Double Trigger and Ovum Retrieval vs. Conventional Antagonist Ovarian Stimulation Protocol in Poor Prognosis Women Undergoing IVF/ICSI: A Pilot Randomized Study
Phase: PHASE4
Conditions: Fertility Disorders
Sponsor: CRG UZ Brussel

 
 
 
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1 
 
Study Protocol  
 
Study Title: Double trigger and ovum retrieval vs. conventional antagonist ovarian stimula- 
tion protocol in poor prognosis women undergoing IVF/ICSI: a randomized pilot study 
Study Acronym: DUOPICK 
Phase of Development: IV 
Protocol Number: 58335  
Protocol Version and Date: version 3, 03/07/2019  
EudraCT Registry Number: 2019-000971-17 
ClinicTrials.gov Registry Number: NCT03846544 
Indication: fertility disorders 
 
 
 
 
 
 
 
Investigational product: Elonva, Puregon 
 
 
 
 
 
 
 
Sponsor: UZ Brussel 
  
Coordinating/Principal Investigator: Prof. Dr. Christophe Blockeel 
 
The information contained in this document is the property of the Sponsor/Coordinating Investiga-
tor and may not be reproduced, published or disclosed to others without written authorization of 
the Sponsor/Coordinating Investigator. 
PROTOCOL SIGNATURE PAGE 
Protocol Version and date: version 3.0, 03/07/2019  
 
 
Protocol Title: Double trigger and ovum retrieval vs. conventional antagonist ovarian  
stimulation protocol in poor prognosis women undergoing IVF/ICSI: a randomized pilot  
study 
 
 
Sponsor: UZ Brussel 
 
 
 
 
 
Principal Investigator: Prof. Dr. Christophe Blockeel 
 
 
I agree: 
- 
to assume responsibility for the proper conduct of this study 
- 
to conduct the study in compliance with this protocol and any future amendments  
- 
not to implement any deviations from or changes to the protocol without prior review 
and written approval from the Ethics Committee, except where necessary to eliminate 
an immediate hazard to the subjects, or for administrative aspects of the study (where 
permitted by all applicable regulatory requirements) 
- 
that I am thoroughly familiar with the appropriate use of the investigational drug, as 
described in this protocol 

 
 
 
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- 
to ensure that all persons assisting me with the study are adequately informed about 
the investigational drug and their study-related duties and functions as described in the 
protocol 
- 
that I am aware of and will comply with the current good clinical practice (GCP) guide-
lines and ethical principles outlined in the Declaration of Helsinki 
- 
to conduct the study in accordance with all applicable laws and regulations 
 
 
 
 
 
Printed name                                                      Signature                                         Date 
 
 
 

 
 
 
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1. Table of Contents 
 
PROTOCOL SIGNATURE PAGE ................................................................................................................... 1 
1. Table of Contents ........................................................................................................................... 3 
2. Trial Registration/Protocol Summary ............................................................................................ 6 
3. Protocol Version History ................................................................................................................ 9 
4. Sponsor/Coordinating Investigator Information .......................................................................... 9 
5. List of Abbreviations ...................................................................................................................... 9 
6. Introduction .................................................................................................................................. 10 
7. Study Schematic and Schedule of Activities ............................................................................... 11 
7.1 Study Schematic ...................................................................................................................... 11 
7.2 Study Activities ........................................................................................................................ 11 
8. Study Objectives and endpoints .................................................................................................. 11 
8.1 Primary Objective ................................................................................................................... 11 
8.2 Secondary Objectives .............................................................................................................. 11 
8.3 Endpoints................................................................................................................................. 12 
9. Investigational Plan ...................................................................................................................... 12 
9.1 Overall Study Design............................................................................................................... 12 
9.2 Study Duration for Subjects .................................................................................................... 12 
9.2.1 Screening ............................................................................................................................... 12 
9.2.2 Treatment Period ................................................................................................................... 12 
9.2.3 Unscheduled Visit(s) ............................................................................................................. 12 
9.2.4 Early Study Termination ........................................................................................................ 12 
9.2.5 End of Study .......................................................................................................................... 12 
10. Selection of Subjects .................................................................................................................. 13 
10.1 Selection of Study Population ................................................................................................ 13 
10.2 Inclusion Criteria .................................................................................................................. 13 
10.3 Exclusion Criteria .................................................................................................................. 13 
10.4 Contraception/Pregnancy Avoidance ................................................................................... 13 

 
 
