K 38/16 20060101
A61K038/16; A61P 15/08 20060101 A61P015/08 |
Claims
1. A pharmaceutical composition consisting essentially of FSH and
hCG in a pharmaceutically acceptable carrier, wherein the amount of
FSH and hCG is selected from the group consisting of: (i) 50 IU FSH
and 100 IU hCG; (ii) 50 IU FSH and 200 IU hCG; (iii) 75 IU FSH and
25 IU hCG; (iv) 75 IU FSH and 50 IU hCG; (v)75 IU FSH and 75 IU
hCG; (vi) 75 IU FSH and 100 IU hCG; (vii) 150 IU FSH and 25 IU hCG;
(viii) 150 IU FSH and 50 IU hCG, (ix) 150 IU FSH and 75 IU hCG; and
(x) 150 IU FSH and 100 IU hCG.
2. The pharmaceutical composition of claim 1 free from any other
proteins of mammal origin.
3. The pharmaceutical composition of claim 1 wherein the amount of
FSH and hCG is selected from the group consisting of (i) 50 IU FSH
and 100 IU hCG and (ii) 50 IU FSH and 200 IU hCG.
4. The pharmaceutical composition of claim 1 wherein the amount of
FSH and hCG is selected from the group consisting of (i) 75 IU FSH
and 25 IU hCG; (ii) 75 IU FSH and 50 IU hCG; and (iii) 75 IU FSH
and 75 IU hCG.
5. The pharmaceutical composition of claim 1 wherein the amount of
FSH and hCG is 150 IU FSH and 25 IU hCG.
6. The pharmaceutical composition according to claim 1, wherein
said FSH is human-derived FSH.
7. The pharmaceutical composition according to claim 1, in
lyophilized form.
8. The pharmaceutical composition according to claim 1, in unit
dosage form.
9. The pharmaceutical composition according to claim 8, in solid
dosage form.
10. The pharmaceutical composition according to claim 9, wherein
the solid dosage form is selected from the group consisting of
capsules, tablets, suppositories, pills, powders, and granules.
11. The pharmaceutical composition according to claim 1 in liquid
form.
12. The pharmaceutical composition according to claim 11 wherein
the liquid form is supplied in a vial.
13. The pharmaceutical composition according to claim 11 wherein
the liquid form is supplied in a pre-filled syringe or
cartridge.
14. The composition of claim 1, wherein said FSH is recombinant and
wherein said hCG is recombinant.
15. An assemblage comprising a first vial and a second vial, each
of said vials containing a pharmaceutical composition according to
claim 1, wherein a ratio of FSH to hCG differs between the first
vial and the second vial.
16. The assemblage according to claim 15 further comprising written
instructions on the timing for administering the compositions
contained in the first and second vials.
17. A method of inducing ovulation, comprising: (A) administering
at least one pharmaceutical composition comprising an amount of FSH
and hCG selected from the group consisting of: (i) 50 IU FSH and
100 IU hCG; (ii) 50 IU FSH and 200 IU hCG; (iii) 75 IU FSH and 25
IU hCG; (iv) 75 IU FSH and 50 IU hCG; (v) 75 IU FSH and 75 IU hCG;
(vi) 75 IU FSH and 100 IU hCG; (vii) 150 IU FSH and 25 IU hCG;
(viii) 150 IU FSH and 50 IU hCG; (ix) 150 IU FSH and 75 IU hCG; and
(x) 150 IU FSH and 100 IU hCG; (B) monitoring serum hormone levels,
follicle size and follicle number; and then (C) administering an
hCG bolus, thereby inducing ovulation.
18. The method of claim 17, wherein the amount of FSH and hCG is
selected from the group consisting of (i) 50 IU FSH and 100 IU hCG
and (ii) 50 IU FSH and 200 IU hCG.
19. The method of claim 17, wherein the amount of FSH and hCG is
selected from the group consisting of (i) 75 IU FSH and 25 IU hCG;
(ii) 75 IU FSH and 50 IU hCG; and (iii) 75 IU FSH and 75 IU
hCG.
20. The method of claim 17, wherein the amount of FSH and hCG is
150 IU FSH and 25 IU hCG.
21. The method of claim 17, wherein step (A) comprises
administering in series a first pharmaceutical composition and at
least one second pharmaceutical compositions wherein (A) said first
pharmaceutical composition comprises an amount of FSH and hCG
selected from the group consisting of: (i) 50 IU FSH and 100 IU
hCG; (ii) 50 IU FSH and 200 IU hCG; (iii) 75 IU FSH and 25 IU hCG;
(iv) 75 IU FSH and 50 IU hCG; (v) 75 IU FSH and 75 IU hCG; (vi) 75
IU FSH and 100 IU hCG; (vii) 150 IU FSH and 25 IU hCG; (viii) 150
IU FSH and 50 IU hCG; (ix) 150 IU FSH and 75 IU hCG; and (x) 150 IU
FSH and 100 IU hCG; (B) said second pharmaceutical composition
comprises FSH and hCG, wherein the amount of FSH and hCG in said
second pharmaceutical composition is the same as or different from
the amount of FSH and hCG in said first pharmaceutical
composition.
22. The method of claim 21, wherein each of said at least one
second pharmaceutical compositions comprises an amount of hCG that
is increased over the preceding pharmaceutical composition in said
series.
23. The method of claim 21, wherein the period of time between
administrations of said compositions of the series is selected from
the group consisting of from 1 hour, 5 hours, 10 hours, 12 hours,
24 hours, 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, 7 days, 8
days, 9 days, 10 days, 11 days, 12 days, 13 days, 14 days, and 15
days.
