Conditions: Infertility
Keywords: Infertility In vitro fertilization IVF
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 105
Healthy volunteers: yes

Brief summary:
This is a randomized, double-blind, single center clinical trial study to compare oocyte competence and risk of ovarian hyperstimulation syndrome (OHSS) after receiving the standard dose of human chorionic gonadotropin (hCG) ovulation trigger or a lower dose of hCG plus concomitant follicle stimulating hormone (FSH) co-trigger in women undergoing in vitro fertilization (IVF).

Detailed description:
The success rate of assisted reproductive technology (ART) has dramatically increased due to the improvements in embryo culture, laboratory conditions, and optimization of different ovarian stimulation protocols. Recent data shows that if hCG is not administered for oocyte maturation, severe OHSS is very rare. However, with gonadotropin releasing hormone (GnRH) agonist cycles, hCG is required. Previous studies have revealed that a smaller dose of hCG used for ovulation trigger versus the standard dose can have the same effect on the induction of final oocyte maturation and can possibly reduce the risk of OHSS . However, the minimal dose required of hCG to maintain maximal success rates of IVF is not known as it has not been adequately studied in randomized controlled trials. Interestingly, our previous randomized controlled study revealed that concomitant administration of FSH and hCG (10,000 IU), a more physiological process, improved developmental oocyte competence. In that study, there was no OHSS in the group that received the FSH co-trigger. A subsequent study performed a randomized trial to determine if FSH co-trigger reduced the incidence of OHSS and found that, it may prevent OHSS. Additionally, our own clinical experience (unpublished data) reveals that administering 1,500 IU hCG plus 450 IU FSH co-trigger is enough to promote adequate (i.e. non-inferior) oocyte maturation while not increasing the risk of developing OHSS in high risk patients. Given these findings, we propose a further modification of ovulation trigger with decreased exposure to hCG. Our objective is to determine if concomitant administration of FSH with a decreased dose of hCG versus a standard dose of hCG alone for ovulation will promote adequate oocyte maturation and quality, while decreasing the risk of OHSS. The selected FSH dose of 450 IU is thought to parallel the physiologic FSH surge observed in a natural cycle. We have chosen 1,500 IU as the designated low dose of hCG based on previous studies showing that even hCG doses as low as 2,000 IU allows oocytes to undergo maturation as well as our own clinical experience that has demonstrated adequate oocyte maturity and fertilization in patients chosen to receive 1,500 IU of hCG, due to the risk of OHSS.

Study participants will be recruited from the Reproductive Endocrinology and Infertility Clinic at University of California at San Francisco Center for Reproductive Health. Couples undergoing IVF will be offered participation in the study.

Approximately 100 subjects will be randomized at the time of enrollment to receive either the standard dose of hCG alone or low dose hCG (1,500 IU) + FSH (450 IU) for oocyte maturation trigger by the research coordinator. There will be about 50 subjects in each study arm.

Each subject will undergo a standard IVF stimulation protocol chosen by their primary physician. Study participants will receive a syringe (prepared by the research coordinator) on the day of ovulation trigger containing either the standard dose of hCG or low dose hCG + FSH according to the randomization. The subjects will be triggered with the following:

1. Control arm: Standard dose of hCG (10,000 or 5,000 IU) or
2. Experimental arm: hCG 1,500 IU SQ + FSH 450 IU SQ.

For the control arm, the standard hCG dose will be given based on the estradiol (E2) level. If the E2 level is less than 3,500 pg/ml then we will trigger with 10,000 IU of hCG. If the E2 level is more than 3,500 pg/ml but less than 5,000 pg/ml then we will trigger with 5,000 IU.

Interventions to prevent OHSS in high risk patients:

Any patients in either arm with an E2 serum level \>5,000 pg/ml on the day of expected trigger administration will be excluded from the study. These patients will be individually assessed by their primary physician. Their primary physician will decide the safest trigger option based on the patient's risk of OHSS. From our own clinical experience, we expect that \<5% of subjects will have an E2 serum level of \>5,000 pg/ml and be excluded.

The hCG and FSH trigger shots for each patient will be prepared by one unblinded physician the same day the patient will administer the medications. The subjects will self-administer the ovulation trigger at the designated time given by the primary physician.