 
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11. Screening and Randomization ................................................................................................... 14 
11.1 Screening and Enrollment ..................................................................................................... 14 
11.2 Randomization ...................................................................................................................... 14 
11.3 Blinding Procedures .............................................................................................................. 14 
12. Interventions/Treatment ............................................................................................................ 14 
12.1 Treatments Administered ..................................................................................................... 14 
12.2 Product characteristics ......................................................................................................... 15 
12.3 Randomization and Stratification ......................................................................................... 15 
12.4 Direction of Administration .................................................................................................. 15 
12.5 Dosing Regimen .................................................................................................................... 16 
12.6 Treatment Compliance ......................................................................................................... 16 
12.7 Known Undesirable Effects of Study Drug ............................................................................ 16 
13 Study  Assessments and Procedures ............................................................................................ 18 
13.1 Study Assessments ................................................................................................................ 18 
13.1.1 Screening ............................................................................................................................. 18 
13.1.2 Baseline ................................................................................................................................ 18 
13.1.3 Treatment Period ................................................................................................................ 18 
13.1.4 Follow-Up ............................................................................................................................. 18 
13.1.5 End of Study ........................................................................................................................ 18 
13.1.6 Laboratory Evaluation ......................................................................................................... 18 
14. Safety Monitoring and Reporting ..................................................................................................... 19 
14.1 Adverse Events ...................................................................................................................... 19 
14.2 Suspected Unexpected Serious Adverse Events (SUSAR) ....................................................... 19 
14.3 Procedures for Handling Special Situations ......................................................................... 20 
14.3.1 Pregnancy ............................................................................................................................ 20 
14.3.2 Overdose Management ....................................................................................................... 20 
14.3.3 Annual Safety Report .......................................................................................................... 20 
15. Data Collection and Management ................................................................................................... 20 
15.1 Data Collection ...................................................................................................................... 20 
15.2 Database Management and Quality Control ........................................................................ 20 
15.3 Statistical Considerations and Data Analysis ....................................................................... 21 
16. Ethical Considerations ...................................................................................................................... 21 

 
 
 
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16.1 Ethical conduct of the study ................................................................................................. 21 
16.1.1 Declaration of Helsinki ....................................................................................................... 21 
16.1.2 Ethics Committee ................................................................................................................ 21 
16.2 Informed Consent.................................................................................................................. 22 
16.3 Patient and Study Data Protection ....................................................................................... 22 
16.4 Subject Identification ............................................................................................................ 23 
16.5 Conflict of Interest ................................................................................................................ 23 
17. Finance and Insurance ...................................................................................................................... 23 
18. Reporting and Dissemination .......................................................................................................... 23 
19. Conflict of interest statement .......................................................................................................... 23 
20. Tables and Figures ........................................................................................................................... 24 
21. References ......................................................................................................................................... 26 
 
 
 

 
 
 
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2. Trial Registration/Protocol Summary 
 
Information 
EudraCT number: 
Date of registration: 
2019-000971-17 
20/02/2019 
Clinical Trial  
Authorization (CTA) from 
FAMHP (FAGG) 
Date of approval: 
 
 
14/06/2019 
ClinicalTrials.gov: 
NCT03846544 
Official Title: 
Double trigger and ovum retrieval vs. conventional antagonist ovarian 
stimulation protocol in poor prognosis women undergoing IVF/ICSI: a 
randomized pilot study 
Study Phase/Type: 
IV 
Condition: 
Fertility disorders 
Objectives: 
To compare the total number of metaphase II (MII) oocytes between the 
two groups 
Investigational Product: 
Elonva , Puregon 
Interventions: 
A single injection of 150mcg of corifollitropin alfa will be admini-
strated at day 2/3 of the cycle, followed by 225IU of recombinant FSH 
(rFSH) in a fixed antagonist protocol. Cycle monitoring will be per-
formed through serum estradiol (E2), progesterone and luteinizing 
hormone (LH) assessments, and serial transvaginal ultrasound exami-
nations.The study will include exclusively patients with ≤9 follicles 
≥11 mm on the day of triggering. Therefore, patients will be randomly 
allocated in two groups: Group A (control group) will undergo conven-
tional triggering with hCG 5000 IU and a single oocyte retrieval (OR) 
will be performed 36 hours later; Group B (study group) will undergo 
triggering with GnRHa 0,2ml and a first OR will be performed 36 
hours later. In both groups, triggering will be formed if two or more 
follicles ≥17 mm are observed and all follicles >10 mm will be aspi-
rated, in line with current clinical practice (Nivet et al., 2016). In Group 

 
 
 
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B (study group), 225 IU of rFSH will continue after the first trigger. An-
tagonist administration will be initiated when at least one follicle 
measuring ≥14 mm will be present in the ultrasound. If one or more 
follicles ≥17 mm are observed, patients will undergo a second trigger-
ing with hCG 5000 IU and a second OR will be performed. In case of 
patients with no follicular development following 13 additional days of 
rFSH, the cycle will be cancelled. Metaphase II (MII) oocytes will then 
be injected according to standard ICSI procedure. In the control group 
a fresh single/double embryo transfer will be performed according to 
clinical practice (day 3 or day 5). For the study group, a freeze-all 
strategy will be applied, followed by a transfer of a maximum two em-
bryos in an artificially prepared frozen-thawed cycle. 
Endpoints: 
 
Number of MII oocytes 
 
Number of COCs 
 
Number of preovulatory follicles 
 
Number of oocytes fertilized 
 
Number of available embryos and their quality 
 
Duration of stimulation 
 
Total dose of gonadotropins administered 
 
Clinical pregnancy and live birth rates of the first frozen cycle 
 
Cumulative live birth rates 
Study population: 
Infertile patients 
Number of patients: 
46  
Overview of  
study design: 
Single center randomized superiority pilot study 
Statistical  
Considerations: 
Our sample size of 46 patients (23 per group) has a power of at least 
90% to detect superiority of the double trigger group (mean 5.4 MII) 
versus control group (mean 3.4 MII), standard deviation (SD=2), using a 
two-sided, t test, at significance level alpha of 0.05 
Sponsor: 
UZ Brussel 
Country(ies) of  
Recruitment: 
 
