The Impact of a Nutritional Supplement (Impryl®) on Male Fertility
Phase: NA
Conditions: Male Subfertility
Sponsor: Radboud University Medical Center

NL61414.091.17/SUMMER-trial                                                              version 11.0 – May 2020 
 
 
 
 
 
 
 
 
 
 
 
 
 
The impact of a nutritional supplement 
(Impryl®) on male fertility  
 
SUMMER-trial 
 
 
 
 

NL61414.091.17/SUMMER-trial                                                              version 11.0 – May 2020 
 
 
 
 
PROTOCOL TITLE ‘The impact of a nutritional supplement (Impryl®) on male fertility’ 
Protocol ID 
NL61414.091.17 
Short title 
SUMMER-trial (SUppleMent Male fERtility) 
EudraCT number  
Not applicable 
Version 
11.0 
Date 
19th of May 2020 
Coordinating investigator 
 
Project leader 
 
 
 
Other research team members 
 
 
W.R. de Ligny, MSc, PhD student 
Wiep.deligny@radboudumc.nl 
Prof. Dr. D.D.M. Braat, gynaecologist, head of 
department of Obstetrics and Gynaecology, 
Radboudumc 
didi.braat@radboudumc.nl 
 
Dr. K. Fleischer, gynaecologist, Radboudumc 
kathrin.fleischer@radboudumc.nl 
Dr. J.P. de Bruin, gynaecologist, Jeroen Bosch 
ziekenhuis 
j.d.bruin@jbz.nl 
R.M. Smits, MSc, PhD student 
roos.smits@radboudumc.nl 
Dr. K.W.M. D’Hauwers, urologist, Radboudumc 
Kathleen.DHauwers@radboudumc.nl 
Dr. L. Ramos, head embryologist and laboratory 
director, copromotor RM Smits 
Liliana.Ramos@radboudumc.nl 
Principal investigator  
(in Dutch: hoofdonderzoeker/ 
uitvoerder) 
 
Statistical analyses 
 
Prof. Dr. D.D.M. Braat, gynaecologist, head of 
department of Obstetrics and Gynaecology, 
Radboudumc 
didi.braat@radboudumc.nl 
 
Dr. J. in ’t Hout, assistant professor Department 

NL61414.091.17/SUMMER-trial                                                              version 11.0 – May 2020 
 
 
 
 
 
 
 
Participating centres 
 
for Health Evidence  
Joanna.intHout@radboudumc.nl 
 
Radboudumc 
Slingeland Ziekenhuis  
Canisius-Wilhelmina Ziekenhuis  
Jeroen Bosch Ziekenhuis 
Elisabeth-TweeSteden Ziekenhuis 
Maasziekenhuis Pantein 
Bernhoven Ziekenhuis 
Maxima Medisch Centrum 
Maastricht UMC+ 
Gelre ziekenhuizen 
Nij Geertgen, behandelcentrum 
Rijnstate 
Medisch Centrum Kinderwens 
Nij Barrahûs 
Fertiliteitscentrum Voorburg 
Catharina Ziekenhuis Eindhoven 
Bravis Ziekenhuis locations Roosendaal en 
Bergen op Zoom 
See appendix I1 for principal investigators 
contact information 
Sponsor (in Dutch: 
verrichter/opdrachtgever) 
Radboud University Medical Centre 
Department of Obstetrics and Gynaecology 
PO Box 9101 6500HB Nijmegen 
The Netherlands 
Subsidising party 
(Unrestricted grant) 
Goodlife Fertility B.V. 
Hollandse Hout 239 
8244 GJ Lelystad 
Independent expert  
Dr. F.M.J. Martens, urologist, Radboudumc 
frank.martens@radboudumc.nl 

NL61414.091.17/SUMMER-trial                                                              version 11.0 – May 2020 
 
 
 
 
Laboratory sites  
(Manufacturer of food 
supplement and placebo)  
Labomar SRL 
I-31036 Istrana (TV) 
Via N. Sauro 35/l 
Italia 
Pharmacy  
Not applicable 

NL61414.091.17/SUMMER-trial                                                              version 11.0 – May 2020 
 
 
 
 
PROTOCOL SIGNATURE SHEET 
 
Name 
Signature 
Date 
Head of Department and principal 
investigator (PI): 
Prof. dr. D.D.M. Braat, Reproductive 
Medicine / Head of Department 
Obstetrics and Gynaecology 
didi.braat@radboudumc.nl 
 
 
 

NL61414.091.17/SUMMER-trial                                                              version 11.0 – May 2020 
 
 
 
 
TABLE OF CONTENTS 
 
INTRODUCTION AND RATIONALE ....................................................................................11 
OBJECTIVES .......................................................................................................................14 
STUDY DESIGN ..................................................................................................................15 
1. STUDY POPULATION .....................................................................................................17 
1.1 
Population (base) ...................................................................................................17 
1.2 
Inclusion criteria .....................................................................................................17 
1.3 
Exclusion criteria ....................................................................................................17 
1.4 
Sample size calculation ..........................................................................................18 
2. 
TREATMENT OF SUBJECTS .......................................................................................18 
2.1 
Investigational product/treatment ............................................................................19 
2.2 
Use of co-intervention (if applicable) ......................................................................19 
2.3 
Escape medication (if applicable) ...........................................................................19 
3. 
INVESTIGATIONAL PRODUCT ....................................................................................20 
3.1 
Name and description of investigational  product(s) ...............................................20 
3.2 
Summary of findings from non-clinical studies ........................................................17 
3.3 
Summary of findings from clinical studies ...............................................................20 
3.4 
Summary of known and potential risks and benefits ...............................................20 
3.5 
Description and justification of route of administration and dosage .........................21 
3.6 
Dosages, dosage modifications and method of administration ...............................21 
3.7 
Preparation and labelling of Investigational Medicinal Product ...............................21 
3.8 
Drug accountability .................................................................................................21 
4. 
NON-INVESTIGATIONAL PRODUCT ...........................................................................23 
5. 
METHODS ....................................................................................................................24 
5.1 
Study parameters/endpoints ...................................................................................24 
5.1.1 
Main study parameter/endpoint .......................................................................24 
5.1.2 
Secondary study parameters/endpoints (if applicable) ....................................24 
5.1.3 
Other study parameters (if applicable) .............................................................25 
5.2 
Randomisation, blinding and treatment allocation ..................................................25 
5.3 
Study procedures ...................................................................................................26 
5.4 
Withdrawal of individual subjects ............................................................................28 
5.5 
Follow-up of subjects withdrawn from treatment .....................................................29 
5.6 
Premature termination of the study .........................................................................29 
6. 
SAFETY REPORTING ..................................................................................................30 
6.1 Temporary halt for reasons of subject safety ...............................................................24 
6.2 
AEs, SAEs and SUSARs ........................................................................................30 
6.2.1 
Adverse events (AEs) ......................................................................................30 
6.2.2 
Serious adverse events (SAEs) .......................................................................30 
6.2.3 
Suspected unexpected serious adverse reactions (SUSARs) .........................31 
6.3 
Annual safety report ...............................................................................................32 
6.4 
Follow-up of adverse events ...................................................................................32 
6.5 
[Data Safety Monitoring Board (DSMB) / Safety Committee] ..................................32 

NL61414.091.17/SUMMER-trial                                                              version 11.0 – May 2020 
 
 
 
