Optimizing Ovulation Induction in the Poor Responder
Optimizing Ovulation Induction in the Poor Responder
The purpose of this randomized controlled trial is to compare the efficacy and effect of
 luteal estradiol and combined oral contraceptive pills (COPC) on follicle recruitment and
 synchrony in a poor responder population. The randomized groups consist of: 1. patients
 receiving luteal estradiol prior to ovulation induction; and 2. patients receiving COCPs for
 1 month prior to ovulation induction. Follicle characteristics and serum biomarkers will be
 followed and compared in each group. Coefficient of variation will be used to evaluate
 follicle size discrepancy. Chi square analysis will be used to compare categorical variables
 between treatment groups. Both estradiol and COPCs are used clinically in assisted
 reproduction, so this study affords no additional risks to the participants.
1. Protocol Title:

 Optimizing ovulation induction in the poor responder: a randomized controlled trial of
 luteal phase estradiol verses combined oral contraceptive pill (COCP) on ovarian
 morphology and biomarkers prior to ovulation induction

 2. Purpose of the Study:

 In women undergoing ovulation induction who are at high risk for poor response, we
 hypothesize that:

 Null Hypothesis: Mean follicular diameter and coefficient of variation between follicles
 in patients receiving luteal COCP are statistically equal to follicular diameters and
 coefficient of variation between follicles in patients receiving estradiol. To test this
 hypothesis, the specific aims of the present proposal are:

 Aim 1: Compare the effect of luteal estradiol and COCP pretreatment on follicle
 synchrony. Mean follicular diameter and the coefficient of variation between follicle
 measurements will be calculated on cycle day 3 the cycle before and during treatment.

 Aim 2: Compare the effect of luteal estradiol and COCP pretreatment on follicle
 recruitment. Markers of follicle recruitment will be measured on cycle day 3 before and
 during the treatment cycle. Previously identified follicle recruitment markers that
 positively correlate with follicle recruitment include: antral follicle count (AFC), AMH
 and androstenedione.

 Aim 3: Compare the efficacy of luteal estradiol and COCP. The number of mature follicles
 greater than or equal to 14 mm on day of hCG and pregnancy outcomes will be recorded.

 The two treatment groups are:

 -  Group 1: Luteal estradiol administration prior to ovulation induction management
 per patient's primary physician.

 -  Group 2: COCP administration for one month prior to ovulation induction management
 per patient's primary physician.

 Upon completion, we will have compared follicular and biochemical ovarian response to
 luteal estradiol and COCPs in poor responders undergoing ovulation induction. The future
 implications of this study are development of clinical strategies for treating patients
 at high risk of poor response.

 3. Background & Significance:

 Ten percent of the United States population, 6.2 million women and their partners,
 reported infertility in the 1995 National Survey of Family Growth. The number of couples
 affected by infertility is predicted to increase to 6.5 million by the year 2025.' Among
 women seeking infertility treatment, a subset will be classified as poor responders due
 to poor ovarian response to treatment. Though the definition of poor response to
 treatment is not standardized, studies estimate that 4-26% of patients undergoing
 treatment are affected.2 The proportion of women classified as poor responders may
 increase as more women delay fertility until an age of decreased fecundity due to
 declining ovarian reserve. Establishing effective treatments for poor responders is
 therefore imperative.

 The principal goal of ovulation induction in infertile patients with regular menstrual
 cycles is to achieve two to three mature synchronous follicles to maximize chance of
 pregnancy and minimize risk of ovarian hyperstimulation syndrome. Poor responders, by
 definition, have a lower likelihood of sufficient follicular recruitment. Lesser
 recruitment can be compounded by follicular dysynchrony that necessitates human
 chorionic gonadotropin (hCG) administration based on larger follicles when lagging
 smaller follicles are less likely to be mature. Follicular dysynchrony can be compounded
 by the rise in follicle stimulating hormone (FSH) in the luteal phase.