The oocyte retrieval will be performed 36 hours after the oocyte maturation trigger. All egg retrievals will be performed using transvaginal ultrasound and the associated needle guide in the standard fashion. Both the physician and the laboratory personnel will be blinded to the study. All visible follicles will be aspirated. The first follicle from each ovary on every patient will be aspirated and the system (needle and tubing) will be flushed into a separate tube prior to aspirating the remaining follicles so that direct correlation of follicular size to oocyte recovery maturation, and embryo development can be separately assessed. Additionally, the follicular fluid from the first aspirate will be collected for future hormone assays. Oocyte stripping will be performed under the standard protocol. The status of oocyte maturation at the time of stripping (approximately 38-40 hours after hCG administration) and at the end of the intracytoplasmic sperm injection (ICSI) procedure (approximately 40-42 hours after hCG administration) will be recorded. Fertilization will be assessed 16-19 hours after insemination. The embryos will be transferred to growth media and cultured with standard protocols.

Subjects will return 12 hours after trigger (T+1), at oocyte retrieval (T+2), and 5 days after trigger (T+5) to assess serum levels of estradiol, progesterone, hCG, FSH, LH, and vascular endothelial growth factor (VEGF), as appropriate, based on the study visit day.

To assess the incidence of OHSS, patients will be evaluated objectively by a change in the abdominal circumference as well as subjectively by clinical symptomatology based on patient's bloating symptoms.

Prior to starting the stimulation, the abdominal circumference (C) and body weight (BW) will also be measured in centimeters at the baseline ultrasound visit (C baseline, BW baseline). Five days after the oocyte retrieval the abdominal circumference and body weight will again be measured in centimeters (C stimulated, BW stimulated). The difference in the abdominal circumference and body weight will be calculated as follows: C baseline - C stimulated = CΔ.; BW baseline - BW stimulated = BWΔ.

The patient's clinical symptoms will be evaluated based on a bloating score reported by each patient before the trigger shot is administered and then 5 days after the oocyte retrieval will be determined. A venipuncture will also be obtained for hormone assays 5 days after oocyte retrieval.

Patients diagnosed with OHSS will be managed by a physician as clinically indicated. The number of follow-up clinic visits and hospitalizations secondary to symptoms of OHSS will be recorded.

Arms:
arm 1: On the day of ovulation trigger the patient will receive hCG 1,500 IU SQ plus FSH 450 IU SQ arm 2: On the day of ovulation trigger the patient will receive standard dose of hCG (10,000 or 5,000 IU SQ)

Interventions: intervention 1: Low dose hCG plus FSH co-trigger intervention 2: Standard dose of hCG
Intervention descriptions: intervention 1: Low dose hCG (1,500 IU) plus FSH (450 IU) co-trigger intervention 2: Standard dose of hCG (10,000 or 5,000 IU) trigger

Protocol document:
Prot_SAP_000.pdf: 
January 16, 2022 
 
Administration of follicle-stimulating hormone (FSH) and low dose human chorionic 
gonadotropin (hCG) for oocyte maturity while decreasing hCG exposure in In Vitro 
fertilization (IVF) cycles 
 
NCT02310919 
 
 
 


Study Protocol 
 
Specific Aims 
 
Primary Aim: 
1)  
To determine if concomitant low dose hCG (1500 IU) and 450 IU FSH for oocyte 
maturation trigger is non-inferior to the standard hCG alone in total fertilization proportion (i.e. 
total competent proportion), according to the primary outcomes involving maturation and 
fertilization: 
Total fertilization proportion (i.e. total competent proportion), defined as the number of 
fertilized oocytes (2PN) divided by the total number of oocytes retrieved, will be compared 
between the two treatment groups. 
 
2)  
To further assess the outcomes of oocyte recovery and developmental competence of 
the mature oocytes the following will be compared between the two treatment groups: 
a)  
Oocyte recovery 
b)  
Oocyte maturity 
c)  
Fertilization rate 
d)  
Embryo quality 
e)  
Pregnancy rates 
3)  
To compare serum and follicular post-trigger steroid hormones levels of estradiol, 
progesterone, hCG, FSH LH, and vascular endothelial growth factor (VEGF) between the two 
treatment groups at different times points: 
a)  
12 hours after trigger (T+1), at oocyte retrieval (T+2), and 5 days after trigger (T+5) to 
assess serum levels of, as appropriate, based on the study visit day. 
b)  
Follicular fluid from the first aspirate of a dominant follicle on each ovary at retrieval 
 
Secondary Aim: To determine if symptoms of OHSS are decreased with low dose hCG (1500 IU) 
and 450 IU FSH compared to standard hCG dose alone. 
 