 
7. 
STATISTICAL ANALYSIS ..........................................................................................33 
7.1 
Interim analysis ......................................................................................................34 
8. 
ETHICAL CONSIDERATIONS ...................................................................................35 
8.1 
Regulation statement .............................................................................................35 
8.2 
Recruitment and consent........................................................................................35 
8.3 
Objection by minors or incapacitated subjects (if applicable) ..................................35 
8.4 
Benefits and risks assessment, group relatedness .................................................35 
8.5 
Compensation for injury .........................................................................................35 
8.6 
Incentives ...............................................................................................................36 
9. 
ADMINISTRATIVE ASPECTS, MONITORING AND PUBLICATION .........................37 
9.1 
Handling and storage of data and documents ........................................................37 
9.2 
Monitoring and Quality Assurance ..........................................................................37 
9.3 
Amendments ..........................................................................................................37 
9.4 
Annual progress report ...........................................................................................37 
9.5 
End of study report .................................................................................................37 
9.6 
Public disclosure and publication policy ..................................................................38 
10. 
STRUCTURED RISK ANALYSIS...............................................................................39 
11. 
REFERENCES ..........................................................................................................40 

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LIST OF ABBREVIATIONS AND RELEVANT DEFINITIONS  
 
ABR 
ABR form, General Assessment and Registration form, is the application 
form that is required for submission to the accredited Ethics Committee 
(In Dutch, ABR = Algemene Beoordeling en Registratie) 
AE 
Adverse Event 
AR 
Adverse Reaction 
ART 
Assisted reproduction technology 
CA 
Competent Authority 
CCMO 
Central Committee on Research Involving Human Subjects; in Dutch: 
Centrale Commissie Mensgebonden Onderzoek 
CV 
Curriculum Vitae 
DSMB 
Data Safety Monitoring Board 
EU 
European Union 
EM 
Expectative management 
EudraCT European drug regulatory affairs Clinical Trials  
GCP 
Good Clinical Practice 
IB 
Investigator’s Brochure 
IC 
Informed Consent 
ICSI 
Intra-cytoplasmic sperm injection 
IUI 
Intra-uterine insemination 
IVF 
In-vitro fertilisation 
IMP 
Investigational Medicinal Product  
IMPD 
Investigational Medicinal Product Dossier  
METC  
Medical research ethics committee (MREC); in Dutch: medisch ethische 
toetsing commissie (METC) 
MOH 
Mild ovarian hyperstimulation 
OI 
Ovulation-induction 
(S)AE 
(Serious) Adverse Event  
SPC 
Summary of Product Characteristics (in Dutch: officiële productinfomatie 
IB1-tekst) 
Sponsor 
The sponsor is the party that commissions the organisation or 
performance of the research, for example a pharmaceutical 
company, academic hospital, scientific organisation or investigator. A 
party that provides funding for a study but does not commission it is not 
regarded as the sponsor, but referred to as a subsidising party. 

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SUSAR 
Suspected Unexpected Serious Adverse Reaction 
Wbp 
Personal Data Protection Act (in Dutch: Wet Bescherming 
Persoonsgevens) 
WMO 
Medical Research Involving Human Subjects Act (in Dutch: Wet Medisch-
wetenschappelijk Onderzoek met Mensen 
 
 

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SUMMARY 
 
Rationale: Infertility is a worldwide problem and about 10%-15% of all couples will be 
affected by the inability to have children. In approximately 50% of infertile couples a male 
factor is involved. In the past decade, the role of oxidative stress on sperm has been 
researched thoroughly and found to be the problem in 30% to 80% of male infertility cases. 
Impryl® is a nutritional supplement which works on the metabolic system and regulation of 
oxidative stress by activating the 1-Carbon cycle and therefore recycling of homocysteine. 
Objective: To determine the effectiveness of nutritional supplement Impryl® in men of 
infertile couples on ongoing pregnancy rate, with or without assisted reproduction technology 
(ART). 
Study design: Multicentre, randomised double blind placebo controlled clinical 
trial/superiority study. 
Study population: All participants in this study are male adults, age 18-50 years, part of a 
couple that is diagnosed with infertility, regardless the outcome of semen analysis. The 
couple will either start or is already started with fertility treatment, i.e. expectative 
management (EM, duration 6 months), intra-uterine insemination (IUI) with or without ovarian 
stimulation (mild ovarian hyperstimulation (MOH) or ovulation induction (OI)), either in vitro 
fertilization (IVF) or intracytoplasmic sperm injection (ICSI) treatment. 
Intervention: Impryl® or placebo, with identical appearance one tablet each day for a total 
duration of maximal 6 months. Patients can start directly with fertility treatment and/or to 
conceive.  
Main study parameters/endpoints: The primary outcome is the number of ongoing 
pregnancies confirmed by ultrasound at ≥ 10-12 weeks, and conceived in the time window 
between randomization up to and including month 6 of intervention use. Secondary 
outcomes are change in semen parameters between baseline and 3 months intervention in 
IUI/IVF/ICSI group, based on (pre-wash) total motile sperm count (TMSC), leading to a 
different fertility treatment categorisation. Furthermore the number of pregnancies conceived 
in the optimal intervention time window, the overall number of pregnancies, time to 
pregnancy, embryo fertilization rate in IVF/ICSI, embryo-utilization rate in IVF/ICSI, number 
of miscarriages and live birth rate are documented within the study period of 15 months. The 
occurrence of adverse events will be reported.  
Nature and extent of the burden and risks associated with participation, benefit and 
group relatedness: Couples with infertility will receive standard fertility treatment, i.e. EM or 
ART. The risks and burden of participating in the trial are small. After a complete diagnostic 
work-up for infertility, the males will be randomised for use of either Impryl®  or placebo. 
Impryl® is a food supplement already free available throughout Europe, online in the 

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Netherlands. Males need to take study medication (one tablet each day) for a maximum of 6 
months in total. For this study, we want to measure improvement of semen parameters after 
at least 3 months use of study medication. Performing a pre-wash TMSC is standard 
procedure at most sites when semen is used for IUI or IVF/ICSI. However, in couples with 
EM performing a TMSC after 3 months is not standard care. We decided not to perform a 
semen analysis in the EM group due to the fact that improvement in fertility treatment from 
expectative management is not possible. Participants are required to collect study 
medication directly at their local hospital or at Radboudumc. At the start of taking study 
medication the couple is asked to fill in a questionnaire about their baseline characteristics. 
To asses lifestyle changes during intervention and amount of used study medication, every 
male will be asked each month (6 times in total) to fill in an online questionnaire, these 
monthly questionnaires stop when a pregnancy has been reached. Every couple will receive 
a final questionnaire, 15 months after inclusion, about the outcome of fertility treatment and 
occurrence of pregnancy. If a women is pregnant, standard care is an ultrasound around 10-
12 weeks to estimate the due date. To limit the amount of extra site visits to zero, we decided 
that this ’due date’ ultrasound at 10-12 weeks of pregnancy is enough for determining the 
primary outcome. The ultrasound can be made in the midwife practice. Information about the 
outcome of this ultrasound is reported in the 15-months questionnaire. In conclusion, the 
burden and risks associated with participation in this trial can be considered negligible. 
 