24. The method of claim 17, wherein the method further comprises
administering a pharmaceutical composition comprising pure FSH.
25. The method of claim 17, wherein the method further comprises
administering a pharmaceutical composition comprising pure hCG.
Description
[0001] This application is a Continuation of application Ser. No.
10/452,926, filed Jun. 3, 2003. The entire content of the
aforementioned application is incorporated herein by reference
FIELD OF THE INVENTION
[0002] The present invention relates to novel gonadotropin
formulations. More specifically, the invention relates to
pharmaceutical formulations, useful for ovarian stimulation, in
which both follicle stimulating hormone (FSH) and human chorionic
gonadotropin (hCG) are present.
BACKGROUND OF THE INVENTION
[0003] Assisted reproduction technology (ART) procedures typically
require treatment with exogenous gonadotropins to stimulate growth
and maturation of the ovarian follicles. When gonadotropins are
used to treat anovulatory females, the goal is to replicate the
normal menstrual cycle, when a single, dominant follicle matures
prior to induction of ovulation. In contrast, for women undergoing
in vitro fertilization (IVF), controlled ovarian stimulation (COS)
is employed to stimulate the growth and maturation of several
ovarian follicles, yielding multiple oocytes, which then are
retrieved for use in the IVF procedure.
[0004] Despite recent advances in ART, ovarian stimulation through
exogenous gonadotropins is not uniformly successful due, in part,
to varying individual responses to treatment with gonadotropins.
This variability complicates patient management and can result in
multiple births and potentially life-threatening complications.
[0005] Gonadotropins are secreted by the pituitary gland under the
control of hypothalamic gonadotropin-releasing hormone (GnRH).
Follicle stimulating hormone (FSH) and luteinizing hormone (LH) are
the pituitary hormones essential for follicular maturation
(folliculogenesis) and luteinization. FSH is required for
follicular recruitment (i.e., the early growth of ovarian
follicles) at the beginning of the spontaneous menstrual cycle, and
it also supports mid- and late-stage folliculogenesis.
[0006] FSH is administered therapeutically to induce
folliculogenesis in anovulatory women and women undergoing COS. In
traditional ovulatory stimulation methods, FSH is administered
throughout treatment until the time that oocytes are retrieved.
This continued stimulation by FSH can cause multiple conceptions
and the potentially fatal condition, ovarian hyperstimulation
syndrome (OHSS). Decreasing the dosage of FSH can reduce the risk
of OHSS, but low FSH dosages yield inadequate follicle quantities
and thus lower the chances of success in assisted reproduction.
[0007] LH functions during all stages of a normal menstrual cycle.
LH stimulates the theca cells of the follicle to produce the
androgen substrate which is converted into estrogen by the
aromatase system in the granulosa cells. During the late stages of
follicle maturation, approximately 5 to 7 days before ovulation,
large ovarian follicles begin to express LH receptors in granulosa
cells, which render those follicles responsive to LH for continued
maturation and development. Hillier et al., Mol. Cell Endocrinol.
100:51 (1994), Campbell et al. J. Reprod. Fertil. 117:244 (1999).
Next, a mid-cycle surge of LH triggers the final stage of
follicular maturation and ovulation in a normal menstrual cycle.
Ovulation follows the mid-cycle LH surge within 24 to 48 hours.
Finally, in the second part of the menstrual cycle, the luteal
phase, LH stimulated production of estrogen and progesterone in the
corpus luteum of the ovary prepares the uterus for implantation and
pregnancy.
[0008] In ovarian stimulation protocols, hCG can serve as a source
of LH activity because hCG and LH act through the same receptor.
Filicori et al. Human Reprod. 17:2009 (2002a); Martin et al.,
Fertil. Steril. 76: 0-49 (2002). Relative to LH, hCG has a longer
half-life and, hence, is more potent than LH, although the
literature tends to treat hCG and LH as fungible. Indeed, the
scientific literature generally does not mention determining the
source of LH activity in naturally-derived gonadotropin
preparations. But see Filicori et al., Human Reprod. Update 8: 543,
552 (2002b) ("likely hCG content of [a particular] hMG preparation"
extrapolated to be ".about.5 IU per ampoule," such that, "of the 75
IU of LH potency contained in this hMG preparation, about 30 IU are
provided by hCG").
[0009] The literature discloses using LH activity or low doses of
hCG in combination with FSH throughout ovulatory stimulation, but
guidance regarding effective amounts and timing of LH activity
supplementation is lacking. For example, the abstract of Martin et
al., Fertil. Steril. 76: 0-49 (2002), discloses administering 2.5
.mu.g recombinant hCG daily (maintaining serum hCG levels from 1-3
mlU/mL) during ovulatory stimulation. Gordon et al. disclose
administering 75 IU FSH with 0, 1, 25, and 75 IU LH activity. Human
Reprod. 12 (Suppl. 1): 52 (1997a); ibid.: 53 (1997b).
[0010] Published studies disclose administering LH activity,
throughout stimulation, at FSH to LH ratios of 150:0, 150:37.5,
150:75, and 150:150. Filicori et al. (2002a). Further, the
literature documents supplementing FSH stimulation with 50 IU
hCG/day (Filicori et al., J. Clin. Endocrinol. & Metabol. 84:
2659 (1999)), and protocols in which 150 IU FSH is administered for
7 days, followed by treatment with FSH-to-hCG ratios of 150:0,
50:50, 25:100, and 0:200 (ibid. 87:1156 (2002c)).
