Is in Vitro Maturation of Oocytes Influenced by the Origin of Gonadotropins Used in Maturation Medium: is There a Difference in Efficiency When Using Urinary Versus Recombinant Produced Follicle Stimulating Hormone and Human Chorionic Gonadotropin

Study Overview
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Brief Summary
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Standard IVM currently contains urinary purified hormones which might contain contaminants possibly affecting maturation of embryo development. The investigators will test if the efficiency in terms of oocyte maturation after IVM of recombinant (without contaminants) is equivalent to urinary gonadotropins. Urinary and recombinant FSH and hCG will be used in equivalent bioactivity as measured in IU/ml and specified by the manufacturer. Sibling oocytes of the patient will be subjected to IVM medium containing urinary or recombinant gonadotropins. Oocyte maturation is the primary outcome, however, fertilization rate and preimplantation embryo development will be investigated.

Detailed Description
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In vitro maturation is a valid option for PCO(S) patients in the daily ART clinic, however maturation and embryologic development are not yet matching the efficiency levels obtained by standard COS treatment (Ho et al. 2019). To further enhance embryo quality after IVM, media and supplements should be efficient, safe and pure. It has been described that a threshold of FSH activity is necessary for maturation in human IVM (Cadenas et al. 2021), but hCG might be redundant (Ge et al 2008). Until now, the investigators have been using highly purified urinary derived gonadotropins to supplement IVM media. However in the last decades more recombinant products are available and thoroughly characterized. In ART, both urinary derived and recombinant produced hormones are used to induce multiple follicle growth and ovulation in an ovarian stimulation cycle. Due to the fear of transmis-sion of pathogens (though not yet documented) and of intolerance caused by contaminants, recombinant products are often preferred in the clinic, with no indications of differences in effectiveness and safety (Nahuis 2009). In an in vitro bioassay, contaminating proteins may alter biological re-sponses with undesired effects. uFSH is documented to contain e.g. Insulin-like growth factor binding protein 1 (IGFBP7), that may inhibit oestrogen production, and Eosinophil Derived Neurotoxin (EDN), with known inhibitory effects on mouse oocyte maturation (Bassett 2009). Hence it is important in an in vitro system to use products with the highest purity available. Moreover the oligosaccharide sialylation is different depending on the production method, altering the acidity and hereby the half-life in the body, but more importantly for an in vitro system, also the receptor binding potency (Bassett 2009, Riccetti 2017). Hence, before changing our standard system for a theoretically better alternative, The investigators need to test the efficiency of recombinant hormones compared to the routinely used urinary hormones in terms of oocyte maturation efficiency in the in vitro maturation system. PCOS patients eligible for an IVM cycle to treat infertility will be included. Patients will receive a mild ovarian stimulation protocol, identical to our standard IVM care program. The investigators will conduct a non-inferiority study for oocyte maturation efficiency with a limit of 10%, significance level of 5% and power of 80%, leading to a sample size of 618 oocytes. The investigators estimate this will be obtained if 35 patients are included in the study. After OR follicle fluids containing COC are filtered over a 70µm mesh filter to eliminate contaminating blood cells and hereby visualizing the COC. The first detected COC will be transferred into a wash droplet of a 4-well dish, the second COC will be kept in the second wash droplet of the 4-well dish, … According to the randomization list, the COC in the first droplet of the 4-well dish will be allocated to the standard or experimental IVM. The randomization list is generated with www.sealedenvelope.com. Mature oocytes will be ferilized by Intracytoplasmic Sperm Injection (ICSI) and fertilization and embryological development will be recorded. Embryos of sufficient quality on day 3 will be vitrified for a deferred vitrified/warmed embryo transfer.

Official Title
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Is in Vitro Maturation of Oocytes Influenced by the Origin of Gonadotropins Used in Maturation Medium: is There a Difference in Efficiency When Using Urinary Versus Recombinant Produced Follicle Stimulating Hormone and Human Chorionic Gonadotropin

Conditions
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In Vitro Maturation of Oocytes

Intervention / Treatment
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* Drug: rhCG= Ovitrelle®, 250g/0.5ml = 26000IU/ml, Merck-Serono
* Drug: rFSH = Gonal F®, 300IU/0.5ml, Merck-Serono


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: PCO(S) patients Anti-Mullerian Hormone ≥ 3.6 ng/mL Basal Antral Follicle Count ≥ 20 All ranks of trial Exclusion Criteria: Surgically obtained semen sample Grade 3 or 4 endometriosis, minor or major uterine abnormalities Preimplantation Genetic Testing Priming with Letrozole

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 36 Years

Sexes Eligible for Study
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Female

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| standard IVM: urinary purified gonadotropins (uFSH and uhCG)<br>uhCG = Pregnyl®, 5000IU/ vial, Organon-Merck: final concentration 100mIU/ml + uFSH = Menopur® 75mIU/ml, Ferring: final concentration 75mIU/ml. Administered during 30h of in vitro maturation culture | |
| Experimental IVM: recombinant gonadotropins (rFSH and rhCG)<br>rhCG= Ovitrelle®, 250g/0.5ml = 26000IU/ml, Merck-Serono : final concentration 100mIU/ml + rFSH = Gonal F®, 300IU/0.5ml, Merck-Serono: final concentration 75mIU/ml. Administered during 30h of in vitro maturation culture | Drug: rhCG= Ovitrelle®, 250g/0.5ml = 26000IU/ml, Merck-Serono<br>* recombinant hCG<br>Drug: rFSH = Gonal F®, 300IU/0.5ml, Merck-Serono<br>* recombinant FSH<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| oocyte maturation | the ability of the oocyte to extrude the first polar body | oocyte maturation is assessed after 30 hours of in vitro maturation | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Fertilization rate | the ability of the oocyte to ba activated and form pronuclei | the presence of 2 pronuclei is assessed between 18-20 hours after ICSI | 
| morphologic parameters describing embryo quality per fertilized oocyte | embryo developmental potential as estimated by morphological characteristics: embryos with 6 cells or more, less than 20% fragmentation, cell size according to division pattern and the absence of multinucleated blastomeres are considered as good quality embryos. As secondary parameters, the presence of vacuoles or granulation in the majority of blastomeres will exclude the embryo from the 'good quality' group regardless of the earlier mentioned parameters. | embryo developmental assessment is performed 3 days after ICSI | 
| utilization rate | the embryos of sufficient quality to be vitrified for a deferred embryo transfer | utilization rate will be established 3 days after ICSI |