 
 

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INTRODUCTION AND RATIONALE 
 
Infertility is a worldwide problem and about 10%-15% of all couples will be affected by the 
inability to have children.(1, 2) In approximately 50% of infertile couples a male factor is 
involved.(3) Male infertility is of multifactorial origin. In the past decade, the role of oxidative 
stress on sperm has been researched thoroughly and found to be the problem in 30% to 
80% of male infertility cases. (4-8)  
 
Reactive oxygen species (ROS) are products of normal cellular metabolism. However, 
oxidative stress occurs when the ROS production overwhelms the semen’s natural antioxidant 
defenses and causes cellular damage.(9) Increased oxidative stress is due to environmental 
and lifestyle factors such as smoking, stress, obesity and nutrition. ROS act by directly altering 
the sperm DNA and by damaging the sperm membrane and therefore affecting the sperm 
motility and ability of the spermatozoa to break down the oocyte membrane during fertilization. 
Men with sperm DNA damage can still have normal seminal parameters, however having a 
poor chance of natural conception.(10) Antioxidants can provide protection against oxidative 
stress by neutralizing the free oxygen radicals. Examples of antioxidants already present within 
seminal plasma are ascorbic acid (Vitamin C), α-tocopherol (Vitamin E), glutathione, amino 
acids (taurine, hypotaurine), albumin, carnitine, carotenoids, flavenoids, urate and 
prostasomes. Despite the common association between male infertility and oxidative damage, 
men are rarely treated or screened for oxidative stress. The latter because of the cost and 
complexity of testing for DNA damage. A recent Cochrane review suggested that antioxidant 
supplementation in male infertility might improve the outcomes in assisted reproductive 
technologies (ART). However, the evidence was rated as low and other clinical studies showed 
contradictory results with even a negative effect of high doses of antioxidants due to reductive 
stress as a rebound effect.(11)The clinical data on the effect of oral antioxidants in female 
infertility are even weaker, which is suggested to be the result of heterogeneity in study 
designs.(12) Alternatives to the straight oral antioxidants were therefore explored. A suitable 
alternative is to support the natural antioxidant defenses that are predicted to act within the 
modulation of the natural cellular homeostasis without generating rebound effects. Studies 
showed a positive effect of a nutritional supplement Condensyl®, the precursor of Impryl®, 
supporting DNA methylation patterns.(13, 14) Homocysteine is the end-product of the 1-
Carbon cycle (feeding DNA methylation) as well the starting substrate for GSH (the tripeptide 
glutathione) de novo biosynthesis (feeding reducing power to the antioxidant defenses). 
Homocysteine is in turn an inhibitor of the methylation process and a powerful pro-oxidant. It 
has a negative effect on spermatogenesis quality and its concentration in the ejaculate is 
inversely correlated with fertility outcome.(15, 16) Dattilo et al stated that the ideal supplement 
should work by favoring homocysteine recycling by restoring the efficiency of the 1-Carbon 
cycle, therefore ensuring the availability of activated methyl groups for DNA methylation and 
by supporting GSH synthesis, feeding the intracellular antioxidant system. (17) In the non-
randomized pilot studies with Condensyl® there was a significant decline of DNA 
fragmentation index leading to an improvement of the clinical pregnancy rate. However, the 
quality of these studies for the impact on pregnancy rate is rather low due to the non-

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randomized nature and in the study of Dattilo et al. performed in 2014 there was no control 
group.(13, 15) 
 
Impryl® is a nutritional supplement mainly consisting of vitamin B, which works on the 
metabolic system by activating the 1-Carbon cycle and recycling of homocysteine without the 
use of any direct strong antioxidants. Compared to Condensyl®, Impryl has the added 
advantage of the activated forms of folate (methylfolate) and B12 (methylcobalamine) to 
neutralize the effect of the enzyme variants and is therefore predicted to be more effective. 
The exact mechanism of action of Impryl® is shown in figure 1, Impryl® provides substrates 
and co-factors in the GSH synthesis to normalize the redox homeostasis. 
 
Figure 1. Working mechanism of Impryl® 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
In conclusion, it is well known that assisted reproduction technologies are expensive and that 
male infertility is being responsible for approximately 30% of problems with conception and to 
be a contributory factor in 50%.(18, 19) The medical and non-medical cost per IVF treatment 
in the Netherlands is estimated to be between 2.885 and 5.259 euro (€) when being 
expressed in the year 2015 euro by means of the consumer price index 
(http://statline.cbs.nl).(20, 21) The medical and non-medical costs per non-stimulated and 
stimulated IUI cycle are respectively 497€ and 1123€ for the year 2015.(22) Therefore, 
substantial cost savings would be made if the use of relatively inexpensive nutritional 
supplements would lead to a higher ongoing pregnancy rate, a shorter time to pregnancy or 
to the use of less expensive, less invasive reproductive techniques.  
 

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OBJECTIVES 
 
Primary Objective: To test the hypothesis that the number of ongoing pregnancies (i.e. ≥ 10-
12 weeks of gestation) , conceived in the time window between randomization up to and 
including month 6 of intervention use, will be different in couples treated with Impryl® for 
infertility, compared to couples with a placebo. 
 
Secondary Objectives:  
Number of pregnancies conceived in the optimal intervention time window, i.e. between start 
of month 4 till the end of month 6. Overall pregnancy rate. Time to pregnancy defined as both 
the time between a) randomization and reaching ongoing pregnancy, and as b) start of 
fertility treatment during the study (EM, IUI, IVF/ICSI) and reaching ongoing pregnancy. 
Change in semen parameters leading to differentfertility treatment categorisation (for more 
details see page 26) between baseline and 3 months intervention, based on pre-wash total 
motile sperm count (TMSC) from the subpopulation from Radboudumc and sites that deliver 
a pre-wash TMSC before IUI/IVF/ICSI. Improvement between Impryl® and control group in 
fertilization rate and embryo-utilization rate in IVF/ICSI group. Fertilization rate is defined as 
the percentage of oocytes with 0 PN or >=2 PN after insemination  (IVF) of injection (ICSI). 
Abnormal fertilization such as 3PN will be recorded, in case this percentage differs or 
increases in the study group. The embryo-utilization rate (EUR) is defined as the number of 
high quality embryos obtained, embryo’s used at transfer plus the number of embryos frozen, 
divided by the number of zygotes obtained in a cycle. Due to the differences in embryo 
evaluation and embryo selection criteria for cryopreservation, we decided to measure the 
relative increase in fertilization and utilization rate observed for each clinic.. Number of 
miscarriages defined as a non-vital intra-uterine pregnancy before 16 weeks of gestation. 
Live birth rate defined as beyond 24 weeks of gestation, the birth of a living child. Live births 
(beyond 24 weeks, defined as the birth of a living child) will be reported within follow-up time 
of 15 months. Furthermore the following adverse events will be reported: gastro-intestinal 
problems such as reflux, obstipation, diarrhea, nausea or vomiting, furthermore loss of 
appetite, headache, dizziness, pruritus or skin rash. 
 
 
 

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STUDY DESIGN 
A multicentre randomised, double blind placebo controlled, clinical trial for Impryl®  
administration will be performed in the Department of Gynaecology and/or Reproductive 
Medicine in both academic and non-academic hospitals in The Netherlands.  
 
The 16 centers participating in the study: 
Hospital 
Principal investigator 
Radboudumc, Nijmegen 
K. Fleischer 
Slingeland Ziekenhuis, Doetinchem 
R.B. Donker 
Canisius-Wilhelmina Ziekenhuis, Nijmegen 
C.F. van Heteren 
Jeroen Bosch Ziekenhuis, Den Bosch 
J.P de Bruin 
Elisabeth-TweeSteden, Tilburg 
J.M.S. Smeenk 
Maasziekenhuis Pantein, Boxmeer 
E. Haagen 
Bernhoven Ziekenhuis, Uden 
M.P. Hoekstra 
Maxima Medisch Centrum, Veldhoven 
J.W.M. Maas 
Maastricht UMC+, Maastricht 
R.J.T. van Golde 
Gelre ziekenhuizen, Apeldoorn 
M.A.F. Traas 
Nij Geertgen, Elsendorp 
M. Schoonenberg 
Rijnstate, Arnhem 
A.W. Nap 
Medisch Centrum Kinderwens, Leiderdorp 
T. Cox 
Nij Barrahûs 
H. Mous 
Fertiliteitscentrum Voorburg 
J. Boxmeer 
Catharina Ziekenhuis Eindhoven 
M.M.E. van Rumste 
Bravis Ziekenhuis locaties Roosendaal en 
Bergen op zoom 
C.M. Boomsma and E. Timmermans 
 
The duration of the study will be approximately 45 months. A run-in period of 6 months is 
needed for the study set up. The inclusion period will be 24 months. A period of 15 months is 
needed for follow-up data collection and report of results. We anticipate on a 50% 
participation rate; the study will be completed in 3.5 - 4 years. Our study design is 
summarized in figure 2 and a time line is shown in figure 3. 
 