[0011] The literature documents other compositions that contain
both FSH and LH activity, as well as use of FSH in combination with
LH activity. For example, PCT application WO 00/67778, published
Nov. 16, 2000, is directed to using LH or an equivalent amount of
hCG in combination with FSH to induce folliculogenesis in
anovulatory women. More particularly, the '778 application
discloses administering LH or "a biologically-active analogue
thereof" in doses of 100 to 1500 IU per day (page 4, lines 26-29)
and in FSH:LH ratios that range from 1:1.5 to 1:20 (id., lines
16-18).
[0012] U.S. Pat. No. 5,929,028 is directed to liquid formulations
that contain one or more natural or recombinant gonadotropins,
including FSH, LH, and hCG. The '028 patent discusses naturally
derived compositions of human menopausal gonadotropin (hMG), which
have FSH and LH activities in a ratio of approximately 1:1, but
mentions no ratio of FSH to LH activity other than the 1:1 ratio of
commercial hMG preparations.
[0013] Additionally, there are commercial formulations that contain
both FSH and LH. Human-derived preparations are available
containing 75 IU FSH with 75 IU LH activity (Pergonal, Humegon,
Menogon, Repronex, and Menopur) and 75 IU FSH with 25 or 35 IU LH
activity (Normegon and Pergogreen).
[0014] It is conventional wisdom, however, that "excessive" LH
levels, albeit ill-defined, result in follicular atresia,
suppression of granulosa cell proliferation, and premature
luteinization. See, generally, Filicori, Fertil. Steril. 79: 253
(2003). Although recent work suggests otherwise, a notion persists
in the field that LH activity levels must be within a certain
range, and that levels below or above an "LH ceiling" impair normal
follicle development. Shoham, Fertil. Steril. 70: 1170 (2002).
[0015] In summary, there is published evidence that supplementing
FSH with LH activity during ovulation induction reduces the
duration of treatment and the amount of gonadotropin used to
achieve proper follicle development. Filicori et al. (1999),
(2002b). On the other hand, the belief persists that "high" LH
activity levels negatively impacts follicle development.
[0016] That belief has guided the conventional ovarian-stimulation
paradigm, which involves administration of FSH throughout
controlled ovarian stimulation. Exogenous LH activity is deemed
unnecessary and even detrimental during the early to middle stages
of follicular development. Accordingly, the traditional means of
ovarian stimulation entails treatment with FSH alone, typically at
75 IU/day. In this traditional protocol, LH activity is
administered to induce ovulation only after the follicle reaches a
certain stage of development. Only recently has LH activity been
administered throughout treatment, and the optimal amount and
timing of LH activity that is effective in this context remains
controversial.
SUMMARY OF THE INVENTION
[0017] Conventional protocols of ovulation stimulation do not
accommodate selective treatment regimens that optimize ovarian
follicle development. Furthermore, available gonadotropic
preparations are not easily adapted to different therapeutic goals.
Thus, a need exists for compositions that combine FSH and hCG in
varying ratios, thereby to enable the practitioner to tailor a
gonadotropin treatment regimen to the needs of the individual
patient. Methodology also is needed for using such compositions to
stimulate folliculogenesis in anovulatory females and in the
context of ART procedures.
[0018] To these ends, inter alia, the present invention provides
pharmaceutical compositions that contain various amounts of FSH and
hCG, as well as various FSH-to-hCG ratios, supplied in a single
preparation. These compounds enable the practitioner to optimize
ovulatory stimulation in flexible manner not possible with
available preparations.
[0019] The present invention also comprehends an approach to
inducing ovulation, by using compositions with varying FSH:hCG
ratios. The inventive methodology allows for incremental
adjustments in the ratio of FSH to hCG, as a function of the stage
of folliculogenesis or of variation in patient response, resulting
in safer and more successful ovulatory stimulation.
[0020] One embodiment of the invention is a pharmaceutical
composition that consists essentially of FSH and hCG in a
pharmaceutically acceptable carrier. According to the invention,
the ratio of FSH to hCG in such a composition is conducive, upon
administration of the composition, to folliculogenesis and to
follicular maturation without ovarian hyperstimulation. In this
regard, use of the phrase "consists essentially of" means that the
composition, while possibly having other constituents, does not
include any component that inhibits or otherwise detracts from the
beneficial properties of the composition with respect to
folliculogenesis or follicular maturation.
[0021] Another embodiment of the invention is an assemblage
comprising a first vial and a second vial, each of said vials
containing a pharmaceutical composition consisting essentially of
FSH and hCG in a pharmaceutically acceptable carrier, wherein the
ratio of FSH to hCG is conducive, upon administration of said
composition, to folliculogenesis and follicular maturation without
ovarian hyperstimulation. The ratio of FSH to hCG differs between
the first vial and the second vial.