 Fanchin et al has demonstrated that luteal estradiol administration suppresses luteal
 FSH rise, reduces antral follicle size, and synchronizes the follicular cohort.3,4,5,6
 Luteal estradiol and GnRH antagonist administration prior to controlled ovarian
 hyperstimulation for in vitro fertilization (IVF) have been shown to decrease
 cancellation rate, increase mean number of oocytes retrieved, and improve fertilization
 rates in poor responders (retrospective study using historic controls presented in
 abstract form).7 Estradiol has also been used in patients with hypergonadotrophic
 amenorrhea to suppress elevated endogenous LH and FSH prior to stimulation with
 exogenous gonadotropins with modest success in achieving ovulation and, in rare cases,
 pregnancy.8

 Combined oral contraceptive pills (COCPs) administered prior to ovulation induction in
 IVF increase the number of oocytes retrieved and suppress cyst formation.9,10,11 In a
 small study of poor responders undergoing controlled ovarian hyperstimulation for IVF,
 pretreatment with COCPs was associated with increased pregnancy rates compared to
 pretreatment with luteal phase gonadotropin releasing hormone agonist (GnRH-a),
 follicular phase GnRH-a, and no pretreatment.12 COCPs prior to ovulation induction with
 microdoses of GnRHa and gonadotropins enhance ovarian responsiveness in poor responders
 resulting in higher peak estradiol (E2) levels, more mature follicles, and larger number
 of retrieved oocytes when compared with traditional luteal GnRH-a downregulation
 followed by gonadotropin stimulation.13 Follicular GnRH-a administration releases
 endogenous gonadotropins producing a gonadotropin "flare" effect. Smaller, more frequent
 "microdosing" of GnRH-a minimizes endogenous FSH suppression while preventing premature
 luteinizing hormone (LH) surges. Oral contraceptive pretreatment prevents formation of a
 corpus luteum that could produce progesterone prematurely during the flare. This
 protocol with the addition of growth hormone (GH) has been shown to produce a 50%
 ongoing pregnancy rate (PR) when used in patients who had prior ovulation induction
 cycles using luteal phase GnRH-a suppression followed by exogenous gonadotropins and GH
 cancelled due to poor response.14

 While both COCPs and luteal estradiol suppress the luteal rise in FSH and synchronize
 follicles, they have not been compared against each other. COCPs, with progestin in
 addition to estrogen, may achieve better suppression of luteal FSH than estradiol and
 result in better synchronization of the follicles. COCPs, however, have been used to
 decrease ovarian responsiveness in patients with polycystic ovarian syndrome who are at
 increased risk of ovarian hyperstimulation syndrome.15 Therefore, COCPs may suppress
 ovarian responsiveness more than luteal estradiol, an unwanted effect in the poor
 responder population. One potential mechanism for greater ovarian suppression with COCPs
 may be the decrease in androstenedione, a marker shown to be positively correlated with
 total and mature oocyte number obtained during IVF, 16 subsequent to the COCP-induced
 increase in sex hormone binding globulin.

 Previously identified follicle recruitment markers include antral follicle count (AFC)
 and androstenedione which positively correlate with follicle recruitment.16 AFC is a
 reproducible predictor of follicular recruitment which has been shown to positively
 correlate with number of oocytes retrieved and IVF pregnancy outcome.18,19, 20 AFC
 measurements are stable throughout the ovarian cycle and before and after GnRH
 downregulation.21

 AMH may serve as a biomarker for both follicle quantity and quality since both serum and
 intrafollicular AMH positively correlate with AFC and number of eggs retrieved during
 IVF.22 The mid-luteal AMH rise may reflect luteal follicle development;23 both estradiol
 and COCP may affect luteal follicle development therefore CD3 AMH levels before and
 after treatment will be of great interest. AMH also exhibits superior cycle to cycle
 reproducibility when compared to FSH, E2, inhibin Band AFC.24

 4. Design & Procedures:

 The study is a randomized controlled trial.

 Pretreatment Evaluation

 Baseline studies preceding ovulation induction:

 Cycle day 3 FSH, inhibin B, estradiol, androstenedione, AMH, and AFC will be performed the
 cycle of OCP or luteal pretreatment and the cycle of ovulation induction.

 Transvaginal ultrasound:

 • Ovarian morphology and dimensions will be obtained using a vaginal probe ultrasound. All
 study ultrasounds will be recorded and read by a single investigator (at each center) blinded
 to patient treatment group.