Belgium 
Inclusion Criteria: 
 
Age ≥ 25 - ≤ 40  
 
BMI ≤ 35 and ≥ 19 

 
 
 
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 
Antimüllerian hormone (AMH) level of ≤1.5 ng/mL or antral fol-
licular count of ≤6 follicles or ≤5 oocytes retrieved in a previous 
cycle following standard conventional ovarian stimulation. 
 
Normal basal ultrasound < 6 months before the start of the treat-
ment (presence of uterus and two ovaries without proof of ab-
normalities) 
 
Signed informed consent 
Exclusion Criteria: 
 
Testicular sperm extraction 
 
History of > 3 three consecutive previous unsuccessful IVF 
      cycles 
 
Use of oral contraceptives <3 months before start of the treat-
ment 
 
PCOS according to the Rotterdam criteria 
 
Ovarian stimulation for pre-implantation genetic testing 
      (PGT-A/M) 
 
Medical/social freezing 
 
History of untreated autoimmune, endocrine or metabolic 
      disorders 
 
Ovarian cystectomy or oophorectomy 
 
Patients will be allowed to participate in the study only once. 
Date of first  
enrolment: 
September 2019 
Target sample size: 
46 
 
 
 
 
 

 
 
 
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3. Protocol Version History 
 
Version No. 
Approval Date Lead EC 
Release Date 
1.0 
 
 
 
 
 
 
 
 
 
4. Sponsor/Coordinating Investigator Information 
 
Coordinating Investigator: Prof. Dr. Christophe Blockeel 
Sponsor: UZ Brussel 
Principal Investigator: Prof. Dr. Christophe Blockeel 
Co-investigators: Prof. Dr. Panagiotis Drakopoulos, Dr. Liese Boudry 
Statistician : Prof. Dr. Panagiotis Drakopoulos 
 
 
 
 
Laboratory: UZ Brussel 
Pharmacy: UZ Brussel 
 
 
 
 
  
Study Coordinator: Elsie Nulens, CRG UZ Brussel 
Study sites and co-investigators: CRG-UZ Brussel 
5. List of Abbreviations 
 
ADR 
Adverse drug reaction 
AMH 
Anti-müllerian hormone 
ART 
Assisted reproductive technologies 
BMI 
Body mass index 
CI 95%  
Confidence Interval 95%  
CC 
Cumulus cells 

 
 
 
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COC 
Cumulus oocyte complexes 
COH 
Controlled ovarian hyperstimulation 
 E2 
Oestradiol  
hCG 
Human chorionic gonadotropin 
FF 
Follicular fluid 
FSH 
Follicle stimulating hormone 
GnRH 
Gonadotropin releasing hormone 
IU 
International units 
Infertility 
The incapacity to conceive after 12 months of 
unprotected intercourse 
IVF/ICSI 
In vitro fertilization/Intra-cytoplasmic sperm 
injection 
IVM 
In vitro maturation 
LH 
Luteinizing hormone 
MII 
Metaphase II oocytes 
OHSS 
Ovarian hyperstimulation syndrome 
OR/OPU 
Oocyte retrieval/ovum pick up 
PGT-A/M 
Pre-implantation genetic testing for aneu-
ploidy/monogenic disorders 
RCT 
Randomised Controlled Trial 
rFSH 
Recombinant follicle stimulating hormone 
6. Introduction 
 
Controlled ovarian hyperstimulation (COH) has been established as a prerequisite in assisted re-
production technologies (ART), as it induces multifollicular development, resulting in a higher 
number of oocytes retrieved. The rationale is that an increase in the number of oocytes harvested 
could yield more available embryos, providing higher cumulative live birth rates in infertile pa-
tients (Drakopoulos et al., 2016). 
On the other hand, multiple major and minor waves in follicular development have been described 
during the intraovulatory period of healthy women (Baerwald et al., 2003). It seems plausible that 
ovarian stimulation does not take full advantage of the whole follicular cohort as even small folli 

 
 
 
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11 
cles (10-14 mm in the study by Nivet et al (Nivet et al., 2016); 8-12 mm in the study by Wirleitner 
et al (Wirleitner et al., 2018) have been shown to produce transferable embryos and viable preg-
nancies (Nivet et al., 2016; Wirleitner et al., 2018). 
However, aspiration of small follicles may not be the optimal strategy to take full advantage of the 
whole follicular cohort: in fact, aspiration of small follicles yields significantly lower oocyte recov-
ery rates and proportion of transferable embryos compared with medium and large follicles (Nivet 
et al., 2016).  
Thus, prolonging COH after the first ovarian aspiration and performing a second egg retrieval 
when small follicles have reached a medium/large size might increase the number of oocytes har-
vested and provide more available embryos. 
7. Study Schematic and Schedule of Activities 
 
7.1 Study Schematic 
 
This is a prospective superiority randomized pilot study which will be performed at UZ Brussel 
 
7.2 Study Activities 
 
The total duration of the study will be approximately 1.5 years 
The duration of treatments is per investigators’ judgment. 
Number of patients included: A total number of 46 women will be analyzed 
8. Study Objectives and endpoints 
 
8.1 Primary Objective 
 
The primary objective measure will be to compare the total number of metaphase II (MII) oocytes 
between the two groups. 
 