[0022] A further embodiment of the invention is a method of
inducing ovulation, comprising: administering at least one
pharmaceutical composition characterized by a ratio of FSH to human
hCG that is selected from the group consisting of 50 IU FSH:1 IU
hCG, 50 IU FSH:5 IU hCG, 50 IU FSH:10 IU hCG, 50 IU FSH:25 IU hCG,
50 IU FSH:75 IU hCG, 50 IU FSH:100 IU hCG, 50 IU FSH:200 IU hCG, 50
IU FSH:300 IU hCG, 50 IU FSH:400 IU hCG, 75 IU FSH:1 IU hCG, 75 IU
FSH:5 IU hCG, 75 IU FSH:10 IU hCG, 75 IU FSH:25 IU hCG, 75 IU
FSH:50 IU hCG, 75 IU FSH:75 IU hCG, 75 IU FSH:100 IU hCG, 75 IU
FSH:200 IU hCG, 75 IU FSH:300 IU hCG, 75 IU FSH:400 IU hCG, 100 IU
FSH:1 IU hCG, 100 IU FSH:5 IU hCG, 100 IU FSH:10 IU hCG, 100 IU
FSH:25 IU hCG, 100 IU FSH:50 IU hCG, 100 IU FSH:75 IU hCG, 100 IU
FSH:100 IU hCG, 100 IU FSH:200 IU hCG, 100 IU FSH:300 IU hCG, 100
IU FSH:400 IU hCG, 150 IU FSH:1 IU hCG, 150 IU FSH:5 IU hCG, 150 IU
FSH:10 IU hCG, 150 IU FSH:25 IU hCG, 150 IU FSH:75 IU hCG, 150 IU
FSH:100 IU hCG, 150 IU FSH:200 IU hCG, 150 IU FSH:300 IU hCG, 150
IU FSH:400 IU hCG, 200 IU FSH:1 IU hCG, 200 IU FSH:5 IU hCG, 200 IU
FSH:10 IU hCG, 200 IU FSH:25 IU hCG, 200 IU FSH:50 IU hCG, 200 IU
FSH:75 IU hCG, 200 IU FSH:100 IU hCG, 200 IU FSH:200 IU hCG, 200 IU
FSH:300 IU hCG, and 200 IU FSH:400 IU hCG, monitoring serum hormone
levels, follicle size and follicle number; and then inducing
ovulation by administration of an hCG bolus.
[0023] Other features, objects, and advantages of the present
invention are apparent in the detailed description that follows. It
should be understood, however, that the detailed description, while
indicating preferred embodiments of the invention, are given by way
of illustration only, not limitation. Various changes and
modifications within the spirit and scope of the invention will
become apparent to those skilled in the art from the detailed
description.
BRIEF DESCRIPTION OF THE DRAWINGS
[0024] FIG. 1 shows useful FSH-to-hCG ratio values, where FSH
amount is expressed in international units (IU) and hCG amount is
expressed in IU (FIG. 1A) and micrograms (FIG. 1B).
[0025] FIG. 2 is a bar graph that depicts a proposed treatment
protocol according to the invention, using FSH:hCG compositions as
described above.
DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS
[0026] The invention provides compositions and methods for a novel
therapeutic paradigm, characterized by administration of hCG in
combination with FSH during all stages of treatment and by an
adjustment of the FSH-to-hCG ratio, to optimize ovulatory
stimulation. This paradigm departs substantially from the
conventional approach, where FSH is administered alone, typically
at 75-300 IU/day, and a bolus of LH activity is administered
mid-cycle to induce ovulation.
[0027] The invention provides pharmaceutical compositions with a
wide range of FSH to hCG ratios. The compositions and methods of
the invention enable the physician to easily tailor treatment to a
given patient's situation, allowing the ratio of FSH to hCG to be
fine-tuned based on different stages of folliculogenesis and
varying patient response to gonadotropins. Further, having a range
of therapeutic compositions available, including those with high
levels of hCG, allows the physician to easily accommodate the
therapeutic requirements of various ART procedures. This
flexibility is not possible with current gonadotropic
preparations.
[0028] Because the compositions of the invention have a broad range
of FSH to hCG ratios, the invention can easily be used to stimulate
folliculogenesis and ovulation in any ovulation induction and ART
procedure including among others, treatment of anovulatory
infertility, in-vitro fertilization (IVF), intracytoplasmic sperm
injection (ICSI), gamete intrafallopian transfer (GIFT), zygote
intrafallopian transfer (ZIFT), cryopreserved embryo transfer,
intrauterine insemination (IUI), donor oocyte transfer,
cryopreserved embryo transfer from donor oocytes, and ART cycles
for host uterus transfer. The compositions and methods of the
invention can also be used to treat anovulatory patients and
patients with hypogonadotropic hypogonadism and the polycystic
ovary syndrome.
[0029] The compositions of the invention employ hCG as a source of
LH activity. hCG binds to LH receptors and exerts through them its
biological actions; separate hCG receptors do not exist. Using hCG
in accordance with the invention has significant advantages over
the use of LH. For instance, human-derived hCG is less expensive
than either human-derived or recombinant FSH. From a cost
perspective, therefore, it is favorable to minimize the amount of
FSH used during the stimulation protocol. Furthermore, the use of
hCG in a pharmaceutical composition of the invention more
physiologically and effectively supports the final stages of
maturation of large and mature ovarian follicles during COS,
increases ovarian and blood estrogen levels, improves oocyte and
embryo quality, lowers the amount and duration of FSH
administration, and reduces the risk of FSH-associated
complications such as multiple conceptions and OHSS.
[0030] In summary, the compositions and methods of the invention
empower treatment regimens that achieve higher rates of success,
that decrease the risk of complications, that are easy to
implement, and that are less costly than those of conventional
practice.
[0031] Unless indicated otherwise, all technical and scientific
terms are used in a manner that conforms to common technical usage.
Generally, the nomenclature of this description and the described
laboratory procedures are well known and commonly employed in the
art. Standard techniques are used for recombinant nucleic acid
methods, microbial culture, cell culture, tissue culture,
transformation, analytical chemistry, organic synthetic chemistry,
chemical syntheses, chemical analysis, and pharmaceutical
formulation and delivery. Generally, enzymatic reactions and
purification and/or isolation steps are performed according to the
manufacturers' specifications. Absent an indication to the
contrary, the techniques and procedures in question are performed
according to conventional methodology disclosed, for example, in
Sambrook et al., MOLECULAR CLONING A LABORATORY MANUAL, 2d ed.
(Cold Spring Harbor Laboratory Press, 1989), and CURRENT PROTOCOLS
IN MOLECULAR BIOLOGY, John Wiley & Sons, 1989).