 -  Ovarian volume will be calculated using the formula for a prolate ellipsoid
 (0.5237xD1xD2xD3; D1, D2, and D3 are the maximal longitudinal anteroposterior and
 transverse diameters, respectively).

 -  Ovarian volume will also be calculated using the VOCAL (volume calculation) GE software
 package on the Voluson ultrasound machine.

 -  Antral follicles will be counted, measured in two dimensions and averaged.

 Blood sampling:

 -  Blood samples will be used to measure FSH, inhibin B, estradiol, androstenedione, AMH,
 and progesterone during the cycle prior to and of ovarian stimulation.

 -  Estradiol, FSH, progesterone, inhibin B, androstenedione, and AMH will be transported
 to, stored and measured in batches at Dr. Sarah Berga's Emory University research
 laboratory, Duke Fertility Center or the Duke Unievrsity Hospital core laboratory.

 Registration/Randomization

 Block randomization will occur by computer algorithm to two groups:

 -  Group 1: Luteal estradiol

 -  Group 2: COCP

 Therapy

 1. Ovarian stimulation for ovulation induction:

 Group 1: Luteal estradiol • Starting cycle day 20, two 0.1 mg/d transdermal estradiol
 patch will be applied every other day until cycle day 2.

 -  Patients will present for baseline ultrasound, AFC, FSH, inhibin B, estradiol,
 progesterone, androstenedione, and AMH measurement on cycle day 3.

 -  Starting on cycle day 3, ovarian stimulation will begin. The treatment protocol for
 ovulation induction will be determined by the patient's primary physician and the
 clinician monitoring the cycle.

 Group 2: Combined oral contraceptive

 • Patients will begin COCP administration on the cycle day one of the cycle prior to
 ovarian stimulation.

 • Patients will present for baseline ultrasound, AFC, FSH, inhibin B, estradiol,
 progesterone, androstenedione, and AMH measurement on cycle day 3.

 • Starting on cycle day 3, ovarian stimulation will begin. The treatment protocol for
 ovulation induction will be determined by the patient's primary physician and the
 clinician monitoring the cycle.

 All participants will be monitored by serum E2 levels and TVUS as determined by the
 patient's primary physician to assess the rise in circulating estrogen levels and
 follicular maturation. Follicles will be measured in two dimensions and the average
 recorded.

 2. The mode of ovulation trigger, and IUI or IVF will be at the discretion of the patient's
 primary physician and the clinician monitoring the cycle.

 Patient Assessment

 Patients will return 14 days after IUI or IVF for serum beta hCG testing. In the event
 of a negative pregnancy test, patients will be given the option of crossing over to the
 other treatment group.

 Data Collection

 Clinical Information/Clinical Data Items:

 • Age

 • Infertility diagnoses

 • Prior dates and specifics of infertility treatments and results

 • Prior cycle characteristics: antral follicle count (AFC) and dimensions, ovarian
 volume, FSH, inhibin A, E2, progesterone, androstenedione, and AMH before and during
 treatment

 • Peak E2

 • Outcome: Mean follicular diameter and the coefficient of variation between follicles
 on cycle day 3 before and during treatment

 • Number of mature follicles greater than or equal to 14 mm on day of hCG

 -  β-hCG result

 5. Selection of Subjects:

 The Emory Reproductive Center (ERC) and Duke Fertility Center (DFC) are assisted reproductive
 technology centers offering ovulation induction, IVF, gamete micromanipulation, and embryo
 cryopreservation. Between the two centers, approximately 250-300 stimulated cycles are
 completed each year. While the study is open, all women at risk for poor response to
 ovulation induction at the two centers will be offered participation by the PI, Co-PI,
 Co-Investigator or coordinating research nurse.

 Inclusion Criteria:

 -  Antral follicle count < 8

 -  Antimullerian hormone (AMH) <1.3

 -  Follicle stimulating hormone (FSH)>10

 -  History of follicular dysynchrony or poor response

 Exclusion Criteria:

 • Menopause

 -  FSH >40

 -  Age > 50

 -  Contraindication to estradiol or COCP (including pre-existing cardiovascular disease,
 familial thrombophilia (factor V Leiden), severe hypercholesterolemia, smoker over age
 35) Ovulation induction during month of estradiol treatment

 6. Subject Recruitment & Compensation:

 Please see section #5. There will be no patient compensation.