8.2 Secondary Objectives 
 
Secondary objectives will be to compare the total number of available embryos, number of cumu-
lus oocyte complexes (COCs) retrieved, number of oocytes fertilized, duration of stimulation, total 
dose of gonadotropins administered, clinical pregnancy and live birth rates of the first frozen cycle 
and cumulative live birth rates (defined as the first live birth following the transfer of fresh and 
subsequent frozen-thawed embryos) between the two groups. A cost-effectiveness analysis will be 
performed in case of superiority of the double trigger group. 
 

 
 
 
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8.3 Endpoints 
 
 
Number of MIIs 
 
Number of COCs 
 
Number of available embryos 
 
Number of oocytes fertilized 
 
Duration of stimulation 
 
Total dose of gonadotropins administered 
 
Clinical pregnancy and live birth rates of the first frozen cycle 
 
Cumulative live birth rates 
9. Investigational Plan 
 
9.1 Overall Study Design 
 
Single center randomized pilot study  
 
9.2 Study Duration for Subjects 
 
9.2.1 Screening 
 
Following first infertility consultation 
 
 
9.2.2 Treatment Period 
 
Approximately 2-3 weeks 
 
9.2.3 Unscheduled Visit(s) 
 
N/A 
9.2.4 Early Study Termination 
 
N/A 
 
9.2.5 End of Study 
 
July 2020 (anticipated) 
 

 
 
 
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10. Selection of Subjects 
 
10.1 Selection of Study Population 
 
The study will include all consecutive infertile women who attend our center, fulfill the inclusion 
criteria and consent to participate. 
 
10.2 Inclusion Criteria  
 
The study will include normo-ovulatory patients with the following criteria: 
 
Age ≥ 25 and ≤ 40 age  
 
BMI ≤ 35 and ≥ 19 
 
Antimüllerian hormone (AMH) level of ≤1.5 ng/mL or antral follicular count of ≤6 follicles 
or ≤5 oocytes retrieved in a previous cycle following standard conventional ovarian stimula-
tion. 
 
Normal basal ultrasound < 6 months before the start of the treatment (presence of uterus 
and two ovaries without proof of abnormalities) 
 
Signed informed consent 
 
10.3 Exclusion Criteria 
 
The exclusion criteria will be:  
 
Testicular sperm extraction 
 
History of more than three consecutive previous unsuccessful IVF/ICSI cycles 
 
Use of oral contraceptives <3 months before start of the treatment 
 
PCOS  according to the Rotterdam criteria 
 
Ovarian stimulation for pre-implantation genetic testing 
      (PGT-A/M) 
 
Medical/social freezing 
 
History of untreated autoimmune, endocrine or metabolic disorders, 
 
Ovarian cystectomy or oophorectomy 
 
Patients will be allowed to participate in the study only once. 
 
 
10.4 Contraception/Pregnancy Avoidance 
N/A 
 
 
 

 
 
 
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11. Screening and Randomization 
 
11.1 Screening and Enrollment 
 
A responsible investigator will identify potential eligible women for this study. They will be 
screened and documented as eligible submitted to inclusion criteria. The investigator will 
obtain informed consents for participation in the study using local IRB approved informed 
consent forms. Consent will be obtained at the follow up consultation 
 
11.2 Randomization 
 
This is a prospective superiority randomized pilot study. Patients will be randomized to either con-
trol group (Group A) or double trigger group (Group B), on the day of triggering, only after patient 
eligibility has been established and patient consent has been obtained. Randomization sequence 
and allocation will be created using a computer-generated randomization list, using 1:1 allocation. 
 
11.3 Blinding Procedures 
 
Clinicians who will perform the oocyte retrievals and embryologists will be blinded. 
12. Interventions/Treatment 
 
12.1 Treatments Administered 
 
A single injection of 150mcg of corifollitropin alfa will be administrated at day 2/3 of the cycle, 
followed by 225IU of recombinant FSH (rFSH) in a fixed antagonist protocol. Cycle monitoring will 
be performed through serum estradiol (E2), progesterone and luteinizing hormone (LH) assess-
ments, and serial transvaginal ultrasound examinations. The study will include exclusively patients 
with ≤9 follicles ≥11 mm on the day of triggering. Therefore, patients will be randomly allocated in 
two groups: Group A (control group) will undergo conventional triggering with hCG 5000 IU and a 
single oocyte retrieval (OR) will be performed 36 hours later; Group B (study group) will undergo 
triggering with GnRHa 0,2ml and a first OR will be performed 36 hours later. In both groups, trig-
gering will be performed if two or more follicles ≥17 mm are observed and all follicles >10 mm will 
be aspirated, in line with current clinical practice (Nivet et al., 2016). In Group B (study group), 225 
IU of rFSH will continue after the first trigger. Antagonist administration will be initiated when at 
least one follicle measuring ≥14 mm will be present in the ultrasound. If one or more follicles ≥17 
mm are observed, patients will undergo a second triggering with hCG 5000 IU and a second OR will 
be performed. In case of patients with no follicular development following 13 additional days of 
rFSH, the cycle will be cancelled. Metaphase II (MII) oocytes will then be injected according to stand-
ard ICSI procedure. In the control group a fresh single/double embryo transfer will be performed 