Unitary Combinations of FSH and hCG
[0032] The invention provides novel pharmaceutical compositions
useful for inducing ovarian stimulation in a mammal. "Mammal"
refers to a human, non-human primate, sheep, pig, cow, horse,
donkey, mouse, rat, rabbit, guinea pig, dog, cat, or captive wild
animal. Preferably, the mammal is a human.
[0033] The pharmaceutical compositions contain 50 to 200 IU FSH
together with 1 to 400 IU human-derived hCG (see FIG. 1A).
Preferably, the compositions contain FSH and hCG in the following
ratios: 50 IU FSH:1 IU hCG, 50 IU FSH:5 IU hCG, 50 IU FSH:10 IU
hCG, 50 IU FSH:25 IU hCG, 50 IU FSH:75 IU hCG, 50 IU FSH:100 IU
hCG, 50 IU FSH:200 IU hCG, 50 IU FSH:300 IU hCG, 50 IU FSH:400 IU
hCG, 75 IU FSH:1 IU hCG, 75 IU FSH:5 IU hCG, 75 IU FSH:10 IU hCG,
75 IU FSH:25 IU hCG, 75 IU FSH:50 IU hCG, 75 IU FSH:75 IU hCG, 75
IU FSH:100 IU hCG, 75 IU FSH:200 IU hCG, 75 IU FSH:300 IU hCG, 75
IU FSH:400 IU hCG, 100 IU FSH:1 IU hCG, 100 IU FSH:5 IU hCG, 100 IU
FSH:10 IU hCG, 100 IU FSH:25 IU hCG, 100 IU FSH:50 IU hCG, 100 IU
FSH:75 IU hCG, 100 IU FSH:100 IU hCG, 100 IU FSH:200 IU hCG, 100 IU
FSH:300 IU hCG, 100 IU FSH:400 IU hCG, 150 IU FSH:1 IU hCG, 150 IU
FSH:5 IU hCG, 150 IU FSH:10 IU hCG, 150 IU FSH:25 IU hCG, 150 IU
FSH:75 IU hCG, 150 IU FSH:100 IU hCG, 150 IU FSH:200 IU hCG, 150 IU
FSH:300 IU hCG, 150 IU FSH:400 IU hCG, 200 IU FSH:1 IU hCG, 200 IU
FSH:5 IU hCG, 200 IU FSH:10 IU hCG, 200 IU FSH:25 IU hCG, 200 IU
FSH:50 IU hCG, 200 IU FSH:75 IU hCG, 200 IU FSH:100 IU hCG, 200 IU
FSH:200 IU hCG, 200 IU FSH:300 IU hCG, and 200 IU FSH:400 IU
hCG.
[0034] More preferably, the compositions contain FSH and hCG in the
following ratios: 50 IU FSH:1 IU hCG, 50 IU FSH:5 IU hCG, 50 IU
FSH:10 IU hCG, 50 IU FSH:25 IU hCG, 50 IU FSH:75 IU hCG, 50 IU
FSH:100 IU hCG, 50 IU FSH:200 IU hCG, 50 IU FSH:300 IU hCG, 50 IU
FSH:400 IU hCG, 75 IU FSH:1 IU hCG, 75 IU FSH:5 IU hCG, 75 IU
FSH:10 IU hCG, 75 IU FSH:50 IU hCG, 75 IU FSH:100 IU hCG, 75 IU
FSH:200 IU hCG, 75 IU FSH:300 IU hCG, 75 IU FSH:400 IU hCG, 100 IU
FSH:1 IU hCG, 100 IU FSH:5 IU hCG, 100 IU FSH:10 IU hCG, 100 IU
FSH:25 IU hCG, 100 IU FSH:50 IU hCG, 100 IU FSH:75 IU hCG, 100 IU
FSH:100 IU hCG, 100 IU FSH:200 IU hCG, 100 IU FSH:300 IU hCG, 100
IU FSH:400 IU hCG, 150 IU FSH:1 IU hCG, 150 IU FSH:5 IU hCG, 150 IU
FSH:10 IU hCG, 150 IU FSH:25 IU hCG, 150 IU FSH:75 IU hCG, 150 IU
FSH:100 IU hCG, 150 IU FSH:200 IU hCG, 150 IU FSH:300 IU hCG, 150
IU FSH:400 IU hCG, 200 IU FSH:1 IU hCG, 200 IU FSH:5 IU hCG, 200 IU
FSH:10 IU hCG, 200 IU FSH:25 IU hCG, 200 IU FSH:50 IU hCG, 200 IU
FSH:75 IU hCG, 200 IU FSH:100 IU hCG, 200 IU FSH:200 IU hCG, 200 IU
FSH:300 IU hCG, and 200 IU FSH:400 IU hCG.
[0035] In a more preferred embodiment, the composition contains 50
IU FSH:100 IU hCG, 50 IU FSH:200 IU hCG, or 50 IU FSH:400 IU hCG.
These ratios are useful in treatment protocols requiring multiple
administrations because more than one ampoule can be easily
administered.
[0036] In another, more preferred embodiment, the composition
contains 100 IU FSH:100 IU hCG, 100 IU FSH:200 IU hCG, or 100 IU
FSH:400 IU hCG. These ratios allow a physician to select
compositions with a higher dose of FSH. These compositions can be
particularly useful at the outset of treatment where higher doses
of FSH may be desired.
[0037] In a further more preferred embodiment, the composition
contains 100 IU FSH:5 IU hCG, 100 IU FSH:10 IU hCG, or 100 IU
FSH:25 IU hCG. Such compositions provide lower doses of hCG which
can be advantageous at the onset of treatment.
