# Gonadotropin preparations

Gonadotropin preparations are drugs that mimic the physiological effects of gonadotropins, used therapeutically mainly as fertility medication for ovarian hyperstimulation and ovulation induction. For example, the so-called menotropins consist of LH and FSH extracted from human urine from menopausal women. There are also recombinant variants.

## FSH and LH preparations

hMG (human Menopausal Gonadotrophins), FSH and LH prepared from human urine collected from postmenopausal women. First extracted in 1953. Injected intra-muscularily (IM) or subcutaneously (SC).
Generic
    menotropins for injections, USP
Brands
   * Menopur, 5 mL vials containing 75 IU FSH and 75 IU LH.
   * Repronex, vials containing either 75 IU FSH and 75 IU LH, or 150 IU FSH and 150 IU LH.
Common side effects of preparations containing FSH and LH are:
* Mild bloating
* Pain, swelling, or irritation injection site
* Rash at injection site or other part of body
* Stomach pain or pelvic pain

## FSH preparations

Preparations of follicle-stimulating hormone (FSH) mainly include those derived from the urine of menopausal women, as well as recombinant preparations. The recombinant preparations are more pure and more easily administered, but they are more expensive. The urinary preparations are equally effective and less expensive, but are not as convenient to administer as they are available in vials versus injection pens. One study reported that users of the purified urinary FSH preparation Bravelle experienced less injection site pain compared to the recombinant preparation Follistim.

### Urinary preparations

    Purified urinary FSH (75 IU FSH and ≤ 2 IU of LH)
       Generic
          urofollitropin for injection, purified.
       Brands
         * Bravelle, U.S., (≤ 2 IU LH)
         * Metrodin, U.S. and Canada, (≤ 1 IU LH)
         * Fertinorm Hp, (Canada)
    Highly purified urinary FSH (75 IU FSH and ≤ 0.1 IU LH/1000 IU FSH)
       Generic
          urofollitropin for injection, (highly) purified.
       Brands
          Fertinex (≤ 0.1 IU LH/1000 IU FSH)

### Recombinant preparations

    Follitropin alfa
       Generic
          Follitropin alfa injection
       Brands
          Gonal-f
          Cinnal-f
          Fertilex
          Ovaleap
          Bemfola
       Generic
          Follitropin alfa / lutropin alfa combination
       Brands
          Pergoveris
    Follitropin beta
       Generic
          follitropin beta injection
       Brands
          Follistim AQ
          Puregon
    Follitropin delta
       Generic
          follitropin delta injection
       Brands
          Rekovelle
The package insert for Gonal-f states that based on physio-chemical tests and bioassays that follitropin beta and follitropin alfa are indistinguishable. Two studies showed no difference. However, a more recent study showed there may be a slight clinical difference, with the alfa form tending towards a higher pregnancy rate and the beta form tending towards a lower pregnancy rate, but with significantly higher estradiol (E2) levels.
The package insert for Puregon states that structural analysis shows that the amino acid sequence of follitropin beta is identical to that of natural human follicle stimulating hormone (hFSH). Further, the ogliosaccharide side chains are very similar, but not completely identical to that of natural hFSH. However, these small differences do not affect the bioactivity compared to natural hFSH.
Gonal-f was approved for medical use in the European Union in October 1995.
Puregon was approved for medical use in the European Union in February 1996.
Rekovelle was approved for medical use in the European Union in December 2016.

#### Biosimilars

Ovaleap was approved for medical use in the European Union in September 2013. It was approved for medical use in Australia in March 2021.
Bemfola was approved for medical use in the European Union in March 2014.

### Side effects of FSH preparations

Side effects of FSH preparations include:
* Local irritation at the injection site
* Feeling of fullness, bloating, and tenderness in the lower abdomen due to increasing size of the ovaries.
* Mood swings
* Fatigue

## FSH analogues

Corifollitropin alfa
Merck received approval on February 15, 2010, from the European Commission for ELONVA (corifollitropin alfa) a long lasting single injection fusion protein lacking LH activity. Only one injection is required for the first seven days, replacing the first seven daily injections of conventional FSH. Initial results demonstrates similar pregnancy rates as daily recombinant FSH injections.

## LH (Luteinizing hormone) preparations

Prepared from recombinant DNA.
    Generic
       lutropin alfa for injection
    Brands
       Luveris

## hCG preparations

Human chorionic gonadotropin (hCG) can be recovered from the urine of pregnant women or be produced from recombinant DNA. It acts similarly to LH, but the larger supply makes it less costly; it also has a longer half-life. In veterinary medicine, equine chorionic gonadotropin (eCG) extracted from pregnant mare serum is used instead on a variety of mammals, sometimes eliciting an immune response in non-horse species.
In Women: Used to induce final maturation of follicle and subsequent ovulation. Also used for luteal phase support.
In men: Used to treat select cases of Hypogonadotropic Hypogonadism in adult males. In off-label use, some urologists prescribe hCG in low doses in combination with testosterone replacement to preserve fertility.
In male children: Also used to treat prepubertal cryptorchidism not due to anatomical obstruction. Therapy is usually administered between ages 4 and 9.

### Urinary preparations

Derived from the urine of pregnant women.
    Generic
       (human) chorionic gonadotropin for injection, USP
    Brands
      * Pregnyl (Merck/Schering-Plough)
      * Follutein
      * Profasi
      * Novarel

### Recombinant preparations

    Generic
       choriogonadotropin alfa for injection (recombinant human Chorionic Gonadotropin, r-hCG).
    Brands
       Ovidrel