 
 
 
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according to clinical practice (day 3 or day 5). For the study group, a freeze-all strategy will be 
applied, followed by a transfer of a maximum two embryos in an artificially prepared frozen-thawed 
cycle (overview of all procedures: tables and figures, fig.2). 
 
12.2 Product characteristics  
 
Elonva (corifollitropin alfa) 150 µg 
Each pre-filled syringe contains 150 micrograms of corifollitropin alfa in 0.5 mL solution for injec-
tion. Elonva is indicated for Controlled Ovarian Stimulation (COS) in combination with a Gonadotro-
pin Releasing Hormone (GnRH) antagonist for the development of multiple follicles in women par-
ticipating in an Assisted Reproductive Technology (ART) program 
 
Puregon (follitropine beta) 225 IU 
One vial contains 225 IU of Puregon. The solution for injection contains the active substance folli-
tropin beta. Puregon is indicated for the treatment of female infertility in the following clinical situ-
ations: 
- Anovulation (including polycystic ovarian syndrome, PCOS) in women who have been 
unresponsive to treatment with clomifene citrate. 
- Controlled ovarian hyperstimulation to induce the development of multiple follicles in 
medically assisted reproduction programs [e.g. in vitro fertilisation/embryo transfer (IVF/ET), gam-
ete intra-fallopian transfer (GIFT) and intracytoplasmic sperm injection (ICSI)]. 
 
 
12.3 Randomization and Stratification 
 
Patients will be randomized to either control group (Group A) or double trigger group (Group B), on 
the day of triggering, only after patient eligibility has been established and patient consent has been 
obtained. Only patients with ≤ 9 follicles of ≥ 11mm will be included. Randomization sequence and 
allocation will be created using a computer generated randomization list, using 1:1 allocation. 
 
 
 
12.4 Direction of Administration 
 
Elonva (corifollitropine alfa) and Puregon (follitropine beta) 
To prevent painful injections and minimize leakage from the injection site the medication should be 
slowly administered subcutaneously (or intramuscularly). The subcutaneous injection site should be 
alternated to prevent lipoatrophy. Any unused solution should be discarded. 
Subcutaneous injections may be carried out by patient or partner, provided that proper instructions 
are given by the physician. Self-administration should only be performed by patients who are well-
motivated, adequately trained and with access to expert advice. 

 
 
 
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12.5 Dosing Regimen 
 
Dosage of Elonva (corifollitropine alfa) is 150 µg and is fixed. Puregon (follitropine beta) 225 IU is 
started after the first week of stimulation.  
 
 
12.6 Treatment Compliance 
 
Self-administration will be performed after adequate training of the patient.  
 
12.7 Known Undesirable Effects of Study Drug 
 
Elonva® and Puregon® have the following side effects:  
OHSS (ovarian hyperstimulation syndrome) 
OHSS is a medical event distinct from uncomplicated ovarian enlargement. Clinical signs and symp-
toms of mild and moderate OHSS are abdominal pain, nausea, diarrhoea, mild to moderate enlarge-
ment of ovaries and ovarian cysts. Severe OHSS may be life-threatening. Clinical signs and symptoms 
of severe OHSS are large ovarian cysts, acute abdominal pain, ascites, pleural effusion, hydrothorax, 
dyspnoea, oliguria, haematological abnormalities and weight gain. In rare instances, venous or ar-
terial thromboembolism may occur in association with OHSS. Transient liver function test abnormal-
ities suggestive of hepatic dysfunction with or without morphologic changes on liver biopsy have 
also been reported in association with OHSS. 
Women with known risk factors for a high ovarian response may be especially prone to the develop-
ment of OHSS during or following treatment with Puregeon. For women having their first cycle of 
ovarian stimulation, for whom risk factors are only partially known, close observation for early signs 
and symptoms of OHSS is recommended. 
To reduce the risk of OHSS, ultrasonographic assessments of follicular development should be per-
formed prior to treatment and at regular intervals during treatment. The concurrent determination 
of serum oestradiol levels may also be useful. In ART there is an increased risk of OHSS with 18 or 
more follicles of 11 mm or more in diameter. When there are 30 or more follicles in total it is advised 
to withhold hCG administration. 
The chance of having a side effect is described by the following categories:  
Common (may affect up to 1 in 10 women)  
 
- 
Ovarian hyperstimulation syndrome (OHSS)  
- 
Pelvic pain  
- 
Feeling sick (nausea)  
- 
Headache  
- 
Tiredness (fatigue)  
- 
Pelvic discomfort  