 7. Consent Process:

 An IRB-approved written informed consent will be obtained from each subject at entry into the
 study; elements of informed consent will include: (a) having the subject review the study
 consent form; (b) having the investigator(s) or study staff meet with the subject to review
 the consent, confirm understanding, and answer any questions; and (c) once the
 investigator(s) or study staff are convinced that the protocol is understood and that there
 is agreement to participate, having the consent signed in the presence of a witness. The
 potential participant will have until the beginning of her first stimulated cycle to decide
 whether or not she is participating in the study. The consent will be discussed and signed in
 person at Emory Reproductive Center or Duke Fertility Center. The consent process, as
 outlined above, will occur in private consultation rooms. There is no time minimum or maximum
 for the consent process. The consent process is determined to be complete when the
 participant verbalizes understanding, states that she has no further questions and signs the
 consent forms. The PI, Co-PI, Co-Investigators and coordinating research nurse will be
 readily available by telephone or in person at ERC and/or DFC to answer questions concerning
 the consent. In order to reduce potential coercion and perceived influence by the study
 personnel, the study details and consent forms will be discussed in a matter-of-fact and
 consistent manner. Only patients who speak and read English will be admitted into the study.

 8. Subject's Capacity to Give Legally Effective Consent:

 Only patients with the capacity to give legally effective consent will be included in the
 study.

 9. Study Interventions:

 Please see section #4.

 10. Risk/Benefit Assessment:

 The treatments used in this study have been studied individually and are used in clinical
 practice. Our goal is to see which one is better. Therefore the risks of this study are the
 same as the risk of ovulation induction to which the subjects will be exposed whether they
 are enrolled in the study or not.

 11. Costs to the Subject:

 There is no additional cost to the subject above the regular fees assessed for ART.

 12. Data Analysis & Statistical Considerations:

 Coefficient of variation will be used to evaluate follicular size discrepancy by the
 following formula: Coefficient of variation = 100 * Standard deviation / mean of the set

 Sample Size

 We predict that a difference of 1.2 mm between mean follicular size before and after COCPs
 will be clinically significant. This is based on observations by Fanchin in which women
 treated with luteal estradiol displayed a decrease in mean follicular size on day 3 of 1.2 mm
 that was associated with a significant decrease in coefficient of variation between follicles
 and an increase in mature follicles >16 mm number on day of hCG administration.

 Power to detect a difference between groups Number cycles/group to demonstrate COCP
 equivalence Number cycles/group to demonstrate COCP superiority 80% 7 25 85% 7 29 90% 9 33
 95% 11 41

 To detect equivalence of COCP to luteal estradiol with a power of 90% at an alpha of .05
 assuming a 10% attrition rate, we will enroll women into each study group so as to achieve
 final number of 10 cycles per treatment group. We assume that an additional 50% decrease in
 follicular size would prove COCP superiority. To detect superiority of COCP to luteal
 estradiol with a power of 80% at an alpha of 0.05 assuming 10% attrition rate, we will enroll
 women into each study group so as to achieve a final number of 28 cycles per treatment group.
 Only newly initiated treatment cycles will be included; only the first cycle of patients'
 crossing over to the other treatment group will count toward this recruitment goal. The
 second cross over cycle will be compared within patient.

 µ1-µ 2 = 4.9 - 3.7 mm = 1.2 (µ1-µ 2)2 = 1.44 (COCP equivalence) µ1-µ 2 = 1.8 - 1.2 mm = 0.6
 (µ1-µ 2)2 = 0.36 (COCP superiority) SD = б=0.75 б2 = 0.5625 2 б2 = 1.125 α = 0.05 Zα = 1.96
 (2-sided test) β = 0.20 1- β = 0.80 Z β = 0.84 (1-sided) (Zα +Zβ)2= 7.84 β =0.15 1- β = 0.85
 Z β = 1.03 (1-sided) (Zα +Zβ) 2= 8.94 β = 0.10 1- β = 0.90 Z β = 1.28 (1-sided) (Zα +Zβ) 2=
 10.498 β = 0.05 1- β = 0.95 Z β = 1.645 (1-sided) (Zα +Zβ) 2 =12.996

 Calculation: n= (Zα +Zβ)2* 2(б2) / (µ1-µ 2)2

 Methods of Analysis

 Chi square analysis will be used to compare categorical variables between treatment groups.
 Student's t test will be used to compare the mean follicle measurements between treatment
 groups.