Compare symptoms related to OHSS using the following outcomes: 
1)  
The change in bloating scores prior to trigger and after trigger 
2)  
The change in abdominal circumference prior to trigger and after trigger 
3)  
The change in body weight prior to trigger and after trigger 
 
Experimental Design and Methods: 
 
Study population: 
The target population includes female patients undergoing IVF. All eligible female patients will 
be asked to join the study. Patients receiving any type of stimulation protocol for IVF will be 
offered participation in the study. Study participants will be recruited from the Reproductive 
Endocrinology Clinic at University of California at San Francisco Center for Reproductive Health. 
 
Inclusion/Exclusion Criteria: 


Inclusions: Only patients undergoing IVF will be offered participation in the study. 
 
Exclusions: 
-  
Age >41 years old 
-  
Antral Follicle Count (AFC; 2-10 mm) < 8 
-  
Body Mass Index > 30 kg/m2 
-  
History of ≥ 2 prior canceled IVF cycles secondary to poor response 
-  
Diagnosis of cancer 
-  
Any significant concurrent disease, illness, or psychiatric disorder that would 
compromise patient safety or compliance, interfere with consent, study participation, 
followup, or interpretation of study results 
-  
Undergoing embryo co-culture 
-  
Use of any of the following medications: Growth Hormone, Sildenafil, or Aspirin (except 
if being used for hypercoagulable state) 
-  
Severe male factor infertility diagnosis. Male factor infertility diagnosis should be 
cleared for eligibility by the PI based on previous patient history of fertilization 
outcomes and/or expected fertilization outcomes of the cause of male factor infertility 
based on known scientific data. 
-  
Ovulation trigger less than or greater than 36 hours to oocyte retrieval 
-  
Serum estradiol level >5,000 pg/ml on the day of expected ovulation trigger 
 
Recruitment Plan: The physician will identify patients eligible for the study at the consultation 
visit. A research coordinator will follow up and meet with eligible participants at the saline 
sonography visit or the patients next clinical visit prior to start of IVF treatment. Informed 
consent will be performed by the research coordinator. 
 
Design: Double –Blinded Randomized trial 
Randomization: 
The patients will be randomized on the day of ovulation trigger for assignment to receive either 
standard dose of hCG (5,000 IU or 10,000 IU) alone or low dose hCG (1,500 IU) + FSH (450 IU) 
for oocyte maturation trigger by the research coordinator. All participants will be assigned a 
unique subject ID, and only the research coordinator and unblinded study physician will be 
aware of what treatment arm each patient is in. All other physicians, nurses, embryologists, 
clinic staff, and patients will be blinded. 
 
Blinding process for the medication administration: 
The hCG and FSH trigger shots for each patient will be prepared by the unblinded study 
physician the same day the patient will administer the medications. Each medication will be 
reconstituted in their own separate syringe so the patient will be presented with two syringes 
for administration that will be labeled with only “hCG” and “other”. The hCG sterile powder will 
be reconstituted with bacteriostatic water, and the designated dose suspended in a total 
volume of 1 ml in a syringe by the unblinded study physician or nurse. It will only be labeled 
with “hCG” and excluding the dose. The FSH sterile powder will also be reconstituted with 
bacteriostatic water and suspended in a total volume of 1 ml in a syringe, then labeled “other”. 


The patients that were not randomized to receive the FSH co-trigger will receive a similar 
syringe with only 1 ml of bacteriostatic water and no FSH, also labeled “other”. Immediately 
after reconstitution and suspension, the trigger medication will be given to the patient. Each 
designated syringe will be placed in an insulated cooler travel container for the patient to take 
to administer that day based on assigned trigger time. Since the unblinded study physician will 
be preparing the trigger shots for each patient they will be aware of what treatment arm each 
patient is in. 
 
Treatment Plan: 
The subjects will undergo ovarian stimulation with IVF protocol stimulation treatment chosen 
by their primary doctor. Baseline antral follicle count (AFC) will be recorded. 
 
Standard of care guidelines for ovarian stimulation to be used as a reference (not part of the 
experimental protocol): 
Type of gonadotropins: FSH, (i.e. Gonal-F) + hMG, (ie. Menopur) 
Starting dose of gonadotropins is 150-450 IU per day of FSH and hMG, which are standard 
starting doses in our clinical practice. Initial dose will be determined by the patient's primary 
doctor based on AFC and body weight. As per standard practice, the minimal dose for the 
desired response will be used. The primary doctor will manage the entire ovarian stimulation 
based on their clinical knowledge, expertise, and standard of care practices. 
 