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Males of infertile couples
n = 1200
Expectant
management
n = 200
Impryl® 
n = 100
Placebo
n = 100
IUI
n = 600   
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n = 300
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n = 300
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n = 400
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n = 200 
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1. STUDY POPULATION 
1.1 Population (base)  
 
The research population will be recruited from couples either presenting for evaluation of  
 
started fertility treatment or newly presenting with infertility to a gynaecologist or after  
 
successful pregnancy. A recruitment of 1200 male patients is proposed. Participants will  
 
be recruited from both tertiary and secondary care hospitals. Expected inclusion period is  
 
24 months, since we expect to enrol around 50 patients per month. With a participation  
 
rate of 50%, the recruitment of 1200 males in 24 months is feasible (see 2.3 sample size  
 
calculation). Due to the existence of the NVOG Consortium 2.0 structure (Dutch  
 
Consortium for Healthcare Evaluation in Obstetrics and Gynaecology) the experience of  
 
the participating hospitals in including patients is high, most clinics have an onsite  
 
research nurse. 
 
1.2 Inclusion criteria 
In order to be eligible to participate in this study, a subject must meet all of the following 
criteria: 
Either: couples with failure to conceive for at least 12 months and starting with EM or 
couples starting with 1st/ 2nd/3rd cycle of IUI (with/without ovarian stimulation) or 1st/ 
2nd/3rd cycle of IVF/ICSI 
Male with age 18-50 years  
Female partner with age 18-43 years  
Willing and able to give informed consent  
 
Exclusion criteria 
A potential subject who meets any of the following criteria will be excluded from 
participation in this study: 
Planned or performed diagnostic testicular biopsy (TESE) or percutaneous 
epididymal sperm aspiration (PESA) 
Use of donor-, cryopreserved- or electro-ejaculated semen 
Ovulation induction (OI) without IUI  
IVF for an absolute tubal factor  
Embryo-transfers after cryopreservation 
Embryo-transfer after pre-implantation genetic diagnosis 
Known endocrine abnormalities related to infertility, or use of fertility enhancing drugs 
Known genetic abnormalities related to infertility 
Known urological abnormality such as a varicocele or bilateral cryptorchism 
Use of other vitamin supplements 
 
 

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1.3 Sample size calculation 
 
The overall success rate (number of ongoing pregnancies, not specified per cycle  
 
number) in IVF and ICSI in the Netherlands was respectively 19.8% and 21.5% per cycle  
 
in 2015.(23) The cumulative number of ongoing pregnancies in IUI is estimated to be  
 
around 5 to 13% per cycle, around 18% after three cycles and 20-30% after six cycles. 
 
(24-26) Based on our Radboudumc data, the ongoing pregnancy rate in EM is estimated  
 
around 20% after 6 months.   
 
  
A  Cochrane review ‘antioxidants for male subfertility’ estimated the increase in clinical 
pregnancy rates after use of antioxidants with an Odds Ratio (OR) of  3.43 ( 95% CI 1.92 
to 6.11, P < 0.0001, 7 RCTs, 522 men, I2 = 0%, low quality evidence). (27) 
However, 
this concerns low quality evidence, and the included population in this Cochrane review 
was couples with male factor subfertility, whereas in our study we also include couples 
with unexplained infertility. Therefore, we assumed a more conservative OR of 1.5. 
Assuming a 20% ongoing pregnancy rate in the placebo group, this reflects in an 
expected pregnancy rate of 27.3% in the Impryl® group 
 
The study is designed as a superiority study. Based on the above mentioned data, we  
expect a 7.3% increase in ongoing pregnancy number when men are treated with Impryl® 
compared to placebo. However, after randomization patients can directly start with both 
intervention and achieving a pregnancy, either spontaneously or with fertility treatment. In 
these first months the effect of the intervention is expected to be suboptimal due to the 
duration of the spermatogenesis (72 days before  whole renewal). Therefore we adjusted 
the expected increase of 7.3% to a more realistic effect of 6.5%. We assume an equal 
increase in all fertility groups (meaning EM, IUI and IVF/ICSI) from 20% to 26.5%.  
 
 
The ratio between the 3 fertility treatment groups (EM 1: IUI 3: IVF/ICSI 2) is based  
 
on the number of new patients treated at Radboudumc and the sites each year. To test  
 
the effect of Impryl on the probability of ongoing pregnancy, a sample size of 600 men per  
 
treatment group (1200 in total) is needed, assuming differences in ongoing pregnancy  
 
rates of 6.5% and an expected ongoing pregnancy rate of 20% in the placebo group, with 
 
a two-sided alpha of 5% and a beta of 24% (i.e. 76% power). As we expect the number of  
 
participants lost to follow up to be minimal. We will allocate 600 patients in both  
 
intervention and control arm. Figure 1 shows the distribution of the number of participants  
 
for the 3 different types of fertility treatment (EM, IUI and IVF/ICSI). 
 
 
2. TREATMENT OF SUBJECTS 
For the purpose of this study subjects will either be treated with a food supplement (Impryl®) 
1 tablet once a day or with a placebo 1 tablet once a day, both for a duration of maximum 6 
months. Use of the food supplement or placebo will be stopped earlier when pregnancy is 
achieved. 
 

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2.1 Investigational product/intervention 
Impryl® tablets will be produced by Labomar SRL who will also produce an identical 
looking placebo tablet. Patients start directly with study medication for a total duration of 
maximum 6 months. 
2.2 Use of co-intervention  
All couples will receive our standard care for infertility according to the guidelines of the 
Dutch Society of Obstetrics and Gynaecology. After diagnostic work up couples will either 
start with EM (6 months), IUI, IVF or ICSI. Participants will take study supplement for a 
maximum of 6 months, even if the fertility intervention (6 x IUI of 1 x IVF/ICSI cycles) is 
not completed. Co-treatment with other vitamins or supplements is prohibited. If vitamins 
or supplements are already used by men, a wash-out period of 3 months is 
recommended. Patients using other supplements will be excluded or reported as protocol 
violation If after randomization it appears that a patient still uses other supplements 
(reported in the online questionnaire), they will be telephonically contacted and asked to 
stop use of other supplements. After this stop, there is a wash-out period of 72 days 
(duration of spermatogenesis). If no pregnancy occurs within this wash-out period the 
patient and data can still be included.   
2.3 Escape medication  
Not applicable 

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3. INVESTIGATIONAL PRODUCT  
Impryl® is a food supplement and is therefore not considered an investigational medicinal 
product. To assess product quality, we have submitted following documents of both the food 
supplement and placebo: Summary of Product Characteristics (SPC), Certificates of Analysis 
(CoA), certificate of Good Manufacturing Practice (GMP) and ISO 9001 form (see documents 
D2 SPC, D2 CoA, D2 GMP Labomar SRL and D2 ISO 9001 Labomar SRL). 
3.1 Name and description of investigational  product(s) 
 
Impryl®. Tablets of ovoid shape sized 20x8 mm, white color, smooth surface, weight 1300   
 
milligram with active ingredients: microcrystalline cellulose, betaine hydrochloride, L- 
 
cysteine, mono and diglycerides of fatty acids, magnesium stearate, disilicio dioxide, zinc  
 
bisglycinate, croscarmellose sodium, niacin (nicotinamide), vitamin B6 (pyridoxine  
 
hydrochloride), vitamin B2 (riboflavin), folic acid [(6S) -5-methyltetrahydrofolate acid,  
 
glucosamine salt], vitamin B12 (cobalamin).  
 