 13. Data & Safety Monitoring:

 Adherence and Monitoirng Statement: The Data Safety Monitoring Plan (DSMP) outlined below
 will adhere to the protocol approved by the IRB at both Emory University School of Medicine
 and Duke University School of Medicine. The Principal investigator (PI) will review all data
 collection forms at least annually for completeness and accuracy of the data as well as
 protocol compliance. The PI will review this protocol on a continuing basis for subject
 safety and include the results of the review in annual progress reports submitted to the IRB.
 Adverse events and serious adverse events will also be reviewed by the PI weekly.

 Patient Monitoring: Performed by the P.I., the Co-P.I. and/or Co Investigators.

 Patient safety data examination, monitoring procedures/oversight: All adverse events (AEs)
 will be graded as to their attribution (unrelated to protocol, or possibly, probably, or
 definitely related to protocol). Any AE that is reported to either the PI or her designated
 research associates by a study subject or by medical staff caring for the subject and which
 meets the criteria will be documented as such.

 Serious adverse events (SAEs) are predefined as any experience that suggests a significant
 hazard, such as events which: a) are fatal, b) are life threatening, c) result in permanent
 disability, d) require inpatient hospitalization, or e) involve cancer, a congenital anomaly,
 or drug overdose.

 Any AEs will be reported to the IRB at Emory and Duke within 24-48 hours of the event. The
 standard Emory and Duke IRB reporting guidelines for AE and SAE reporting will be followed.
 The investigators and staff will evaluate the SAEs in close coordination with the Emory and
 Duke IRB.

 Expected adverse events are detailed in the Consent Form and include the following: side
 effects of estradiol and combined oral contraceptive pills (breakthrough bleeding, nausea,
 headaches, depression, breast tenderness, changes in blood pressure, and increase in risk of
 blood clotting); risks of ovulation induction (multiple birth, ovarian hyperstimulation
 syndrome, ovarian cyst development, failure to achieve pregnancy); risks of multiple birth
 and ovarian hyperstimulation syndrome are less in poor responders regardless of treatment
 used; risk of failure to achieve pregnancy is greater in poor responders regardless of
 treatment used.

 Procedures for minimizing risks: Monitoring with serial ultrasound and blood work will be
 used to minimize risks.

 Plans for transmission of temporary or permanent suspension actions: Any actions that mandate
 temporary or permanent suspension of study will be transmitted to the Emory and Duke IRB,
 and, if appropriate, to the FDA and the National Institutes of Health.

 Plans for assuring data accuracy and protocol human safety compliance: The above detailed
 plans should assure data accuracy and protocol human safety compliance. These include
 computerized database management, and IRB oversight and communication. This plan, together
 with proposed monitoring by the IRB, should be sufficient without the addition of more
 faculty members to constitute a DSMB.

 14. Privacy, Data Storage & Confidentiality:

 All information and materials will be obtained for research purposes only and the data will
 be kept in strict confidence. Confidentiality will be assured by the use of subject codes
 rather than personal identifiers. The study database will be secured, and information will
 only be entered using subject identifier codes rather than personal identifiers. Electronic
 communication will involve only coded, unidentifiable information. All adverse event reports
 and annual summaries will not include subject-identifiable material.
Inclusion Criteria:

 -  Antral follicle count < 8

 -  Antimullerian hormone (AMH) <1.3

 -  Follicle stimulating hormone (FSH)>10

 -  History of follicular dysynchrony or poor response

 Exclusion Criteria:

 -  Menopause

 -  FSH >40

 -  Age > 50

 -  Contraindication to estradiol or COCP (including pre-existing cardiovascular disease,
 familial thrombophilia (factor V Leiden), severe hypercholesterolemia, smoker over age
 35) Ovulation induction during month of estradiol treatment