 
 
 
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- 
Breast  
 
Uncommon (may affect up to 1 in 100 women)  
 
- 
Ovarian torsion (twisting of the ovary resulting in extreme lower stomach pain)  
- 
Liver enzyme increases  
- 
Miscarriage  
- 
Pain after oocyte retrieval  
- 
Procedural pain  
- 
Releasing an egg too early (premature ovulation)  
- 
Abdominal distension  
- 
Vomiting  
- 
Diarrhoea  
- 
Constipation  
- 
Back pain  
- 
Breast pain  
- 
Bruising or pain at the injection site  
- 
Irritability  
- 
Mood swings  
- 
Dizziness  
- 
Hot flush 
 
Not known (cannot be estimated from available data)  
 
- 
Allergic reactions (hypersensitivity reactions, both local and generalized, including  
rash).  
- 
Pregnancy outside the uterus (an ectopic pregnancy) and multiple pregnancies have  
also been reported. These side effects are not considered to be related to the use of cori-
follitropin alfa, but to Assisted Reproductive Technology (ART) or subsequent pregnancy.  
- 
In rare instances, blood clots (thrombosis) that formed inside a blood vessel, broke off, and 
travelled inside the bloodstream to block another blood vessel (thromboembolism) have 
been associated with Corifollitropin alfa therapy as with other gonadotropins. 
 
 
 
 
 
 
 
 
 

 
 
 
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13. Study Assessments and Procedures 
 
13.1 Study Assessments 
 
13.1.1 Screening 
 
A responsible investigator will identify potential eligible women for this study. They will be screened 
and documented as eligible submitted to inclusion criteria. The investigator will obtain informed 
consents for participation in the study using local IRB approved informed consent forms. 
 
13.1.2 Baseline 
 
A normal baseline ultrasound (<6 months before starting) has to be available before inclusion in the 
trial.   
Before starting treatment, the hormonal profile will be checked with a blood analysis, performed on 
day 2 or 3 of the menstrual cycle. 
 
13.1.3 Treatment Period 
 
The duration of the treatment itself will depend on every patient’s response. The frequency of further 
follow-up visits with endocrine monitoring and ultrasound is individualized and is based on the 
growth of the follicles. 
 
13.1.4 Follow-Up 
 
Follow-up in case of pregnancy will be planned until 7-8 weeks of amenorrhea. From that moment 
patients are referred to their treating obstetrician. Information on the pregnancy and delivery will 
be collected once available. 
 
13.1.5 End of Study 
 
46 patients (23 in each group) need to be included. 
 
13.1.6 Laboratory Evaluation  
 
Blood samples 

 
 
 
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During the course of the treatment, several blood samples will be taken. All of them are collected in 
order to evaluate the hormonal profile and the response to ovarian stimulation (LH, FSH, E, P).  
Furthermore, follow-up with hCG will take place 12 days after the embryo transfer (overview of all 
additional blood samples: tables and figures, fig.2) 
 
Follicular fluid and cumulus cells 
In both groups, measurement (mean diameter) of all aspirated follicles will be performed on the day 
of the first and second OR (for group B). At each OPU, the follicles will be individually aspirated and 
searched for the presence of COCs. All oocytes will be further cultured separately, therefore allowing 
individual tracing of the oocyte and its correspondent embryo. The correlation between the follicular 
size and the embryological/reproductive outcome will be further evaluated. In addition, from each 
individual follicle two samples will be collected i) follicular fluid (FF) and ii) cumulus cells (CC) from 
the corresponding COC. The COCs will be individually collected and denuded before ICSI. The CCs 
obtained after denudation will be individually collected in cryo-vials and labelled with the same iden-
tification code as the FF from where the COC was recovered. The FF and CC samples will be kept at 
-196 or -80°C. Both CC and FF are in the standard procedure not used for the patient and are there-
fore considered waste material. The CC and FF will be analysed in a later stage. 
14. Safety Monitoring and Reporting  
 
14.1 Adverse Events  
 
An AE is any untoward medical occurrence in a patient participating in a trial. It includes: 
 
Any laboratory abnormality, vital sign or finding from physical or gynaecological examina-
tion assessed as clinically significant by the investigator (note: findings from assessments 
and examinations done during screening are not adverse events, but are recorded as medi-
cal history). 
 
Accidental injuries, reasons for any change in medication (drug and/or dose), reasons for 
any medical, nursing or pharmacy consultation, or reasons for admission to hospital or sur-
gical procedures. 
 
14.2 Suspected Unexpected Serious Adverse Events (SUSAR) 
 
All adverse drug reactions (ADR) to gonadotropins, whether serious or non-serious, are to be cap-
tured in the consultations and investigator must record the ADRs in the ADR Log provided in each 
patient’s consultations with information about:  
 
Adverse Drug Reaction  
 
Date and time of onset  
 
Intensity  
 
Action taken to  

 
 
 
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 
Other action taken  
 
Date and time of outcome  
 
Outcome  
 
Seriousness criteria if applicable  
 
Short description of ADR (if not serious)  
 
 
14.3 Procedures for Handling Special Situations 
 
14.3.1 Pregnancy 
 
The first blood test that will be performed on day 2 or 3 of the menstrual cycle will also include 
the hCG in order to detect possible pregnancies before starting the treatment. Patients with a posi-
tive pregnancy test will be excluded from the trial. 
 