[0038] Purified FSH can be obtained by any methods known in the
art. FSH, as used herein, includes human-derived and recombinant
FSH, FSH analogs, as well as deglycosylated, unglycosylated, and
modified glycosylated forms.
[0039] Human-derived FSH can be purified by any means known in the
art from natural sources such as urine, pituitary, and placenta.
Procedures for isolating human-derived FSH are described in, e.g.,
Fevold et al. Endocrinology 26:999 (1940), Fraenkel-Conrat et al.,
Proc. Soc. Exp. Biol. Med. 45:627 (1940), McShan and Meyer, J.
Biol. Chem. 135:473 (1940), Greep et al., ibid. 133:289 (1940), Li
et al., Science 109:445 (1949), and Roos and Gemzell, CIBRA
FOUNDATION STUDY GROUP, No. 22 (Little, Brown and Co., Boston,
Mass., 1965).
[0040] Purified human-derived FSH is commercially available and is
sold under the names Fostimon.RTM. (AMSA/IBSA), Metrodin HP.RTM.
(Serono), and Bravelle (Ferring). Recombinant FSH can be obtained
by any of several known means. For example, Keene et al., J. Biol.
Chem. 26:4769 (1989), and WO 86/04589 describe expression and
purification of biologically active human FSH in rodent cells.
[0041] Recominant FSH is also commercially available under the
names Follistim.RTM. (Organon), Puregon.RTM. (Organon), and
Gonal-F.RTM. (Serono. It can be advantageous to employ FSH isoforms
that differ in the extent to which they are post-translationally
modified. Due to different modifications, the isoforms exhibit
differences in overall charge, degree of sialic acid (a terminal
sugar) or sulfate incorporation, receptor binding affinity and
plasma half-life. Chappel et al., Endocrine Reviews 4:179 (1983);
Snyder et al. Mol. Cell. Endocrin. 54:115 (1987). These forms are
separable from each other on the basis of their overall charge and
all isoforms exhibit biological activity. Isoforms that exhibit a
greater net negative charge are more heavily sialylated, exhibit a
longer metabolic clearance rate and a greater biologic activity due
to their extended plasma survival time.
[0042] hCG can be obtained by any means known in the art. hCG, as
used herein, includes human-derived and recombinant hCG.
Human-derived hCG can be purified from any appropriate source (e.g.
urine, and placenta) by any method known in the art as disclosed in
Zondek and Aschheim, Klin. Wochenschr. 7: 931 (1928), Katzman et
al., ibid. 148:501 (1943), and Claesson et al., Acta Endocrinol. 1:
1 (1948), among others. Purified human hCG is commercially
available and is sold under the names Profasi HP.RTM. (Serono),
Gonasi.RTM. (AMSA/IBSA), and Choragon, Novarelin (Ferring). Methods
of expressing and purifying recombinant hCG are known in the art
and are disclosed, for example, in Gupta and Dighe, J. Mol.
Endocrinology 22: 273 (1999).
[0043] Recombinant hCG possesses approximately 25 times greater
activity by weight as compared human-derived hCG. For example, see
Chang et al., Fertil. Steril. 76: 67 (2001); The European
Recombinant Human Chorionic Gonadotrophin Study Group, Fertil.
Steril. 75: 1111 (2001). Thus, the amount of hCG can be adjusted
accordingly to provide the desired international units of hCG
activity when recombinant hCG is used in the compositions. An
adjustment along this line, based on the values of FIG. 1A, is
represented in FIG. 1B.
[0044] The amount of FSH and hCG activity can be determined using
assay methods known in the art. 1 IU of hCG is equivalent to 5-7 IU
LH in the pharmacopaeia Van Hell bioassay. Van Hell et al., Acta
Endocrin. 47: 409 (1964). hCG activity in a composition can be
determined using any assay methods known, including the Van Hell
bioassay, radioreceptor assays as described, for instance, in Dighe
& Moudgal. Arch. Biochem. Biophys. 225: 490 (1983), whole
animal bioassays, ovarian ascorbic acid depletion assay, and the
MA10 Leydig cell bioassay disclosed Ascoli, Endocrinology 108: 88
(1981). Similarly, FSH activity can be determined using receptor
binding assays and whole animal bioassays.
[0045] The amount of FSH and hCG protein in a given composition can
be determined by the weight of the solid compound, protein assays,
such as Bradford and Lowry assays, and immunoassay techniques such
as ELISA and Western blotting.
[0046] FSH:hCG compositions can be formulated by admixing, in an
aqueous solution, purified FSH and hCG products, with batch-wise
adjustments to achieve the desired FSH:hCG ratio, followed by
sterile filtration, sterile filling, and, if desired,
lyophilization. The FSH:hCG composition also can be formulated
using a method, wherein purification conditions are established
that yield the desired FSH:hCG ratio in the first instance (i.e.,
without compounding as such).
[0047] The pharmaceutical compositions of the present invention can
be formulated into well known compositions for any route of drug
administration, e.g., oral, rectal, parenteral (intravenous,
intramuscular, or subcutaneous), intracisternal, intravaginal,
intraperitoneal, local (powders, ointments or drops), or as a
buccal or nasal spray. A typical composition for such purpose
comprises a pharmaceutically acceptable carrier, such as aqueous
solutions, non-toxic excipients, including salts, preservatives,
buffers and the like, as described in REMINGTON'S PHARMACEUTICAL
SCIENCES, 15th Ed. (Mack Publishing Co., 1975), at pages 1405-12
and 1461-87, and THE NATIONAL FORMULARY XIV, 14th Ed. (American
Pharmaceutical Association, 1975), among others.