Standard Guidelines: 
Gonadotropin medications will be started as designated by the patient's primary doctor and 
baseline ultrasound is performed. Ultrasounds will be performed and serum estradiol (E2) will 
be checked as determined by the patient's primary doctor. Gonadotropin dose will be adjusted 
based on ultrasound findings and serum E2 level as needed to be determined by the patient’s 
primary doctor. Gonadotropin injections will be continued until ovulation trigger. 
The day of administration of ovulation trigger will be determined by the patient's primary 
doctor. 
 
Guidelines for the experimental protocol: 
Study participants will receive a syringe on the day of ovulation trigger containing either the 
standard dose of hCG or low dose hCG + FSH according to the randomization. The subjects will 
be triggered with the following: 
a)  
Standard dose of hCG (10,000 IU or 5,000 IU) or 
b)  
Low dose of hCG 1,500 IU SQ + FSH 450 IU SQ 
 
For the control arm, the standard hCG dose will be given based on the E2 level on the day of 
ovulation trigger. If the E2 level is less than 3,500 pg/ml, then the trigger will be 10,000 IU of 
hCG. If the E2 level is more than 3,500 pg/ml but less than 5,000 pg/ml, then the trigger will be 
5,000 IU. 
 
On the day of ovulation trigger, the subject's body weight and abdominal circumference will be 
measured. The subject will also complete a questionnaire regarding her current symptoms. In 


addition to the standard of care estrogen lab, residual blood from that draw will be retained by 
the study for an additional lab to assess additional hormone levels. Subjects will return 12 hours 
after trigger (T+1), at oocyte retrieval (T+2), and 5 days after trigger (T+5) to assess serum levels 
of estradiol, progesterone, hCG, FSH, LH, and vascular endothelial growth factor (VEGF), as 
appropriate, based on the study visit day. 
 
The oocyte retrieval will be performed 36 hours after the ovulation trigger. All egg retrievals 
will be performed using transvaginal ultrasound and the associated needle guide in the 
standard fashion. On the day of the oocyte retrieval, the patient will have a blood draw to 
assess serum hormone levels. When possible, efforts will be made to use pre-existing 
venipuncture, such as an intravenous line, to minimize needle sticks. In these instances, 
approximately 3-5 mL of blood will be drawn and discarded as waste to clear the line of 
possible heparin and/or saline flush, and have been factored into the total blood draw volumes 
required by the study. 
 
Both the physician performing the oocyte retrieval and the laboratory personnel will be blinded 
to the study. All visible follicles will be aspirated. The first follicle from each ovary on every 
patient will be aspirated and the system (needle and tubing) will be flushed into a separate 
tube prior to aspirating the remaining follicles. The follicular fluid from the first aspirate from 
each ovary will be collected to assess follicular hormone levels. Oocyte stripping will be 
performed under the standard protocol. The status of oocyte maturation at the time of 
stripping (approximately 38-40 hours after hCG administration) and at the end of the ICSI 
procedure (approximately 40-42 hours after hCG administration) will be recorded. Fertilization 
will be assessed 16-19 hours after insemination. The embryos will be transferred to growth 
media and cultured with standard protocols. 
 
Subjects will return five days after ovulation trigger for blood draw to assess serum hormone 
levels. The subject's body weight and abdominal circumference will be measured. The subject 
will complete a questionnaire regarding her current symptoms and bloating score. 
 
Interventions to prevent OHSS in high risk patients: 
Any patients in either arm with an E2 serum level >5,000 pg/ml on the day of expected trigger 
administration will be excluded from the study. These patients will be individually assessed by 
their primary physician. Their primary physician will decide the safest trigger option based on 
the patient’s risk of OHSS. From our own clinical experience, we expect that <5% of subjects will 
have an E2 serum level of >5,000 pg/ml and be excluded. 
 
Interventions to avoid ovulation trigger failure: 
In order to avoid failure of ovulation trigger, the post trigger day serum hCG will be determined 
and communicated to the unblinded clinician. If the serum hCG level is less than 18 IU/L, then 
the subject will be excluded from the study and assessed by their primary doctor for possible 
re-trigger. If the ovulation trigger fails then administration of a second trigger medication is the 
standard of care. 
 


Assessment of OHSS related symptoms: 
To assess the incidence of OHSS related symptoms, patients will be evaluated objectively by a 
change in the abdominal circumference as well as subjectively by clinical symptomatology 
based on patient’s bloating symptoms using a questionnaire. 
Prior to starting the stimulation, the abdominal circumference (C) and body weight (BW) will be 
measured in centimeters at the baseline ultrasound visit (Cbaseline, BWbaseline). Also, the 
abdominal circumference (C) and body weight (BW) will be measured in centimeters on the day 
of ovulation trigger. Five days after the oocyte retrieval the abdominal circumference and body 
weight will again be measured in centimeters (Cstimulated, BWstimulated). The difference in 
the abdominal circumference and body weight will be calculated. 
The patient’s clinical symptoms will be evaluated based on a bloating score reported by each 
patient on the day of ovulation trigger and then 5 days after the oocyte retrieval will be 
determined. A venipuncture will also be obtained for hormone assays 5 days after oocyte 
retrieval. 
 