 
Placebo tablet of identical appearance produced by Labomar SRL. 
 
List of ingredients of placebo (composition):  
 
E num. 
Common name 
Grams per dose 
E 460 
Cellulose 
0,852 
E 341 
Calcium phosphates 
0,300 
E 172 
Iron oxides 
0,024 
E 551 
Silicon dioxide 
0,012 
E 470b 
Magnesium salts of fatty acids 
0,012 
 
3.2 Summary of findings from (non-) clinical studies 
To date no (non-)clinical research with a primary focus on increasing the ongoing 
pregnancy number by Impryl® has been performed. There is evidence that Impryl® 
reduces oxidative stress and DNA damage, this is based on research performed with the 
previous version of the supplement (Condensyl®) in humans.(13)  
3.3 Summary of known and potential risks and benefits 
 
There is substantial evidence that supplementation with the precursor of Impryl®, named  
 
Condensyl®, is safe and of beneficial in case of absolute (low content in the diet) or  
 
relative (increased demand) deficiency.(17) These deficiencies may associate to altered  
 
homocysteine metabolism and other disturbances to the defense against oxidative  
 
aggressions and are often observed in men and women with reproductive problems. It is  
 
to be noted that disturbances of homocysteine metabolism and of oxidative defenses may  
 
occur more frequently in subjects carrying a defective genetic variant of one of the main  
 
enzymes of homocysteine metabolism including those denominated ethyltetrahydrofolate  
 
reductase (MTHFR), methionine transferase reductase (MTRR), Betaine Homocysteine  
 
Methyl Transferase (BHMT) and cystathionine beta synthase (CBS).(13) Impryl® has  
 
been formulated so to compensate these defects by providing an already activated  

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substrate (i.e. methylfolate for MTHFR and methyl cobalamin for MTRR), or by providing  
 
an excess of substrate (i.e. betaine for BHMT) or by delivering a ready substrate for  
 
downstream to the genetic blockade (i.e. cystine for CBS). Thus, Impryl® will deliver an  
 
effective dietary support to everybody independently of their genetic substrate for the  
 
mentioned enzymes.  
 
 
Impryl is safe by administering only essential micronutrients that are usually occurring in  
 
food, supplied according the recommended daily dose. There are no major warning, there  
 
are no reports on side effects or allergies, it is gluten- and lactose free. 
3.4 Description and justification of route of administration and dosage 
 
The route of administration of both Impryl®  and placebo is by oral intake with a small  
 
amount of water, preferentially without food. The recommended daily dose is 1 tablet per  
 
day. The assumption of a smaller amount does not guarantee full coverage of the daily  
 
need in all subjects. The recommended daily dose should not be exceeded. 
3.5 Dosages, dosage modifications and method of administration 
 
All subjects will receive the same dosage of 1 tablet (1.3 gram) taken between  
 
meals once a day. No dosage modifications are possible. The medication will be taken  
 
orally. 
3.6 Preparation and labelling of Investigational Medicinal Product 
 
Manufacturing, preparation, labelling and packaging of both the active verum (Impryl®)  
 
and placebo tablets will be performed by Labomar SRL compliant with EU GMP. The  
 
labels will be in Dutch. A flaglabel (to be teared off) is used to identify placebo and  
 
Impryl®. Distribution of study medication will be organised by either the Radboudumc,  
 
department of Reproductive Medicine, or at the local department of Gynaecology at every  
 
site. Every centre was given the option to perform randomisation and distribute the study  
 
medication at their own hospital or asking their included patients to collect study  
 
medication after randomisation at Radboudumc at the above mentioned department. 
 
  
3.7 Drug storage accountability 
 
The coding and distribution to the trial will be organised by Labomar SRL in  
 
collaboration with the principal and coordinating investigators of the Radboudumc. The  
 
study medication has to be stored in a dry place at room temperature. No special  
 
precautions have to be taken into account. Patients are not asked to return study  
 
medication. Since it is a supplement and not medication there are no specials precautions 
 
for destruction or disposal.  
 
Drug accountability will be performed in line with GCP requirements. The investigator is 
responsible for drug accountability and these tasks will be delegated to the primary 
investigators at the sites. We will log all dispensing of the investigational product on a drug 

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accountability log . See paragraph 5.2 of this protocol for further details on the dispensing 
and logging. 
 
 
 
 
 
 
 

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4. NON-INVESTIGATIONAL PRODUCT 
Not applicable 

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5. METHODS 
5.1 Study parameters/endpoints 
5.1.1 Main study parameter/endpoint 
Number of ongoing pregnancies, conceived in the time window between 
randomization up to and including month 6 of intervention use. Ongoing pregnancy 
is defined as a visible embryonic heartbeat at ultrasound from 10-12 weeks of 
gestation onwards. 
5.1.2 Secondary study parameters/endpoints  
Number of pregnancies conceived in the optimal intervention time window, i.e. 
between start of month 4 till the end of month 6. 
 
Overall number of pregnancies meaning the cumulative pregnancy number up to 9 
months after start of intervention 
 
Time to pregnancy defined as  
 
a) the time between start randomization and reaching ongoing  
 
pregnancy (confirmed by ultrasound) 
 
 
b) the time between start of fertility treatment during the study (EM, IUI,  
 
IVF/ICSI) and reaching ongoing pregnancy 
 
Change in semen parameters in IUI/IVF/ICSI group based on pre-wash total motile 
sperm count (TMSC), leading to different fertility  treatment categorisation (EM, IUI, 
IVF, ICSI), from a subpopulation of patients: Radboudumc patients and patients 
from other sites having pre-wash TMSC as standard procedure when semen is used 
for IUI or IVF/ICSI.  
 
Improvement between Impryl® and control group in fertilization rate and embryo-
utilization rate in IVF/ICSI group. Fertilization rate is defined as the percentage of 
oocytes with 0 PN or >=2 PN after insemination  (IVF) of injection (ICSI). Abnormal 
fertilization such as 3PN will be recorded, in case this percentage differs or 
increases in the study group. The embryo-utilization rate (EUR) is defined as the 
number of high quality embryos obtained, embryo’s used at transfer plus the number 
of embryos frozen, divided by the number of zygotes obtained in a cycle. Due to the 
differences in embryo evaluation and embryo selection criteria for cryopreservation, 
we decided to measure the relative increase in fertilization and utilization rate 
observed for each clinic. 
.  
Number of miscarriages (defined as non-vital intra-uterine pregnancy before 16 
weeks of gestation)  
 

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Live birth rate (beyond 24 weeks, defined as the birth of a living child) within study-
period of 15 months 
 
Adverse effects 
5.1.3 Other study parameters 
Baseline parameters are age, length, weight, ethnicity, alcohol/drugs/nicotine use, 
use of vitamins/steroids or other supplements, diet specifics (normal, vegetarian, 
vegan, gluten-free, diary free, other), medication use, activities that cause increased 
scrotal temperature such as often visiting a sauna, taking a hot bath or race cycling, 
general health, operations or trauma in genital area, exposure to toxins in 
environment, conception of previous children, duration of infertility and type of 
diagnosis of infertility. Furthermore the age and parity of the female partner has to 
be documented, as well as the occurrence of endometriosis or anovulation. 
Furthermore, when IVF/ICSI is performed, the amount of embryos transferred will be 
reported, either a single-embryo transfer (SET) or double-embryo transfer (DET). 
 