14.3.2 Overdose Management 
 
Patients that will use more medications than the one suggested will be monitored in their referral 
centre with blood test and ultrasound; although, there are no specific side effects due to the over-
dose of these medications 
 
14.3.3 Annual Safety Report 
 
An annual safety report will be prepared with all the new information and the notifications that the 
patients will provide within the study period. 
15. Data Collection and Management 
 
15.1 Data Collection 
 
Data will be collected in a secure and encrypted eCRF created specifically for the trial using Fi-
lemaker Pro® version 13 (Filemaker Inc.) hosted on a dedicated server at the CRG-UZ Brussel. 
 
15.2 Database Management and Quality Control  
 
The database has inbuilt validation procedures to ensure the correct introduction of data and 
avoid cases of missing information where such is not applicable. The doctors, study nurses and 
research assistants collaborating in the trial will be responsible for the data collection. Data will be 
stored for 10 years.  
No data safety monitoring board will be established.  

 
 
 
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21 
The results of the study will be publicly disseminated following submission in peer-reviewed scien-
tific journals. 
 
15.3 Statistical Considerations and Data Analysis 
 
Analyses were performed in intent-to-treat fashion and per-protocol. Consequently, in the intention-
to-treat analysis, all patients will be included in the final analysis as long as after fulfillment of the 
inclusion criteria they were randomly allocated to one of the treatment groups, whereas the per-
protocol analysis will include only those patients who completed the treatment originally allocated. 
Continuous data will be presented as mean ± SD or median [range] and categorical data will be 
described by number of cases, including numerator and denominator, and percentages, in line with 
the CONSORT statement (www.consort-statement.org). Categorical data and continuous data that 
do not show a normal distribution will be analyzed by Pearson's χ2test/Fisher exact test or Mann-
Whitney`s U test as appropriate. 
The normality of the distributions will be assessed with Kolmogorov-Smirnov’s test and graphical 
methods. All tests will be two-sided. Differences will be considered as statistically significant if the 
null hypothesis could be rejected with >95% confidence (p<0.05). All tests will be performed with 
the STATA version 13.  
 
Power/Sample Size: 
Our sample size of 46 patients (23 per group) has a power of at least 90% to detect superiority of 
the double trigger group (mean 5.4 MII) versus control group (mean 3.4 MII), standard deviation 
(SD=2), using a two-sided, t test, at significance level alpha of 0.05.  
16. Ethical Considerations 
 
16.1 Ethical conduct of the study 
 
16.1.1 Declaration of Helsinki 
 
The study protocol will follow the ethical principle established in the declaration of Helsinki. 
 
 
16.1.2 Ethics Committee 
 
The protocol will be submitted to the local Ethics Committees of Universitair Ziekenhuis Brussel. 
Strict confidentiality of all personal and research data will be ensured.  
No specific reimbursement will be given to patients participating in the study. 
 

 
 
 
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22 
16.2 Informed Consent 
 
The informed consents were written in Dutch, French and English. 
 
 
16.3 Patient and Study Data Protection  
 
Participation in this study is voluntary and women are free to withdraw from the study at any time 
and for any reason without prejudice. 
All information about the treatment received during the study remains confidential.  
The subjects name and any data related to her identity will not be disclosed when the results of the 
study will be published for scientific purposes.  
Access to the medical record and information obtained regarding participation in the trial will be 
limited to the study staff, the Ethics Committee and the health authorities.  
The investigator will never reveal the subjects name in the context of a publication or conference 
but he/she will also encode (the identity will be replaced by an ID code in the study) the data before 
sending them to the manager of the database of collected data. The investigator and his/her team 
will therefore be the only ones to be able to establish a link between the data transmitted throughout 
the study and the medical records. For the study data manager designated by the head investigator, 
the data transmitted will not allow the subject to be identified. The latter is responsible for collecting 
the data gathered by all investigators taking part in the study, processing them and protecting them 
in accordance with the requirements of the Belgian law on the protection of privacy and by the law 
on patient’s rights of 22 August 2002.  
The new European General Data Protection Regulation (GDPR), in force since 25 May 2018, imposes 
additional requirements on how companies or organizations may use personal data. One of these 
requirements is that the data controller provides the following information.  
As also indicated in the informed consent form, personal data are collected in the context of the 
investigation in which the subject participates. The sponsor is responsible for the correct processing 
and the information obligation that goes with it.  
In addition to the personal data, such as data on age and sex, 'special categories' of personal data 
are also collected (such as ethnic background, state of health and medical conditions, including 
medical history, treatments and response to treatments, biological samples, e.g. blood samples, 
tissue, and the results of their analysis, medical imagery, e.g. scans, x-rays, and the results of their 
evaluation).  
Of course, personal data may only be used for the scientific research purposes described in the form 
for informed consent.  
The data may be accessed by persons located in countries that do not use the same standards of 
legal data protection as the EU. The conditions of the European and Belgian legislation on the pro-
tection of personal data must be respected.  
In accordance with the relevant legislation, the data collected as part of the research will be kept for 
at least 20 years, or 30 years if these data are also part of the medical file.  