[0048] Examples of suitable aqueous and non-aqueous carriers,
diluents, solvents or vehicles include water, ethanol, polyols
(such as glycerol, propylene glycol, polyethylene glycol, and the
like), carboxymethylcellulose and suitable mixtures thereof,
vegetable oils (such as olive oil), and injectable organic esters
such as ethyl oleate.
[0049] The compositions of the present invention also can contain
additives such as but not limited to preservatives, wetting agents,
emulsifying agents, and dispersing agents. Antibacterial and
antifungal agents can be included to prevent growth of microbes and
includes, for example, paraben, chlorobutanol, phenol sorbic acid,
and the like. Furthermore, it may be desirable to include isotonic
agents such as sugars, sodium chloride, and the like.
[0050] In some cases, to effect prolonged action it is desirable to
slow the absorption of FSH and hCG from subcutaneous or
intramuscular injection. This can be accomplished by the use of a
liquid suspension of crystalline or amorphous material with poor
water solubility. The rate of absorption of FSH and hCG then
depends upon its rate of dissolution which, in turn, can depend
upon crystal size and crystalline form. Alternatively, delayed
absorption of a parenterally administered FSH and hCG combination
form is accomplished by dissolving or suspending the FSH and hCG
combination in an oil vehicle.
[0051] Injectable depot forms can be made by forming microencapsule
matrices of the FSH and hCG combination in biodegradable polymers
such as polylactide-polyglycolide. Depending upon the ratio of FSH
and hCG combination to polymer and the nature of the particular
polymer employed, the rate of FSH and hCG combination release can
be controlled. Examples of other biodegradable polymers include
poly(orthoesters) and poly(anhydrides). Depot injectable
formulations are also prepared by entrapping the FSH and hCG
combination in liposomes or microemulsions which are compatible
with body tissues.
[0052] Injectable formulations can be sterilized, for example, by
filtration through a bacterial-retaining filter, or by
incorporating sterilizing agents in the form of sterile solid
compositions which can be dissolved or dispersed in sterile water
or other sterile injectable medium just prior to use. Injectable
formulation can be supplied in any suitable container, e.g. vial,
pre-filled syringe, injection cartridges, and the like.
[0053] The pH and exact concentration of the various components of
the pharmaceutical composition are adjusted in accordance with
routine practice in this field. See GOODMAN AND GILMAN'S THE
PHARMACOLOGICAL BASIS FOR THERAPEUTICS, 7th ed.
[0054] In a preferred embodiment, the compositions of the invention
are supplied as compositions for parenteral administration. General
methods for the preparation of the parenteral formulations are
known in the art and are described in REMINGTON: THE SCIENCE AND
PRACTICE OF PHARMACY, supra, at pages 780-820. The parenteral
compositions can be supplied in liquid formulation or as a solid
which will be mixed with a sterile injectible medium just prior to
administration. In an especially preferred embodiment, the
parenteral compositions are supplied in dosage unit form for ease
of administration and uniformity of dosage.
[0055] "Dosage unit form" in this description refers to physically
discrete units that are suited as unitary dosages for a mammalian
subject to be treated, where each unit contains a predetermined
quantity of active material calculated to produce the desired
therapeutic effect in association with the required pharmaceutical
carrier. The specification for the novel dosage unit forms of the
invention are dictated by and directly dependent on the unique
characteristics of the active material and the particular
therapeutic effect to be achieved and the limitations inherent in
the art of compounding active materials for use in mammalian
subjects.
[0056] A unit dosage form can contain, for example, 50, 75, 100,
150, and 200 IU FSH in combination with 1, 5, 10, 25, 50, 75, 100,
200, 300, and 400 IU hCG. Expressed in proportions, FSH and hCG
each are generally present in from about 0.1 .mu.g to about 2000
mg/ml.
[0057] Suspensions can contain rheology modifying agents such as,
e.g., ethoxylated isostearyl alcohols, polyoxyethylene sorbitol and
sorbitan esters, microcrystalline cellulose, aluminum
metahydroxide, bentonite, agar-agar, and tragacanth, and mixtures
thereof.
[0058] One of ordinary skill will appreciate that effective amounts
of the FSH and hCG and the proper ratios of FSH to hCG can be
determined empirically. The compositions can be administered to a
subject, in need of ovarian stimulation, as pharmaceutical
compositions in combination with one or more pharmaceutically
acceptable excipients. It will be understood that, when
administered to a human patient, the total daily usage of the
agents or composition of the present invention will be decided by
the attending physician within the scope of sound medical judgment.
The specific therapeutically effective dose level for any
particular patient will depend upon a variety of factors: the type
and degree response to be achieved; activity of the specific agent
or composition employed; the specific agents or composition
employed; the age, body weight, general health, sex and diet of the
patient; the time of administration, route of administration, and
rate of excretion of the agent; the duration of the treatment, and
like factors well known in the medical arts.
Use of "Single-Vial" Combinations of FSH and hCG in Ovulatory
Stimulation
[0059] Based on the treatment goals, a composition with the proper
FSH to hCG ratio can be selected and the composition or a series of
compositions can be administered throughout the period of ovarian
stimulation. The physician can initiate stimulation with one ratio
and then adjust the ratios of FSH to hCG throughout the cycle.
Adjustments made during treatment can be based on the timing of
administration during the cycle or in response to folliculogenetic
or steroidogenetic indicators, such as the number and size of
follicles and patient hormone levels.