5.2 Randomisation, blinding and treatment allocation 
RANDOMISATION AND TREATMENT ALLOCATION: All couples visiting a fertility 
specialist for the first time or for evaluation of fertility treatment will be informed on 
this study. Prior to or at their actual appointment they will receive the patient 
information (PIF). Randomisation will be performed, after signed informed consent 
has been obtained, using a web-based application (Castor). We will use permuted 
block-design, stratified for fertility treatment (1st) and recruiting centre (2nd). Block 
sizes are flexible. Participants will be randomised in a 1:1 ratio to study medication 
(Impryl®) or placebo. Assignment to medication, using the randomisation list, will 
either performed at the local centre or at Radboudumc by an independent person. 
This person is neither participating in clinical treatment nor processing the study 
data. Randomisation outcome is either A (Impryl®) or B (placebo). 
CODING: coding starts immediatly after informed consent has been obtained. In 
Castor each patient will receive a combination of one letter and 3 numbers. The 
code will be assigned as followed: Radboudumc (A), Slingeland (B), Canisius-
Wilhelmina (C), Jeroen Bosch (D), Elisabeth-TweeSteden (E), Maasziekenhuis 
Pantein (F), Bernhoven (G), Maxima Medisch Centrum (H), Maastricht UMC+ (I), 
Gelre ziekenhuizen (J), Nij Geertgen (K) Rijnstate (L), Medisch Centrum Kinderwens 
(M), Nij Barrahûs (N),Fertiliteitscentrum Voorburg (O), Catharina Ziekenhuis 
Eindhoven (P) and Bravis Ziekenhuis (Q). For example, the first patient included in 
Radboudumc will receive the code A001. The code will not provide any information 
about the received intervention (Impryl® or  placebo). The list of codes 
corresponding with patient information and received medication will be saved in an 

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separate file, locked (either digital with password or a locked cabinet), only 
accessible for the independent person who did the randomisation.  
BLINDING: The study is double blinded. All personnel, the researchers and patients 
will remain blinded to the intervention being received, except the personnel 
performing randomisation and distributing the study medication.  
DEBLINDING: The indications for breaking the randomisation code are: SAE, SAR 
and SUSAR, as instructed by METC, or in a dire emergency, as directed by the 
principal investigators or trial manager. Every site has access to a deblinding form 
(“Formulier verbreken randomisatie code”) in which patients details, reason for 
deblinding, statement of principal site investigator, date and time of intervention stop 
and randomisation allocation will be reported. The principal site investigator will 
inform the coordinating investigator about the deblinding.  
DISTRIBUTION: In Radboudumc and at the local study sites the person distributing 
the study medication is an unblinded employee of the department of Reproductive 
medicine or Gynaecology who is not involved in the treatment of the patient nor 
involved in the data collecting of the research. Every study site can decide to 
perform randomisation and distribution of medication at local site or at Radboudumc. 
On every distributing study site there will be a batch of study medication stored at 
room temperature, no special precautions. An unblinded authorized employee of the 
department of Reproductive medicine (or Gynaecology) will distribute the study 
medication after randomisation has been performed by Castor. The flag label 
(identification A = Impryl® or B = placebo) will be removed from the box and the 
randomisation number noted (handwritten) on the medication box. Thereafter, the 
box  will be handed over to the patient. On the patient identification & drug 
accountability log (either digital or on paper) the following details will be reported: 
date of issue, study (randomisation) number, batch number, expiration date, amount 
dispensed, current storage amount, randomizer/distributor initials, hospital number, 
patient name and initials, date of birth and monitoring check.  
 
All unblinded personel performing randomisation will be trained by a site intiation to 
perform randomisation in Castor EDC and distribution of medication. A log list of all 
personel involved in the study, with blinding status, responsibilities and signature, 
will be saved. 
 
Unblinding will be performed when the study has ended, database is locked and 
protocol violators have been defined. 
 
5.3 Study procedures 
Couples matching the inclusion criteria will be asked to participate in the trial. If after 
diagnostic work up the diagnosis infertility for the couple remains, both are asked for 
informed consent. After signing informed consent, the male patient will be 
randomised and allocated to Impryl® or placebo (double blinded).  
 

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Medication  
Patients can directly start using the food supplement or placebo. Impryl® or placebo 
will be taken for a total duration of 6 months and will be directly stopped after having 
a positive pregnancy test.  
 
Baseline characteristics 
Patients are asked to report on these characteristics by a short questionnaire. 
Patients will receive an automatic email invitation directly after randomisation and 
are asked to provide this information online in the Castor database system 
 
Lifestyle and outcome characteristics 
Patients will be asked once every month to report on occurrence of pregnancy (with 
date of positive test), changes in weight and diet, changes in habit of smoking and 
drug or alcohol use, occurrence of fever and change in activities increasing scrotal 
temperature (hot baths, sauna, race cycling). Furthermore patients are instructed 
about taking note of the total amount of consumed study medication (used boxes 
and tablets). There is a question about the occurrence of adverse events. Patients 
will receive an automatic email and are asked to provide this information online in 
the Castor database system. When a pregnancy has been reached during the 6 
months use of study medication the monthly questionnaires will be stopped, 
because there is no more necessity to record on lifestyle changes and treatment 
compliance. 
 
Semen analysis 
Semen analysis will be performed two times: once during diagnostic work-up 
(standard care, analysis according to WHO criteria(28) and once more after 
approximately 3 months of using study medication (ie. after three months of IUI 
treatment or  IVF/ICSI). At several sites, a pre-wash TMSC is standard care when 
performing an insemination (IUI group) and will be performed on the semen 
produced for IVF/ICSI as part of routine measurement before procedure. Because 
semen analysis performed at the time of treatment cannot be fully performed 
according to the WHO criteria,  we will categorize the TMSC quality according to the 
allocated treatment category. This means, that the TMSC (evaluated at the start of 
treatment and after 3 months) will be analyzed according to changes in allocated 
treatment category based on the NVOG guideline(29).The criteria for treatment are 
given in the table below.  A change in treatment category means an improvement in 
sperm quality that would allow a lower treatment category (e.g, from ICSI to IVF)  
 
TMSC outcome (x106) 
WHO Diagnostic category 
NVOG Treatment category 
> 10 
Normospermia 
EM 
3 -10 
Mild OAT 
IUI  
1-3 
OAT 
IVF/ICSI  
(if after wash VCM is <0,5) 
<1 
Extreme OAT/Azoospermia 
ICSI 

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OAT = oligo-astheno-teratozoospermia.  
* Or IVF depending on the prediction model of Hunault and other clinical characteristics 
 
We decided not to perform a semen analysis in the EM group due to the fact that 
they already have normal semen parameters at intake and the burden of an extra 
visit is high.  
 
Fertilization and embryo-utilization rate 
In IVF/ICSI patients fertilization rate and embryo-utilization rate are standard 
reported by every IVF-laboratory. Fertilization rate is the percentage of oocytes with  
>=2 PN after insemination  (IVF) of injection (ICSI). The embryo-utilization rate 
(EUR) is defined as the number of high quality embryos obtained, embryo’s used at 
transfer plus the number of embryos frozen, divided by the number of zygotes 
obtained in a cycle. Due to the differences in embryo evaluation and embryo 
selection criteria for cryopreservation, we decided to measure the relative increase 
in fertilization and utilization rate observed for each clinic.  
 