 
 
 
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23 
According to the GDPR, the subject has a number of rights regarding the processing of the data. If 
any further questions about this, the subject can always contact the investigator.  
The data protection officer of the research department is also available for contact details: DPO (data 
protection officer) via dpo@vub.be The subject also has the right to submit a complaint about how 
the information is handled. This can be done with the Belgian supervisory authority responsible for 
enforcing data protection legislation. 
 
16.4 Subject Identification  
 
Every woman will be identified by a study specific subject number. 
 
 
16.5 Conflict of Interest 
 
There are no conflicts of interest to declare. 
 
17. Finance and Insurance 
 
If the patient will decide to take part in this study, this will not involve any extra costs for her or her 
insurer. The additional costs of the study (extra medication for prolonged stimulation, ovum pick-
up, additional sampling) will be covered by founding from MSD.  
Any participation in a clinical study involves a risk, however small it is. Even if there is no fault, the 
investigator accepts responsibility for damage caused to the participant (or in the event of death, 
his/her dependents) and directly or indirectly linked to his/her participation in the study. The spon-
sor has taken out insurance for this responsibility. 
18. Reporting and Dissemination 
Missing efficacy and safety outcomes will be considered as negative, regardless of the cause which 
may justify the lack of said information (e.g. cycle cancelled due to the survival after warming of 
no embryo or loss to follow-up). These patients will be included in the analysis following the ITT 
principle. 
 
19. Conflict of interest statement 
This study is financially supported by MSD.  
None of the other investigators have conflict of interest to declare. 

 
 
 
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24 
 
20. Tables and Figures 
 
Fig. 1 study design 
 
 
Table 1: Summarizing table of all investigations and procedures 
Group A (control group) 
Day 2 of the 
cycle 
Day 8 of the 
stimulation 
Every 1 or 
2 days 
Final 
maturation 
trigger 
Ovum 
pick-up*  
Day 3 or 5 
after egg 
retrieval 
12 days after 
embryo transfer 
Informed consent 
x 
 
 
Inclusion/ 
exclusion criteria 
x 
x 
 
Infertility/ 
menstrual/ 
reproductive 
history 
x 
 
 
Blood sample for 
endocrine 
monitoring (LH, 
FSH, estradiol, 
progesteron) 
x 
x 
x 
 
x 
Ultrasound with 
follicle 
measurement 
x 
x 
 
 
Embryo transfer 
 
 
x 
Blood sample for 
pregnancy 
hormone (hCG) 
 
 
x 
 
(*) with collection of follicular fluid and cumulus cells 

 
 
 
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25 
Group B (study group) 
Day 2 of 
the cycle 
Day 8 of 
the 
stimulatio
n 
Every 1 
or 2 
days 
Final 
maturatio
n trigger 
1st Ovum pick-
up*  
with freezing 
of 
all embryos 
4 days after 
first pick-up 
and 3-4 times 
after that 
2nd Ovum 
pick-up* 
with 
freezing of 
all embryos 
In the 
next cy-
cle 
Informed consent 
x 
 
 
 
 
 
Inclusion/ 
exclusion criteria 
x 
 
 
x 
 
 
 
Infertility/ 
menstrual/ 
reproductive 
history 
x 
 
 
 
 
 
Blood sample for 
endocrine 
monitoring (LH, 
FSH, estradiol, 
progesteron) 
x 
x 
x 
 
x 
x 
x 
 
Ultrasound with 
follicle 
measurement 
x 
x 
 
 
x 
 
 
Embryo transfer 
 
 
 
 
 
 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
(*) with collection of follicular fluid and cumulus cells 

 
 
 
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26 
 
21. References 
 
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Drakopoulos, P., Blockeel, C., Stoop, D., Camus, M., de Vos, M., Tournaye, H., et al. (2016). Conven-
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need to maximize cumulative live birth rates after utilization of all fresh and frozen embryos? 
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Humaidan, P., Polyzos, N.P., Alsbjerg, B., Erb, K., Mikkelsen, A.L., Elbaek, H.O., et al. (2013). GnRHa 
trigger and individualized luteal phase hCG support according to ovarian response to stim-
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Nivet, A.L., Leveille, M.C., Leader, A., and Sirard, M.A. (2016). Transcriptional characteristics of dif-
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Papanikolaou, E.G., Pozzobon, C., Kolibianakis, E.M., Camus, M., Tournaye, H., Fatemi, H.M., et al. 
(2006). Incidence and prediction of ovarian hyperstimulation syndrome in women undergo-
ing gonadotropin-releasing hormone antagonist in vitro fertilization cycles. Fertil Steril 85(1), 
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Wirleitner, B., Okhowat, J., Vistejnova, L., Kralickova, M., Karlikova, M., Vanderzwalmen, P., et al. 
(2018). Relationship between follicular volume and oocyte competence, blastocyst develop-
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