[0060] For example, in treating anovulatory females characterized
by hypogonadotropic amenorrhea, compositions of the invention can
be selected and administered to mimic the levels of FSH and LH
activity that occur during a normal menstrual cycle. A composition
with an FSH to hCG ratio of 100:5 initially would be administered
daily. Starting on day six, for example, the levels of serum
estradiol and follicle number and size would be monitored. Once at
least two follicles greater than 12 mm and estradiol levels higher
than 200 pg/mL are detected treatment will continue using a
composition with an FSH to hCG ratio of 50:200 which will be
administered until the final maturation parameters of at least one
follicle greater than 17 mm and estradiol levels higher than 400
pg/mL are achieved. Upon reaching the final maturation parameters,
ovulation will be triggered with 10,000 IU of hCG.
[0061] During COS, compositions are selected to maximize the number
of large, mature follicles while minimizing the number of small,
potentially dangerous follicles. A composition with an FSH to hCG
ratio of 250:10 initially would be administered daily. Beginning on
day six, the levels of serum estradiol and follicle number and size
would be monitored. Once at least four follicles greater than 12 mm
and estradiol levels higher than 600 pg/mL are detected a
composition with an FSH to hCG ratio of 50:200 will be administered
until the final maturation parameters of at least five follicles
greater than 17 mm and estradiol levels higher than 1,500 pg/mL are
achieved. Then, ovulation would be triggered with 10,000 IU of
hCG.
[0062] The pharmaceutical compositions can be coadministered with
one or more other compounds or molecules. "Coadministered" refers
to simultaneous administration in the same formulation or in two
different formulations.
[0063] The compositions of the invention can be administered with
or following GnRH agonists and antagonists. GnRH agonists and
antagonists are used for ovulation induction procedures to prevent
spontaneous ovulation during gonadotropin administration. GnRH
antagonist abolishes endogenous LH activity, resulting in fewer
viable oocytes. Accordingly, the compositions of the invention can
be administered at the commencement of treatment with GnRH
antagonists to provide LH activity levels which are sufficient to
stimulate follicle development and oocyte maturation.
[0064] To provide additional flexibility, the compositions of the
invention can be coadministered with the currently available
gonadotropin preparations, such as pure FSH, pure hCG, pure LH, and
hMG preparations. For example, 1 ampoule of the FSH:hCG combination
composition having FSH 75 IU and hCG 200 IU can be coadministered
with 1 ampoule of highly purified FSH containing FSH 75 IU
resulting administration of 150 IU of FSH and 200 IU of hCG.
[0065] FSH:hCG compositions are administered sequentially
throughout ovarian stimulation. "Sequential" administration refers
to a time difference of from seconds, minutes, hours or days
between the administration of the compositions. Each subsequent
sequential administration can be comprised of a composition with
the same ratio of FSH to hCG as the previous administration or a
different ratio of FSH to hCG. In a preferred embodiment,
sequential administration is performed with FSH:hCG compositions
that differ in the ratio of FSH to hCG. In a more preferred
embodiment each succeeding composition contains a greater amount of
hCG over the preceding composition in the series. In an especially
preferred embodiment, the ratio of FSH to hCG is changed
incrementally as shown in FIG. 2.
[0066] In the most preferred embodiment, the ratio of FSH to hCG is
adjusted throughout the series in response to patient reaction to
the FSH:hCG composition as indicated by folliculogenetic and
steroidogenetic markers. When 2-4 intermediate follicles (12-14 mm)
are formed and estradiol levels of 200-600 pg/mL are achieved, this
is an indication that adequate folliculogenesis has been achieved
by an FSH-rich preparation and it is appropriate to switch to an
hCG-rich preparation.
[0067] Folliculogenesis and steroidogenesis should be monitored
throughout ovarian stimulation by any means known in the art.
Monitoring hormone levels and follicle size provides information
regarding ovarian response during the treatment regimen and allows
the physician to adjust the ratio of FSH to hCG during treatment.
Follicle size can be determined, for example, using transvaginal
pelvic ultrasonography. Follicles are categorized as large (>14
mm), intermediate (10-14 mm) or small (<10 mm). Transvaginal
pelvic ultrasound can be performed frequently, for example on
treatment days 0, 6, 8, 10, 12, 14, 16, 18, and 20, until
preovulatory hCG administration.
[0068] The levels of estradiol can be measured using any means
known in the art from any appropriate body fluid (e.g., blood,
urine, and saliva), using an immunoassay or a chemiluminescence
assay.
[0069] The following example illustrates the present invention. It
should be understood, however, that the invention is not to be
limited to the specific conditions or details described in these
examples.
Controlled Ovulatory Stimulation for In Vitro Fertilization
[0070] Treatment is initiated in the mid-luteal phase of a
spontaneous menstrual cycle when a GnRH agonist is administered.
Ovulation induction is started 1-2 weeks later, after spontaneous
menses. Alternatively, a GnRH antagonist is administered starting
on the 6.sup.th day of ovarian stimulation. Patients receive daily
injections of 200 IU FSH:10 IU hCG from day 1 and continuing until
the appearance of at least 4 follicles >11 mm and serum
estradiol levels of >600 pg/mL. Starting on this day and until
the end of treatment patients receive daily administration of 50 IU
FSH:200 IU hCG.
[0071] Treatment monitoring is conducted throughout FSH:hCG
administration. Each day one blood sample is drawn between
0800-0900 and serum samples are prepared in the standard fashion.
Estradiol levels are determined. Transvaginal ultrasound is
performed frequently during FSH:hCG treatment and until just prior
to preovulatory hCG administration. Estradiol levels are monitored
using chemiluminescence assays (Chiron Corp. Diagnostics ACS 180,
Milan, Italy).
[0072] Upon achievement of final maturation parameters--four
follicles of >14 mm and 17 .beta.-estradiol levels of 800-1500
pg/mL--a bolus of hCG, e.g. 10,000 IU hCG is administered to
trigger ovulation and oocytes are retrieved.
* * * * *