 
 
Transvaginal ultrasonography 
If there is a clinical pregnancy in fertility patients, a routine (standard care) 
ultrasound will be performed in the first trimester between 5 to 9 weeks to determine 
the viability. Also routine (standard care) is an ultrasound around 10-12 weeks to 
estimate the due date. To limit the amount of extra site visits to zero, we decided 
that this ’due date’ ultrasound at 10-12 weeks of pregnancy is enough for 
determining the primary outcome. The ultrasound can be made in the midwife 
practice. Information about the outcome of this ultrasound is reported in the 15-
months questionnaire. 
 
Questionnaire pregnancy/treatment outcome 
To allow follow-up for treatment and pregnancy outcome, all couples will receive an 
automatic email with invitation for a short questionnaire 15 months after inclusion. 
They will receive questions about fertility treatment and pregnancy outcome (ability 
to achieve a pregnancy, occurrence of miscarriage or childbirth, date of delivery, 
gestational age, mode of delivery, complications of delivery, birth weight and sex of 
neonate). An email will be sent if the questionnaire is not returned after one month. 
If there is no reaction to the reminder email, either the patient or his general 
practitioner will be contacted by telephone to answer follow-up questions.  
 
5.4 Withdrawal of individual subjects 
Subjects can leave the study at any time for any reason if they wish to do so without 
any consequences. The investigator can decide to withdraw a subject from the study 
for urgent medical reasons. There are no specific criteria for withdrawal. 

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5.5 Follow-up of subjects withdrawn from treatment 
As the statistical analysis is planned according to intention to treat principle, patients 
that violate the study protocol will be analysed in the group that they were allocated 
to. All patients will receive full follow-up. 
5.6 Premature termination of the study 
The principal investigator at the initiating centre Radboudumc, may temporarily or 
permanently discontinue the trial at a single site or at all sites for safety, ethical, 
compliance or other reasons. If this is necessary, the principal investigator will 
endeavour to provide advance notification to the site. If the site or trial is suspended or 
discontinued, the principal investigator will be responsible for ensuring prompt 
notification to the METC (CMO Arnhem Nijmegen). Where required by local 
regulations, the principal investigator will be responsible for informing the METC of 
trial or site discontinuation. In such cases, all trial data must be returned to the 
principlal investigator at the Radboudumc.  

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6. SAFETY REPORTING 
6.1 Temporary halt for reasons of subject safety 
In accordance to section 10, subsection 4, of the WMO, the sponsor will suspend the 
study if there is sufficient ground that continuation of the study will jeopardise subject 
health or safety.  The sponsor will notify the accredited METC without undue delay of a 
temporary halt including the reason for such an action. The study will be suspended 
pending a further positive decision by the accredited METC. The investigator will take 
care that all subjects are kept informed.  
6.2 AEs, SAEs and SUSARs 
6.2.1 Adverse events (AEs) 
Adverse events are defined as any undesirable experience occurring to a subject 
during the study, whether or not considered related to Impryl®. All adverse events 
reported by the subject or observed by the investigator or his staff will be recorded. 
6.2.2 Serious adverse events (SAEs) 
A serious adverse event is any untoward medical occurrence or effect that  
- 
results in death; 
- 
is life threatening (at the time of the event); 
- 
requires hospitalisation or prolongation of existing inpatients’ hospitalisation; 
- 
results in persistent or significant disability or incapacity; 
- 
is a congenital anomaly or birth defect; or 
- 
any other important medical event that did not result in any of the outcomes listed 
above due to medical or surgical intervention but could have been based upon 
appropriate judgement by the investigator. 
An elective hospital admission will not be considered as a serious adverse event. 
 
The investigator will report all SAEs to the sponsor without undue delay after 
obtaining knowledge of the events. 
 
The sponsor will report the SAEs through the web portal ToetsingOnline to the 
accredited METC that approved the protocol, within 7 days of first knowledge for 
SAEs that result in death or are life threatening followed by a period of maximum of 8 
days to complete the initial preliminary report. All other SAEs will be reported within a 
period of maximum 15 days after the sponsor has first knowledge of the serious 
adverse events. 

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6.2.3 Suspected unexpected serious adverse reactions (SUSARs) 
Adverse reactions are all untoward and unintended responses to the food 
supplement or placebo related to any dose administered. 
 
Unexpected adverse reactions are SUSARs if the following three conditions are met: 
1. the event must be serious (see chapter 9.2.2); 
2. there must be a certain degree of probability that the event is a harmful and an 
undesirable reaction to the medicinal product under investigation, regardless of 
the administered dose; 
3. the adverse reaction must be unexpected, that is to say, the nature and severity 
of the adverse reaction are not in agreement with the product information as 
recorded in: 
- 
Summary of Product Characteristics (SPC) for an authorised medicinal 
product; 
- 
Investigator’s Brochure for an unauthorised medicinal product. 
 
The sponsor will report expedited the following SUSARs through the web portal 
ToetsingOnline  to the METC:  
− SUSARs that have arisen in the clinical trial that was assessed by the METC; 
− SUSARs that have arisen in other clinical trials of the same sponsor and with the 
same medicinal product, and that could have consequences for the safety of the 
subjects involved in the clinical trial that was assessed by the METC. 
The remaining SUSARs are recorded in an overview list (line-listing) that will be 
submitted once every half year to the METC. This line-listing provides an overview 
of all SUSARs from the study medicine, accompanied by a brief report highlighting 
the main points of concern.  
The expedited reporting of SUSARs through the web portal Eudravigilance or 
ToetsingOnline is sufficient as notification to the competent authority. 
 
The sponsor will report expedited all SUSARs to the competent authorities in other 
Member States, according to the requirements of the Member States.  
 
The expedited reporting will occur not later than 15 days after the sponsor has first 
knowledge of the adverse reactions. For fatal or life threatening cases the term will 
be maximal 7 days for a preliminary report with another 8 days for completion of the 
report.  

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6.3 Annual safety report 
 
In addition to the expedited reporting of SUSARs, the sponsor will submit, once a year 
throughout the clinical trial, a safety report to the accredited METC, competent authority, 
and competent authorities of the concerned Member States. 
This safety report consists of: 
− a list of all suspected (unexpected or expected) serious adverse reactions, along with 
an aggregated summary table of all reported serious adverse reactions, ordered by 
organ system, per study; 
− a report concerning the safety of the subjects, consisting of a complete safety analysis 
and an evaluation of the balance between the efficacy and the harmfulness of the 
medicine under investigation. 
 
6.4 Follow-up of adverse events 
There will be no follow-up of adverse events. There are no adverse events reported in 
previous use of Impryl. Therefore these are not expected. However, all SAEs and 
SUSARs will be followed until they have abated, or until a stable situation has been 
reached. Depending on the event, follow up may require additional tests or medical 
procedures as indicated, and/or referral to the general physician or a medical specialist. 
SAEs need to be reported till end of study within the Netherlands, as defined in the 
protocol  
 
6.5 Data Safety Monitoring Board (DSMB) / Safety Committee 
Due to the known safety of Impryl®, we do have the opinion that establishing a DSMB is 
not necessary. 
 

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7. STATISTICAL ANALYSIS 
All data will be analyzed on an intention-to-treat basis. Data of patients who are lost to follow-
up, will be included in their randomised group  
will be included in their randomized group: 
▪ Patients who are lost to follow-up during the treatment period are considered not to have 
achieved a pregnancy.  
▪ Patients, who are lost to follow-up right after achieving a pregnancy of less than 8 weeks 
of gestation, are considered not to have achieved an ongoing pregnancy 
▪ Patients, who are lost to follow-up right after achieving a pregnancy of 8 or more weeks of 
gestation, are considered to have achieved an ongoing pregnancy.  
 