The bloating score will range from 0-5, and will be determined as follows: 
0 - No bloating 
1 - Mild bloating. Able to continue daily activities without discomfort. 
2 - Mild to moderate bloating. Able to continue daily activities but with mild discomfort. 
3 - Moderate bloating. Able to continue daily activities but with moderate discomfort. 
4 - Moderate to severe bloating. Difficulty performing daily activities. 
5 - Severe bloating. Abdomen feels very tense and unable to perform daily activities. 
 
The difference in the bloating score will be calculated. 
 
Sample Collection: 
The serum samples will be collected and stored in a freezer (-80°C). The follicular fluid samples 
will be labeled and identified with the unique subject ID. The follicular fluid samples will be 
spun down immediately after the oocyte retrieval and the supernatant then aliquoted into 2ml 
cryo-vials and stored at -80°C for later analysis. The serum and follicular samples will be 
batched and the serum assays will be run by the Center for Reproductive Health Endocrinology 
laboratory at UCSF. The following hormone levels will be measured with commercially available 
electrochemiluminescence immunoassays on a Cobas E 411 Analyzer (Roche Diagnostics 
International Ltd): (estradiol, progesterone, hCG, FSH and LH). The analysis of VEGF serum and 
follicular fluid concentrations will be performed by an outside lab at the Zuckerberg San 
Francisco General Hospital laboratory. Serum and follicular fluid assays were calibrated to 
known standards and validated by serial dilution. 
 
Sample size and power analysis: 
Primary outcome: 
The sample size was calculated for the primary outcome of fertilization proportion (i.e. total 
competent proportion) which was defined as the number of fertilized eggs (2 Pro-nuclei (PN) 
divided by the total number of oocytes. The average fertilization rate in our clinic is 0.7 and the 


average number of mature oocytes from a cohort of oocytes is 0.7. Therefore, the average 
fertilization proportion (i.e. total competent proportion) is approximately 0.7 x 0.7=0.49 or 
about 0.5. The alternative trigger would be regarded as non-inferior if it is at least 80% effective 
in promoting oocyte competence compared to the standard trigger, for a non-inferiority margin 
of 20%. Considering a cluster size of 15 oocytes (the average number of oocytes retrieved per 
patient in our clinic) and an estimated intra-cluster correlation of 0.1, we calculated that 
approximately 50 participants were needed in each study arm when the non-inferiority 
difference is -0.1 (i.e. 20% of 0.5 total competent proportion) with a power of 0.8 and a one-
sided alpha of 0.05.    
 
Data collection: 
All data will be recorded in a secured database at the Reproductive Endocrinology Clinic at 
University California San Francisco, Center of Reproductive Health. Each subject will be 
deidentified and assigned a unique personal ID. 
 
Statistical analysis: 
Analyses will be performed based on intention-to-treat (ITT). Using the standard trigger as 
reference, the relative risk and associated 95% confidence interval (CI) for the probability of 
laboratory outcomes was calculated using log-binomial regression models. Generalized 
estimating equations (GEE) with an exchangeable correlation structure was applied to account 
for clustered data (i.e. oocytes and embryos originating from the same patient). Continuous 
laboratory outcomes were compared using generalized linear modeling with log link function. 
For pregnancy outcomes, relative risk and 95% CI were calculated to estimate effect size. 
Hormone concentrations were compared using Wilcoxon rank sum test. For the non-inferiority 
hypothesis testing of the primary outcome, a one-sided 95% CI was constructed for the relative 
risk. The alternative trigger will be considered non-inferior to the standard trigger if the lower 
bound of the one-sided CI of the relative risk is not less than 0.8 (i.e. risk reduction limit of 
20%). For secondary outcomes, the statistical significance was based on a two-sided alpha of 
0.05. Data were analyzed using SPSS version 28.0.1.0 (Statistical Package for Social Sciences; 
Chicago, IL). 
For the secondary aim evaluating OHSS related symptoms, the abdominal circumference, body 
weight, and bloating score will be analyzed using t-tests to determine if the change is 
significantly different between the trigger groups. For these secondary aim outcomes, we do 
not expect to have sufficient numbers of events to conduct a formal analysis.