In addition, a per-protocol analysis will be performed for the primary outcome and the 
secondary outcomes overall pregnancy number, time to pregnancy, number of 
miscarriages and live birth rate. 
 
Descriptive statistics will be calculated to check for major dissimilarities between study 
groups with respect to baseline information. Baseline data will be described quantitatively. 
For continuous variables, we will examine the distribution of the observations, and if 
normally distributed we will summarise them as means with standard deviations (SDs). If 
they are not normally distributed, then medians and inter-quartile ranges (IQRs) will be 
reported. For dichotomous data, we will provide counts and proportions. 
 
The primary outcome variable ‘ongoing pregnancy’ will be assessed as follows. The 
ongoing pregnancy percentages as observed in the trial will be presented  for both 
treatment arms, overall, and separately for the three strata (i.e. EM, IUI, IVF/ICSI). In 
order to adjust for possible imbalances between the treatment groups, the pregnancy 
percentages and differences in pregnancy percentages between the experimental and 
control group, and the corresponding 95% confidence intervals will be estimated using a 
fixed effects binomial model with an identity link, including intervention, fertility treatment, 
centre and female age (centered). If this model does not converge, a logit link will be 
used. 
 
Time to ongoing pregnancy will be evaluated by the Kaplan-Meier approach; differences 
between the two arms will be tested with the log-rank test. Similar analyses will be 
conducted per stratum (EM, IUI or IVF/ICSI). The other secondary outcomes (overall 
pregnancy number, number of miscarriages, live birth rate, fertilization rate, embryo-
utilization rate) will be evaluated similarly to the primary outcome. Changes in semen 

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analysis, leading to different fertility treatment categorisation, will be first calculated with 
descriptive statistics, with the following codes: 
- 
0: if there is no change in treatment category 
- 
1: if there is 1 category change (i.e. from IUI to EM), or -1 if it goes from less 
severe to severe (i.e. IUI to IVF) 
- 
2: if there are 2 category changes (i.e. from IVF to EM) 
The changes will be summarized with descriptive statistics (mean, SD, median, range) 
and frequency tables per treatment and stratum. Further, the difference between the 
experimental and control group  will be assessed with a fixed effects linear model, 
adjusted for centre and stratum.  
Furthermore, adverse events will be summarized. Sensitivity analyses will be performed 
to evaluate possible effects in case of protocol amendments. 
 
The per-protocol population will consist of all randomised patients without any major 
deviation from the protocol. A major protocol deviation is defined as 
Use of other nutritional supplements without a wash-out period 
Intake of study medication of less than 75% of the prescribed amount 
 
Participants will be asked by automatic email to report in Castor their actual compliance 
to the intervention by taking note of total amount of consumed study medication (used 
boxes and tablets). Patients will also be asked to report about major changes of their 
lifestyle occurring during the study period (see page 22). 
 
The results will be extracted from Castor. If there are missing data this will be mentioned 
along with the reason. 
7.1 Interim analysis 
Given the low risk on adverse events of a nutritional supplement, there are no 
planned interim analyses. 
 
 

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8. ETHICAL CONSIDERATIONS 
8.1 Regulation statement 
The study will be conducted according to the principles of the Declaration of Helsinki as 
amended most recently by the 64th WMA General Assembly, Fortaleza, Brazil, October 
2013 and in accordance with the Medical Research Involving Human Subjects Act 
(WMO). 
8.2 Recruitment and consent 
Potential subjects will be informed by the treating physician about the study. All subjects 
will be handed an PIF at their intake consultation. The information letter also contains 
contact information of the coordinating investigator. If requested the (potential) subject 
could also receive additional information from the coordinating investigator (R.M Smits) or 
they will get a telephonic consultation with an onsite research nurse. Only after 
counselling and reading the additional information the (potential) subject will be asked for 
their informed consent. A consent form must be signed by both the couple as the 
physician or research nurse who provided the information. Couples will receive the 
information preferably at or before (together with appointment letter) their first 
consultation. The following consultation the subject will be asked whether he will or will 
not participate. If a patient needs more time or only has one evaluation consult in 
between IVF/ICSI treatment, they will be telephonically contacted by the onsite research 
nurse or research coordinator to ask for participation. The information letter and informed 
consent are attached.  
8.3 Objection by minors or incapacitated subjects  
Not applicable. 
8.4 Benefits and risks assessment, group relatedness 
As this study compares a food supplement with placebo, it will not impose extra risk on 
participants. Infertility is a common problem which affects many couples. Therefore 
research in order to optimize treatment is imperative.  
8.5 Compensation for injury 
The sponsor/investigator has a liability insurance which is in accordance with article 7 of 
the WMO. The sponsor (also) has an insurance which is in accordance with the legal 
requirements in the Netherlands (Article 7 WMO). This insurance provides cover for 
damage to research subjects through injury or death caused by the study. 
The insurance applies to the damage that becomes apparent during the study or within 4 
years after the end of the study. 

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8.6 Incentives  
Subject will receive no special incentives or compensation. 

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9. ADMINISTRATIVE ASPECTS, MONITORING AND PUBLICATION 
9.1 Handling and storage of data and documents 
Data will be collected in an online registration system (Castor) by the coordinating 
investigator or research nurses. Data handling will be done anonymously, with the patient 
code only available to the local investigator and the research nurse working in the local 
centre. The data will be preserved for the duration of 15 years. The handling of personal 
data complies with the Dutch Personal Data Protection Act (in Dutch: De Wet 
Bescherming Persoonsgegevens, WBP). 
9.2 Monitoring and Quality Assurance  
Monitoring will be performed in compliance with Good Clinical Practice (GCP) and other 
rules and regulations in order to achieve high quality research and secure patient safety.  
9.3 Amendments  
A ‘substantial amendment’ is defined as an amendment to the terms of the METC 
application, or to the protocol or any other supporting documentation, that is likely to 
affect to a significant degree: 
- the safety or physical or mental integrity of the subjects of the trial; 
- the scientific value of the trial; 
- the conduct or management of the trial; or 
- the quality or safety of any intervention used in the trial. 
 
All substantial amendments will be notified to the METC and to the competent authority. 
Non-substantial amendments will not be notified to the accredited METC and the 
competent authority, but will be recorded and filed by the sponsor.  
9.4 Annual progress report 
The sponsor/investigator will submit a summary of the progress of the trial to the 
accredited METC once a year. Information will be provided on the date of inclusion of the 
first subject, numbers of subjects included and numbers of subjects that have completed 
the trial, serious adverse events/serious adverse reactions, other problems, and 
amendments.  
9.5 Temporary halt and (prematurely) end of study report 
The sponsor will notify the accredited METC and the competent authority of the end of 
the study within a period of 90 days. The end of the study is defined as the last patient’s 
last visit, in case of not achieving a pregnancy this will be a telephonic consultation.  
 

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The sponsor will notify the METC immediately of a temporary halt of the study, including 
the reason of such an action. 
 
In case the study is ended prematurely, the sponsor will notify the accredited METC and 
the competent authority within 15 days, including the reasons for the premature 
termination. 
 
 Within one year after the end of the study, the investigator/sponsor will submit a final 
study report with the results of the study, including any publications/abstracts of the study, 
to the accredited METC and the Competent Authority.  
9.6 Public disclosure and publication policy 
The results will be disclosed unreservedly. The sponsor did not provide the investigators 
with any restrictions. 

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10. STRUCTURED RISK ANALYSIS  
Not applicable.  
 
 
 
 
 
 

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